Need for Improved Timeliness of Reporting on Drug Overdose Fatalities: The HEALing Communities Study

OBJECTIVE

Timely data on drug overdose deaths can help identify community needs, evaluate the effectiveness of interventions, and allocate resources. We identified variations in death investigation and reporting systems within and between states that affect the timeliness and accuracy of death certificate information.

METHODS

The HEALing Communities Study (HCS) is a community-engaged, data-driven approach to combating the opioid crisis in 67 communities in 4 states: Kentucky, Massachusetts, New York, and Ohio. HCS conducted a survey of coroners and medical examiners to understand variability in drug overdose death data. We compared survey results in Massachusetts, New York, and Ohio with national data to investigate the completeness of provisional death counts by type of death investigation system.

RESULTS

Communities in each HCS state had different ways of collecting and reporting mortality data. Completion of death certificates for drug overdoses ranged from <2 weeks in 23% (7 of 31) of those surveyed to more than 3 months in 10% (3 of 31) of those surveyed. Variabilities in the timeliness of reporting drug overdose deaths were not associated with type of coroner or medical examiner office in each state, urban versus rural setting, or specificity of drug information on the death certificate.

CONCLUSION

Having specific drug information on the death certificate may increase death certificate quality, comparability, and accuracy. We recommend the following: (1) all coroners and medical examiners should be trained on conducting death investigations, interpreting toxicology reports, and completing death certificates; (2) 1 office in each state should oversee all coroners and medical examiners to increase data consistency; and (3) communities should identify and address barriers to timely death certification.

Patient termination of a life-sustaining medical device: Suicide or natural death?

Medical technology has made tremendous strides in extending the lives of patients who have suffered organ failure. Machines can now replace the function of the kidneys, the heart, and other vital organs. Much has been written about a patient's right to refuse or direct the withdrawal of medical treatment, especially at the end of life, under the guise of "death with dignity." However, little attention has been paid to the situation where a patient elects to deactivate their life-sustaining medical device without a physician's involvement. This raises the challenging question of whether the patient's manner of death should be classified as suicide or natural. Surprisingly, common law, statutes, medical ethics, and public health practice are not in alignment on the answer. This article will explore the ramifications and far-reaching impact that such divergence has on the survivors and the medical community, as well as recommend corrective actions and practical approaches for the medical and legal practitioner.

The effects of the (fentanyl-fueled) drug overdose epidemic on medicolegal death investigation in the United States

The evolving opioid epidemic in the United States, fueled by illicit fentanyl, has greatly increased deaths from illicit drug use. These nonnatural deaths require formal death investigation. The National Association of Medical Examiners states in its Forensic Autopsy Performance Standards that autopsy remains a necessary component for proper investigation of suspected acute overdose deaths. If a death investigation office lacks adequate resources to investigate all deaths under its jurisdiction while meeting expected standards, then that office may be forced to consider altering its protocols for investigation by changing the types of deaths investigated or the extent of its investigations. Drug death investigations take longer to complete because novel illicit drugs and mixtures of drugs complicate toxicological analyses, prolonging a family's wait for completion of a death certificate and autopsy report. Public health agencies must also wait for results, but some agencies have developed mechanisms for rapid notification of preliminary results to allow timely deployment of public health resources. The increased deaths have strained the resources of medicolegal death investigation systems throughout the United States. Given the significant workforce shortage of forensic pathologists, newly trained forensic pathologists are too few to meet the demand. Nevertheless, forensic pathologists (and all pathologists) must make time to present their work and themselves to medical students and pathology trainees to encourage an understanding of the importance of quality medicolegal death investigation and autopsy pathology and to provide a model that can encourage interest in a career in forensic pathology.

