CHAPTER 17. Forensic Nurse Examiners in Death Investigation
Virginia A. Lynch
The Culture of Death
“The fundamental law of the social order is the progressive control of life and death.”
—Jean Baudrillard, 1976
Death was once considered to be due to invisible vectors and forces. It was remote, but it was familiar. Care of the dead involved a personal commitment, and the community marked it with funerary rituals and long periods of mourning. Variable attitudes, customs, and beliefs relating to death and dying, as well as the care of the dead impacted the behavior of people from all levels of society. In recent years, as death and dying are better understood in terms of scientific explanations, many of the longstanding rituals surrounding death, dying, funerals, and mouring have been abandoned, especially in certain social classes and within some religions.“Life for the living” took center stage, and the business of dying became less fashionable. In a fast-paced society, long days of mourning, elaborate funeral rites and the funeral cortege to the gravesite became obstacles to the existing pace of life. Slowly moving funeral processions could no longer be tolerated where impatient drivers move rapidly to their next venue. The current economy prohibits costly funeral details when considering the casket, the flowers, the vault, the gravestones and more. Drive-by visitations, email condolences, prompt disposal of the bodies by cremation or donation to science are contemporary practices that seem to be more appropriate for this century.
A new culture of death is seeping into our new social order. Alternatives to grief-laden funerals embrace the celebration of life instead of death. Rather than flowers to honor the deceased, we give donations to charities that benefit the living. Environmentalists are concerned about the impact of human remains, cemeteries, and gravestones consuming the landscape. With body parts needed for transplantation, the recovery of implanted medical devices and hardware for re-use, the dead have become a valuable commodity. The criminal element of our society has seized the opportunity to profit from certain aspects of death, such as the preparation for burial or cremation. There have been cases where the body has not been buried properly or buried at all! The re-use of expensive caskets and gravesites is not unheard of. Cremations and burials which have not been carried out in accordance with social, religious and legal expectations occur with some regularity. The news media reports all too often about incidents of commingled cremains, organ thefts, and confiscation of the deceased’s personal property.
The rise of science and technology brought a death-rich culture into our visible environments through mass media documentaries and entertainment. Death in the twenty-first century is no longer a remote concept. Death is no longer invisible. War, mass destruction, gang bloodshed, interfamilial violence and aggression have become death denial in the contemporary world of disposable and replaceable lives. The younger generation considers violent death a fact of contemporary life or the exponential number of acts of violent fatalities witnessed daily through the media, videos, or films to be artificial, unreal, and certainly unrelated to them. The older generation perceives death as fear related to abuse, abandonment, isolation, institutionalization, disease, or violent home invasions, but there is no denial of genuine death. Thus, in the broad scheme of things, we are left with the perspective that individuals’ lives and deaths are commercial and, by extension, inconsequential. There have been profound changes in the demographics of developing societies that indicate a new role in who dies, how we die and why we die, as well as the quality of death. Yet, increasing privatization of death and the institutionalization of the dying has removed the socialization and personal management of death from our culture leaving questions of how and why we die to the medical and legal processes and systems of society.
Death as a Phenomenon
Death is considered one of the great rites of passage in human existence. Death involves more than the physical medical sciences that require attention to postmortem procedures and burial practices. Death is one factor that defines each culture and the theological concepts surrounding the bioanthropology of its people. Regardless of any given society’s belief—that life continues beyond death, or that it ends at that moment of death, or that existence after death is unknown—death is a shared phenomenon of the human experience. As nurse scientists, skilled in the forensic investigation of death, each of these societal beliefs are to be considered as one ventures into the realm of questioned deaths. It is the forensic nurse examiner’s duty, then, to tread cautiously as interpretations are made, taking particular care to avoid judgmental reactions toward attitudes of death that may differ from one’s own (Lipson, 1996). The scientific and social phenomenon of death represents the two primary aspects of death investigation on which the practice and philosophy of forensic nursing science is founded. These principles will guide the forensic nurse examiner (FNE) toward the expected outcomes of holistic forensic care, which include body, mind, spirit, and the law.
The medicolegal aspects of death investigation are defined by forensic thanatology ( thanatos meaning “death” and logos meaning “science,” or simply the study of death). It is a known phenomenon that death occurs in two stages: (1) somatic, systemic, or clinical death and (2) cellular or molecular death. The term death as commonly employed refers to somatic death, which is due to complete and irreversible cessation of vital functions of the brain, followed by the heart and lungs. Previously, cessation of the beating heart and respirations were used as the criteria for death. Now, with the advent of cardiac transplantation, the emphasis has shifted to irreversible cessation of brain function (Parikh, 1999).
