Forensic Pathology (aka Medicolegal Pathology)

1. Forensic Pathology (aka Medicolegal Pathology)

2. What is Pathology? • Pathology: The scientific study of the nature of disease, its causesand consequences. • Subdisciplines are Clinical, Anatomical and Forensic Pathology.

3. Forensic Pathology • A branch of medicine that applies the principles and knowledge of the medical sciences to problems in the field of forensics (medicolegal). Investigates and determines cause and manner of death. • Forensics: The scientific application of methods, techniques and procedures to the resolution of problems pertaining to the law.

4. History of Death Investigations • Death investigation techniques used in the U.S. today originated in England. • A Death Investigator was given the title of Coroner (crown) • Elected to protect the crown’s interests from corrupt sheriff’s. • A Coroner could arrest suspects including the sheriff. • This is still the case in Missouri.

5. The coroner was required to assemble a group of peers to judge a suspect’s guilt or innocence. The group also considered the necessity of a postmortem (after death) examination or autopsy. Antemortem (prior to death) The Inquest

6. History of the Medical Examiner • New York city established the 1st city wide death investigations division. • In 1939, Maryland developed the 1st statewide death investigations division. • Today death investigations are performed differently from state to state and county to county.

7. Coroner/ME Jurisdiction • Sudden or Unexpected Death • Violent Deaths, e.g. homicide, suicides • Unattended Deaths • The person had not seen a physician for more than 20 days prior to death • Contagious Diseases, e.g., AIDS • Occupational Diseases, e.g. COPD

8. Coroner/ME System • California has Coroner/ME System separated by county. • We have more Coroner than ME systems. • Some States have either a CO or ME system or it is split by Region.

9. Coroner/ME System • Across the U.S., there are MORE Coroner Systems; these are generally represented under the setting of the Sheriff’s Office. • Some Coroner’s offices are also the local Funeral Homes. • U.S. (Federal) Government has their own system.

10. Coroner • Usually an elected official • May be appointed by the Sheriff’s department • May be a physician • May be a medical examiner • It all depends on the county/state

11. Medical Examiner (also known as a Forensic Pathologist) • Must be a Pathologist who is a M.D. or D.O. • A doctor must have advanced training to become a ME or Forensic Pathologist. • To Become a Forensic Pathologist • Four years of undergraduate school • Four years of medical school • Internship and residency in pathology • Residency in Forensic pathology • Less than 1,000 board certified forensic pathologists in the U.S.

12. Medical Examiner’s Duties • Visits death scene on request • responds or has an investigator respond to all homicide related deaths • Reviews field investigative information • Performs autopsy (aka “posts”) • Autopsy means to “see for yourself” • Orders all ancillary tests & exams • Provides consultation to DA • Provides conclusions as to cause and manner of death

13. What types of death need investigating? • Violent Deaths (homicide, accidents, suicide) • Suspicious Deaths • Sudden and unexpected • Deaths without a physician in attendance • Death in custody • Deaths during or after a medical or surgical procedure

14. Death Investigator • Works for Coroner/ME Office • Reports to the medical examiner or pathologist performing the autopsy. • Goes to the death scene and make an evaluation. • Gathers relevant medical history as well as talks to witnesses and relatives about the decedent’s last whereabouts. • Reports death to the next of kin.

15. Death Investigator • Usually an individual with law enforcement training or a: • Licensed registered nurse or • Trained mortician • Must attend the PC 832 course. • Must attend the coroner’s investigations academy after being hired by the coroner’s office.

16. Crime Scene Technician • Usually a member of local law enforcement. • Typically civilian personnel • The technician’s expertise includes: • Photographing and diagramming the death scene. • Collecting all potentially important evidence. • Recovering fingerprints • Recovering other prints such as shoes and tires

17. Criminalist • The expert who works in the forensic lab. • Has a Master’s degree in criminalistics/forensic science • Most criminalists work with one particular type of evidence, such as: • Blood • Bullets • Ammunitions • Fibers • Hair • Impressions

18. Other Types of Forensic Investigators • Other specialists include: • Serologists • Questioned Document Examiner • Toxicologist • Anthropologist • Odontologist • Radiologist • Entomologist • Botanist • Meteorologist

