Autopsy or Not (Discussion Board)

Medicolegal death investigation, as you would expect, involves both medical and legal elements. A medicolegal autopsy occurs "pursuant to a medical investigation of death for legal purposes" (Houck & Siegel, 2006, pp. 158–159) in cases where the medical examiner/coroner responsibilities are defined by law.

Medicolegal death investigations are conducted by either a medical examiner or a coroner, depending on the jurisdiction. Some states require such investigation be performed by a medical examiner, who is a "government official, always a physician and often a forensic pathologist, charged with investigating sudden and unexpected deaths or deaths from injuries" (James & Nordby, 2005, p. 726). Other states, by contrast, allow death investigations to be performed by a coroner, an elected official who is rarely a physician. Later in this module, we will explore some of the differences between these systems, and we'll discuss the potential shortcomings of allowing medicolegal autopsies to be performed by someone other than a forensic pathologist.

The medicolegal death investigator's primary responsibility is to investigate deaths under the direction of a medical examiner or coroner (James & Nordby). Although in this module we will focus on autopsies, keep in mind that death investigations have many other elements that are also important. The processing of the death scene; determination of events surrounding the death; police reports; and evaluation of the medical, social, and mental history of the deceased precede the actual external and internal autopsy. The medicolegal autopsy results are then correlated with the toxicology analysis and other analyses, as well as the other investigative information, to produce a final cause-of-death determination. A competent and comprehensive medicolegal autopsy is pivotal to a final death determination, but preautopsy and postautopsy processes and investigations must be integrated into the final determination.

The NIJ guide provides an excellent summary for the medicolegal crime scene investigation. Upon arrival at the scene, the medicolegal investigator or investigators—that is, the medical examiner(s) or coroner(s)—identify themselves to the individual in charge of the scene, usually a law enforcement officer or a detective. The medicolegal investigator then makes sure that the scene is secured. Because medicolegal investigators have primary responsibility for the body at a crime scene, they should focus on their legal mandates. Their legal authority and responsibilities vary with jurisdictions, but in general, the medicolegal investigator performs all of the following tasks (National Medicolegal Review Panel [NMRP], 1999, p. 17):

· locate and view the body

· check for pulse, respiration, and reflexes, as appropriate

· identify and document the individual who made the official determination of death, including the date and time of determination

· ensure death is pronounced, as required

Once death has been determined, the medicolegal investigator works with other crime scene personnel as appropriate in the documentation of the scene and preliminary investigative details. The medicolegal investigator should, in most circumstances, perform a walkthrough of the area to assess the overall scene, the pertinent evidence, and the location of the body within the scene. In most jurisdictions, crime scene investigators from state or local police agencies collect evidence that is not on the body and ensure that the scene has been properly documented, photographed, and secured. Medicolegal investigators are involved only with the body and investigative functions pertaining directly to the body, including its secure transportation to the morgue for the autopsy.

Because photographs are used to document the scene, it is important that appropriate, comprehensive, and accurate photographs of the scene, with and without scale devices, are taken and preserved. (To see photographs taken at a death scene, click on the tab labeled Death Scene Documentation at the top of this page.) The NIJ guide (p. 29) recommends that the investigator take the following actions:

· photograph the body and immediate scene, including the decedent as initially found

· photograph the decedent's face

· take additional photographs of the body after removal of objects/items that interfere with photographic documentation (e.g., body removed from car)

· photograph the decedent with and without measurements

· photograph the surface beneath the body after the body has been removed

The clothing, the body, the scene with and without the body, tattoos, scars, marks, indications of trauma or injury, personal artifacts, evidence of treatment or resuscitative efforts, and any other physical characteristics should also be photographed (NMRP, 1999).