Among death’s phenomena, perhaps the most difficult for families to understand is the beating-heart cadaver. What emotional trauma could be greater than having to make the ultimate decision to remove someone from a perceived life source: artificial ventilation. It is often confusing to the family and to the nursing staff to accept that death exists while oxygen still infuses the lungs, the blood still circulates, and the body is soft and warm. These phenomena reflect centuries of confusion over how, exactly, to define death, that precise moment when the intangible life force ceases to exist. Before brain activity could be measured, the absence of a beating heart had long been considered the defining moment. Yet the brain survives for 6 to 10 minutes after the heart has failed. Considerable fears surround the family while contemplating these issues: Could there be hope? What if we make the wrong decision? How can we live with the anxiety and doubt once the decision is made?
When emotional support is needed at times such as this, who is up to the task? Who can explain brain death with clarity, but nonetheless in a way that a person in denial can understand? What about the need for compassion, for empathy? Or what if the bereaved is a suspect in the death of the patient? Of all the issues involved, this circumstance presents the most difficult professional responsibility while, at the same time, requiring the necessary psychosocial intervention in case the suspicion is invalid. Experience in forensic nursing and guidelines in death investigation help provide the ways of knowing and critical thinking that determine the basis on which accurate case management of questioned deaths can be provided.
Science of Death Investigation
Death has become a respectable field of inquiry, particularly in the social and behavioral sciences, as well as an acceptable topic of study in the curricula of institutions of higher learning. The science of death investigation joins with nursing science to address the physiological, psychological, and legal aspects of death and dying. Certainly, the most refreshing change is the emphasis on a human caring. This approach to the scientific investigation of death seems to parallel trends in other sectors of society, which are attuned to the advancement of humanity. Previously the emphasis on mechanism of injury, cause, and manner of death and knowledge of the law stood alone within the forensic arena of death investigation.
Death brings with it innocent, living victims by extension, those who survive the loss of lives they cherished. According to those who work with individuals, families, and communities that suffer from the catastrophic impact of tragic death, the forensic response alone is not enough. Grief psychologist Jerry Harris in Fort Worth, Texas, stated, “In a science which stresses the careful collection and accurate documentation of evidence, it is interesting that the psychological impact of traumatic death on survivors receives little attention in actual practice” (personal communication, Jerry Harris, February 11, 1989). Recognition of this concept reflects the distinction between normal and pathological mourning, unresolved grief, and mental illness, and it calls for a complete reexamination of the premise on which views of death and dying are traditionally based. There is definitely a place in nursing and other health sciences for the recognition and application of a more empathic discipline pertaining to questioned death than has existed in the past. Intervention in grief must be seen and supported as a means toward adaptation and health (Lynch, 1993).
Historically, an acknowledged deficit has existed in the U.S. death investigation system, one that has often resulted in miscarriages of justice because of the insufficient, ineffective, and often insensitive investigation of questioned deaths. Traditionally, persons who performed this role have an extensive background in law enforcement or are laypersons without sufficient professional training. Advances in the medical and legal sciences indicate a greater need for biomedical requirements to prepare investigators in the medical cause of deaths. Criminal investigators are present at such scenes, providing a duplication of services where police-trained death investigators are used, rather than providing a medically trained investigator in the endeavor of medical investigation.
Art and Science of Forensic Nursing
One solution to these concerns has been identified in the development of a forensic specialist in nursing. This discipline, known as forensic nursing science (FNS), represents a mutual responsibility between medical science, forensic science, and criminal justice. It pertains to the medical investigation of death, the forensic management of medical evidence, and a professional concern for the families of the deceased. This science defines the role of the forensic nurse death investigator (FNDI) in both basic and advanced preparation of the forensic nurse examiner (FNE) whose practice addresses crime-related trauma, death from natural disease processes, catastrophic deaths, abuse, violence, sexual assault, liability concerns, traumatic accidents, mechanism of injury, multiorgan system failure, cause and manner of death, basic chemistry and physics, human psychology, knowledge of the law, and other pertinent medicolegal issues. The FNE with a specialty practice in the science of death is considered an expert in this field. This involves a broad acumen of knowledge, skills, and attention to justice concerns that has previously been unavailable in most nonmedical jurisdictions.
