The%20Vermont%20Medical%20Examiner%20System

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The Vermont Medical Examiner System

• Paul L.Morrow, MD
• Forensic Pathologist, Glebe, NSW
• Former Chief Medical Examiner, VT USA

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Death Investigation

• Functions
• Cause of death
• Mechanism of death
• Manner of death
• Identification
• Time of death
• Location of death

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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

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Death Investigation Key Concepts

• Manner of death
• One word summary of circumstances of death
• Manners of death
• Natural
• Accident
• Suicide
• Homicide
• Undetermined

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Death Investigation Types of Death Investigator
Systems

• Coroner
• Medical Examiner

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Death Investigation SystemsCoroner

• Ancient English office
• Norman Conquest
• Officially established 1194
• Appointed judicial officer (Australia/England)
• Qualifications legal ( medical in England)
• Elected office in US
• Qualifications varied

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Death Investigation SystemsMedical 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

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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

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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

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VERMONT
Population(2005) 623,050 Area 9,250 sq mi
(24,000 sq k)
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Vermont Medical Examiner System History

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

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Vermont Medical Examiner System History

• Early 1950s
• M E laws passed
• Medical Examiner System established with
  physician RMEs
• Late 1990s early 2000s
• Crisis in RME System
• Law amended to create AME
• AME system established

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Vermont State wide Medical Examiner System Case
s

• ca. 800 case referrals annually
• ca. 400 autopsies annually

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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 MEs
• Regional MEs
• Toxicology, histology, other lab services by
  contract

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VT Medical Examiner System

• ME Statute (T18505-509 5205)
• Medical Examiner Jurisdiction
• Death Investigative Team
• Authority to Order Autopsies

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Medical Examiner Jurisdiction

• 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

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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

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The Death Investigative Team

• Medical Examiner
• Chief Medical Examiner
• Regional Medical Examiner
• Assistant Medical Examiner
• Law Enforcement Officer
• States Attorney

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The Death Investigative Team
Medical Examiner

• 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)

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The Death Investigative Team
Chief Medical Examiner

• Forensic Pathologist
• Appoints regional and assistant medical examiners
  (RMEs AMEs)
• Supervises AMEs and RMEs
• Authority to authorize autopsies
• Performs autopsies

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The Death Investigative Team
Regional Medical Examiner

• 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

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Problem in Rural Death Investigation
In 1990s Increasing Maldistribution of RME
coverage

• Inability of dispatchers to find RME to respond
  to call
• Inability of RMEs 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
  RMEs as they retired

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Increasing Maldistribution of RME coverage

• 1997

• 1987

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The Death Investigative Team
Assistant Medical Examiner

• Qualified medical professional (as defined by
  CME)
• Nurse, experienced EMT, physicians 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

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The Death Investigative Team
Law Enforcement Officer

• Investigates the circumstances of death
• Is responsible for all law enforcement aspects of
  death investigation
• States Attorney creates list of qualified law
  enforcement officers

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The Death Investigative Team
States Attorney

• 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

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Autopsies VSA 18 5205

• Authority Chief Medical Examiner and States
  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 States Attorney and Attorney
  General

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Indications for Autopsy
- Medical - Legal
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Criteria for autopsy legal

• States 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)

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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)

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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

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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

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VT Medical Examiner System

• Police and AME/RME are called and make a proper
  preliminary investigation
• States Attorney is notified (technically in
  charge of body)

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Suspicious case or scene Criminal (Police)
Investigation
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Medical Investigation

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

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Autopsy
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Follow up investigation
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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)

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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