Locating physical evidence that is essential to the determination of the cause and manner of death is critical to the scene investigation. The NIJ guide's advice for the recognition and documentation of this physical evidence (pp. 25–26) includes taking the following actions:

· document the location where death was confirmed

· if the decedent was transported, determine how and from where the body was transported to scene

The medicolegal authority, whether a medical examiner or a coroner, has distinctive, legally defined responsibilities regarding death investigations. The main function of the medical-examiner or coroner system is the medicolegal autopsy. Additional responsibilities can include the following (NMRP, 1999, p. 39):

· ensuring the protection, identification, and transportation of the deceased

· identifying, locating, and notifying the next of kin

· establishing and noting the decedent's vital statistics

· documenting related events that occurred near the time of the fatal incident

· obtaining relevant medical and antemortem records

· documenting medical, mental health, and social histories

· releasing the body to a funeral director

The medical examiner/coroner staff may also provide the family of the deceased with information regarding the autopsy, support services, and the release of the decedent.

A comprehensive medicolegal autopsy typically has three phases (Wagner, 2004). Premorgue analysis involves the death scene investigation and pertinent statements. Morgue analysis (the medicolegal autopsy) includes the examination of the body and any associated physical evidence collected from the body. Postmorgue analysis involves tissue sampling and toxicological, chemical, fingerprint, dental, and/or DNA analyses pertinent to the death investigation. As we have already discussed the premorgue processes—that is, the investigation of the death scene—the following sections will be devoted to morgue and postmorgue processing.

Morgue

During the autopsy, the pathologist collects evidence. Clothing from the victim may contain physical evidence, which is collected and appropriately preserved. Clothing may also contain holes due to gunshots or stabbings. Foreign materials such as hairs, fibers, and fragments of glass, soil, or wood should be collected in suspicious cases.

Blood and urine samples are usually collected for toxicological and drug analyses. Blood and/or mouth swabs may also be collected for DNA analysis. In cases of suspected sexual assault, anal, vaginal, and oral swabs are taken. Samples of hair from the head, pubic area, and other parts of the body may be collected for comparisons, DNA testing, or detection of other physical evidence. Vitreous humor (fluid from within the eye) may be collected for drug or alcohol screening and is also useful for measuring glucose and electrolyte levels.

External Examination of the Body

The autopsy begins with a thorough external examination of the body, including a detailed description of any clothing. Bloodstains and holes in clothing are noted. The physical description of the body includes the decedent's sex and race, a brief description of physique and apparent level of nourishment, the decedent's weight and height, and his or her reported or estimated age. Rigor, body temperature, livor, facial or other body hair, eye color, skin color, tattoos, marks, scars, and other remarkable physical characteristics are noted (Dix, 1999).

Internal Examination of the Body

After the external examination of the body, a standard Y-shaped incision is made. The short arms of the Y-incision begin at the shoulders and converge at the breastbone, where the incision continues in a straight line down to the pubic region. The skin is reflected back, and the chest plate (made of bone) is removed. The pericardial sac, the sac around the heart, is opened, and blood is collected for toxicological testing. The organs are then removed together or individually, and microscope slides may be prepared from them for later examination. The scalp is cut and reflected back to expose the skull, which is then cut away so that the brain can be extracted (Dix, 1999). The organs are weighed and examined for abnormalities.

Gastric (stomach) contents are examined to determine the total volume and description of food, liquid, or other materials that may be present. This information may be helpful in determining the composition of the decedent's last meal. Gastric emptying time is usually two to six hours, depending on the meal, but some foods take longer, and the rate of digestion varies with the decedent's mental and physical condition (Dix, 1999).

Specific Considerations Regarding Gunshot Wounds

Firearms often figure in death investigations, and gun-related cases warrant specific considerations. According to reports in the year 2000, firearms incidents resulted in 28,663 deaths in the United States, a decline from about 36,000 deaths in 1990 (Mokdad et al, 2004, p. 1239), with the largest declines in homicides and accidental discharges of firearms. Of that total, more than half were attributed to suicide, and more than one third were the result of homicidal firearms assaults. Figure 1.2 shows the distribution of the underlying causes of firearms deaths in the United States in 2000.

Figure 1.2 Causes of Firearms-Related Deaths

Source: Created from data found in Mokdad et al, p. 1239

Firearms-related death investigations are handled in much the same manner as other scene investigations, but determining whether a firearms-related death was the result of a homicide or a suicide may be difficult. In a recent study of shotgun wounds, wounds to the back, face, and extremities, as well as multiple wound locations, were common in homicides, while head, intraoral, and under-the-chin wounds were prevalent in suicides (Molina et al, 2007). Contact wounds were present in most suicides, whereas homicides most often involved shots fired from some distance (Molina et al).

