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The Vermont Medical Examiner System Paul L.Morrow, MD Forensic Pathologist, Glebe, NSW Former Chief Medical Examiner, VT USA – PowerPoint PPT presentation

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Title: The%20Vermont%20Medical%20Examiner%20System


1
The Vermont Medical Examiner System
  • Paul L.Morrow, MD
  • Forensic Pathologist, Glebe, NSW
  • Former Chief Medical Examiner, VT USA

2
Death Investigation
  • Functions
  • Cause of death
  • Mechanism of death
  • Manner of death
  • Identification
  • Time of death
  • Location of death

3
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

4
Death Investigation Key Concepts
  • Manner of death
  • One word summary of circumstances of death
  • Manners of death
  • Natural
  • Accident
  • Suicide
  • Homicide
  • Undetermined

5
Death Investigation Types of Death Investigator
Systems
  • Coroner
  • Medical Examiner

6
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

7
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

8
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

9
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

10
VERMONT
Population(2005) 623,050 Area 9,250 sq mi
(24,000 sq k)
11
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

12
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

13
Vermont State wide Medical Examiner System Case
s
  • ca. 800 case referrals annually
  • ca. 400 autopsies annually

14
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

15
VT Medical Examiner System
  • ME Statute (T18505-509 5205)
  • Medical Examiner Jurisdiction
  • Death Investigative Team
  • Authority to Order Autopsies

16
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

17
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

18
The Death Investigative Team
  • Medical Examiner
  • Chief Medical Examiner
  • Regional Medical Examiner
  • Assistant Medical Examiner
  • Law Enforcement Officer
  • States Attorney

19
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)

20
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

21
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

22
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

23
Increasing Maldistribution of RME coverage
  • 1997
  • 1987

24
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

25
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

26
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

27
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

28
Indications for Autopsy
- Medical - Legal
29
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)

30
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)

31
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

32
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

33
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)

34
Suspicious case or scene Criminal (Police)
Investigation
35
Medical Investigation
  • May or may not involve scene
  • Options
  • Waive jurisdiction
  • Certify death (write death certificate)
  • Autopsy

36
Autopsy
37
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38
Follow up investigation
39
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)

40
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41
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
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