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10 CLOSING REMARKS Richard Bonnie Many of the workshop participants made the observation that that there are significant weaknesses in this country’s current "system" of death investigation, and as a result, there are significant gaps in the adequacy of the information now available. It is clear that there is a need to study this problem in greater depth and to propose solutions. One possibility is through an IOM study, which, after thorough investigation, could consider many of the solutions proposed during this workshop. Based on the discussions, it is clear that there is a substantial public need for accurate death information. One particularly compelling need is for information about the cause and manner of death for criminal adjudication. It is paramount necessity to protect the interests of the innocent and to convict the guilty. Often overlooked is substantial public interest in public health and civil adjudication, notwithstanding the fact that civil disputes are often between private parties. One example is the use of autopsies as a means of documenting medical errors and of promoting quality and trust in medicine. Another area of substantial public need is in victim identification; again, the personal interests of families are subsumed with the overall interest of the community in identifying and memorializing its lost ones. The public also has a powerful and broad interest in learning from data assembled about death to facilitate prevention interventions. That interest is dependent on adequate and
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systematic surveillance, especially of deaths due to injury and infectious disease. That enables the society to detect causal factors, and thereby to design interventions. Concerns about containing incipient bioterrorism have been added to the very long list of problems that can be addressed with good data about circumstances and causes of death. All those public needs are national needs. For many historical reasons, the responsibility for death investigation is rooted largely, although not entirely, at the state and local level, particularly at the county level. Yet, over time, the national need has become increasingly apparent. Consequently, there has to be greater priority at the national level. The national need is not being adequately met in most parts of the country. If death information is being obtained at all, it often is not obtained carefully and accurately. Research has borne this out, as have the professional experience of the workshop speakers. Approximately 20 % of the nation's deaths are subject to death investigations. While this fraction was the focus of the workshop, it also must be pointed out that, in the other 80 percent of deaths, the information is also deficient for purposes of compiling valid vital statistics. Further, how do we know that deaths are selected for the in-depth medicolegal death investigation? There are deficiencies and inconsistencies in the referral processthe decision-making surrounding which deaths to investigate in the first place. We have heard anecdotal evidence that the budget of a medical examiner or coroner office is the overriding determinant of the number of autopsies and the types of tests conducted. However, there do not appear to be any systematic studies. That leaves a gross deficit in our knowledge about the way the ME/C system is working. The deficit appears greatest for deaths in hospitals, hospices, and nursing homes. The only area in which the system appears to be working is mass disaster, in which the jurisdiction is sometimes federal. But even at the federal level there are gaps in the response, particularly with respect to infectious diseases. In all probability, the adequacy or inadequacy of death information can be aligned on a continuum. The major determinants appear to be resources, quality of expertise and professionalism, and
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the legal structure. At one end of the continuum is a sparsely populated county with a coroner system, few resources, and insufficient expertise. On the other end is the gold standarda highly professional, well-endowed medical examiner office with access to all necessary technical expertise. The variation between those two ends is determined by those three factors. Many workshop participants felt, as was argued in the 1928 NRC report, that the coroner system should be replaced by the medical examiner system. The coroner system lacks proper training and is fraught with potential conflicts of interest, particularly when coroners are funeral directors, as they often are, for whom publicity affects business. What are the deficiencies in the ME/C system? To a varying extent, depending on jurisdiction, the major deficiencies are inadequate resources; inadequate expertise; imperfect legal structure; inadequate facilities; inadequate technical infrastructure especially for detecting infectious diseases and bioterrorism; inadequate training of the professional disciplines involved in death investigations; lack of practice standards and standardization of information; lack of quality measures and quality control mechanisms; lack of adequate access to and use of information technology and information systems to collect and retrieve data; and lack of research. The foremost area for improvement regards system financing. Creative thinking is needed to develop funding mechanisms that support a major leap forward. Another area for improvement regards legal structure, including the requirement that the coroner or medical examiner have the proper training and expertise; the scope of the ME/C jurisdiction; and state responsibility for planning and overall quality. The question is not whether the system should be state or local, but rather whether all states should have better planning for effective death investigations throughout their state. That may involve having a state medical examiner system, a well-organized regional system, or multiple county system. Other areas of focus include manpower training, infrastructure (capital investment in physical plant), and information. The speaker's observation is that many agencies and institutions of government rest on the backs of a very small group of death investigators.
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A final area to explore is impediments to change. Concerns have surfaced about the ME/C system for almost a century. Even though progress has been made, it seems to have stalled. Understanding impediments to change will help to rejuvenate the system. One impediment, reported by several speakers, is the lack of prestige associated with death investigations. Another raised by several speakers is the lack of advocacy and political support for the dead. Speaker Victor Weedn captured it best by characterizing the entire death investigation system as a political orphan. The emerging emphasis on mass disasters and bioterrorism has illuminated longstanding neglect of death investigations by the federal government despite the broad public need that has been highlighted by this workshop.
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