CHAPTER 16. Forensic Investigation of Death
Virginia A. Lynch and Steven A. Koehler
Health and Justice
Society’s need to understand the disease mechanisms and biomechanical factors associated with various forms of death is essential to systems of public health and the administration of justice. These processes, which help to determine the precise precipitating factors and causes of death, not only benefit medical science but also serve the public’s general welfare by ensuring that natural, accidental, and crime-related fatalities are systematically identified and investigated in regard to cause, manner, and mechanism of death.
Regardless of the circumstances of death, there are usually acute emotional reactions of significant others as well as inherent legal consequences. For example, the precise way individuals die and the events that surround the dying process can determine the execution of last wills and testaments, life insurance distributions, rights of survivorship, and more.
In a typical social structure, the loss of a loved one is a disruptive and often devastating experience. In addition, if death comes suddenly or unexpectedly or involves a violent act, it now becomes a forensic case, demanding a systematic legal inquiry. Historically, nurses have been among the key individuals to care for both the dying patient and the bereaved in that delicate period before and after death. They often participate in lifesaving intervention or resuscitation efforts and perhaps later prepare the deceased for postmortem procedures or release to a funeral home. Furthermore, contemporary nursing practice mandates forensic accountability as a priority in sudden, unexpected, and questioned deaths, a duty deemed second only to lifesaving interventions or resuscitation efforts. With these factors in mind, one can readily appreciate the appeal of death investigation as a forensic nursing career choice.
Historical Perspective of Forensic Death
Death is the permanent cessation of all vital bodily functions: the end of life ( Dorland’s, 2000). The causal factors of death establish the principal foundation of medical science: sustaining and improving the quality of life. Without knowledge regarding why people die, it would be virtually impossible to establish preventive healthcare practices. From the beginning of civilization, death roused the interest and curiosity of the public to determine what separated the living from the dead. Because of human deaths, medical science and the law initiated a search that has lasted from antiquity until the present. The question of why people die has unfolded criteria for both natural and unnatural death, yet even now there remains a requisite mystery surrounding unexplained deaths. The need for absolute accuracy is compelling. Forensic medicine becomes the “application of clinical and scientific knowledge that provides answers to questions of law and/or patient treatment involving court related issues” (American Academy of Forensic Science [AAFS], 2002).
In the United States, forensic pathology is a subspecialty of anatomical pathology and forensic medicine charged with the responsibility of determining the cause and manner of questioned deaths. The manner of death will determine whether a crime has been committed. This is an important area where the forensic nurse examiner (FNE) can bring clinical management skills and expertise to the grieving and bereaved.
A Multidisciplinary Task
Justice Blackmun referred to the circumstances of death investigation as the unavoidable intersection between law and medicine that requires cooperation and understanding, rather than distance and isolation between investigating agencies ( Law & Politics Book Review, 1998). Accordingly, nurses must be aware of the circumstances of death and the legal statutes that unite them with law enforcement agencies in the role of a clinical investigator. The universal application of nursing accountability includes the scientific investigation of death.
The earliest application of forensic medicine dealt with suicide, generally regarded as a crime against public interest since classical times (Baden, 1989). The criminality of suicide and the penalty involved included condemnation of the offender by the Roman Catholic Church. For the violation of canon law by suicide to be confirmed, the investigation of death evolved from the need to determine the accurate cause of suicidal deaths (Spitz & Fisher, 1993). During these times, the investigation relied solely on the circumstances of death without a specific examination of the body.
Not until the thirteenth century did the autopsy become a standard of practice in the postmortem evaluation of death. China is the first country known to have developed extensive, detailed instructions on necropsy pathology and the autopsy. The Chinese handbook Hsi Yuan Lu specified precise protocols addressing the types of wounds inflicted by sharp versus blunt instruments, death by drowning versus submersion in water after death, and death by fire versus burning after death (Hsi Yuan Lu in Camps, Robinson, & Lucas, 1976).
Since these earliest beginnings, there has been an intense and ever-expanding interest in death investigation, specifically as it relates to solving crimes. New technologies have emerged to complement the examination and dissection of the body. Contemporary death investigation incorporates the application of infrared video-graphic, ultraviolet lights, lasers, spectrographs, neutron activation analysis, computer software, scanning electron microscopes, and DNA analysis. However, the contribution of the autopsy has remained unchanged and irreplaceable.