19. Forensic Pathologist • At scene of death controls body • Performs autopsies • Determines cause of death • Death Investigator • Works for the CO/ME office • Investigates cause of death • Crime Scene Investigator • Works for law enforcement • Collects evidence • Takes photographs • Criminalistic Specialist • Processes evidence in the laboratory

20. Forensic medicine is the application of various medical specialties to legal issues. • Pathology refers to the study of disease. • Forensic Pathologist is a medical doctor who studies injuries and disease to determine the cause and manner of death. (in suspicious deaths) • Medical Examiner is a forensic pathologist who conducts autopsies to determine the cause, manner, and mode of death by examining the internal organs of the corpse. • Coroner isa public officer whose primary function is to investigate by inquest any death thought to be of other than natural causes.

21. Is a coroner the same as a medical examiner? • Each state has a law requiring that either a coroner or a medical examiner oversee the investigation of unexpected deaths. • Click here to watch video-clip Medical Examiners vs Coroners • As you watch the video record the differences and similarities between medical examiners and coroners

22. Forensic Evidence • Evidence: Anything that can be used to determine whether a crime has been committed. • May exonerate the innocent • Corroborate or refute an alibi or statement of a witness • Identify a perpetrator or victim • Induce a confession

23. Forensic Evidence • Direct Evidence: Establishes a fact • Eyewitness testimony • Confession • Circumstantial Evidence: Requires that a judge and/or jury make an indirect judgment or inference about what happened. No absolute proof; provides a general idea of what happened. Often much more reliable than Direct Evidence. • Fingerprints • Hair • Fibers

24. Forensic Evidence • Forensic evidence can’t find and convict the criminal unaided. • It provides an additional weapon in the detective’s armory. • It can offer clues to help the detectives track down the criminal and • It can help detectives prove a suspect was present at the crime scene or committed a particular act of violence.

25. Medicolegal Investigations • Duties of the medicolegal system • Determine cause, manner, mechanism and time of death • Four important medicolegal elements of death investigation. • Identify the deceased if unknown • Collect evidence from body • Document injuries or lack thereof • Deduce how injuries occurred • Provide expert testimony if case goes to trial

26. Definition of Death • In 1968 Black’s Law Dictionary defined Death as: the cessation of life; the ceasing to exist; defined by physicians as the total stoppage of the circulation of the blood, and cessation of vital functions consequent thereon, such as respiration, pulsation, etc.

27. What is Death? • Cellular Death • The tissues and their constituent cells are dead. • No longer function or have metabolic activity, primarily aerobic respiration • From cardiorespiratory failure • Different tissues die at different rates

28. Definition of Death • Clinical Death • The cessation of respiration and circulation functioning. Resuscitation may or may not be possible. • Anoxia and hypothermia • May live for more than 5 minutes after cessation of respiration and circulation.

29. What is Death? • Somatic Death • Irreversible loss of personality, being unconscious, unable to be aware of or communicate with one’s environment, unable to appreciate any sensory stimuli or to initiate any voluntary movement. • Reflex nervous activity may persist and circulatory and respiratory functions continue either spontaneously or with artificial support so that the tissues and cells of the body, other than those already damaged in the central nervous system, are alive and functioning.

30. Definition of Death • Brain Death • An irreversible process. • Irreversible cessation of all brain functions, including brain stem. • PVS – Persistent Vegetative State = permanent damage to frontal lobe function and not brain stem.

31. Definition of Death • Brain Death is determined by: • Coma and cerebral responsiveness • Apnea • Fixed and Dilated Pupils • Absence of Cephalic Reflexes (brainstem) • Absence of Electrical Impulses in the Cerebrum(no EEG pattern) • Two physicians required to pronounce brain death; one must be a neurologist in California.