Significance of the Role
In most jurisdictions throughout the United States, the medical examiner/coroner (ME/C) has the responsibility of investigating all violent, suspicious, and sudden deaths as well as natural deaths in certain categories. It is the dramatic intrusion of the unexpected that is so often responsible for arousing suspicion. Every unexpected death has actual or potential medicolegal aspects. Medical interest lies in accurately establishing the nature of a fatal disease or injury. The legal importance derives from the availability of objective data for the administration of justice, whether civil or criminal. In all such situations, the forensic nurse in the role of medicolegal investigator can make an important contribution to the investigation process for the family and the community at large. The nurse’s knowledge and experience can be invaluable in recognizing signs and symptoms of unexplained deaths (such as fatal infectious diseases and unnatural, unknown, or unattended deaths) where the signs are so subtle that the untrained eye would overlook or misinterpret valuable medical evidence.
Death under any circumstance is difficult to accept, especially if it is sudden and unexpected. It is most common to insulate oneself until other defenses are marshaled. Denial is the first response to unanticipated death and permits hope to exist but it is short lived. The next most common expression is anger. The nurse investigator can expect this response and not take it personally. It is better to permit the bereaved to express their anger, their sense of helplessness, and their outrage. By doing this, their feelings will have been vented, allowing them to move more rapidly into a stage where they can begin the unfinished business of their own lives, including helping to complete the investigation and funeral arrangements. Nurses are regularly and effectively used as medicolegal investigators, thus clearly revealing that the forensic nurse can establish a significant role in the scientific investigation of death and make important contributions (Box 17-1).
Box 17-1
The Forensic Nurse Death Investigator (FNDI) or other medicolegal investigator is responsible for items that may include, but are not necessarily limited to, the following:
1. Collecting medical, physical, and other evidence that pertains to the cause and manner of death
2. Collecting information on the circumstances before, at the time of, and following the person’s death, as well as the decedent’s medical history or hospital records
3. Preparing an investigative report detailing all necessary biographical data, as well as summarizing all the information relevant to the time of death and the immediate precedent and subsequent events
4. Notifying the next of kin
5. Maintaining appropriate confidentiality of records while ensuring that all relevant records are promptly and properly delivered to appropriate designated persons
6. Managing dialogue with the media in cases attracting media attention (protecting both the public’s right to know and the privacy rights of the victim and significant others)
7. Educating law enforcement professionals regarding aspects of unexplained or unidentified deaths such as evidence recovery, confidentiality issues, public relations—especially vis-à-vis the media and relevant community resources (e.g., hospitals)—and relating to the deceased’s family and friends
8. Assisting in autopsy/medicolegal examination as appropriate; not as an official function, but adducing to the investigator’s knowledge base regarding cause, manner, and mechanism of death while providing the forensic pathologist with direct on-the-scene information
9. Testifying in court, at inquests, at civil law hearings, or at criminal law trials
10. Counseling the deceased’s family/significant others or reviewing/explaining the autopsy report/death certificate
Unique to Nursing
As health and justice systems enter the twenty-first century, forensic nursing provides the partnership that has historically existed in every medical specialty with the exception of one: forensic medicine. In 1975, John Butts, chief medical examiner in Alberta, Canada, was the first to recognize that the registered nurse represented a valuable resource to the field of death investigation. After conducting a five-year study to determine the ideal professional related to medical investigation, he concluded that it was the registered nurse who provided the qualities and professionalism essential to a scientific, social, and cultural investigation of death. Butts established a program using nurses as medical examiners’ investigators, citing the nurses’ biomedical education and emphasizing their knowledge of natural disease processes, medical terminology, and pharmacology, as well as their ability to empathize as their most important qualifications. The nurse’s experience in public relations is also a major priority in representing the medical examiner at the scene of death, handling confidential material and being comfortable relaying sensitive information to family members (Lynch, 1993).
Butts stressed the importance of coordination and cooperation between the criminal and biomedical investigative personnel. He expressed concern that medically untrained officers often disregarded medical evidence, maintained poor sensitivity, and were noncommunicative with grieving families. Conversely, healthcare professionals recognize the integrity of criminal evidence, the suspect interview, and the investigation of leads.
