When a Natural Death Isn’t Natural

Amanda JamesChevas Yeoman

Division of Aging Services

Joseph Shepter

• Died at age 76 in a Nursing Home• The nursing home’s chief medical officer

explained that the cause was heart failure brought on by clogged arteries• No coroner review (attended death)

Natural Death Right?

http://www.propublica.org/article/gone-without-a-case-suspicious-elder-deaths-rarely-investigated

Joseph Shepter• Tip from a nursing home staffer prompted state officials to re-

examine the case• Later determined that he had actually died of a combination

of ailments related to poor care, including an infected ulcer, pneumonia, dehydration and sepsis

• Also concluded death was hastened by the inappropriate administration of powerful antipsychotic drugs

Not a Natural Death

http://www.propublica.org/article/gone-without-a-case-suspicious-elder-deaths-rarely-investigated

NOT ALL DEATHS ARE NATURAL

“No elder death should be automatically assumed to have a

natural manner based solely on age and past medical history.”

K. Collins, 2015 AFP

• Pre-existing conditions

• Fatal GSW – Head

• Manner: Homicide

• Pre-existing conditions

• Fatal Neglect (by other)

• Manner: Natural

Manner

• Cardiovascular Disease• COPD• Cancer• Dementia• Falls – susceptibility •Medications – adverse reactions• Over/Under

Changes Attributed to Aging

• Hip fractures• Subdural hematomas• Dementia• Untreated decubitus ulcers• Sepsis• Malnourishment• Improper medications

Presence may obscure indicators of abuse, neglect & exploitation.

May Hasten Death

Within a year, • 30% of people 65 and older had a fall• 50% of people 80 and older had a fall

38%-47% are fatal

Sometimes people are pushed or tripped

Falls

• Time/Date of Fall• Witnesses• Location• Landing Surface• Use of throw rugs• Strike intermediary object during fall (furniture)

Causes given for both accidental and homicidal falls:• Medications• Frailty

Totality of circumstances should be evaluated.

Falls

Additional Issues

• Attended Deaths – Hospital, Hospice, Nursing Home• Lack of Space for Medical Examiners and

Coroners• Complexity of Cases

“This [case] was a prolonged situation of being malnourished and starved.”

Metro prosecutor about child neglect case and consideration of death penalty.

Child Neglect

Older adults and adults with disabilities are neglected everyday.

When are those deaths suspicious?

Adult Neglect

Not enough time and resources to investigate every older adult death,

so what can a medical examiner/coroner look for?

• Prior/Frequent “911” calls to location

• History with Adult Protective Services (Decedent)

• History with Healthcare Facility Regulation (Facility)• Repeated citations for serious violations• Frequent name changes to Long-Term Care Facility

• Decubitus ulcers - untreated

• Evidence of Malnutrition, Dehydration, Starvation

• Weight below normal• For disease process and age

Table 1 Investigation of Elder Deaths

Red Flags

• Overall poor condition of body (hygiene, presence of urine/feces)

• Poor condition of residence/location (unsafe/unhealthy)

• Marks or Injuries to the body • Unexplained or inconsistent with story provided

• Medications missing or inconsistent

• Efforts to prevent/obstruct investigation

• Incomplete or reluctant witness accounts

• Multiple unemployed adults in shared living arrangements

Table 1 Investigation of Elder Deaths

Red Flags

Considerations:• Scene investigation• Medicolegal death investigator’s report• Photos• Medical records (physical/psychiatric)• Dietary/Rx• Therapy recs• Tox/Hist/Chem/etc.• Financial history• Social history• Residence• Independence• Competency History:

Medical * Social * Financial

Autopsy

Addressing the Problem

•Medical Examiner/Coroner Training• Standard Investigation Checklist• Training of First Responders and Mandated

Reporters

Fulton County Medical Examiner’s Office Data

• Elder Abuse, Neglect, and Exploitation• Prevalence of the wrongfully assigned

manner of death as natural• Recognizing trends in health care facilities• Setting a case definition based on a

combination of ME, APS, and HFR data

Prospective Collection – Medical Examiner Sources• Many different sources of Data• Demographics• Scene Information (Narrative and Pictures)• Medications• Medical conditions• Evidence• Narratives (Initial vs Follow-up)• Autopsy Results• Lab Results• Police Reports

Outside Supplemental Sources

• HFR – Healthcare Facility Regulation• Nursing Homes, Assisted Living Facilities,

Personal Care Homes, Community Living Arrangements• Licensing, Inspection, and Violation records

• APS – Adult Protective Services• Any intake or referrals, cases opened, cases

closed, substantiated vs unsubstantiated• Family status• Medical Hx

Outcomes

• Number of cases that were wrongfully recognized as a natural manner that can be attributed to abuse, neglect, and/or exploitation with auxiliary data points• Trends of suspicious deaths related to specific nursing

homes, personal care homes, and assisted living facilities• Failure to report: Mandated Reporters• Geolocated location of the incidents and place where

declared deceased for mapping• New data points and revised protocol so not to miss

critical data to discover abuse, neglect, and exploitation

Fulton County Medical Examiner Project • June 2014 initiated• Review cases - decedents 65+

No Abuse – Possibly Not Abuse – Possibly Abuse – Abuse

1st 100 cases reviewed: 27 + for possible ANE

Next step:• Compare data to protective and regulatory data, ER

Data, & DV Registry• To identify: trends, markers, etc.

Current Project

Importance of Reporting

• Can’t have history or red flags without reporting• Extremely important with attended deaths

If you suspect abuse, neglect or exploitation, you need to report!!!

Reporting

•Many resources available to learn red flags and when to report. •Mandated Reporter training available.

Adult Protective Services

1-866-552-4464Press “3”

www.aging.ga.gov“Report Elder Abuse”

In the Community

Healthcare Facility Regulation

1-800-878-6442

www.dch.ga.gov Go to:

“Healthcare Facility Regulation”Go to:

“File A Complaint”

In a LTC Facility

Many older adults die with their diseases and not of

their diseases.

Forensic Special Investigation UnitCase ReviewsCurrent Research Project with FCMEO

Investigation of Elder Deaths, (2014) Academic Forensic PathologyCollins, K., Howe, K., King, P., Yeoman, C.

Source Material