forensic pathology: you learn the most from the post deaths associated with surgical or medical...

Forensic Pathology: You Learn the Most From the Post

Deaths associated with surgical or medical intervention

February 21, 2015

Kent E. Harshbarger, M.D., J.D., M.B.A

Montgomery County Coroner

Pretest QuestionsWhat medical therapy should be removed prior to reporting a death to the Coroner’s Office?

A)Endotracheal tubesB)Central LinesC)Blood pressure cuffD)None *

Why should medical facility or procedure deaths be investigated by the Coroner?

A)Civil litigationB)Community protection/safety *C)Mandated by liability insurance companyD)Ohio LAW requires facility deaths to be investigated by the Coroner

The Coroner Must Determine Cause and Manner of Death

• What Happened, Not Who Did It

• Up to Law Enforcement, Prosecutor, and the Judicial System to Decide Who Did It

• Cooperation with Your Law Enforcement Personnel is Key to Success (Avoid the Clinical Vacuum)

Coroner’s System

• In most communities, 50% of the deaths are reported to the Coroner/Police

• ¼ to ½ of these (12 to 25%) are autopsied– 50% natural– 30% accidental– 11% suicide– 8% homicide

Investigation Summary - 2013

• Deaths reported – 5179• Accepted for autopsy – 1416 (622)• Accepted for external exam – 288 (BB-36)• Accepted for records review - 82• 2013 breakdown

– Natural – 291 (28%)– Accident – 576 (56%) 220 overdoses/201 falls– Suicides – 84 (8%)– Homicides – 63 (6%)– Undetermined – 19 (2%)

Who Must Call The Coroner?

• Anyone Who Obtains Knowledge thereof Arising from His Duties, Shall Immediately Notify the Office of the Coroner

• Known Facts Concerning the Time, Place, Manner, and Circumstances of the Death Should Be Given

• Any Other Information Required

In What Types of Death is the Coroner Called?

• Deaths by Criminal or Violent Means (Homicides)

• Casualty (Accident)

• Suicide

• Suspicious or Unusual Manner

• Previous Apparent Good Health

• Child Under the Age of Two


• Often jurisdictions or States have special rules– Alzheimer’s disease– Children– Sexual abuse/Elder abuse– Deaths in custody– Maternal or fetal death– Occupational deaths


• The time period from the incident to the time of death is irrelevant.– If the decedent did not regain their health to a

status equal to or better than that which was present at the time of the incident

• Notification does not equal jurisdiction– Coroner decides what cases need further

investigation and/or autopsy

Death Investigation

• Other objectives/goals/needs– Reduction in crime– Impartial justice, civil lawsuits, and family

rights protection– Home and work accident reduction– Vehicle accident reduction– Understand and reduce unexpected adult and

infant deaths– Track public health, terrorism, infectious

diseases

Delaware

Madison

Union

Licking

Fairfield

PickawayFayette

Clark

Champaign

Logan

Hardin

Allen

Hancock

Wyandot

Marion

Crawford

Huron

Richland

Ashland

Morrow

Knox

Coshocton

Tuscarawas

Carroll

Harrison

BelmontGuernsey

Muskingum

MonroeNoble

PerryMorgan

Washington

Athens

Hocking

Meigs

Gallia

Vinton

Jackson

Lawrence

SciotoAdams

Pike

Ross

Highland

Shelby

Miami

Montgomery

Greene

Darke

Preble

MercerAuglaize

Van Wert

Paulding

Defiance

Williams

Putnam

Henry

Fulton

Wood

Lucas

Ottawa

Sandusky

Seneca

Erie LorainCuyahoga

Medina

Wayne

Holmes

Lake

Geauga

Ashtabula

Trumbull

PortageSummit

Stark

Mahoning

Columbiana

Jefferson

Clinton

Brown

Clermont

WarrenButler

Hamilton

Franklin

Counties Contracted Through The Montgomery County Coroner For Autopsies

Montgomery County Coroner’s Office

Delaware

Madison

Union

Licking

Fairfield

PickawayFayette

Clark

Champaign

Logan

Hardin

Allen

Hancock

Wyandot

Marion

Crawford

Huron

Richland

Ashland

Morrow

Knox

Coshocton

Tuscarawas

Carroll

Harrison

BelmontGuernsey

Muskingum

MonroeNoble

PerryMorgan

Washington

Athens

Hocking

Meigs

Gallia

Vinton

Jackson

Lawrence

SciotoAdams

Pike

Ross

Highland

Shelby

Miami

Montgomery

Greene

Darke

Preble

MercerAuglaize

Van Wert

Paulding

Defiance

Williams

Putnam

Henry

Fulton

Wood

Lucas

Ottawa

Sandusky

Seneca

Erie LorainCuyahoga

Medina

Wayne

Holmes

Lake

Geauga

Ashtabula

Trumbull

PortageSummit

Stark

Mahoning

Columbiana

Jefferson

Clinton

Brown

Clermont

WarrenButler

Hamilton

Franklin

Counties Contracted For Autopsies

Counties Contracted for Toxicological Services Only

*Licking County-Provide Toxicological Services

and Back-Up Autopsies

Montgomery County Coroner’s Office

Coroner/Medical Examiner Systems

• Coroners – Elected– In Ohio: MD, DO– Elected Lay Person

(Illinois, Indiana)• Funeral Director

– Adult, Non-felon

• Coroner can arrest the Sherriff

• Coroner is back up Commissioner

• Medical Examiner– Appointed

Professional, Generally Forensic Pathologist

– State control vs. Local control

– Medical Examiner/Coroner (Ohio, Kentucky, Illinois)

