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By Julie A. Jervis, MD, RN

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Death Investigation
Nursing on the Cutting Edge
By Lori J. Allert, RN, BSN, D-ABMDI and Melissa Becker, RN, D-ABMDI

Forensic nursing is one of the burgeoning new specialty areas within the field of nursing and includes the subspecialty area of death investigation. Medico-legal death investigation involves a methodical and systematic approach; therefore, nurses, through the application of the nursing process and their patient-care experience, are uniquely qualified to serve as medico-legal death investigators.

The primary purpose of a death investigation is to identify "what happened." This is achieved through a thorough scene investigation, knowledge of the circumstances of the death and, if necessary, a postmortem examination. These three components, like legs of a tripod, are essential to accurately be able to say what happened. One is no more important than the other, nor can any one of them stand in isolation from the other. Each one is vital to the stability of the entire process. Only after the entire process is complete, can the cause of death and the manner of death be accurately determined.

Manner of death is simply a classification of the type of death: homicide, suicide, accident, undetermined or natural. The cause of death is determined by a "medical or traumatic (environmental) condition that caused death." For example, medical conditions leading to death might be a myocardial infarction, cerebral vascular accident or a pulmonary embolus, whereas a traumatic or environmental condition causing death might be a gunshot wound, carbon monoxide poisoning or severe head or chest injuries.1 Determination of manner and cause of death is essential for accurate completion of the death certificate, without which the family cannot even begin to settle the affairs of the decedent's estate.

At the time of death, there may be many legal, religious and emotional issues that need to be addressed. Once an individual has died, all of their legal rights are terminated. Thus, determining who is the legal next of kin becomes vitally important. Without knowledge of the legal next of kin, property cannot be released, organ/tissue donation cannot be approved, funeral arrangements cannot be made and obtaining or releasing information regarding the death investigation is inhibited.

Death investigation plays an important role in judicial, insurance and community issues as well, by determining if the death was a natural, accidental, suicidal or homicidal event. A thorough investigation will provide crucial information necessary for determining potential criminal or civil charges, death benefits or identifying potential public health concerns.

Death investigation is usually provided through either a coroner system or a medical examiner system. The role of each system is uniquely defined in each state's statutes.2 Historically, coroners were lay persons and medical examiners were physicians; however, investigation proves there is wide variation in the United States with regard to requirements, terms and education.3 In , a study revealed that 64 percent of the population was served by a physician death investigator and of that, 44 percent was served by a physician with pathology board certification or training/experience in death investigation.4 Regardless of the system employed, the role of the coroner/medical examiner is to identify appropriate cases for the assumption of jurisdiction. Assuming jurisdiction simply means the coroner/medical examiner will sign the death certificate. Although any medical doctor can sign a death certificate for a natural death, only the coroner/medical examiner can sign death certificates in all other cases (i.e., homicides, suicides, accidents or undetermined).5

Before signing the death certificate, the coroner/medical examiner must ensure an adequate investigation has been completed. The coroner/medical examiner may personally conduct the entire investigation or appoint deputies/medico-legal death investigators to assist with the process. However, the actual implementation of the investigative process varies widely by state and jurisdiction depending upon the system employed and the funding available to coroners/medical examiners. In an effort to promote standardization and training, the United States Department of Justice issued guidelines which urge thoroughness and consistency for all death investigations.6 The investigative process includes establishing positive identification of the decedent, determining date and time of death, obtaining the history of events leading to death (medical and psychosocial history), gathering appropriate medico-legal evidence, establishing cause and manner of death, notifying next of kin, protecting decedent's personal property, facilitating tissue/organ donation and determining if an autopsy is needed and accepting or declining jurisdiction.5

Before initiating an investigation, one must first determine if the death meets jurisdictional criteria. Each state has enacted legislation in an attempt to outline types of deaths to be investigated; however, review of these statutes reveals wide variation.4,7 Additionally, statutory language is often vague and difficult to interpret.

These guidelines5 were designed to be a user-friendly tool to assist investigators and the communities in identifying deaths which need to be reported to the coroner/medical examiner for investigation. Although overt homicides, suicides and accidents are easily identifiable as reportable deaths, there are many other cases, which are less obvious. It is these cases that often present unique and complicated challenges for the medico-legal death investigator. The following case studies illustrate these challenges.

