Research, practice, and data informed investigations of child and youth suicide: A science to service and service to science approach

BACKGROUND

Suicide rates for children and adolescents have been increasing over the past 2 decades. In April 2023, the National Institute of Mental Health (NIMH) convened a two-day workshop to address child and youth suicide.

PURPOSE

The workshop focus was to discuss the state of the science and stimulate a collaborative response between researchers, death investigators, and data collection teams to build a science to service and service to science approach toward understanding - and ultimately preventing - this growing problem of child and youth suicide.

HIGHLIGHTS

Topics that meeting participants highlighted as worthy of further consideration for research and practice were: increasing awareness among death investigators, medical examiners, and coroners that child suicide deaths under age 10 years do occur and should be investigated and documented accordingly; emphasizing the value of science based protocols for child and youth death investigations to enhance consistency of approaches; and articulating needs for postvention services to suicide loss survivors.

OUTCOMES

The importance of collecting an accurate and complete cause and manner of death (i.e., unintentional, suicide, homicide, undetermined) among all child decedents, and demographic information such as race, ethnicity, and sexual/gender minority status was underscored as critical for enhanced surveillance. For prevention efforts, approaches to assessing and understanding suicidal thoughts and behaviors among diverse groups of children, and the variability in proximal and distal risk factors are needed to inform opportunities for preventive interventions for diverse communities. The need for consistent measures and processes to improve death investigations, fatality review committees, and coordination between data collection systems and agencies was also raised.

PRACTICAL APPLICATIONS

Collaborations among researchers, death investigators, and data collection teams can help to fully describe the child and youth suicide crisis and provide actionable information for new research, and prevention and response efforts.

The Intersection of Death Investigation and Organ Donation Systems: A Scoping Review

Introduction

Death investigators (DIs) such as coroners, medical examiners, and forensic pathologists play important and evolving roles in deceased organ donation. DIs communicate with organ donation organizations (ODOs) to gather case-specific information and release or restrict organs depending on the medicolegal requirements. This scoping review aims to identify the breadth of roles and decision-making processes that may facilitate or hinder deceased donation in DI cases.

Methods

This study was conducted using a scoping literature review and subsequent thematic analysis.

Results

Thirty-one eligible papers described 8 common themes with region-specific nuances. These include: 1) shared (ODO and DI) protocols for early communication around each case; 2) shared standards and education for death investigation practices related to organ donation; 3) DI support staff or teams to facilitate organ donation; 4) DI authority to order additional testing and imaging before organ recovery; 5) donation-specific legislation to enhance DI and/or ODO operations; 6) legally trained DI authority to veto medical decisions to proceed with organ donation; 7) DI attendance at organ recovery; and 8) surgeons recording specific DI evidence during organ recovery.

Conclusion

These findings have cultural and resource-allocation implications and expose gaps in the international literature describing practices at the intersection of deceased organ donation and death investigation. A better understanding of the rationale and execution of various systems for DI and ODO cooperation may serve to advance both organ donation and death investigation.

Reform of the death investigation system in Japan

The autopsy rate in Japan is lower than that in other countries, and most death investigations have historically been conducted by police officers through external inspection. Although medicolegal autopsy was not performed during the samurai administration, the European death investigation system was adopted in the second half of the 19th century and judicial autopsy began in universities' forensic medicine departments. After World War II, the medical examiner system was introduced under US influence, but it was only adopted in certain areas. Further reforms were introduced in the 21st century-in 2012, two laws relating to death investigation were enacted: The Act on Promotion of Death Investigation (Promotion Act), which provided foundational principles and included measures for investigating the causes of death and identification of bodies, and the Act on the Investigation of Cause of Death and on Identification of Bodies Handled by the Police, which recommended a procedure for death investigation, including a new autopsy system.The Death Investigation Promotion Program was to meant to be decided by the government in 2014. However, the relevant Act expired after it ran out of time. Later, in 2019, the Basic Act for Promotion of Death Investigation, the successor to the Promotion Act, was passed. This Act is significant because it sets the basic foundational principle and imposes plans created by the government. However, it remains unclear how these measures can be implemented, so further discussion and financial investment are now required.

Perspectives on the death investigation during the COVID-19 pandemic

The pandemic of COVID-19 caused by 2019-nCoV outbreaks in most of the countries, has subsequently spread rapidly and become a pandemic worldwide. Due to the strong infectivity of COVID-19 and lack of experience of performing an autopsy in infectious disease-induced death, the pandemic created some challenges for forensic practitioners. In this article, we summarize the experience of how we handle the confirmed or suspected infectious cases and give some perspectives for the future.

Australian no-body homicides: Exploring common features of solved cases

Offenders successfully disposing of a homicide victim's body creates challenges to the criminal justice process, yet no research literature exists on no-body homicide cases. We explored 25 solved homicides in Australia where no part of the victim's body was recovered. Coroners' findings, case law, and media reports from 1983 to 2017 were examined qualitatively and descriptively. Features of the cases differed based on whether the homicide was related to organized crime, serial sexual offences, or domestic violence. Challenges posed by each type of case are discussed and opportunities for solving these cases are examined.