The ability to review health histories and medical records; understand medical terminology; interpret medical abbreviations; communicate with physicians and paramedical personnel; evaluate the impact of surgical or chemical interventions prescribed and performed before death; and relate social, financial, and interpersonal relationship factors of a psychological autopsy must also be included in the armamentarium of the investigator of forensic deaths. These skills are unique to nursing. Essential knowledge regarding the investigation of sudden and unexpected death or the clarification of suspicious or natural deaths across the life span must begin with an incisive understanding of the phenomenon of death. An elucidation of these issues may become a point of contention in a court of law.
Forensic Intervention
Medical professionals, criminalists, and police officers alike recognize the strategic benefits of the forensic nursing role. Nurses recognize this as an opportunity to expand their professional horizons and promote their professional goals. The concept of forensic nursing, which embraces a multidisciplinary approach to abuse detection and community mental health, enhances the quality of community life through effective systems coordination. The tri-care systems approach, involving healthcare, forensic science, and the law, provides an interdisciplinary team technique as the nurse death investigator works closely with the crime laboratory, law enforcement operatives, and community legal service agencies to identify possibilities of human abuse in questioned deaths. A comprehensive total health and justice program in any progressive community will provide the three major components of forensic intervention: (1) prevention of death, (2) intervention at the time of death, and (3) postdeath care (post-vention) for the decedent’s significant others. To recognize these essential elements of dying as a life process, with a greater shift toward human caring, is to provide an insightful contribution to nursing science and to humanity.
Related research has sought to identify behavioral responses to death, both physiological and psychological, in an attempt to categorize significant etiological factors that promote or inhibit change in the public health status. Forensic nurses are in a position to make primary contributions to the long process of restoring homeostasis to the bereaved. These strategies are supported by what seems to be of paramount importance as new perspectives arise for considering the familiar phenomena of health, illness, and death in relation to human life.
Forensic nurse investigator
Nurses are exceptionally capable of interacting with police, physicians, and grieving families and collaborating with other professionals in forensic investigations. In the initial phases of establishing a forensic nurse investigative team, however, police, prosecutors, or physicians without awareness of the accomplishments forensic nurses have attained will often express objections and fail to fully support the integration of a nurse into their investigative agenda.
Forensic nurses do not participate as criminal investigators but rather as clinical investigators, though the interface and assistance to criminal investigation is extensive. It has been noted, however, that the interface between clinical nurses and law enforcement officers has often been characterized by strife and resentment in hospital scenarios. This is not limited to nurses and police in the emergency department setting; it also arises between forensic nurses and criminal investigators at scenes of crime or death. Law enforcement officers have, at times, resented the idea of working with nurses, of having to share responsibility, or communicating with a discipline so foreign to their own. Frequently, this professional friction is based on suspicion of the unknown, untested, or simply untried. Although the benefits of forensic nursing are well documented and increasingly accepted, arguments against the concept have been raised in the fields of medicine and justice. The significance of FNEs in death investigation and the unique qualifications they contribute to a field often lacking in biomedical professionals is primarily based on a lack of understanding—or funding. This can create professional jealousy, rejection, and lack of acceptance.
However, according to Z. G. Standing Bear, retired federal agent and criminologist, “Forensic nursing brings together the necessarily neutral, detached and suspicious arena of the law enforcement investigator with the empathic, involved and accepting dimensions of psychosocial nursing” (Standing Bear, 1987, p. 7). He further advised:
Forensic nurse examiners and forensic nursing services are a revolutionary concept for utilizing nursing abilities in an arena of human services not previously explored by nurses. Nurses can make significant contributions to the area of death investigation as well as services to survivors. In a world where academic camps are alienated from and even hostile toward one another, this idea speaks to a refreshing blend of energy and cooperation. Breaking down these old barriers of competition and building up new cooperative programs cannot help but benefit humankind. The obvious benefits of this new idea contribute to the quality of community life, as well as bringing together of two historically different disciplines with a common and worthwhile purpose. (Standing Bear, 1995, p. 63)
Other arguments oppose the use of registered nurses in death investigation because nursing education is primarily based on the common assumption that the goal of nursing is the preservation of life. This view holds that using nurse death investigators is inappropriate or even a waste of resources, that nurses would do well to disregard the carnage and loss of human life and rather focus on the needs of the living. Countering this argument are those who assert that death and dying are as much a part of the life cycle as birth and that those who die leave the living in need of care as a result of their deaths (Lynch, 1993). Further arguments are that the forensic pathologist, medical examiner, or medical coroner are first physicians whose fundamental education and training are also perceived to simply focus on those who endure and survive life—not those who die.