Reportable Deaths

  • Any death which may be due entirely or in part to any factor other than natural disease
  • Any death which may be an accident, suicide, or homicide
  • Any sudden, unexpected death in which there is no previous history of significant heart disease or any other condition associated with sudden death
  • Any death which is apparently due to natural causes but in which the deceased doe not have a personal physician familiar with the patient's medical history, social/environmental situation or the circumstances of the terminal event
  • Any death considered to be a result of Sudden Infant Death Syndrome (SIDS)
  • Any death which occurs during, in association with, or as a consequence of a diagnostic, therapeutic or anesthetic procedure
  • Any death in which a fracture of a major bone has occurred within the past six months
  • Any death in which the person was an inmate of a public institution or was in the custody of law enforcement personnel

CASE STUDY I

Initial Information: KA was a 55-year-old male who presented to the hospital with complaints of shortness of breath and coughing for several days. Past medical history included anemia, hypertension, adrenal insufficiency, abdominal aortic aneurysm, colostomy and traumatic spinal cord injury with quadraparesis. In spite of treatment for urosepsis, his condition deteriorated, resulting in development of sinus bradycardia, thrombocytopenia and renal failure requiring dialysis. He died six days later.

Investigation: The investigation revealed KA sustained a traumatic spinal cord injury 20 years earlier, resulting in quadraparesis. Since his death was related to urosepsis, which was a complication of his quadraparesis resulting from a fall, his death was reportable.

The death certificate listed the cause of death as follows:

1. Sepsis
2. Urinary tract infection.
3. Complications of quadriplegia secondary to spinal injury from fall 20 years ago.
4. Other significant conditions: Chronic obstructive lung disease, hypertension, decubitus ulcers, status post hemicorporectomy, Addison's disease.

The manner of death was ruled accidental.

CASE STUDY II

Initial Information: AC was an 88-year-old man who presented to the hospital with a subdural hematoma. Since he was on coumadin for atrial fibrillation, he was admitted for medical management of this hematoma. Vitamin K and two units of fresh frozen plasma were given to reverse his coagulopathy. His condition slowly declined, he was made DNR/DNI, and died in the hospital five days after admission.

Investigation: The investigation revealed AC was walking up some wooden steps at his son's house when he lost his balance and fell backward, striking his head on the driveway. Since his death was related to his head injury resulting from a fall, his death was reportable.

The death certificate listed the cause of death as follows:

1. Intracranial injuries.
2. Blunt force injuries.
3. Fall.
4. Other significant contributing conditions: hypertension, congestive heart failure, and atrial fibrillation.

The manner of death was ruled accidental.

CASE STUDY III

Initial Information: VJ was a 46-year-old male admitted to the hospital with a grand mal seizure, metabolic acidosis and a blood sugar of 920. Past medical history was significant for ethanol abuse with increased liver function tests. He underwent multiple diagnostic tests, exploratory surgery for ischemic bowel and finally developed hepatic and renal failure. Although placed on multiple IV vasopressors to support cardiac function, he subsequently expired.

Investigation: The investigation revealed VJ struggled with chronic ethanol abuse and, on the day of admission, had fallen several times at home. VJ's wife reported he had been drinking. An admission blood alcohol was obtained showing a level of 0.068 ng/dl (0.10 is considered legally intoxicated). A head CT scan revealed a right subdural hematoma. Since his death was related to a complex medical history but his admission involved a recent fall, his death was reportable.

The death certificate listed the cause of death as follows:

1. Multisystem organ failure.
2. Hepatic failure.
3. Chronic ethanol use.
4. Other significant contributing factors: Chronic and acute subdural hematomas due to falls.

The manner of death was ruled natural.

The case studies presented for illustration demonstrate a need for medico-legal death investigators to have a working knowledge of medical terminology, disease processes, interventions/treatments and prognoses. In addition, investigators need to be skilled with assessing the body, assessing the scene and interviewing family members/witnesses and health care providers to gather essential medical/psychosocial history and the history of events surrounding the death. Since these requisite skills and knowledge are a natural extension of nursing assessment skills and training, nurses are well suited to the role of medico-legal death investigator.

Nurses are valued members of the coroner/medical examiner's office. Often, nursing/medical knowledge is key in helping to determine if deaths are due to natural or other causes. Knowledge of medications and medical paraphernalia found at scenes assists in identifying and documenting the extent of underlying medical disease(s) that may have contributed to the death. Consulting with the decedent's personal physician(s) to obtain medical history and discuss signing the death certificate is also an aspect of the investigative process that draws heavily on nursing knowledge and experience.

Although there is yet no standardized training for nurses to become medico-legal death investigators, there are a variety of seminars and short courses offered through various coroner/medical examiner offices around the country. Death investigation courses teach the essential processes to use in investigating the death as well as identifying, preserving, packaging and protecting evidence. The didactic courses provide the foundation for practicing as a forensic nurse/medico-legal death investigator. Nurses interested in pursuing a career in the death investigation field should contact their local coroner/medical examiner. Credentialing is available through the American Board of Medico-legal Death Investigators (this credential is open to all medico-legal death investigators meeting the requirements regardless of medical or law enforcement background).

Lori J. Allert, RN, BSN, D-ABMDI, a registered nurse and registered medico-legal death investigator, is the education and investigation coordinator for a multi-county regional coroner system in Minnesota.

Melissa L. Becker, RN, D-ABMDI, a registered nurse and registered medico-legal death investigator, is a deputy coroner in Minnesota.

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