Forensic Nurses as Coroners and Death Investigators
By Maryann Fulton, RN, BSN

Death investigation systems can be a mix of coroner, medical examiner, or a combination system consisting of coroners or medical examiners. In some states the elected or appointed coroner may be a funeral director, farmer or police officer. Also depending on the state, the only requirement may be a high school diploma. Cumming¹ stated, "The coroner is a public official who is primarily charged with the duty of determining how and why people under the coroner's jurisdiction die (these jurisdictions vary from state to state, but typically include sudden, unexpected, unexplained, or traumatic death)."

A medical examiner is a physician who may or may not have pathology experience. Forensic pathology is an uncommon subspecialty. There is an average of only 11.3 active forensic pathologists available to work in all 50 states and the District of Columbia.² The task of all death investigators is to represent and act as an advocate for the deceased. It is necessary for death investigators to possess scene and evidence preservation skills to effectively perform his or her duties. Cumming¹ also stated: "This person must possess medical knowledge in order to be able to make judgments based upon symptomology, history, post-mortem appearance, toxicology and other diagnostic studies, combined with evidence revealed by other aspects of the investigation."

Forensic nurses can learn the investigative skills necessary to process a death scene. Forensic nurses already possess the nursing knowledge of anatomy, physiology, pharmacology and growth and development necessary to investigate deaths. This nursing knowledge allows the investigator to sort predisposing and precipitating factors involved in a death. In addition, forensic nurses also possess advanced communication skills and knowledge of the grief process. These skills are imperative for notifying next-of-kin and interviewing witnesses. Forensic nurses do not present a potential conflict of interest, as there may be if the death investigator was a funeral director or police officer.

Cause, Manner and Mechanism of Death

Cause, manner and mechanism are important features on death certificates for statistical and insurance purposes. "Cause of death is the injury or disease or combination of the two which is responsible for initiating the sequence of disturbances, brief or prolonged, which produce the death."³ Cause and mechanism of death are frequently misrepresented on death certificates due to a lack of understanding and knowledge of the differences between cause and mechanism of death. "Mechanism of death is the physiologic derangement or biochemical disturbance incompatible with life, which is initiated by the cause of death, e.g. cardiac arrest."³ Forensic nurses are well educated in physiology and are therefore prepared to accurately distinguish between the cause and the physiologic mechanism of death.

"Manner of death is the circumstances in which the cause of death arose, i.e. natural, accident, homicide, suicide, and undetermined."³ In some cases manner of death may be difficult to determine and may appear accidental (i.e. in a suicide without a note). Forensic nurses possess the skills necessary to complete a psychological autopsy and interpret the subtle nuances of medications, health history and circumstances surrounding suspicious deaths.

Inaccurate death certificates can cause misrepresentation of homicide and suicide rates which can affect, among others, public health policy and medical research. Insurance companies may deny payment if a death certificate inaccurately reports a death as suicide when in fact it was accidental. Also, care should be taken to provide accurate information for the next-of-kin. The death certificate is the next-of-kin's final link to the decedent.

Death Investigation

Forensic investigation of a crime scene involves interagency cooperation. Law enforcement may be present to complete an investigation; however, the death investigator completes a separate and concurrent investigation. Law enforcement and the death investigator must function as a team. Both may interview witnesses and next-of-kin. However, the interviews may have a different focus. Forensic nurses are prepared to participate and facilitate the interagency cooperation needed at the scene and throughout the investigation.

Notification of Death

The death investigator's role in death notification not only includes piecing together the circumstances surrounding the death, but also includes informing the decedents' next of kin. Charles⁴ stated, "The approach is tailored to this goal; the interview is for a very specific purpose, which is not intended to be therapeutic." Therefore, when the coroner locates the next-of-kin, multiple issues are addressed. However, contrary to Charles' statement, nurses are equipped with the communication skills necessary to elicit the information from the next-of-kin and family of the deceased in a therapeutic manner.

During the notification of death the coroner must have advanced interviewing skills, the ability to establish a rapport and the capability and knowledge to facilitate the grief process. Creativity, flexibility, empathy, sensitivity and compassion are essential characteristics in a coroner. In the midst of intensified interaction with family members, they (coroners or death investigators) must develop a connection, collect information, and display an ability to move throughout the scene in a sympathetic manner.⁴ Forensic nurses are well equipped to perform these investigative and notification tasks with empathy, sensitivity, and compassion, as these characteristics are a part of nursing. Nurses utilize creativity and flexibility on a daily basis when tailoring nursing interventions to individual patient needs. Empathy, sensitivity and compassion are also key concepts of nursing practice.