Transnational comparison of the impact of COVID-19 on medicolegal death investigations and the administration of justice: Early stages of the pandemic

COVID-19 has had an unprecedented impact on arguably every sector of our criminal justice system. To assess the impact that this global health crisis has had on our medicolegal investigations and administration of justice during the early stages of the pandemic, this research aims to give voice to the lived experiences of medicolegal death investigators (coroners, medical examiners and pathologists). This research involved in-depth interviews and follow-ups with experienced personnel from Canada (3), Italy (1), the United Kingdom (1) and the United States (4). Results suggest that despite facing similar challenges, each individual office has had to develop their own strategies to overcome obstacles during the early stages of the pandemic. These results help identify overlapping areas for constructive policy and procedural changes, including recommendations for workflow adaptations, strategic partnerships and other approaches to best prepare for subsequent health crises.

The application of SUDEP in forensic diagnosis: a mini review

In the epilepsy population, the risk of sudden death from epilepsy is rare but is ~24 times greater than the risk of sudden death from other causes. Sudden unexpected death in epilepsy (SUDEP) has been widely recognized in clinical studies. Despite its significance as a cause of death, SUDEP is rarely used in forensic practice. This review focuses on the forensic characteristics of SUDEP, analyzed the reasons for its underuse in forensic practice, and illustrated the prospect of establishing uniform diagnostic criteria for sudden unexpected death in epilepsy and molecular anatomy in aiding forensic diagnosis.

Learning from hospital deaths

Current guidelines and regulations require trusts to take full responsibility for deaths within their premises. Higher than expected deaths indicate poor standards of care or negligence. NHS Trusts need to put systems in place to ensure that they learn and extrapolate risk factors through in-depth review of care provided to patients prior to their deaths, curb and ultimately diminish relative mortality through improved practices, and improve care and safety for the whole organisation. Mortality reviews can provide insight into the standard of care that dying patients receive; this matters as NHS Hospitals are the main providers of terminal care, nationally.

Coroner county systems are associated with a higher likelihood of unclassified drug overdoses compared to medical examiner county systems

Background: There is a striking geographic variation in drug overdose deaths without a specific drug recorded, many of which likely involve opioids. Knowledge of the reasons underlying this variation is limited.Objectives: We sought to understand the role of medicolegal death investigation (MDI) systems in unclassified drug overdose mortality.Methods: This is an observational study of 2014 and 2018 fatal drug overdoses and U.S. county-level MDI system type (coroner vs medical examiner). Mortality data are from the CDC's National Center for Health Statistics. We estimated multivariable logistic regressions to quantify associations between MDI system type and several outcome variables: whether the drug overdose was unclassified and whether involvement of any opioid, synthetic opioid, methadone, and heroin was recorded (vs unclassified), for 2014 (N = 46,996) and 2018 (N = 67,359).Results: In 2018, drug overdose deaths occurring in coroner counties were almost four times more likely to be unclassified (OR 3.87, 95% CI 2.32, 6.46) compared to medical examiner counties. These odds ratios are twice as large as in 2014 (difference statistically significant, P < .001), indicating that medical examiner counties are improving identification of opioids in drug overdoses faster than coroner counties.Conclusions: Accurate reporting of drug overdose deaths depends on MDI systems. When developing state policies and local interventions aimed to decrease opioid overdose mortality, decision-makers should understand the role their MDI system is playing in underestimating the extent of the opioid overdose crisis. Improvements to state and county MDI systems are desirable if accurate reporting and appropriate policy response are to be achieved.

Medicolegal death investigator workplace safety hazards: A scoping review of the literature

In the United States, medicolegal death investigation practices and policies pertaining to sudden unexpected deaths are mandated by state government. Practices vary across states, which contributes to inconsistency in job prerequisites and training. In preparation for a study focused on occupational safety and health of medicolegal death investigators in their on-scene and follow-up activities, a scoping review was conducted to document known occupational safety risks and health-related conditions associated with death investigation. Searches used Boolean and subject heading operators both broad and narrow in scope, and search terms included scene responder, hazard, investigator, forensic pathology, injury, and safety. Twenty-five articles met inclusion criteria, which included seventeen survey-mixed method designs, two systematic reviews, five quasi-experimental designs, and one case study. Twelve articles addressed mental health and eleven focused on risks associated with infectious disease. One article addressed the risk of chemical exposure from cyanide among autopsy personnel (including forensic pathologists) and nine included a wide range of employees within the setting of medical examiner or coroner offices. One article, addressing burnout, included employees in a forensic science laboratory setting as well as medicolegal death investigators and two articles included forensic pathologists and medicolegal death investigators. Only one article addressed medicolegal death investigators specifically. Articles addressing occupational and environmental hazards of medicolegal death investigators associated with musculoskeletal, respiratory, cardiovascular, radiological, nuclear, electrical, or explosive threats were not identified. There is little published about safety risks inherent in conducting death investigations. Research is needed to adequately inform health promotion and injury prevention strategies.

