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OVERVIEW OF THE MEDICOLEGAL DEATH INVESTIGATION SYSTEM IN THE UNITED STATES

Randy Hanzlick

The medicolegal death investigation system is responsible for conducting death investigations and certifying the cause and manner of unnatural and unexplained deaths. Unnatural and unexplained deaths include homicides, suicides, unintentional injuries, drug-related deaths, and other deaths that are sudden or unexpected. Approximately 20% of the 2.4 million deaths in the US each year are investigated by medical examiners and coroners, accounting for approximately 450,000 medicolegal death investigations annually.

Death investigations carry broad societal importance for criminal justice and public health. Death investigations provide evidence to convict the guilty and protect the innocent, whether they are accused of murder, child maltreatment, neglect, or other crimes. Death investigations aid civil litigation, such as in malpractice, personal injury, or life insurance claims. Death investigations are critical for many aspects of public health practice and research, including surveillance, epidemiology, and prevention programs, most often in injury prevention and control but also in prevention of suicide, violence, or substance abuse. And death investigations are emerging as critically important in evaluating the quality of health care and the nation's response to bioterrorism.

The term medicolegal death investigation system is something of a misnomer. It is an umbrella term for a patchwork of highly varied state and local systems for investigating deaths. Death investigations are carried out by coroners or medical examiners. Their role is to decide the scope and course of a death investigation, which includes



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3 OVERVIEW OF THE MEDICOLEGAL DEATH INVESTIGATION SYSTEM IN THE UNITED STATES Randy Hanzlick The medicolegal death investigation system is responsible for conducting death investigations and certifying the cause and manner of unnatural and unexplained deaths. Unnatural and unexplained deaths include homicides, suicides, unintentional injuries, drug-related deaths, and other deaths that are sudden or unexpected. Approximately 20% of the 2.4 million deaths in the US each year are investigated by medical examiners and coroners, accounting for approximately 450,000 medicolegal death investigations annually. Death investigations carry broad societal importance for criminal justice and public health. Death investigations provide evidence to convict the guilty and protect the innocent, whether they are accused of murder, child maltreatment, neglect, or other crimes. Death investigations aid civil litigation, such as in malpractice, personal injury, or life insurance claims. Death investigations are critical for many aspects of public health practice and research, including surveillance, epidemiology, and prevention programs, most often in injury prevention and control but also in prevention of suicide, violence, or substance abuse. And death investigations are emerging as critically important in evaluating the quality of health care and the nation's response to bioterrorism. The term medicolegal death investigation system is something of a misnomer. It is an umbrella term for a patchwork of highly varied state and local systems for investigating deaths. Death investigations are carried out by coroners or medical examiners. Their role is to decide the scope and course of a death investigation, which includes

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examining the body, determining whether to perform an autopsy, and ordering x-ray, toxicology, or other laboratory tests. There are broad differences between medical examiners and coroners in training and skills and in the configuration of state and local organizations that support them. Medical examiners are physicians, pathologists, or forensic pathologists with jurisdiction over a county, district, or state. They bring medical expertise to the evaluation of the medical history and physical examination of the deceased. A coroner is an elected or appointed official who usually serves a single county and often is not required to be a physician or to have medical training. The evolution of today’s diverse death investigation system traces back to medieval England. Historical Origins Coroners date back to 9th and 10th century England. They were formalized into law in the 12th century under King Richard I (Richard the Lion-Hearted). The king dispatched coroners to death scenes to protect the crown’s interest and collect duties (coroner is derived from Anglo-Norman corouner, the “guardian of the crown’s pleas”). Coroner laws were imported into the colonies with the early colonists. For example, the British Colony of Georgia followed British Common Law in 1733; the first state constitution mentioned coroners; and subsequent statutes described coroner duties. The first move toward reliance on a medical examiner took place in 1860 with the passage of Maryland legislation requiring the presence of a physician at the death inquest. Thus, the role of the coroner and medical examiner evolved from a highly decentralized system rooted in local or county ordinances. With awareness of the need for expertise in death investigations, there has been a nationwide trend, since 1877, to replace coroners with medical examiners, but efforts have been stalled since the middle 1980's (Hanzlick and Combs, 1998). Current Distribution of Coroner and Medical Examiner Systems Today, 11 states have coroner-only systems, wherein each county in the state is served by a coroner. Another 22 states have medical examiner systems, most of which are statewide and are administered by state agencies. And 18 states have mixed systems: some counties are served by coroners, others by medical examiners,

