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The Vermont Medical Examiner System

The Vermont Medical Examiner System. Paul L.Morrow, MD Forensic Pathologist, Glebe, NSW Former Chief Medical Examiner, VT USA. Death Investigation. Functions Cause of death Mechanism of death Manner of death Identification Time of death Location of death.

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The Vermont Medical Examiner System

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  1. The Vermont Medical Examiner System Paul L.Morrow, MD Forensic Pathologist, Glebe, NSW Former Chief Medical Examiner, VT USA

  2. Death Investigation • Functions • Cause of death • Mechanism of death • Manner of death • Identification • Time of death • Location of death

  3. Death Investigation: Key Concepts • Cause of death • That disease or event that set in motion the medical chain of events that resulted in death • Mechanism of death • That medical chain of events that resulted in death

  4. Death Investigation: Key Concepts • Manner of death • One word summary of circumstances of death • Manners of death • Natural • Accident • Suicide • Homicide • Undetermined

  5. Death Investigation: Types of Death Investigator Systems • Coroner • Medical Examiner

  6. Death Investigation Systems:Coroner • Ancient English office • Norman Conquest • Officially established 1194 • Appointed judicial officer (Australia/England) • Qualifications: legal (& medical in England) • Elected office in US • Qualifications: varied

  7. Death Investigation Systems:Medical Examiner • American innovation • Massachusetts , first state ME law - 1877 • New York City, ME replaced coroner- 1915 • Maryland, first statewide ME System- 1939 • Appointed medical officer • Qualifications: medical, usually forensic pathologist

  8. Death Investigation Systems • Australia/England • Coroner System • United States • Medical Examiner - 22 states • 19 state wide • Coroner - 11 states • Mixed - 18 • Canada • Medical Examiner - 4 provinces • Coroner - 8 provinces

  9. Vermont: example of a rural death investigation system • State-wide Office of Chief Medical Examiner : • Oversees local medical death investigation • Backs up local death investigation • Performs autopsies

  10. VERMONT Population(2005): 623,050 Area: 9,250 sq mi (24,000 sq k)

  11. Vermont Medical Examiner System: History • Before 1950’s • Town Selectmen, AG, SA, Sheriff/Local PD • Late 1940’s • Dr. Joseph Spelman • Creation of Vermont State Police • Design of Medical Examiner System

  12. Vermont Medical Examiner System: History • Early 1950’s • M E laws passed • Medical Examiner System established with physician RME’s • Late 1990’s – early 2000’s • Crisis in RME System • Law amended to create AME • AME system established

  13. Vermont State wide Medical Examiner System: Case #’s • ca. 800 case referrals annually • ca. 400 autopsies annually

  14. VT ME System: staff • Office of Chief Medical Examiner • 2-3 pathologists (CME/DCME) • Administrative staff • LME coordinator • Police investigator/liason (VSP) • Local Medical Examiners • Assistant ME’s • Regional ME’s • Toxicology, histology, other lab services by contract

  15. VT Medical Examiner System • ME Statute (T18§505-509; 5205) • Medical Examiner Jurisdiction • Death Investigative Team • Authority to Order Autopsies

  16. Violence Suddenly when in apparent good health Unattended by a physician Casualty Suicide As a result of injury Jail or prison Mental institution Unusual, unnatural or suspicious circumstances Medical Examiner Jurisdiction

  17. Jurisdiction: Thumbnail Sketch • All non-natural deaths (or deaths suspected to be non-natural ) • Accidents, suicides, homicides • Sudden unexplained apparently natural deaths • Jail, prison or mental institution • Truly unattended deaths • Hazard to public health, welfare or safety

  18. The Death Investigative Team • Medical Examiner • Chief Medical Examiner • Regional Medical Examiner • Assistant Medical Examiner • Law Enforcement Officer • State’s Attorney

  19. The Death Investigative Team • Responsible for the investigation of medical aspects of death • Determines the cause of death • Certifies the cause and manner of death (responsible for the death certificate) MedicalExaminer