Custodial deaths seen in the Office of the Chief Medical Examiner, Lagos, Nigeria: An 11-year autopsy study

INTRODUCTION

Deaths in custody are a matter of global concern. However, such information is often missing in developing countries. This study aimed to examine retrospectively the profile, cause and manner of deaths amongst cases of custodial deaths in Lagos State, Nigeria.

METHOD

An 11-year study (June 2008-June 2019) was done of all autopsy cases of custodial deaths in the Office of the Chief Medical Examiner. Variables including age, sex, offence, place of death, duration in custody prior to death and cause and manner of death were extracted from the records. Results were analysed using frequencies and percentages.

RESULTS

Out of 9894 autopsies over the study period, 45 custodial deaths were identified. Males and females constituted 84.4% and 15.6%, respectively (M:F = 5.4:1). Ages ranged from 20 to 64 years, with a mean age of 37 ± 11.0 years. These deaths were most common in the third decade. Armed robbery and financial crime were the two leading reasons for arrest, while most deaths occurred within 24 hours of arrival in custody. The two leading causes of death were acute cardiac failure from hypertensive heart disease and cranio-cerebral injury from blunt-force trauma.

CONCLUSION

Deaths in custody need to be properly investigated and particular attention needs to be paid to unlawful deaths if and when they arise.

Rural-Urban Differences in Suicide Mortality: An Observational Study in Newfoundland and Labrador, Canada: Différences de la Mortalité Par Suicide en Milieu Rural-Urbain: Une Étude Observationnelle à Terre-Neuve et Labrador, Canada

BACKGROUND

Suicide rates are higher in rural compared to urban areas. Although this pattern appears to be driven by higher rates among men, there is limited evidence about the characteristics of rural people who die by suicide in Canada. The objective of this study was to examine the demographics, manner of death, and social and clinical antecedents of people who died by suicide in rural areas compared to urban areas.

METHODS

We conducted an observational study of all suicide deaths that occurred among Newfoundland and Labrador residents between 1997 and 2016 using a linked data set derived from a comprehensive review of provincial medical examiner records. We used t tests and χ² to assess associations between rural/urban status and variables related to demographics, circumstances, and manner of death, as well as social and medical history. Logistic regression was utilized to assess the independent contribution of any variable found to be significant in univariate analysis.

RESULTS

Rural people who died by suicide accounted for 54.8% of all deaths over a 20-year period. Overall, 81.6% of people who died were male. Compared to urban, rural people who died by suicide were younger, more likely to use firearms or hanging, and had a higher mean blood alcohol content at the time of death (27.69 vs. 22.95 mmol/L). Rural people were also less likely to have had a known history of a prior suicide attempt, psychiatric disorder, alcohol or substance abuse, or chronic pain.

DISCUSSION

The demographic and clinical differences between rural and urban people who died by suicide underscore the need for suicide prevention approaches that account for place-based differences. A key challenge for suicide prevention in rural communities is to ensure that interventions are developed and implemented in a manner that fits local contexts.

Suicides Among Lesbian, Gay, Bisexual, and Transgender People: Medical Examiner Reports in the Special Wards of Tokyo, Japan, 2009-2018

Purpose: We aimed to report the occurrence of suicide death and to reveal the characteristics among LGBT people in the special wards of Tokyo. Methods: All suicide deaths between 2009 and 2018 were identified from the Tokyo Medical Examiner's Office database, and the characteristics were compared between LGBT people and non-LGBT people by retrospective review of the medical examiner reports. Results: Among 17,638 people who died by suicide, 84 (0.5%) were identified as LGBT people, of which a large proportion was gay males (51.2%) and transgender people (42.9%). Smaller proportions of lesbian (3.6%) and bisexual (2.4%) females were identified. Compared with suicides among non-LGBT people, there were several differences in the circumstances surrounding suicides among LGBT people, namely method of suicide, source of income, and number of household members (transgender people), and toxic substance in poisoning and medical history (gay males). Conclusions: The results tentatively suggest the risk or supportive factors that should be considered for preventing suicides among LGBT people; however, the present data are likely to be underestimated. To better understand suicides among LGBT people, systematic efforts to collect sexual orientation and gender identity data for suicide are needed.