High-Altitude Illness Death Investigation

High altitude illness (HAI) is the current accepted clinical term for a group of disorders including acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE), which occur in travelers visiting high-altitude locations. High-altitude illness is due to hypobaric hypoxia, is not associated with age or physical conditioning, and mild forms are easily treated. High-altitude cerebral edema and HAPE are medical emergencies that are fatal if not promptly treated and fortunately are uncommon. The cause of most high-altitude fatalities is not related to HAI and can be easily distinguished from HACE and HAPE; however, other causes of death may have symptoms and physical findings that overlap with HAI, making postmortem diagnosis challenging. Fatalities due to HAPE and HACE are diagnoses of exclusion. Medical examiners and coroners who work in jurisdictions with high-altitude locations should be aware of the risk factors, physiology, pathology, differential diagnosis, and classification of HAI to accurately recognize HAI as a cause of death. Medical examiners who do not work in jurisdictions with high-altitude locations may be asked to evaluate deaths that occur overseas associated with high-altitude trekking and mountaineering activities.

Medicolegal Death Investigation: Coroner and Forensic Pathology Functions and Processes in Victoria, Australia

The medicolegal death investigation in Victoria, Australia is a traditional coroner system based on the model in England and Wales in the early 20th Century. In 1985, the first of a series of legislative amendments were made that proved the vanguard of reform of the coroners' jurisdictions in Australia. The Victorian Institute of Forensic Medicine (the Institute) was established by the Coroners Act 1985 (Vic.), now the Victorian Institute of Forensic Medicine Act 1985 (Vic.), to provide forensic pathology, medical, and related scientific services needed by the justice system. In addition to death investigation, other forensic and scientific services are performed by the Institute including: clinical medical examinations and support services for assault victims and perpetrators, forensic toxicology services and molecular biology, and anthropology and odontology services in relation to human identification. Medical and nursing staff provide medical information and support to families in a therapeutic setting, as well as direct referral to clinical medical specialists. This takes place where a medical death investigation procedure uncovers genetic or familial disease that may place other family members at risk of future illness. A donor tissue bank ensures that a death also provides the opportunity for families to donate organs and tissues from the deceased for transplantation. Today, the traditional autopsy is one of several modalities of death investigation with postmortem radiology and imaging playing a significant role. This paper describes the principles and new processes at the Institute that support the coroner in death investigation and prevention as well as the therapeutic services designed to relieve the burden of disease on the community.

South Africa: Vulnerable Persons and Groups in a Vulnerable Democracy - Can Forensic Medical Services Help to Ensure Justice in Critical Times?

The role and contribution of an objective and professional medicolegal death investigation service should be valued and strengthened, especially in countries and communities where institutional and governmental corruption, incompetence, and abuse of power may exist, and where there are weak civil watchdog agencies such as a free press. South Africa is a fledgling democracy and is now at a critical juncture from a sociopolitical perspective. A number of incidents and historical perspectives are presented, all of which have specific relevance to the forensic medical community and which serve to illustrate the importance of ensuring the protection of the rights of vulnerable groups and persons who may easily suffer from disregard and abuse by state agencies and their representatives and which may ultimately impact very negatively on the broader society. Strengthening the organizational and legislative framework within which forensic pathologists can function is vital to ensure effective investigation in matters such as deaths in custody and of institutionalized persons/patients as well as deaths associated with police action and mob killings, to name but a few.

The Utility of a Prescription Monitoring Program in Death Investigation: The Virginia Experience

The Virginia Prescription Monitoring Program (VPMP) has been in effect since 2002, providing reports for prescribers, pharmacists, and other stakeholders in the growing opioid epidemic. The Office of the Chief Medical Examiner is one such stakeholder and has found great efficacy in the program in investigating suspected drug-related deaths. This review examines the origins of the VPMP, its benefits, and limitations for use during death investigation.

An Unusual Feature of Graze Gunshot Wounds

All graze wounds that occurred in the jurisdiction of the Fulton County Medical Examiners Center over a ten-year period (2005-2014) were inspected. Of a total of 227 graze wounds, 31 (14%) exhibited a previously not well-described feature. At one end of the graze wound, two small, subtle, parallel abrasions separated by a band of spared skin extended away from the wound. This finding occurred more often at the proximal corner (16 times) than the distal corner (seven times) when a direction was able to be determined. The mechanism of this feature does not appear to be related to jacketed ammunition expected to deform into petals. Possible mechanisms for the creation of this feature are random irregularities in skin resistance along with slight wobble (yaw) of the bullet or pressure waves generated by the bullet that causes buckling of the skin.