  20. The Death Investigative Team • Forensic Pathologist • Appoints regional and assistant medical examiners (RME’s & AME’s) • Supervises AME’s and RME’s • Authority to authorize autopsies • Performs autopsies Chief Medical Examiner

  21. The Death Investigative Team • Physician • Appointed by the Chief Medical Examiner • Investigate medical aspects of death • May draw toxicology samples and such • Signs death certificate when there is no autopsy Regional Medical Examiner

  22. Problem in Rural Death Investigation: In 1990’s Increasing Maldistribution of RME coverage • Inability of dispatchers to find RME to respond to call • Inability of RME’s to respond when called • Increasing difficult of OCME to act as RME, especially in distant regions of the state • Difficulty recruiting new physicians to replace RME’s as they retired

  23. 1987 1997 Increasing Maldistribution of RME coverage

  24. The Death Investigative Team Assistant Medical Examiner • Qualified medical professional (as defined by CME) • Nurse, experienced EMT, physician’s assistant • Trained by OCME • Responds to calls/initial triage • Visits scene of death • Investigates medical aspects of death • May draw toxicology samples • Death certified by OCME or RME

  25. The Death Investigative Team • Investigates the circumstances of death • Is responsible for all law enforcement aspects of death investigation • State’s Attorney creates list of qualified law enforcement officers Law Enforcement Officer

  26. The Death Investigative Team • Has jurisdiction of body • Authority to authorize an autopsy • Is responsible for “legal” aspects of death investigation, including any prosecutions • Creates list of qualified law enforcement death investigators State’s Attorney

  27. Autopsies: VSA 18 §5205 • Authority: Chief Medical Examiner and State’s Attorney • “necessary and in the interest of public health welfare and safety, or in furtherance of the administration of the law” • Performed by (or under supervision of) Chief Medical Examiner • Report submitted to State’s Attorney and Attorney General

  28. Indications for Autopsy: - Medical - Legal

  29. Criteria for autopsy: legal • State’s Attorney • To determine or document cause and manner of death in cases of criminal investigation or “legal” interest • To identify medical factors in criminal and “legal” investigations • To gather evidence “in furtherance of the administration of the law” (e.g., homicides)

  30. Criteria for autopsy: medical • Chief Medical Examiner • To determine the cause and manner of death • To document the medical cause and mechanism of death • To gather necessary material to determine cause of death ( e.g. drug deaths) • To identify contributory medical factors • To “rule out” alternative causes where diagnosis is by circumstances (e.g. hypothermia, hyperthermia, drowning) • Identification of body • Public heath concerns (e.g. infectious disease)

  31. The inspection option • Formal external examination of the body by the pathologist at the Office of the Chief Medical Examiner • Used in cases where the cause of death is obvious, but circumstances may require “extraordinary” documentation

  32. VT Medical Examiner System • So what happens? How does it work on a day to day basis? • A body is found….. - or dies in an emergency room…… - or dies under circumstances that appear to fall under the Medical Examiner jurisdiction……

  33. VT Medical Examiner System • Police and AME/RME are called and make a “proper preliminary investigation” • State’s Attorney is notified (technically in charge of body)

  34. Suspicious case or scene: Criminal (Police) Investigation

  35. Medical Investigation May or may not involve scene Options • Waive jurisdiction • Certify death (write death certificate) • Autopsy

  36. Autopsy

  37. Follow up investigation

  38. Advantages • Medical Examiner model • Medically trained person examines body, reviews medical history and certifies death • Cause of death is a medical determination • Mechanism is a medical chain of events • Forensic pathology is more than just pathology • Appointed vs elected official (US) • Coroner model • Inquest by judicial officer (Australia)

  39. And one final thought….. “Show me the manner in which a nation cares for its dead, and I will measure with mathematical exactness their tender sympathies of its people their respect for the laws of the land, and their devotion to high ideals.” - William E. Gladstone 1809-1898

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