In all firearms cases, precautions should be taken to ensure that gunshot residue is properly preserved and collected. Generally, the hands should be protected at the scene with brown paper bags covering the hands to the lower part of the forearm; plastic bags should not be used because any water vapor that condenses inside the bag can adversely affect fingerprint or other trace evidence.

A weapon and spent cartridges may or may not be found at the crime scene. The medicolegal investigator should thoroughly search the scene for firearms and related evidence, such as bloodstain patterns, potential weapons, and other wounds or trauma, all of which must be noted and documented at the scene. Even if no gunshot wounds are evident at the crime scene, a careful examination of the clothing and body might later reveal concealed gunshot wounds. In most cases, the medicolegal investigator is not directly involved in the actual firearms examinations, but the findings of those analyses are integrated into the medical examiner's or coroner's final report.

A gunshot wound necessitates some specific additional tasks before and during the autopsy. The hands are examined for gunpowder grains, fibers, hairs, or other trace evidence. Gunshot residue on the hands is collected using the appropriate swabs or lifts. Fingernail clippings are collected, and fingerprints are taken. Generally, two sets of fingerprints are taken: one for law enforcement and one for the autopsy file.

At the morgue, X-rays are taken, usually before clothing is removed, to assist in locating any potential bullets or fragments. The clothing is examined for gunpowder or other trace evidence, and any clothing damage that corresponds to a wound on the body is noted. The clothing is carefully dried and separately packaged as evidence. The body may then be cleaned and examined for other wounds. Photographs of the wounds are taken: both medium and close-up photographs, with and without a scale indicator, are appropriate. Each gunshot wound should be carefully examined and documented as to its exact location, appearance, and physical characteristics (DiMaio, 1999). These steps are performed before the Y-incision is made.

During the autopsy, the tracks of any bullets are X-rayed, noted, and photographed, and the bullets' entrance and exit points are determined. Bullets found in the body are carefully recovered, packaged, and identified, taking care not to damage or destroy any fine markings on the bullet or fragments. Fragments or pellets from shotgun cases should be recovered as completely as possible. Shell wads are often found within a wound track, and those are collected and documented as well, as they can help determine the gauge and manufacture of the shotgun.

A typical autopsy report includes all of the following elements:

· a case file number, usually assigned by the medical examiner's office at the morgue

· descriptive information regarding the deceased

· cause-of-death determination

· report of external examination

· descriptions of injury evidence

· report of internal examination

· pathological or injury diagnoses

· toxicological analyses

· opinion of the medical examiner about the cause of death

The forensic autopsy is designed to look backward to determine why a death has occurred. (Click on the tab labeled Autopsy Report at the top of this page to see an actual report.) The forensic pathologist starts at the beginning of the death investigation, with a deceased victim, and makes no assumptions about the cause of death. The facts are determined by the examination of the decedent and his or her unique set of medical conditions and injuries (Wagner, 2004). These facts will be integrated with the other information collected from the crime scene, the investigation, and the eyewitness and relevant statements, and from other pertinent sources.

The autopsy report summarizes the opinions and conclusions of the forensic pathologist. This report is reviewed by a chief medical examiner or, in a coroner system, is sent to the coroner.  The forensic autopsy performance standards (Peterson & Clark, 2006, p. 223) suggest that the autopsy report should be formulated in the following manner:

Postmortem inspection and forensic autopsy reports must be readable, descriptive of findings, and include interpretations and opinions to make them informative. The report typically includes two separate parts of the forensic pathologist's work product, (1) the objective forensic autopsy with its findings including toxicological tests, special tests, microscopic examination, etc., and, (2) the interpretations of the forensic pathologist including cause and manner of death.

The forensic autopsy report should reflect all of the relevant elements of the death investigation. Some cases, particularly those involving criminal acts, may remain open for years, and the forensic autopsy report will remain a critical component of the successful resolution of the case.

