The Vermont Medical Examiner System

Paul L.Morrow, MD

Forensic Pathologist, Glebe, NSW

Former Chief Medical Examiner, VT USA

Death Investigation

• Functions– Cause of death

• Mechanism of death

– Manner of death– Identification– Time of death– Location of death

Death Investigation: Key Concepts

• Cause of death– That disease or event that set in motion the

medical chain of events that resulted in death

• Mechanism of death– That medical chain of events that resulted in

death

Death Investigation: Key Concepts

• Manner of death– One word summary of circumstances of death– Manners of death

• Natural

• Accident

• Suicide

• Homicide

• Undetermined

Death Investigation: Types of Death Investigator Systems

• Coroner

• Medical Examiner

Death Investigation Systems:Coroner

– Ancient English office• Norman Conquest

• Officially established 1194

– Appointed judicial officer (Australia/England)• Qualifications: legal (& medical in England)

– Elected office in US• Qualifications: varied

– American innovation• Massachusetts , first state ME law - 1877

• New York City, ME replaced coroner- 1915

• Maryland, first statewide ME System- 1939

– Appointed medical officer• Qualifications: medical, usually forensic pathologist

Death Investigation Systems:Medical Examiner

Death Investigation Systems

• Australia/England – Coroner System

• United States– Medical Examiner - 22 states

• 19 state wide

– Coroner - 11 states– Mixed - 18

• Canada– Medical Examiner - 4 provinces– Coroner - 8 provinces

Vermont: example of a rural death investigation system

• State-wide Office of Chief Medical Examiner :– Oversees local medical

death investigation

– Backs up local death investigation

– Performs autopsies

VERMONT

Population(2005): 623,050

Area: 9,250 sq mi (24,000 sq k)

Vermont Medical Examiner System: History

• Before 1950’s– Town Selectmen, AG,

SA, Sheriff/Local PD

• Late 1940’s– Dr. Joseph Spelman

– Creation of Vermont State Police

– Design of Medical Examiner System

Vermont Medical Examiner System: History

• Early 1950’s– M E laws passed– Medical Examiner System

established with physician RME’s

• Late 1990’s – early 2000’s– Crisis in RME System– Law amended to create AME – AME system established

Vermont State wide Medical Examiner System: Case #’s

• ca. 800 case referrals annually

• ca. 400 autopsies annually

0100200300400500600700800900

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

TotalME Cases

Autopsies

VT ME System: staff

• Office of Chief Medical Examiner– 2-3 pathologists (CME/DCME)– Administrative staff– LME coordinator– Police investigator/liason (VSP)

• Local Medical Examiners– Assistant ME’s – Regional ME’s

• Toxicology, histology, other lab services by contract

VT Medical Examiner System

• ME Statute (T18§505-509; 5205)– Medical Examiner

Jurisdiction

– Death Investigative Team

– Authority to Order Autopsies

Medical Examiner Jurisdiction

• Violence• Suddenly when in

apparent good health• Unattended by a

physician• Casualty• Suicide• As a result of injury

• Jail or prison• Mental institution• Unusual, unnatural or

suspicious circumstances

Jurisdiction: Thumbnail Sketch

• All non-natural deaths (or deaths suspected to be non-natural )– Accidents, suicides, homicides

• Sudden unexplained apparently natural deaths

• Jail, prison or mental institution• Truly unattended deaths• Hazard to public health, welfare or

safety

The Death Investigative Team

• Medical Examiner– Chief Medical Examiner– Regional Medical Examiner– Assistant Medical Examiner

• Law Enforcement Officer

• State’s Attorney

The Death Investigative Team

• Responsible for the investigation of medical aspects of death

• Determines the cause of death

• Certifies the cause and manner of death (responsible for the death certificate)

Medical Examiner

The Death Investigative Team

• Forensic Pathologist• Appoints regional and assistant medical

examiners (RME’s & AME’s)– Supervises AME’s and RME’s

• Authority to authorize autopsies• Performs autopsies

Chief Medical Examiner

The Death Investigative Team

• Physician

• Appointed by the Chief Medical Examiner

• Investigate medical aspects of death– May draw toxicology samples and such

• Signs death certificate when there is no autopsy

Regional Medical Examiner

Problem in Rural Death Investigation:

• Inability of dispatchers to find RME to respond to call

• Inability of RME’s to respond when called• Increasing difficult of OCME to act as RME,

especially in distant regions of the state• Difficulty recruiting new physicians to replace

RME’s as they retired

In 1990’s Increasing Maldistribution of RME coverage

Increasing Maldistribution of RME coverage

1987 1997

The Death Investigative Team

• Qualified medical professional (as defined by CME)– Nurse, experienced EMT, physician’s assistant– Trained by OCME

• Responds to calls/initial triage• Visits scene of death• Investigates medical aspects of death• May draw toxicology samples• Death certified by OCME or RME

Assistant Medical Examiner

The Death Investigative Team

• Investigates the circumstances of death

• Is responsible for all law enforcement aspects of death investigation– State’s Attorney creates list of qualified law

enforcement officers

Law Enforcement Officer

The Death Investigative Team

• Has jurisdiction of body

• Authority to authorize an autopsy

• Is responsible for “legal” aspects of death investigation, including any prosecutions

• Creates list of qualified law enforcement death investigators

State’s Attorney

Autopsies: VSA 18 §5205

• Authority: Chief Medical Examiner and State’s Attorney– “necessary and in the interest of public health welfare

and safety, or in furtherance of the administration of the law”

• Performed by (or under supervision of) Chief Medical Examiner

• Report submitted to State’s Attorney and Attorney General

- Medical

- Legal

Indications for Autopsy:

Criteria for autopsy: legal

• State’s Attorney– To determine or document cause and manner of

death in cases of criminal investigation or “legal” interest

– To identify medical factors in criminal and “legal” investigations

– To gather evidence “in furtherance of the administration of the law” (e.g., homicides)

Criteria for autopsy: medical

• Chief Medical Examiner– To determine the cause and manner of death – To document the medical cause and mechanism of

death– To gather necessary material to determine cause of

death ( e.g. drug deaths)– To identify contributory medical factors– To “rule out” alternative causes where diagnosis is by

circumstances (e.g. hypothermia, hyperthermia, drowning)

– Identification of body– Public heath concerns (e.g. infectious disease)

The inspection option

• Formal external examination of the body by the pathologist at the Office of the Chief Medical Examiner

• Used in cases where the cause of death is obvious, but circumstances may require “extraordinary” documentation

VT Medical Examiner System

• So what happens? How does it work on a day to day basis?

• A body is found…..

- or dies in an emergency room……

- or dies under circumstances that appear to fall under the Medical Examiner jurisdiction……

VT Medical Examiner System

• Police and AME/RME are called and make a “proper preliminary investigation”– State’s Attorney is notified (technically in

charge of body)

Suspicious case or scene: Criminal (Police)

Investigation

Medical Investigation

May or may not involve scene

Options– Waive jurisdiction

– Certify death (write death certificate)

– Autopsy

Autopsy

Follow up investigation

Advantages

• Medical Examiner model– Medically trained person examines body, reviews

medical history and certifies death• Cause of death is a medical determination• Mechanism is a medical chain of events

– Forensic pathology is more than just pathology – Appointed vs elected official (US)

• Coroner model– Inquest by judicial officer (Australia)

“Show me the manner in which a nation cares for its dead, and I will measure with mathematical exactness their tender sympathies of its people their respect for the laws of the land, and their devotion to high ideals.”- William E. Gladstone 1809-1898

And one final thought…..