Identifying gaps and improving investigation of fatal elder abuse and/or neglect

Death investigator and autopsy reports for decedents 65 years and older within a major metropolitan area over a five-year period were assessed for the possibility of elder abuse and/or neglect. The study consisted of two stages. A simple two-question screening criteria was used to determine whether the decedent was (1) dependent on another for at least one activity of daily living and (2) had a presence of at least one indicator of abuse and/or neglect. Second, only cases with affirmative criteria responses were reviewed to identify inconsistent or deficient variables that precluded (or if present, allowed) determination of abuse and/or neglect. A multidisciplinary panel of local and national experts, including forensic pathologists, law enforcement, and geriatricians assessed these indicators as indicative of presence of abuse/neglect, and these indicators were subsequently developed as a supplemental data collection tool. Of a possible 2798 cases, 2324 (83%) were excluded using the screening criteria. This reduced the number of cases that warranted further investigation to 474 (17% of elderly deaths in this timeframe). All 474 decedents were dependent on another for at least one ADL and 322 (68%) had unexplained injuries. In 180 (38%) cases had recorded notation of a suspicion of abuse and/or neglect at the time of death. The results support the premise that a simple, two-criterion screening can effectively identify cases of potential abuse and/or neglect and, when followed by a supplemental data collection tool, cases can be efficiently evaluated.

Severe Acute Respiratory Syndrome Coronavirus 2 Surveillance in Decedents in a Large, Urban Medical Examiner's Office

Background

SARS-CoV-2 has become a global pandemic. Given the challenges in implementing widespread SARS-CoV-2 testing, there is increasing interest in alternative surveillance strategies.

Methods

We tested nasopharyngeal swabs from 1094 decedents in the Wayne County Medical Examiner’s office for SARS-CoV-2. All decedents were assessed by a COVID-19 checklist, and decedents flagged by the checklist (298) were preferentially tested. A random sample of decedents not flagged by the checklist were also tested (796). We statistically analyzed the characteristics of decedents (age, sex, race, and manner of death), differentiating between those flagged by the checklist and not and between those SARS-CoV-2 positive and not.

Results

A larger percentage of decedents overall were male (70% vs 48%) and Black (55% vs 36%) compared to the catchment population. Seven-day average percent positivity among flagged decedents closely matched the trajectory of percent positivity in the catchment population, particularly during the peak of the outbreak (March and April). After a lull in May to mid-June, new positive tests in late June coincided with increased case detection in the catchment. We found large racial disparities in test results: despite no statistical difference in the racial distribution between those flagged and not, SARS-CoV-2 positive decedents were substantially more likely to be Black (82% vs 51%). SARS-CoV-2 positive decedents were also more likely to be older and to have died of natural causes, including of COVID-19 disease.

Conclusions

Disease surveillance through medical examiners and coroners could supplement other forms of surveillance and may serve as a possible early outbreak warning sign.

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.