Until now, a limited number of job opportunities posed the greatest argument in preparing nurses for professional roles in this field. Because of the existing medicolegal systems, there is little demand or opportunity for nurses to become involved in the death investigation field. Although interest in the field remains high, without hope of employment, there is limited motivation to pursue advanced practice for those not already in the system. There are, however, numerous archaic death investigation systems in the United States and abroad that are, albeit slowly, converting toward biomedical professional models. As this occurs, the potential for the employment of nurses in greater numbers appears promising. Because this is a pioneering arena for nurses, salaries are typically low in contrast to clinical nursing. Conversely, with the emerging emphasis placed on higher standards in death investigation, forensic nurse examiners in enlightened jurisdictions are receiving competitive salaries, commensurate with advanced education and clinical forensic experience.
Previously, forensic investigative staff generally consisted of nonbiomedical personnel, often retired law enforcement officers or morticians. On being interviewed, one forensic pathologist, when asked why police officers without education in the physical and psychosocial sciences were used to investigate traumatic death and interface with grief-afflicted families, stated that “retired homicide detectives were more economically budgeted because they receive a retirement salary and can subsist on the low-salary position created for nonmedical personnel.” As forensic nurses pursue advanced education in the forensic and nursing sciences, attaining postgraduate degrees as well as doctoral studies in the forensic investigation of death and specializing in a variety of related fields such as forensic anthropology, bioterrorism, and disaster management, government agencies and scientific institutions are investing in these professionals to enhance the medicolegal management of death investigation.
Workforce development has become a critical challenge across all federal departments, and justice is facing an increasing challenge with demographics (caused by the current world financial crisis), new advances in technology, and new threats of terrorism. Previously employed ME/C law enforcement investigators who worked for an extra income to supplement retirement cannot be replaced at the current salary. Now is the time for nurses seeking training/instruction on the scientific methodology of medicolegal death investigation to pursue their education so they are prepared as new positions become available. This recession will recede, new jobs will become available, and death investigation agencies will begin to hire forensic nurse investigators. With attention to the success of ME programs in Texas and Michigan, replication of these innovative roles combining nurses and police death investigation units will become one of the future forensic trends (see Chapter 19). The existing training/information/education programs will also be of benefit to current nurse educators, who can adopt/adapt these courses to meet their needs as required to teach forensic nursing science.
One of the most significant contributions to nurses in death investigation was initiated in Canada as early as 1975. At the insistence of John Butts, who initiated the first formal position for FNDIs, the salary and benefits were established to be equivalent to that of clinical nurses with equal education and experience. These pioneering nurses were also required to maintain their nursing licensure and national nursing association membership. These requirements should be incorporated into any forensic nurse investigator or nurse coroner program. Failing to do so was the single greatest mistake made by those employing nurses in medicolegal investigation as this concept moved from Canada into the United States. Although many clinical nurses have chosen to work in this field, they were unable to do so without sufficient financial compensation. This alone would have moved FNEs forward into the realm of forensic pathology and the investigation of death decades ago.
Caring for the dead
Although nurses have traditionally been recognized as the primary caretakers of the living, it must be recognized that nurses throughout history have also been the caretakers of the dead. In addition, as a component of the caregiver role, nurses comfort or console those who survive, including other members of the healthcare team who share in the grief and mourning process. Hospice nurses become experts in death and dying. Oncology nurses are prepared to provide terminal patients and their families with insightful perspectives on the stages of death and essential emotional support during those last moments of life. Neonatal nurses are exceedingly familiar with loss of life in the neonatal intensive care unit and the impact of grief that undermines the traditional joy accompanying birth. No department in the hospital faces the trauma of death and dying more frequently than the emergency department, as those who are admitted suddenly and unexpectedly because of random violence, catastrophic mass disasters, and natural or unknown causes often fail to survive.
To identify and recover microscopic bomb fragments while debriding a wound and to relate them to a detonator associated with known criminals, to relate wound characteristics to distinctive weaponry from crimes of this century and the last (such as the Unabomber, the World Trade Towers, Guantanamo Prison, and other incidents of custodial torture and more), is to acknowledge healthcare’s accountability in combating crime. The United States has displayed great national sensitivity in the recovery, identification, and memorial of the public, private, national dead. So, too, have other nations where civility and respect for death has brought together governments and families in mourning. The forensic sciences are responsible for the primary identification and repatriation of the war dead. Military nurses have launched initiatives in forensic nursing and Veterans Administration hospitals have established specific procedures to guide the clinical investigations of suspicious deaths among their patient populations.