History of Death Investigation

• Coroner’s system traced to England

• Earliest record of a Coroner’s office is 925

• Office formally described in 1194– 3 knights and 1 clerk in every county– “keepers of pleas of the crown”

– Knight, B. The Medieval Coroner, 58 Medical Legal Journal 65-80, (1990).


• “Keepers of pleas of the crown”– Circuit court (General Eyre) every 7 years– Record crimes for later trial– If criminal cases forgotten the King would lose

possible revenue

• “Crowners”

– Knight, B. The Medieval Coroner, 58 Medical Legal Journal 65-80, (1990).


• Suicide

• Act of rebellion against the Gods– Denial of funeral rights

• King was entitled to decedents property


• American Coroner’s System– Essentially the same system as in 1600

England– First recorded inquest in 1635, New England


• First recorded autopsy in 1647– Medical students

• First recorded medical legal autopsy 1665– Mr. Francis Carpenter suspected of murdering

his servant Samuell Yeoungman– Found depressed skull fracture and bruising

– Achieves of Maryland

Hospital Death Investigations

Hospital/Nursing Home Deaths Quality of Care

Patient/Community Safety – Coroner’s Jurisdiction Standard of Care – Civil Law Issue

Patient/Community Safety – Can policies and procedures be updated? Are certain procedures simply unsafe at a particular

institution? Proper patient supervision and support


Investigation Patient Safety Quality of Care Medications Equipment

Raising the index of suspicion Altered scenes Information gaps


NH death; 85 yo female Pronounced dead: 5:20 AM Death reported: 5:50 AM Police and EMS respond and

call Coroner Altered scene:

Decedent cleaned, evidence thrown away or moved, decedent moved

History: Suicidal ideations (family,

staff, psychologist) Recent death of husband,

OD attempts x 3


Investigation/Scene: Team Approach Interoffice

communication Importance of

relayed info versus medical record and gaps

Medical history

Historical Information: Injections IV Lines/IV Line Flush Transfusions Procedures Sequence of events Unusual Symptoms/signs Diagnostic testing Time of death versus time

of report Persons involved


IV Line Flush Error Elderly Male with

central line Heparin flush of central

line to keep open Approximately 1 hour

later he was unresponsive with initial glucose of 13 two hours after line flush

Blood insulin: 297 mcU/ml (0-23) Testing on same tube

as glucose level

C-peptide was low- external source


IV Line Flush Errors Where is the insulin stored? What does the container look like? How is the container labeled? Who has access? How many patients to RN? RN Training and procedures? Who on the floor is supposed to get insulin?

Manner of death? Accident or intentional


Digoxin overdose: Middle aged female Digoxin ordered RN first week of service

Dosing error by decimal point, injected wrong dose by order of ten

Death occurred within an hour of dose Diagnosis made clinically as symptomatic

quickly

Hospital Death Investigations 91 year old white female, NH

patient NH patient x 5 years Bedridden and severe

osteoporosis Unwitnessed fall from bed to

floor Fracture distal right

femur, no surgery Two weeks later, still

pain, gastric ulcer and hematemesis, to hospital, LUQ bruise

Family suspects patient dropped, QC issues

Hospital Death Investigations Postmortem Examination:

Fracture verified Pulmonary Edema with consolidation Atherosclerosis

COD: Multiple Drug Toxicity (Morphine and Oxycodone) Nursing notes document O.D. and adverse

effects Manner: Accident


Immediate deaths and delayed deaths Manner of death?

Determined based on circumstances


Epidemiology: Database to track information:

Facility Room number Attending/nurse Drugs used Frequency Patient sex DNR status

Keep asking questions!


Post procedure deaths Most common reason

for notification Most related to family

concerns about the standard of care (Civil)

Needs investigation to assure patient or community safety (Coroner’s jurisdiction)


Cardiac catheterizations


Middle age male Many procedures,

same surgeon, symptomatic

Coded hours after ventral abdominal hernia repair


Patient/Community Safety – Coroner’s jurisdiction similar to roadway safety

Quality of Care – Can be a safety issue

Medications – Errors happen Equipment – Failures happen

forensic pathology: you learn the most from the post deaths associated with surgical or medical...

Documents

homicide slide

time of death

death investigation

manner of death

types of death

facility deaths

infant deaths

procedure deaths