A Census of Medicolegal Death Investigation in the United States: A Need to Determine the State of our Nation's Toxicology Laboratories and Their Preparedness for the Current Drug Overdose Epidemic

In 2007, the Bureau of Justice Statistics reported on 2004 data collected from the Census of Medical Examiner and Coroner Offices (CMEC). The CMEC was one of the first comprehensive reports on the state of the medicolegal death investigation system in the United States and included information on administration, expenditure, workload, specialized death investigations, records and evidence retention, and resources. However, the report did not include responses on questions that were related to toxicology such as specimen retention and type of testing. The purpose of this publication is to provide the community with toxicology laboratory-specific responses from nearly 2000 medical examiner and coroner (MEC) offices. Data obtained from a BJS CMEC public use dataset for any remaining information that was not reported in the 2007 BJS report were evaluated specific to the operation of toxicology laboratories within a MEC office or specific to toxicology testing. The CMEC includes information on average operating budget for MEC offices with internal or external toxicology services, budget for toxicology/microbiology services, respondents' routine uses of toxicology analysis, toxicology specimen retention time, average turnaround times, use of computerized information management systems, and participation in federal data collections. These historical data begin to address the present state of our nation's toxicology laboratories within the medicolegal death investigation system and their preparedness for the current drug overdose epidemic.

Solitary Deaths in the Tokyo Metropolis and Labor Force Status: Characteristics of Unnatural Deaths at Home among Persons Living Alone

OBJECTIVE

To identify associations of solitary death with social determinants of health, namely, labor force status and welfare status, in Tokyo in 2015.

METHODS

We obtained data on solitary deaths in 2015 in the 23 special wards of Tokyo and calculated the incidence rate and postmortem interval of solitary death in relation to sex, age, and labor force status.

RESULTS

Data for 3,972 solitary deaths (2,785 males, 1,187 females) were analyzed. The non-employed rate was 79.3% among males and 89.5% among females. The incidence rate was significantly higher among non-employed persons than among employed persons in both sexes. Moreover, with the exception of women 65 years or older, the postmortem interval was significantly longer among non-employed persons than among employed persons in both sexes.

CONCLUSIONS

The incidence rates of solitary death were significantly higher among non-employed persons than among employed persons in both sexes, and the postmortem interval was significantly longer for non-employed persons.

Epidemiology of alcohol-related accidental death in Tokyo Metropolitan area (2015)

Background

Alcohol consumption may be a risk factor for accidental deaths; however, characteristics of alcohol-related deaths are unclear. We investigated characteristics of alcohol-related accidental deaths to facilitate target strategies.

Methods

In this article, 1060 cases of accidental deaths examined by the Tokyo Medical Examiner’s Office (2015) were divided into two groups: deceased individuals who drank alcohol (alcohol; n = 212) and those who did not (control; n = 848). Age, sex, alcohol consumption patterns, and manners/causes of deaths were compared. Places where individuals in the alcohol group met with an accident, and their blood alcohol concentration was assessed.

Results

Lower mean age (60.5 vs. 73.7 years) and a higher male ratio (75.9% vs. 58.5%) were observed in the alcohol group. Daily alcohol consumption was more common in the alcohol group (70.8% vs. 13.4%). Falling was the leading cause of death in the alcohol group, but without a significant difference (alcohol: 31.6%, control: 30.4%). Incidence rates of drowning (22.2% vs. 7.9%) and poisoning (11.3% vs. 2.0%) were significantly higher in the alcohol group. The mean blood alcohol concentration was 1.6 mg/mL. Of the total alcohol-related accidents, 60.8% occurred at home. Falling down the stairs was the primary type of falling, and majority of drownings occurred in a bathtub.

Conclusion

Male habitual drinkers (middle-aged to older adults) should be targeted to prevent alcohol-related accidental deaths. More than 50% of deaths occurred at home and care should be taken when performing daily activities, including using stairs and while bathing.

Factors Influencing the Filing of Complaints, Their Investigation, and Subsequent Legal Judgment in Cases of Sexual Assault

In Geneva, examination of victims of sexual assault is performed by a gynecologist and a medical examiner. 48% of the victims file a complaint and we wanted to investigate the factors leading to file a complaint, those leading the Prosecutor to go to trial, and those influencing a conviction. Between 2006 and 2012, 676 victims of sexual assault were investigated (averaged age 26 year, mean 22). Information on injuries, perpetrators, and circumstances of the assault was collected and analyzed. The attacker being the ex-spouse or a friend and the presence of semen were factors leading to file a complaint. The assailant being a family member or ex-spouse and the presence of genital/anal lesions were factors influencing the Prosecutor. The presence of nongenital lesions, the assailant being known by the victim, influenced conviction. This study shows that the medical examiner plays a vital role in the investigation of cases of sexual assault.