William Gladstone, a nineteenth-century British prime minister, spoke of the value of caring for the dead as a reflection of the morals and ethics of a society when he wrote one of his most famous statements, one that has memorialized the dead of wars over the centuries: “Show me the manner in which a Nation cares for its dead and I will measure with mathematical exactness, the tender mercies of its people” (Jalland, 1996). (Cited at the dedication of the Vietnam Veterans Memorial in Washington, D.C., in 1986). This statement has specific meaning for those who have lost loved ones in war or in peace.
Gladstone addressed death from a diverse perspective, as both good and bad. He stated that “death is an inevitable experience for us all, but the manner of dying varies greatly, as do individual and family responses to death and their mourning rituals” (Jalland, 1996). The French historian Michel Vovellehas observed that death “in the human adventure stands as an ideal and essential constant” (Jalland, 1996). Though it remains a constant in the reality of death, it is relative in relationship to the times of the social and religious perspectives of death. As times of social change continue to evolve, so does the manner in which people die. Pierre Chaunu further emphasized this concept by observing that every society gauges and assesses itself in some way by its system of death resolution. In the same manner, the study of death and bereavement in the past has helped people to understand the present; the study of medicolegal death investigation, historical or in the recent past, helps people to evaluate and improve a systems approach to the scientific investigation of death. Cumulative experience with death and dying and the social interaction derived from helping grief-stricken survivors combine to shape the beliefs and behaviors that the FNDI brings into practice. It should not be surprising that the forensic nurse examiner has been found to be an ideal clinician to fulfill the requirements of the death investigator role.
Death investigation is an essential part of the healthcare and judicial systems. However, clinical physicians are typically ill prepared to assume the responsibility inherent to the medicolegal management of questioned death cases. In North America, few medical schools provide curricula that include forensic medicine; even fewer address the psychosocial interventions associated with death. These two topics are essential aspects of developing a socially appropriate death investigation system. Furthermore, many physicians are not attracted by the prospect of becoming a public governmental employee with fixed income, continuing public scrutiny, and bureaucratic constraints. This has led to a dearth of qualified forensic medicine practitioners to work within the death investigation systems at a point in history when the need for this role is expanding exponentially. These circumstances have resulted in an increased opportunity for nurses to fulfill forensic roles in death investigation and clinical forensic practice. FNEs are stepping forward to assume these responsibilities in hospitals, clinics, and the community at large.
Forensic nurse examiner
Nurses are serving as the officiator of death in numerous areas throughout the United States. The FNE specializing in death investigation as an elected coroner (an independent authority) or medical investigator (under the direction of a forensic pathologist) has brought a higher standard of administration and case management to questioned deaths than has existed in the past. Titles vary from one jurisdiction to another depending on the role and preference designated by the chief medical examiner or coroner. These titles evolve as nurses fill existing roles or as new roles are developed for nurses in the forensic investigation of death.
As an elected or appointed official, the title of coroner or deputy coroner is used in South Carolina, Wisconsin, Georgia, Colorado, and California, among others. In some states (e.g., in North Carolina), the forensic nurse has replaced the non-forensic physician. This nurse holds the title of district medical examiner and serves under the authority of the state medical examiner. In certain settings, such as the military or international death investigation systems, titles such as special investigator or chief forensic nursing officer may be appropriate. Among other titles assumed by nurse investigators in medical examiner systems are field investigator, field agent, forensic investigator, forensic nurse investigator, medical investigator, medicolegal investigator, medicolegal death investigator, and FNDI. Where nurses fill a supervisory role, titles may include chief investigator, senior investigator, or coordinator of the investigative team. Regardless of the title, authority and jurisdiction over the body at the scene of death remain the same. FNEs present the requisite skills and knowledge acquired as a natural extension of their nursing assessment proficiency and healthcare education. Nurses are valued components of the medicolegal death investigation team in jurisdictions of both coroners and medical examiners (Allert & Becker, 2002).
The title forensic nurse examiner (FNE) is appropriate for any of the subspecialties of forensic nursing where forensic examinations are performed. The FNE conducts an investigation of trauma or death; provides an examination of physical, psychological, or sexual assault trauma; and examines the questioned analysis of medical records (e.g. legal nurse consultant) or court-ordered evaluation of mental status, provided the education, experience, and other qualifications of a forensic nurse are met. It is important to recognize that FNE is a title and does not designate certification.