Nursing Process

Forensic nurse investigators utilize the nursing process; it is just applied differently and some of the steps are performed simultaneously with others. Assessment, planning, implementation and evaluation are components of every death investigation. These components are utilized to determine what is natural and what is not at a death scene.⁵

When a forensic nurse enters a death scene, he or she begins to collect information and assess the scene immediately. The assessment is essentially the investigation of the death. The body, immediate environment, remote environment, medical/social records (dictated by need), and individuals present at the scene are assessed.⁵

The forensic nurse will conduct a family assessment to determine the needs of the next-of-kin and if assistance is needed. The family assessment may include assessment of the safety of the environment, whether the decedent had adequate nutrition and shelter and possible factors to the death.

A community assessment may be necessary to determine community safety and risk. The assessment would include identifying community risk factors for accidental deaths for example, the death investigator may identify: the risk of train vs. vehicle accident recurrence at a particular railroad crossing; trends in teen suicide for risk factors present for suicide clustering; trends in drug overdoses; and trends in child deaths. Another component of community assessment may consist of monitoring motor vehicle accident trends for driving and substance use.

Planning occurs simultaneously with the investigation. When a need is identified, planning for successful resolution begins immediately. The forensic nurse may have a short span of contact with the family; therefore, the planning must occur in conjunction with other steps in the nursing process. Planning also includes how to proceed with the investigation and how and when to interact with the family of the deceased.

Implementation is utilizing the assessment data and following through with the plan. For example, the forensic nurse assesses that the decedent (a child) was abused, interview questions are planned, and the nurse then would implement the interview. The forensic nurse can also initiate referrals to programs, advocates, and resources if necessary. At the scene, the forensic nurse provides the next-of-kin with contact information to facilitate communication. It is important to provide next-of-kin with a contact for questions they may have after the shock of the death recedes. This process of caring for the survivors is an essential component of the forensic nurse death investigators duties.

Implementation may also include education, i.e. a teen suicide education program provided at the decedent's school may prevent a suicide cluster. Educating county government officials of treacherous railroad crossings and inappropriately placed road signs can prevent further accidents at these hazardous sites. Sudden Infant Death Syndrome (SIDS) education can decrease SIDS rates. Education can take many forms. Public service announcements, hospital-based education programs, marketing and advertising, and health fairs are just a few examples of effective community education methods.

The evaluation process may be completed by a follow-up study of death rates to determine if intervention was successful. In the case of a child abuse death, evaluation would include reviewing the interview process to determine if future interviews could be improved. Evaluation may also include contacting referral agencies to determine if intervention was initiated. The nursing process itself is evaluated to determine if the assessment, planning, and implementation of each investigation was appropriate and thorough. This evaluation improves further death investigations.

Unique Contributions to Death Investigation

During an internship at the Charleston County Coroner's Office the author learned of contributions the nursing process and forensic nurses have provided to death investigation. The Charleston County Coroner's Office employs three registered nurses, each having completed a bachelor of science in nursing. The coroner, Susan J. Chewning, BSN, RN, was elected in . Rae H. Wooten, BSN, RN, was appointed in and is the chief deputy coroner, and appointed in , Bobbi Jo O'Neal, BSN, RN, is a deputy coroner.

Chewning, Wooten and O'Neal recognized a trend of deaths during assessments of infant scenes. Based upon these assessments a plan was formulated to implement a change in the investigations of child deaths. This plan also included a retrospective chart review including infant deaths spanning to within Charleston County. The analysis revealed that many of the infant deaths may have been inaccurately attributed to SIDS. Sixty-eight percent of the infants were from 0 to 3 months of age; 56 percent were sleeping face down when the death occurred; 61 percent were sleeping with others; and 65 percent were sleeping in an adult bed at the time of death.⁶ Three conclusions reached attributed many of the possible SIDS deaths to "overlie," laying the infant on his or her face to sleep, and having too much bedding in the crib. Overlie occurs when an individual unintentionally suffocates an infant when the infant is sleeping in the "family bed."⁶

Based upon this assessment and study, the Charleston County Coroner's Office implemented a change in child-death investigation procedure and recording. A knowledge deficit was also identified as a result of the assessment and a massive community education effort targeting hospitals, medical personnel, businesses, retail stores selling infant merchandise and the lay public was implemented. Public service announcements and participation in health fairs were utilized to disseminate the risk behaviors found. Policy changes in discharge planning education were implemented in the community's hospitals as a result.

A reduction in infant deaths in Charleston County occurred after the prevention program and child death reviews were implemented ⁶ The child death reviews are now standard practice for the Charleston County Coroner's Office.

Maryann Fulton RN, BSN, is currently working toward her MSN and adult nurse practitioner degree at Beth El College of Nursing and Health Sciences at the University of Colorado at Colorado Springs. She also is completing a forensic minor.

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