PICU Autopsies: Rates, Patient Characteristics, and the Role of the Medical Examiner

OBJECTIVES

Autopsy rates in North American Children's hospitals have not been recently evaluated. Our objectives were 1) to determine the autopsy rates from patients cared for in PICUs during a portion of their hospital stay, 2) to identify patient characteristics associated with autopsies, and 3) to understand the relative role of medical examiner cases.

DESIGN

Secondary analysis of data prospectively collected from a sample of patients (n = 10,078) admitted to PICUs affiliated with the Collaborative Pediatric Critical Care Research Network between December 2011 and April 2013.

SETTING

Eight quaternary care PICUs.

PATIENTS

Patients in the primary study were less than 18 years old, admitted to a PICU and not moribund on PICU admission. Patients included in this analysis were those who died during their hospital stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sociodemographic, clinical, hospital, and PICU data were compared between patients who had autopsies conducted and those who did not and between medical examiner and nonmedical examiner autopsies. Of 10,078 patients, 275 died of which 36% (n = 100) had an autopsy performed. Patients with cancer who died were less likely to receive autopsies (p = 0.005), whereas those who died after trauma or cardiac arrest had autopsies performed more often (p < 0.01). Autopsies were more common in patients with greater physiologic instability at admission (p < 0.001), and those who received more aggressive PICU care. Medical examiner cases comprised nearly half of all autopsies (n = 47; 47%) were conducted in patients presenting with greater physiologic instability (p < 0.001) and more commonly after catastrophic events such as cardiac arrest or trauma (p < 0.001).

CONCLUSIONS

In this first multicenter analysis of autopsy rates in children, 36% of deaths had autopsies conducted, of which nearly half were conducted by the medical examiner. Deaths with autopsy are more likely to be previously healthy children that had catastrophic events prior to admission.

Educational Case: Death Certification and the Role of the Medical Examiner/Coroner

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.

Are Statutory Requirements Followed in the Certification of Traumatic, Unexpected, and Unattended Deaths in Missouri?

Medical examiners and coroners (ME/Cs) investigate deaths important to public health. This cross-sectional study evaluated 343,412 death certificates from 2007 to 2012 in Missouri. We examined agreement between cause and manner of death by year and ME/C contact as well as 2010-2012 trends in ME/C contact. There was near perfect agreement between cause and manner of death when an ME/C was contacted (kappa=0.97, p < 0.0001) and a significant increase in the proportion of deaths with ME/C contact from 2010 to 2012 (p =< 0.0001). There was a significantly higher proportion of ME/C-certified deaths using the electronic system in 2010-2012 (aOR = 1.18, 95% CI 1.15, 1.21) compared to the manual system in 2007-2009. Black, non-Hispanic (aOR = 1.50, 95% CI 1.43,1.57) and Hispanic (aOR = 1.31, 95% CI 1.13, 1.51) deaths, compared to White, non-Hispanic deaths, were associated with a significantly greater odds of ME/C certification. Race as an independent predictor of ME/C death certification warrants further research.

Certifying Death in the United States

Accurately identifying death and its causes is integral to the compilation of mortality data and ultimately to the operation of the criminal justice and public health systems. A clear understanding of who is in charge of such processes is paramount to establishing the quality, or lack thereof, of the information provided in death certificates. Our study provides a comprehensive overview of all state statutes identifying death investigators charged with classifying and certifying death in the United States. We found that state statutes designate a broad range of individuals as responsible for the classification and certification of death. Those vary by state and set of circumstances and can include medical examiners, coroners, pathologists, other physicians, registered nurses, and more. Our findings highlight the important need for a unified standard of qualifications in the medico-legal system, as well as, regulatory reform at the state level regarding who can complete and sign death certificates.