Nurse coroner
Where the law does not require the coroner to be a physician, this position often remains open to anyone who has reached the minimum age of 18 years, can provide proof of county residency for the past one or two years, and obtains the majority of votes. Although the statutes regulating this position vary from state to state, it remains accessible to the unskilled, untrained, nonmedically oriented, and politically driven elected official known as a lay-coroner. However, according to Cumming, “This person must possess medical knowledge in order to be able to make critical judgments based on symptoms, medical history, postmortem appearance, toxicology and other diagnostic studies, combined with evidence revealed by other aspects of the investigation” (Cumming, 1995, pp. 29-33).
Contemporary communities recognize that the expectations and qualifications for an officiator or investigator of questioned deaths must incorporate medical, psychological, and environmental acumen in a scientific and accurate determination of cause and manner of death. These communities elect and employ forensically skilled nurses who are well qualified to differentiate between postmortem changes and signs of victimization, understand interpretative toxicology, correlate mechanism of injury to cause of death, associate psychosocial histories with manner of death, comfort survivors, and provide appropriate referrals and support (Cumming, 1995).
A Nurse Coroner’s Perspective
Charles E. Kiessling Jr., RN, BSN, CEN, Lycoming County coroner in Williamsport, Pennsylvania, is one example of an FNE who exemplifies quality death investigation. According to Kiessling, nurses are well qualified to fill the role of an officiator of death. Kiessling describes his role and experiences as typical of those who serve as the elected official in a growing number of U.S. jurisdictions (Kiessling, no date):
Nurse coroners have a thorough understanding of the pathophysiology necessary in determining the cause of death. In most counties across Pennsylvania the coroner is called to the scene to investigate the cause and manner of death. Registered Nurses, through their nursing education and clinical experience, make excellent medical legal death investigators. Nurses also have significant experience in dealing with death and dying, frequently helping patients and families during some of the most difficult times of their lives. Who better to serve as an advocate for injury and death prevention than nurses who have experienced firsthand the catastrophic loss of life in their communities?
The nurse coroner has the ability to monitor causes of death in the community and effect changes through such organizations as: SAFE KIDS, Child Fatality Review Teams, DUI Advisory Boards, Emergency Medical Services, Health Improvement Coalition and Driver Safety Task Force. Nurse coroners are also well versed on community resources to not only deal with the investigation of the death scene, but also to assist families deal with the aftermath of sudden deaths including such services as grief counselors and support groups as necessary. As elected officials, nurse coroners are generally well positioned with political contacts to recommend legislative changes when necessary.
Law enforcement personnel in Lycoming County generally perceive most nurses as fellow professionals. As long as nurses recognize their limited knowledge regarding processing of crime scenes and legal procedures and remain willing to work cooperatively with law enforcement personnel, they will work well as nurse coroners. Conversely, law enforcement personnel will generally look to the nurse coroner for their expertise in medical pathophysiology, pharmacology, toxicology and mechanisms of injury in traumatic deaths.
Kiessling is presently working to change hospital policy and procedures regarding the retention of specimens pertaining to critically ill and or injured patients that may eventually end up as coroner’s investigations. Presently the local hospitals hold blood and urine specimens for three days and then discard these specimens unless directed to do otherwise. In 2003, a drug trafficking case resulting in death was nearly lost because of the loss of these initial specimens. Fortunately, autopsy findings were consistent with a methadone overdose, witnesses identified the suspect, and he then confessed. In the future these specimens will be retained until the patient is discharged or dies and the coroner clears these specimens for disposition. This change will assure that specimens are available to develop the prosecution’s case against illegal drug dealers who deliver drugs that result in deaths. Specimens are now retained for at least one year or more on all cases that may involve criminal charges.
Kiessling knew firsthand that no matter how small or rural a county was, such incidents could bring the focus of the entire world on their operations, for example, Somerset County, PA on 9/11/01. Kiessling served as a regional vice president for the Pennsylvania State Coroner’s Association and as a liaison to the Pennsylvania State Coroner’s Education Board. One of the State Coroner’s Association’s four disaster assistance trailers is housed in Lycoming County and is ready to respond to any requesting county whenever a disaster exceeds local resources. The trailer contains digital dental x-ray equipment, portable autopsy tables, personal protective equipment including masks, gowns, gloves, respirators, body bags, and evidence collection and scene processing equipment.
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