Delayed homicides and the proximate cause

Unsuspected systemic Epstein-Barr virus-positive T-cell lymphoma of childhood diagnosed at autopsy in a potential homicide case

Systemic Epstein-Barr virus (EBV)-positive T-cell lymphoma of childhood (SETLC) is a rare, rapidly progressive, and often fatal disease of children and young adults characterized by monoclonal expansion of EBV-positive T cells in tissues or peripheral blood following infection with EBV. Its distinction from other EBV-positive T-cell lymphoproliferative disorders with overlapping features can be difficult, and particular diagnostic features may not be manifest until autopsy examination. We present the case of a 10-year-old boy with significant disability due to remote traumatic brain injury following non-accidental head trauma who died unexpectedly at home. Given the history of physical abuse and the potential for homicide charges, significant medicolegal implications arose with this case. Pathologic investigation ultimately revealed conclusive diagnostic features of SETLC including extensive proliferation of EBV-positive T cells in multiple organs. A natural manner of death was confirmed, thereby excluding delayed homicide related to complications of non-accidental head trauma.

Blunt force homicides in Denmark 1992-2016

Blunt force trauma is a common homicide method, inflicted in three different ways: bodily force, assault with blunt objects of various types and falls from height. The objective of this study is to provide thorough information on blunt force homicides with data on the victims, the offenders, the surrounding circumstances, the injury methods, the extent of injuries, and survival time, which will help inform the inexperienced as well as the seasoned forensic pathologist in their daily work with death investigation and as expert witnesses in court. We have analyzed autopsy reports and available case files of 311 blunt force homicides, making up 21.9% of all homicides in Denmark during 1992-2016. Most victims and offenders were male. Altercation in the setting of nightlife and intoxication was common in male victims, while most female victims were killed in a domestic setting. Bodily force was the most common primary homicide method, followed by assault with a blunt object and fall from height. The head was the region that most often had external injuries, with no noteworthy difference between cases with bodily force and blunt objects. Two out of three victims had one or more lacerations, most often located on the head and more often on the front. Brain injury was the primary cause of death in at least 72.0% victims. Compared to bodily force victims of blunt object assault were especially prone to skull and brain injuries, had a higher trauma score, and more died at the crime scene and had a shorter survival time.

A review of causal inference in forensic medicine

The primary aim of forensic medical analysis is to provide legal factfinders with evidence regarding the causal relationship between an alleged action and a harmful outcome. Despite existing guides and manuals, the approach to formulating opinions on medicolegal causal inference used by forensic medical practitioners, and how the strength of the opinion is quantified, is mostly lacking in an evidence-based or systematically reproducible framework. In the present review, we discuss the literature describing existing methods of causal inference in forensic medicine, especially in relation to the formulation of expert opinions in legal proceedings, and their strengths and limitations. Causal inference in forensic medicine is unique and different from the process of establishing a diagnosis in clinical medicine. Because of a lack of tangibility inherent in causal analysis, even the term “cause” can have inconsistent meaning when used by different practitioners examining the same evidence. Currently, there exists no universally applied systematic methodology for formulating and assessing causality in forensic medical expert opinions. Existing approaches to causation in forensic medicine generally fall into two categories: intuitive and probabilistic. The propriety of each approach depends on the individual facts of an investigated injury, disease, or death. We opine that in most forensic medical settings, probabilistic causation is the most suitable for use and readily applicable. Forensic medical practitioners need, however, be aware of the appropriate approach to causation for different types of cases with varying degrees of complexity.

Medicolegal Investigation for Cremation Clearance: How and Why?

This study on cremation clearance examines whether physical inspections detect more unnatural unreported deaths than medicolegal investigations without inspections. We reviewed all deaths reported to the medical examiner for cremation clearance during 2 distinct years and compared subsequent amendments of death certificates after 2 different investigative methodologies (1 with and 1 without physical inspection). Of 10,367 deaths in 2012, there were 86 deaths (0.83%) in which the investigation with physical inspection resulted in amendments to the death certificate. Of 11,906 deaths in 2016 without physical inspection, there were 153 that resulted in amendments (1.3%) including 2 homicides. For the detection of accidents, there was no statistically significant difference (χ = 0.8119, P = 0.367552). For cremation investigations, the work effort and costs of performing physical inspections do not appear justified given the similar detection rates (approximately 1%) for unnatural deaths among the 2 groups. Both methods, however, do detect unreported unnatural deaths.

National Association of Medical Examiners Position Paper: Recommendations for the Investigation and Certification of Deaths in People with Epilepsy

Sudden unexpected death of an individual with epilepsy (SUDEP) can pose a challenge to death investigators, as most deaths are unwitnessed and the individual is commonly found dead in bed. Anatomic findings (e.g., tongue/lip bite) are commonly absent and of varying specificity, limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus, it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden, unexpected death in a person with epilepsy is encountered.