32. Death Certificate • Medicolegalrequirement of the death certificate • Cause and • Manner of Death

33. Death Certificate • The death certificate has two major groupings for the cause of death: • Primary or immediate cause of death • Secondary cause of death

34. Primary Cause of Death • The Primary cause of death is subdivided into a three-link sequential chain • Primary cause of death: • Hypoxemic necrosis of brain (brain death) due to • Exsanguination due to • Gunshot wound (GSW) of abdomen

35. Secondary Cause of Death • Includes conditions which are not related to the primary cause of death but are substantially contributory to the individual’s demise • Emphysema of the lungs • Arteriosclerotic cardiovascular disease

36. Cause of Death • The reason someone dies is the cause of death • Proximate cause of death refers to an underlying cause of death as opposed to the final cause. • The “original” underlying medical condition which initiates a lethal chain of events culminating in death. • i.e.. a shotgun blast to the head, stab wound to the chest or coronary atherosclerosis. • Immediate cause of death • What kills a person now, but was originally precipitated by something else (proximate)

37. Mechanism or Mode of Death • An abnormal physiological state that pertained at the time of death • i.e. coma, congestive heart failure, cardiac arrest, pulmonary edema, septicemia and hemorrhage • Mechanism of death describe the specific change in the body that brought about the cessation of life. • **usually only “Cause” and “Mechanism” are listed on the dead certificate**

38. Manner of Death • The circumstances surrounding a death or how the cause of death came about. • Circumstantial events or manner of death may be: • Natural due to disease or • Unnatural due to: Accident, Suicide, Homicide, Questionable/Undetermined. • NASH/Q

39. Certification of Death • Five Classifications of Death (NASH/Q) • Referred to Manner of Death • Natural: pathology; death caused by disease. • Accident: not intentional or by a criminal act. • Suicide: death by one’s own hand. • Homicide: death by another. • Questionable: cause and/or motive is not known; generally when other classifications are not used. Also “Undetermined” death is used. “Equivocal” has also been used as well.

40. Examples: Manner of death: - homicide Cause of death:- smothering Mechanism of death: - asphyxia Manner of death: - homicide Cause of death:- stabbing Mechanism of death: - loss of blood

41. Man shot during robbery. Man stabilizes. Develops pneumonia. Followed by kidney failure, liver failure, heart failure, death. Had prior lung and heart disease, and probably would have survived if not for these diseases. Manner of death: - homicide Cause of death:- gunshot Mechanism of death: - heart failure

42. REVIEW CAUSES AND MECHANISMS OF DEATH • Examples of causes of death: • heart attack, gunshot wound, skull fracture, diseases or injuries, stroke, burning, drowning, strangulation, hanging, suffocation, massive trauma, bludgeoning • Examples of mechanisms of death: • Exsanguination (bleeding to death) • Sepsis (infection in blood stream) • Brain trauma (cerebral contusion) • Brain bleeding (intra-cerebral bleed) • Stop breathing (asphyxia) • Pulmonary arrest • Cardiac arrest

43. Whitney Houston death certificate:No cause of death listed Click here ← to read the news article.

44. The manner, cause and mechanism of death of: • Jon Bennet Ramsey • Manner – homicide • Cause – strangulation • Mechanism – asphyxiation - respiratory arrest • Whitney Houston • Manner – accidental • Cause – drowning • Mechanism – Pulmonary arrest

45. Michael Jackson • Manner – homicide • Cause – acutepropofol intoxication • Mechanism – cardiac arrest • Hugo Chavez • Manner – natural • Cause – heart attack • Mechanism – Pulmonary arrest

46. You try • Write a short scenario that includes information about cause, manner and mechanism of death, without labeling them as such. • Exchange your scenario with other students and try to classify theirs.

47. Death Certificate • Cause of death written on the death certificate: • Primary or Immediate • Secondary

48. Death Certificate • Primary cause of death • Subdivided into a three-link sequential chain, eg. • Hypoxemic necrosis of brain (brain death) • Due to • Exsanguination • Due to • Gunshot wound

49. Death Certificate • Secondary cause of death • Includes conditions which are not related to the primary cause of death but are substantially contributory to the individual’s demise • Emphysema of lungs, • Hypothermia • Arteriosclerotic cardiovascular disease

50. Autopsy Reports • Cause of death: Heart failure with cardiac arrhythmia due to a pulmonary emboli. • Contributing cause: Intestinal dismobility, on chronic pain management. • Manner of Death - Undetermined.