Postmortem biochemistry: Current applications

The results of biochemical analyses in specimens obtained postmortem may aid death investigation when diabetic and alcoholic ketoacidosis is suspected, when death may have been the result of drowning, anaphylaxis, or involved a prolonged stress response such as hypothermia, and in the diagnosis of disease processes such as inflammation, early myocardial infarction, or sepsis. There is often cross-over with different disciplines, in particular with clinical and forensic toxicology, since some endogenous substances such as sodium chloride, potassium chloride, and insulin can be used as poisons. The interpretation of results is often complicated because of the likelihood of postmortem change in analyte concentration or activity, and proper interpretation must take into account all the available evidence. The unpredictability of postmortem changes means that use of biochemical measurements in time of death estimation has little value. The use of vitreous humour is beneficial for many analytes as the eye is in a physically protected environment, this medium may be less affected by autolysis or microbial metabolism than blood, and the assays can be performed with due precaution using standard clinical chemistry analysers. However, interpretation of results may not be straightforward because (i) defined reference ranges in life are often lacking, (ii) there is a dearth of knowledge regarding, for example, the speed of equilibration of many analytes between blood, vitreous humour, and other fluids that may be sampled, and (iii) the effects of post-mortem change are difficult to quantify because of the lack of control data. A major limitation is that postmortem vitreous glucose measurements are of no help in diagnosing antemortem hypoglycaemia.

Undetected patricide: Inaccuracy of cause of death determination without an autopsy

Patricide (killing the father) is uncommon form of homicide. Usually the assaults occur at home in the absence of witnesses and adult sons are frequently involved. Homicides in a domestic context usually do not tend to recurrence, because the motivation for the crime ends with the death of the parent. However, this is not what was observed in the present case study dealing with the death of a 70 years old white man originally misclassified as accident and discovered three years later only after an additional homicide in a family context of a 60 years old white lady. Multiple stab wounds to the neck and thorax were misinterpreted at the external male body examination as blunt trauma falling down stairs. No forensic autopsy was requested and no comparison of medical findings with the results from the death scene, such as a bloodstain analysis was performed by the police officers nor required by the judicial authority. This was quite surprising because an additional but preliminary post-mortem external examination performed by a general practitioner on the male body already raised the suspicion that the external lesions were stab wounds thus requiring a forensic autopsy. Only the exhumation of the elderly body, performed years later, confirmed the diagnostic hypothesis raised by the first physician. The present case is quite representative of a death investigation not run professionally and performed by individuals with no specific training where most of the medico-legal investigations (especially for traumatic and violent deaths) are restricted to an external body examination without subsequent autopsy. Although misinterpretation of external lesions is inevitable and significant discrepancies between external body examination and forensic autopsy are not rare, in the case of contradictory results of post-mortem external examination or unclear/suspicious cause and manner of death, investigation should proceed necessarily with a forensic autopsy.

Population genetic structure of an invasive forensically important insect

The forensic utility of an insect can depend in part on its population structure. Although some native North American species have been characterized in this fashion, information is lacking for species that were introduced from elsewhere and that might have lower genetic diversity and less geographic differentiation. We surveyed Chrysomya megacephala, an Asian fly present in the continental USA since the 1980s. Amplified Fragment Length Polymorphism profiles were generated from adult insects collected across Florida and in Mobile, Alabama. Analysis of Molecular Variance on 151 polymorphic loci found significant but very small variation among samples. STRUCTURE and principal coordinate analyses produced the same two clusters in the population, consistent with C. megacephala in Florida having originated from two separate source populations. A weak negative correlation between genetic and geographic distances probably reflected the geographic arrangement of the genetic clusters. A positive relative relatedness coefficient for each sample indicated that flies arriving at a bait within a short time were likely to be close relatives, consistent with the earlier results for native North American carrion flies. However, genetic diversity estimated for the introduced Florida C. megacephala was lower than for native species or for published data on Malaysian C. megacephala, perhaps reflecting the genetic effects of being introduced to a new geographic region. Genetic assignment, a method that has been proposed as a way to infer corpse postmortem relocation, was much less successful for C. megacephala compared to the native species, possibly reflecting a history of admixture.

Trends in forensic autopsy in Chiba prefecture over the past decade

The death investigation system in Japan is in the midst of a great transformation. As part of efforts to revise this system, in this study we analyzed the reasons the police refer unnatural death cases for forensic autopsy and, from an understanding of the trends of such referrals, we discuss the future direction of handling unnatural deaths in our country. For 1618 forensic autopsy cases handled by the First Investigation Division of Chiba Prefectural Police that were referred to our institution for forensic autopsy between 2003 and 2012, we tallied the number of autopsies by sex, age group, and reason for forensic autopsy for each year and investigated trends in the referrals over time. The results revealed that the number of autopsies increased annually from 2003 to 2012, with a marked increase from 2010. The number of autopsies increased particularly for cases of suspected criminal deaths, where it was unclear to the police before the forensic autopsy whether or not the death resulted from a criminal act. Our findings suggest that the number of forensic autopsies will continue to increase into the future in Chiba prefecture, and is a trend that is inevitable if we are to prevent criminal death cases from being overlooked. Although referrals for forensic autopsy in Japan are made only when criminal activity is suspected, the original purpose of death investigations is not only to avoid overlooking crimes, but also to flag public health issues. Therefore, together with the police, we need to review the original purpose and conduct more in-depth discussions about when referrals are necessary.