Death Investigation and the Law
Every death has actual or potential legal implications. Health or disability insurance payments, survivor benefits, transfer of estates, anatomical tissue or organ donations, and criminal charges all depend on information that emerges from the death scene investigation and the results of the forensic autopsy. Data that suggest suicide, evidence of torture, presence of toxicological residue, or the discovery of an unknown pregnancy can significantly affect subsequent judicial proceedings, as well as determining the corpus delicti in criminal liability. Corpus delicti refers to the substantial and fundamental fact necessary to prove the commission of a crime ( Dorland’s, 2000). This term is often used erroneously to designate the physical body of the homicide. For example, the corpus delicti of homicide is the fact that a person died from unlawful violence (Adelson, 1974). This legal term literally refers to the body of the crime or offense, not the corpse of the decedent, and must be determined for successful prosecution of a criminal death.
The cause of death is the factor that initiated the sequence of events that culminated in death, such as cancer or multiple injuries from a vehicle incident.
The manner of death refers to the circumstances from which the cause of death emerged—that is, natural, accidental, homicidal, suicidal, or undetermined.
Fundamentals of Death Investigation
Death investigation is a process that involves the identification, collection, analysis, interpretation of physical evidence, and the circumstances of the event from which conclusions are derived or hypothesized. The investigation process is systematic and ongoing. The actual conduction of an investigation, evaluation of data obtained during the investigation, and the reinvestigation and reevaluation of new data as necessary is part of the medicolegal investigation of death.
Death is the actual state of nonbeing. Death investigators should possess a deep understanding of the medical process of death, the signs of death, the sequence of physiological events surrounding death, and the laws governing determination of death. This responsibility demands knowledge of the presumptive signs of death as well as laws governing determination of death. The ability of an individual to declare an individual dead varies from state to state and even from county to county within the same state. In some states while lay individuals can pronounce someone dead, emergency medical services (EMS) personnel typically conduct this task. In other jurisdictions, the forensic nurse death investigator (FNDI) or registered nurse deputy coroner (RNDC) pronounces the death at the time of their arrival at the scene. Consequently, the time of their arrival at the scene is noted as the estimated time of death unless it has been witnessed. Pronouncements made by EMS involve placing three electrocardiogram (EKG) patches to determine if any electrical activity can be detected in the heart. A flat line indicates no cardiac activity and death. In cases of obvious deaths such as those seen in decapitation or decomposition, firefighter or police officers at the scene can make the pronouncement. Although most legal rights are suspended at death, certain laws pertain to an inquiry into the circumstances of death, security of personal property, and disposition of the body, as well as individual human rights, which remain in death. The rights of the decedents and their families become legal issues once the processes of death are complete.
The forensic medical investigation of deaths includes has two main objectives:
1. Determining the positive identity of the individual
2. Determining the cause and manner of death
Classic questions are asked:
• Who is/was the person? (confirm the identity beyond any doubt)
• What happened? (stabbing, beating, fall, collision, or exsanguination)
• When did the person die? (the best estimate of the time of death)
• Where did it happen? Where did the person die? (e.g., in the street and then in the hospital)
• Why did it happen? (argument, lost consciousness, defective product)
• How did it happen? (a car spun on ice, rotated, glanced off a building, then struck a pedestrian)
The initial issue in the investigation is to determine who the decedent is. The methods used to determine the positive identity range from low-tech methods of visual identification to highly sophisticated techniques such as facial reconstruction. The method used to determine identification is dictated by the level of decomposition or extent of trauma.
The next phase is to determine what events happened to cause the death. A detailed examination of the surroundings often provides a clue to what precipitated the death. Did the victim fall out the window? Was he pushed out the window? Did he deliberately jump out the window in an act of suicide?
When the death occurred is often essential information to help determine the circumstances and manner of death. Methods used to ascertain the time of death begins by a detailed examination of the body for stages of livor mortis, rigor mortis, and algor mortis. Other methods used to determine time of death include stomach content analysis and entomological evaluation.
Where represents the location of the body when it was found. Was the individual killed elsewhere and then moved? Did the person walk to her or his death, or was the body transported to this particular place?