The medical-examiner and coroner systems were established to ensure the successful determination of cause and manner of death in a death investigation. This complex process requires the expertise of the forensic pathologist, death scene investigators, crime scene investigators, forensic analysts, law enforcement officers, prosecutors, and numerous other supporting personnel. The focus of this module has been mostly on the medicolegal investigator, but it is clear that the medicolegal investigator's role is only one component of the process. The medicolegal investigator helps to establish the connections between the legal and medical aspects of a death investigation. The investigator assists in the collection and integration of the death scene, medicolegal autopsy, and postmorgue information obtained through and with the medical examiner's or coroner's office. The medicolegal investigator's function is essential in the coordination of critical information and contributes directly to the effectiveness and efficiency of the medical examiner's or coroner's office.

References

DiMaio, V. J. M. (1999). Gunshot Wounds: Practical Aspects of Firearms, Ballistics, and Forensic Techniques (2nd ed.). Boca Raton, FL: CRC Press.

DiMaio, V. J. M., & DiMaio, D. (2001). Forensic Pathology (2nd ed.). Boca Raton, FL: CRC Press.

Dix, J. (1999). Handbook for Death Scene Investigators. Boca Raton, FL: CRC Press.

Geberth, V. J. (2006) Practical Homicide Investigation (4th ed.). Boca Raton, FL: Taylor and Francis.

Haglund, W., & Song, M.(Eds.). (1997). Forensic Taphonomy: The Postmortem Fate of Human Remains. Boca Raton, FL: CRC Press.

Hickman, M. J., Hughes, K. A., Strom, K. J., & Ropero-Miller, J. D. (2007). Medical Examiners and Coroners’ Offices, 2004. NCJ 216756. Bureau of Justice Statistics, U.S. Department of Justice: Washington, DC: Government Printing Office.

Houck, M. M., & Siegel, J. A. (2006). Fundamentals of Forensic Science. Burlington, MA: Elsevier Academic Press.

James, S. H., & Nordby, J. J. (Eds.). Forensic Science, An Introduction to Scientific and Investigative Techniques (2nd ed.). Baton Rouge, LA: Taylor and Francis.

Joint Committee of the American Academy of Forensic Sciences (AAFS) and the Society of Forensic Toxicologists (SOFT). (1991). Forensic Toxicology Laboratory Guidelines, . Colorado Springs, CO: AAFS & SOFT.

Karch, S. B. (Ed.). (2007). Drug Abuse Handbook (2nd ed.). Boca Raton, FL: CRC Press.

Medical Examiner and Coroner Information Sharing [MECIS] program (2006). Death Investigation Description Systems – New York. Retrieved November 28, 2007, from http://www.cdc.gov/epo/dphsi/mecisp/new_york.htm

Mokdad, A. H., Marks, J. S., Stroup, D. F. & Gerberding, J. L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291, 1238–45.

Molina, D. K., Wood, L. E., & DiMaio, V. J. M. (2007). Shotgun wounds, a review of range and location as pertaining to the manner of death. American Journal of Forensic Medicine and Pathology, 28, 99–102.

National Academy of Sciences, National Research Council, Committee for the Workshop on the Medicolegal Death Investigation System. (2003). Medicolegal Death Investigation System: Workshop Summary. Washington, DC: The National Academies Press.

National Medicolegal Review Panel, National Institute of Justice. (1999). Death Investigation: A Guide for the Scene Investigator. Retrieved November 28, 2007, from http://www.ncjrs.gov/pdffiles/167568.pdf

Peterson, G. F., & Clark, S. C. (2006). Forensic autopsy performance standards. American Journal of Forensic Medicine and Pathology, 27, 200–225.

Saferstein, R. (2007). Criminalistics, An Introduction to Forensic Science (9th ed.). Upper Saddle River, NJ: Pearson/Prentice Hall.

University of Georgia, Carl Vinson Institute of Government. (n.d.). Georgia Constitution of 1777. Retrieved November 28, 2007, from http://www.cviog.uga.edu/Projects/gainfo/con1777.htm

Wagner, S. A. (2004). Color Atlas of the Autopsy. Boca Raton, FL: CRC Press.