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