Why refers to the series of sequential circumstances pertaining to events that occurred before death, at the time of death, and immediately afterward.
How refers to a descriptive account of the circumstances of why in an investigator’s report.
Answers to these questions will help establish the cause of death and the manner of death. Although what is often the most controversial issue in the investigative process and courtroom debate, each aspect of the investigation must interface with the others to provide a precise conclusion. Determining what occurred depends on the quality of scene investigation, recovery and preservation of evidence, the autopsy, and toxicology evaluation.
The final diagnoses are based on the answers to these issues. The issue of what occurred is of paramount importance in determining whether a crime has been committed. The need for absolute accuracy is vital for establishing the cause of death (Besant-Matthews, personal communication, April 2004). These questions and their answers will guide the investigator through a plan of action and provide an evaluation of outcomes.
Causes of death
The cause of death is the event or condition that resulted in death due to natural or traumatic conditions.
Natural deaths are a result of disease processes such as the occlusion of a coronary artery resulting from plaque, cirrhosis of the liver resulting from chronic alcohol use, or hemorrhage resulting from an aneurysm of an artery in the brain. A death is deemed occurring from a natural cause if it stems from congenital anomalies or involves a degenerative disease, an infection, or is the result of a metabolic or neoplastic disease that interferes or disables vital organ functions.
A death can be the result of injury from trauma that is sufficient enough to affect a vital organ or system. Trauma can result from an intentional or nonintentional act as in the case of a gunshot wound, indicating a homicide, suicide (self-inflicted), or accident. Nonintentional trauma can include injuries received during a motor vehicle collision (blunt force trauma), falling down steps, being injured on a construction site, or from being hit by a baseball during a game.
A cause of death can also occur without trauma but not be natural. Deaths from drug overdose (accident or suicide) typically show no external signs of trauma. Drowning and certain types of asphyxiation also leave no external detectable signs of trauma.
Basic knowledge regarding the scientific investigation of death involves the following:
• Identification of trauma, natural disease processes, self-inflicted wounds versus those inflicted by another, pharmacology, toxicology, entomology, anthropology, anatomy and physiology, risk factors, statistics, and human behavior
• Recognition of wound characteristics related to injuries resulting from weapons used to inflict death range from the subtle, innocuous signs of abuse or neglect to catastrophic fatal injuries or mutilation of bodies before and after death
• Recovery and documentation of evidence, collection and preservation of highly perishable and fragile specimens, and the security of such materials (related to the cause of death) are primary responsibilities of the medical death scene investigator.
• Notification of next of kin in a personal, timely, compassionate, and sensitive approach
At the scene of death, the responding investigator assesses the circumstances of death, observing for indicators of violence, poisoning, homicide, suicide, or accident. The investigator interviews the decedent’s family or significant others at the scene to determine if the person has a notable medical history, obtains the name of the attending physician, and documents any medications or other clues at the scene that might reveal an associated medical condition. The investigator may request the family to contact a mortuary and inform them that the body will be sent to a morgue for further assessment. In the latter case, the investigator is responsible for arranging legally secure transportation of the body to the medical examiner’s or coroner’s (ME/Cs) facility. Emergency medical personnel on the scene will rarely assume this role because they must be immediately available to respond to calls involving living persons. If the death is deemed a natural death, and if the decedent’s physician has agreed to sign the death certificate, the medical examiner or coroner may permit the body to be taken to the funeral home while awaiting certification.
The body should not be embalmed prior to a postmortem examination. It is vital to ensure that the death is not a forensic case before any mortuary procedures are initiated, because embalming may introduce artifacts or destroy evidence, especially in cases of poisoning.
Although embalming temporarily preserves the condition of the body and significantly reduces the risk of infection from the corpse, it is essential that any investigative procedures are accomplished first. When the body is released for burial, the mortician will obtain permission to proceed with embalming techniques according to the wishes of the family (Adelson, 1974).
Forensic Pathologist/Medical Examiner/Coroner at the Scene
The ME/C may not be required by law to go to the death scene and may decide to send a designee, either a death investigator or a deputy coroner (such as the FNDI or RNDC), to oversee the death scene investigation. The presence of these professionals enhances the understanding of the case. Although it would be ideal to have a forensic pathologist at all scenes of death, these professionals may only go to the most complicated scenes because of their low numbers, limited time, and limited opportunity.