National Association of Medical Examiners position paper: Recommendations for the investigation and certification of deaths in people with epilepsy

Sudden unexpected death of an individual with epilepsy can pose a challenge to death investigators, as most deaths are unwitnessed, and the individual is commonly found dead in bed. Anatomic findings (eg, tongue/lip bite) are commonly absent and of varying specificity, thereby limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention constituted an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden unexpected death in a person with epilepsy is encountered.

Evaluation of meteorological and epidemiological characteristics of fatal pulmonary embolism

The objective of the present study was to identify risk factors among epidemiological factors and meteorological conditions in connection with fatal pulmonary embolism. Information was collected from forensic autopsy records in sudden unexpected death cases where pulmonary embolism was the exact cause of death between 2001 and 2010 in Budapest. Meteorological parameters were detected during the investigated period. Gender, age, manner of death, cause of death, place of death, post-mortem pathomorphological changes and daily meteorological conditions (i.e. daily mean temperature and atmospheric pressure) were examined. We detected that the number of registered pulmonary embolism (No 467, 211 male) follows power law in time regardless of the manner of death. We first described that the number of registered fatal pulmonary embolism up to the nth day can be expressed as Y(n) = α ⋅ n (β) where Y denotes the number of fatal pulmonary embolisms up to the nth day and α > 0 and β > 1 are model parameters. We found that there is a definite link between the cold temperature and the increasing incidence of fatal pulmonary embolism. Cold temperature and the change of air pressure appear to be predisposing factors for fatal pulmonary embolism. Meteorological parameters should have provided additional information about the predisposing factors of thromboembolism.

Investigation of Deaths of Chronically Disabled Persons and Institutionalized Persons

The investigation of deaths involving chronically disabled and/or institutionalized persons represents an important challenge to the medicolegal death investigation community. For the purposes of this review, the chronically disabled and/or institutionalized are considered to include three non-mutually exclusive subcategories: the disabled elderly, the severely disabled, and psychiatric patients. Because deaths within certain of these populations tend to be common and expected, a very important goal when such deaths occur is the appropriate referral of cases to the medical examiner/coroner. Although each subcategory has distinct issues of importance regarding death investigation, there is also a reasonable amount of overlap between the three groups. This review provides an overview of the three subcategories, the reasons such persons may be at risk for premature, unexpected, or unnatural death, the many important issues of concern when investigating deaths within these vulnerable populations, and important preventative strategies within each group.

The Consistency and Advantage of Therapeutic Complication as a Manner of Death

The standard manners of death of the Vital Statistics Bureau of the United States include: natural, accident, suicide, homicide, and undetermined. The therapeutic complication (TC) manner of death is used in some jurisdictions for fatalities caused by predictable complications of appropriate medical therapy; it is not a synonym for medical malpractice. The usefulness of the TC manner, and whether it can be applied consistently, has never been formally assessed. A survey was conducted that asked for the manner of death in 16 case vignettes of a variety of fatal medical complications. This survey was completed by forensic pathologists from a jurisdiction that routinely uses the TC manner of death and by forensic pathologists from other jurisdictions that do not have the TC option. The forensic pathologists from the TC jurisdiction had the option of selecting TC as the manner of death in the survey while the other group did not. There was excellent consistency for the TC fatalities among the TC-jurisdiction respondents. Among the non-TC group there was less agreement, particularly with allergic reactions and some procedural complications. In that one instance there was a 57% to 43% disagreement between a natural and accidental manner. The therapeutic complication manner of death may be more easily applied in a consistent fashion and may improve agreement of certification in certain types of deaths. Without the TC option, some forensic pathologists will certify deaths due to medical complications as natural and others will certify them as accidents.

Cause and Manner of Death in Traumatic Spinal Cord Injuries: A 20 year Retrospective Review at a Statewide Medical Examiner Office

In the United States approximately 250,000 persons have a traumatic spinal cord injury (TSCI) and most will die from complications related to their injury. Interpretation of TSCI deaths by medical examiners is evolving as understanding of SCI pathophysiology increases. We queried our electronic database for deaths meeting inclusion criteria from 1989 to 2008 and identified 305 cases, of which 81% were males and 19% were females. A full autopsy was performed in 38.7% of cases and an external exam was performed in the remaining cases (61.3%). The manner of death distribution was accident (80%), homicide (7%), natural (7%), suicide (4%) or undetermined (2%). The most common mechanisms of spinal cord injury were motor vehicle accidents (42.6%), fall from a standing height (12.8%), fall from above a standing height (9.2%) and gunshot wounds (8.8%). The mechanism of spinal cord injury significantly impacted survival (p=0.0001) with decedents injured from motor vehicle accidents having a mean survival time of 14.4 years compared to 0.7 year from falling from a standing height. Analyzing patterns of deaths due to TSCI in a medical examiner office provides excellent epidemiological data for injury tracking and prevention as well as a context for medical examiners evaluating TSCI.