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and still others by a hybrid known as a referral system, in which a coroner refers cases to a medical examiner for autopsy (Hanzlick and Combs, 1998). Approximately, half the US population is served by coroner systems and the other half by medical examiners. Regardless of who runs the system, most death investigations are handled at the county level. Approximately 2185 death investigation jurisdictions are spread across the nation’s 3137 counties. System Variability The historical origin of death investigations as a local responsibility has led to wide variation in the scope, extent, and quality of investigations. The variability is manifest in the responsible office’s organizational placement in the government; statutory requirements, including credentials and training of personnel performing the investigations; and funding levels. The most common placement for a medical examiner or coroner office is as a separate office of city, county, or state government. About 43% of the US population is covered by this type of system placement. The second most common placement is under a public safety or law enforcement office. The least common placement (14% of the US population) is under a forensic laboratory or health department. Thus, at a time of growing public health needs, few coroner or medical examiner offices have formal relationships with health departments. The quality of a death investigation system is difficult to assess, but it can be measured with several indicators. One is accreditation by NAME, the professional organization of physician medical examiners. Only 42 of the nation’s medical examiner offices, serving 23% of the population have been accredited by NAME in recent years. Most of the population (77%) are served by offices lacking accreditation. Another indicator of quality is statutory requirements for training: about 36% of the US population lives where minimal or no special training is required of those responsible for death investigations (Hanzlick, 1996). In Georgia, for example, the typical requirements for serving as a coroner are being a registered voter at least 25 years old, not having any felony convictions, having a

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high-school diploma or the equivalent, and receiving annual training of 1 week. Funding levels also vary greatly. County systems range from $0.62 to $5.54 per capita, with a mean of $2.6 per capita. Statewide systems are generally funded at lower levels: $0.32-$3.20 per capita, with a mean of $1.41 per capita. Third-party payers generally do not support the costs of operations, nor are there medical billing systems. Funding is almost exclusively from tax revenues. Because of insufficient funding, salaries of medical examiners are much lower than those of other physicians. Lower salaries lead to difficulty in recruiting and retaining skilled personnel. Major Issues Facing the Medicolegal Death Investigation System One major issue is the shortage of skilled personnel. Since 1959, only about 1,150 forensic pathologists have been board-certified. There are 41 training programs that can accept approximately 70 forensic residents each year, however, many of those positions remain unfilled. Given that there are 2,000 death investigation jurisdictions in the United States, it is clear that there are not enough board-certified forensic pathologists to meet the nation’s public health and criminal justice needs. The shortage of skilled personnel contributes to the overall problem of inadequate death investigations in many jurisdictions. The problem is perpetuated by insufficient funding by local governments for operations and personnel. The other major issue is readiness of the death investigation system for the growing nationwide demands of public health and criminal justice. Two emerging issues are ensuring the quality of the nation’s health care system, especially for nursing home care, and responding to the threat of bioterrorism. The medicolegal death investigation system could be improved by: Creating a referral-based medical examiner system. A county-based (local) system would be best with regard to the need for communication, travel, and investigative response time, but it may

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be impossible because of an insufficient population or tax base. A referral-based medical examiner system could improve the function of coroner systems that do not have ready access to qualified pathologists and needed services. Insuring that death investigation systems are headed by trained and qualified medical professionals. The qualifications of those in charge of and working in death investigations need to be raised at virtually all job levels in many areas of the United States. Inspection and accreditation of systems should eventually be required. Increasing the investment in personnel and facilities. Increases in medical examiner salaries and incomes. Current salaries are substandard and need to be higher to attract qualified people. Increasing the level of education, training, and qualifications of death investigators, and in modernization of facilities. Revisiting of the Model Postmortem Examinations Act of 1954 (Model legislation developed by the National Association of Counties to promote the shift from coroners to professional medical examiners trained and credentialed in medicine). Death investigation statutes in various states should be more uniform and modernized.