The majority of deaths are expected, caused by natural diseases, and are well documented within the medical history. These cases do not require the involvement of the ME/Cs office and are commonly reported by a physician or next-of-kin (NOK) to the ME/C office by phone providing a detailed past medical history. In most jurisdictions, the deputy coroner or the death investigator can authorize the transfer of the body from the scene directly to the funeral home if he or she is satisfied that the death was the result of a natural process and that there was no foul play or signs of trauma.
When the presence of a death investigator or deputy coroner is required at a scene, this individual is notified by either the responding police office or emergency medical responder once it has been determined a death has occurred. The ME/C or the investigator has the authority by local or state law to conduct an inquiry and a death scene investigation. The ME/C will determine if a forensic autopsy will be performed to determine the decedent’s identity and the cause and manner of death.
The ME/C or designee has the authority to take custody and control of the body, respond to and investigate the scene, take possession of evidence, and obtain and review medical records. Only the ME or coroner, however, is authorized to certify the cause and manner of death under independent authority, unfettered by political or other influences.
The forensic nurse, medical investigator, or deputy coroner who is representing the ME/C collects information that may be used to confirm the identification of the decedent and establish an approximate date and time of death. These data will assist the forensic pathologist at the time of autopsy and contribute to the determination of cause, manner, and mechanism of death.
Death Scene Control and Processing
Body at the scene
Once the person is declared dead, the body, the area surrounding the death scene (crime scene), and the associated medical forensic evidence comes under the jurisdiction of the ME/C office investigating the death. The law enforcement officials are responsible for ensuring the security of the crime scene, the safety of the investigators, conducting detailed interviews with family, friends, and witnesses and begin to create a list of possible suspects. Securing and protecting the death scene are the initial roles of the law enforcement personnel.
The forensic investigation of a crime scene involves interagency cooperation, scene examination, and preservation as well as photography and field notes. Law enforcement is present to accomplish a criminal investigation; however, the coroner or medical investigator achieves a separate and concurrent medical investigation. The two entities must function as a team. Both may perform interviews of witnesses and next of kin. The objectives of each agency are different, as are the responsibilities.
Before the processing of the scene, the body and its surroundings must be photodocumented. This is typically conducted by a forensic crime-scene photographer employed by a ME office or associated with a coroner’s office. The forensic nurse death investigator (FDNI) or deputy coroner may also be highly skilled in scene photography and assume this responsibility for the ME/C. These individuals photograph the scene in a specific sequence starting from a distance and working their way toward the body. The body and evidence cannot be touched or moved until it has been photographed and the scene forensic photographer grants permission. Photographs are important in that they present the state of the scene at the time of the death, the position of the body, its relationship to other objects, and a general layout of the scene. These photographs allow those not at the scene to gain an overview of the scene without being there. The images are also viewed by the forensic pathologist before conducting the autopsy, as well as homicide detectives, lawyers, and possibly juries in a court of law.
Once the scene has been photodocumented, the next step is to identify, photograph, and collect trace evidence from the body and the surrounding scene that may be lost or destroyed during the transport of the body. The identification and collection of forensic evidence is handled by the FDNI, RNDC, or forensic scientists trained in varies subspecialties such as fingerprinting, blood splatter, trace evidence, and ballistics from the ME/C office. After the body has been processed at the scene, it is placed onto a white sheet and then into a body bag for transport to the morgue.
Place of death
Because 60% to 75% of reportable deaths occur without an attendant physician, it is reasonable to expect death to transpire in a residence. When the decedent has not been admitted to the hospital before death or when the individual lives alone, a significant amount of time may lapse before the body is discovered. Without prior arrangements with legal and medical authorities, such as hospice cases, the investigators must proceed to the residence to pronounce and examine the scene of death.
When death occurs in a public area, prompt removal of the body from the scene or from public view may be in the best interest of the family, bystanders, or traffic. However, a thorough investigation is time consuming, and related legal statutes are specific regarding the protection of the body and scene. Generally, it is a violation of the law to remove a body from the scene of death or to remove any items from the body before the scene investigation has been completed. There are a few exceptions. For instance, if the body is in an unsafe location or is blocking traffic, it maybe removed to a site near the place of death until the investigation is complete. If the death occurs in a hospital, all medical devices such as central IV lines, dressings, or other paraphernalia should remain intact and be transported to the morgue.