Organ Procurement in Forensic Deaths: Specific Features of Nonheart-Beating Donors

The need for organs has increased in the recent years, and this shortage will only worsen. In addition to the organs procured from brain-dead donors, a procedure for non-heart-beating donors was therefore developed. When deaths involve legal proceedings, the medical examiner makes the decision of whether or not to remove organs. To assist medical examiner in their decision-making, a number of forensic scientific societies aimed to develop recommendations, and legal adjustments were adopted. Nevertheless, these do present certain limits in special cases of procurement: Maastricht class I and II non-heart-beating donors. The peculiarity of this procedure stems from the urgency of the process. Compliance with temporal criteria would require that the deceased subject be removed from the crime scene even before the arrival of the authorities. This is extremely problematic legally and technically because forensic teams must collect evidence at crime scenes. Developments will have to be made to further minimize the restrictions on donations in forensic deaths.

Medical examiner and coroner reports: uses and limitations in the epidemiology and prevention of late-life suicide

OBJECTIVE

Late-life suicide is a growing public health concern in many parts of the world. Understanding the contributory factors to completed suicide is essential to inform the development of effective suicide risk assessment and management. The aim of this study is to synthesise the findings in studies that used coroner or medical examiner records to determine these contributory factors.

METHODS

The databases of Scopus (from 1960), MEDLINE (from 1946) and PsychINFO (from 1806) were searched in August 2013, to identify studies that used coroner or medical examiner records for investigating the epidemiological, sociodemographic characteristics and clinical aspects of late-life suicide.

RESULTS

In total, 25 studies were identified. There was a lack of standardisation of variables assessed between studies leading to incomplete datasets in some work. However, a diagnosis of depression was found in 33%, and depressive mood/symptoms in 47% of cases. About 55% had a physical health problem. Terminal illness was associated with a smaller proportion (7.1%) of the cases. Older people were more likely to have had contact with primary care rather than mental health services prior to suicide.

CONCLUSIONS

Despite their limitations, coroner and medical examiner records provide an opportunity for examining suicide epidemiology. Targeting primary care providers where late-life depression and physical illness can be detected and treated is a potential strategy to address late-life suicide.

Comparative Analysis of the Public Health Role of Two Types of Death Investigation Systems in Texas: Application of Essential Services

The purpose of this research was to assess the practices of death investigation agencies in Texas and to investigate the differences between justices of the peace (JPs) and medical examiner perceptions of their role and responsibilities. A survey was conducted in which justices of the peace and medical examiners (MEs) were questioned on their agency's policies and practices in regard to essential services provided using a recently published 50-item instrument subdivided into 10 essential services areas. The study used a quantitative descriptive cross-sectional design in which nonparametric analysis was used to ascertain differences between groups. The sample size for analysis was composed of 10 (83%) ME offices and 112 (15.5%) JPs. This statewide study found significant differences between MEs and JPs. These differences reflect the variation in educational background, understanding and implementation of essential services, and the appreciation of the needs of a system to be both collaborative and independent.

Medical examiner and medical toxicologist agreement on cause of death

Poisoning is a significant public health threat as the second leading cause of injury-related death in the US. Disagreements on cause of death determination may have widespread implications across several realms of public health including policy and prevention efforts, interpretation of the poisoning literature, epidemiologic data analysis, medical-legal case outcomes, and individualized autopsy interpretation. We aimed to test agreement between the cause of death determined by the medical examiner (ME) and a medical toxicologist (MT) adjudication panel (MTAP) in cases of poisoning. This retrospective 7-year study evaluated all deaths attributed to poisoning in one large urban catchment area. Cross-matched data were obtained from Department of Vital Statistics and the Poison Control Center (PCC). Out of >380,000 deaths in the catchment area over the study period, there were 7050 poisonings in the Vital Statistics database and 414 deaths reported to PCC. Cross-matching yielded 321 cases for analysis. The ME and MTAP concurred on cause of death in 66%, which was only fair agreement (κ 0.25, CI 0.14-0.38). Factors associated with the likelihood of agreement were peri-mortem fire exposures, prehospital cardiac arrest, and timing of drug toxicity (chronic versus acute). In conclusion, agreement for poisoning cause of death between specialties was much lower than expected. We recommend an improved formal process of information sharing and consultation between specialties to assure that all existing information is analyzed thoroughly to enhance cause of death certainty.