Death Investigation Systems
Within the United States, there are two primary types of death investigation systems: the medical examiner’s system and the coroner’s system. There may also be a combination of the two known as a mixed system, as well as a law enforcement/coroner system such as a sheriff coroner.
Medical examiner system
In a medical examiner’s office, the chief ME is a forensic pathologist certified by the American Board of Forensic Pathology and is an appointed position. These examiners often operate with several deputy medical examiners (also forensic pathologists) under their command. In the United States and Canada, there is a significant lack of board-certified forensic pathologists (fewer than 400); the distribution is uneven, and smaller states may have far fewer than needed to cover the number of deaths in their jurisdiction. The ME’s death investigators can include laypersons, paramedics, and forensic nurses who have received extensive training in death investigation. These investigators represent the authority of the chief ME at the scene of death.
Coroner’s system
The current U.S. coroner’s system can trace its origins back to the year 1194 in England. The coroner is an elected public officer with the requirements dictated by state laws; however, coroners typically are not physicians and have minimal or no medical experience. The title of coroner is also dictated by law and may become a dual title if the coroner is also a forensic pathologist. In this case, the correct title is coroner/medical examiner to differentiate from the lay coroner. The coroner typically appoints deputies, whose qualifications are also set by each state. According to Marion Cumming, a forensic nurse coroner for 17 years, “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” (Cumming, 1995).
Forensic nurse examiners have functioned as elected coroners, investigators for forensic pathologists, or deputy coroners, and have conducted external postmortem examinations, exhumations, and site recovery during disasters, as well as documentation of torture in cases of political asylum. Efficient, well-equipped, well-trained investigators contribute significantly to a successful investigation and removal of remains in catastrophic, unexpected, or unattended natural deaths. Smooth functioning and close cooperation between the first responders, police agencies, fire department officials, emergency services, mortuary personnel, and death scene investigators demonstrate a high level of confidence to the community in medicolegal matters.
Systems structured for the investigation of death are organized to conduct a professional practice within the framework of standards developed and approved by the discipline’s governing body and within the parameters of legislative authorities.
Governing statutes, administrative rules, and professional performance standards define the duties and responsibilities of those who are appointed to conduct a forensic death investigation. Medical examiner’s or coroner’s systems are responsible for determining the cause and manner of questioned deaths.
Where the law provides for a system of death investigation under the jurisdiction of the medical examiner’s, coroner’s, or mixed system, the death will become a point of legal inquiry from both a medical and a legal perspective. The law states that certain categories of deaths are to be reported to the county or state death authority for its participation in the investigation.
Types of Deaths That Require a Forensic Investigation
Not all deaths require a forensic investigation. Although each individual medical examiner’s and corner’s office determines the types of cases it can legally accept, the following categories of deaths are typically investigated:
1. All sudden deaths when the cause of death cannot be properly certified by a physician based on prior (recent) medical attendance
2. All deaths occurring under suspicious circumstances, including but not limited to those in which alcohol, drugs, or other toxic substances may have had a direct bearing on the outcome
3. All deaths occurring because of violence or trauma, whether apparently homicidal, suicidal, or accidental, including but not limited to those resulting from mechanical, thermal, chemical, electrical, or radiation injuries, drowning, cave-ins, or subsidence, regardless of the time elapsed between the time of the injury and death
4. Natural deaths in which the decedent does not have a personal physician familiar with the patient’s medical history, social or environmental situation, or the circumstances of the terminal event
5. Any stillbirth or infant death occurring within 24 hours of birth where the mother has not been under the care of a physician or where the mother has suffered trauma at the hand of another person
6. Deaths suspected to be a result of sudden infant death syndrome (SIDS)
7. All criminal abortions, regardless of the gestational age of the fetus
8. All hospital deaths that occur as a result of accidental injury during diagnostic or therapeutic procedures, including but not limited to surgical procedures, and all deaths following the accidental administration of excessive amounts of a drug, including but not limited to blood or blood products; in addition, all operative, perioperative, and postoperative deaths in which the death is not readily and clearly explainable based on prior disease
9. Deaths of all persons while in legal detention, jails, or police custody, including any prisoner who is a patient in a hospital, regardless of the duration of hospital confinement
10. Deaths resulting from disease, injury, or a toxic agent that occurs during active employment
11. Any death wherein the body is unidentified or unclaimed.
12. Any death in which there is uncertainty as to whether it should be reported
Intuitively, it appears to be a better choice to have someone with a healthcare background and clinical expertise fill this important role. Nurses are particularly prepared to recognize signs and symptoms of natural disease processes, to interact with physicians or other healthcare professionals, and to interact with grieving families. The nurse investigator or nurse coroner must also collaborate with scientific and legal personnel, law enforcement agents, and other investigative agencies involved in the medicolegal investigative process.
Jurisdiction of Death
Legislative statutes of the state, province, or country of residence establish jurisdiction and authority for the medical examiner’s, medical investigator’s, and coroner’s systems in forensic deaths. Legal statutes defining jurisdiction differ according to the local, state, federal, or provincial levels, and they vary in different countries; however, the categories of death generally remain the same or similar in nature.
State or provincial statutes define jurisdiction over the body of any person who dies as a result of trauma, violence, accident, suicide, or homicide, or whose death is unattended or involves any suspicion of foul play. The ME or coroner may also be notified depending on the circumstances of death of persons who have no known pertinent medical history. This category of death is intended to include those about whom nothing medical can be found—for instance, a traveler passing through the state who dies at the bus station. It does not include a person who is found dead under nonsuspicious circumstances whose regular attending physician or other clinical physician is unwilling to certify death simply because the physician was not present to observe the death. Certification of death is based on the physician’s ability to determine the cause of death based on reasonable medical certainty. The ME or coroner can assume jurisdiction over the body of a person who has died of an obvious natural disease (no trauma or foul play) if the decedent’s private physician is temporarily unavailable or unwilling to sign the death certificate. In these deaths, the ME/C office will release the body to the funeral home, determine the cause of death from information contained within the patient’s medical records, and issue the death certificate. Some jurisdictions do not include nursing home deaths, as all patients have attending physicians, unless suspicious circumstances are reported or suspected.
Furthermore, it is necessary to eliminate natural deaths from being sent to the forensic pathologist when possible. This is an important consideration in situations in which forensic nurse investigators or nurse coroners can examine and evaluate the death from a medical perspective and then release the body directly to the funeral facilities. The ability to divert the natural deaths from the forensic facility helps by reducing the workload on the forensic pathologist, lessening the emotional trauma to the family, and decreasing the operating cost to the office.
Death Defined
The diagnosis of death is traditionally made using the Triad of Bichat, which states that death is “the failure of the body as an integrated system associated with the irreversible loss of circulation, respiration and innervation.” This is also known as somatic death or clinical death (University of Dundee, 2003). The American College of Legal Medicine defines legal death as “a human body with irreversible cessation of total brain functions, according to usual and customary standards of medical practice, shall be considered dead” (Liang & Snyder, 2004).
Brain death
Brain death is a state in which that organ is incapable of sustaining spontaneous respiration and circulation as a result of severe and irreversible injury (American Bar Association and the National Conference of Commissioners of Uniform State Laws 1968, cited in Spitz & Fisher, 1993). Brain death was further defined by the Iowa State-wide Organ Procurement Organization as the irreversible loss of all functions of the brain. The criteria for brain death includes the following: (1) no electrical activity occurring within the brain as demonstrated by an electroencephalogram (EEG), (2) no blood flowing to the brain, and (3) an absence of functioning in all parts of the brain as determined by clinical assessment (no movement, no response to stimulation, no breathing, no brain reflexes).
Brain death can occur as a result of anoxia, ischemia, intracranial hematoma, gunshot wound to the head, intracranial aneurysm, or tumor mass. These conditions cause the brain to swell. Because the brain is enclosed in the skull, it cannot expand, thus increasing intracranial pressure. This can stop blood flow to the brain, kill brain cells, and cause herniation of the brain. When brain cells die, they do not regenerate; thus, any damage caused is permanent and irreversible (Emory, 2003).
