Transcript North Carolina Medical Examiner System and the Office of

North Carolina
Medical Examiner System
and the
Office of the Chief Medical Examiner
Deborah Radisch, MD, MPH
January 24, 2014
Organization of Death Investigation Systems
in the US
• Coroner – elected, usually lay official. County centered and funded. A few
jurisdictions require that candidates be physicians and/or provide
sufficient funding to obtain medical expertise. May hire pathologists to
conduct exams but final decisions about/certification of cause and manner
of death in individual cases may be made by the coroner.
• Medical Examiner – appointed, physician / medical knowledge. May have
county or statewide jurisdiction. May be a forensic pathologist or not.
County centered systems, county systems with central oversight, district
systems.
• Justice of the peace, district attorney
• Systems can be mixed and vary from state to state and in some states from
county to county
THERE IS NO STANDARDIZED NATIONAL DEATH INVESTIGATION
SYSTEM
North Carolina ME System
• Based on model legislation similar to that already in place in
Maryland and Virginia. It was intended to utilize the pre-existing
facilities and personnel that comprised the medical health care
delivery system, local hospitals and physicians, to provide
county medicolegal death investigation services
• Central oversight and professional support for the local MEs
would be provided by the Office of the Chief Medical Examiner
which would be a state function
• While it was originally intended that only MDs would serve as
MEs the original statute allowed the coroner to serve as
“acting” ME until a physician could be found and over the years
PAs and RNs have also served as “acting” MEs
• It can be seen as a public/private cooperative enterprise with
the current funding ~ 60% state dollars and 40% county
Major Program Areas
• Medicolegal Death Investigation
– State
• County Medical Examiners
• “de facto” Regional Centers /Pathologists
– Central Office
•
•
•
•
•
•
Administrative
Support
Pathologists
Toxicologists
IT
Child Fatality Prevention Team
ME Cases in NC
• ~ 11,000 cases investigated per year
• Of those, ~ 4500 are autopsied
• 2013 estimate:
– OCME 1175 autopsies
– OCME 779 externals
Deaths Requiring Medicolegal Investigation
Unattended natural deaths
• No physician
• Physician but no life-threatening illness
• Break in medical care, but no specific time limit since last visit
• Visitors to NC, stranger from afar, non attendance by virtue of geography
Sudden, unexpected, apparently natural deaths
Deaths due to external causes = unnatural
• Manner: accident, suicide, homicide, undetermined
• Injury can be due to physical, chemical, thermal, electrical forces or
radiation
• The injury may be the sole cause of death or contributory
• There is no time limit between the time of injury and death as long as the
two can be linked causally, even if years have passed (proximate cause)
Deaths Requiring Medicolegal Investigation
Other Cases
Deaths possibly due to contagious disease – public health threat
when a diagnosis must be established in order to determine
whether others have been exposed and might need prophylactic
treatment
Bioterrorism
Deaths in jail, prison or other correctional facility, under police
custody or control
Suspicious deaths
Deaths in certain state institutions (Divisions of Mental Health,
Developmental Disabilities and Substance Abuse Services)
County Medical Examiners
•
•
•
•
•
Physicians
Physician Extenders (PA, FNP)
Nurses
EMT-Paramedics
Lay
ME Records and Payments
• ME Report of Investigation
– Must be sent to the OCME within 14 days
– Serves as an invoice ($100)
• ME Death Certificate - medical certification must be
completed within 3 days and the DC filed with the health
department within 5 days. The health dept. sends a copy
to the OCME
• Autopsy Report
– To the OCME by 180 days
– $1250
ME Records
• ME Reports, ME Autopsy Reports, and results of
toxicology tests become public records available to
any requester after receipt and review at the OCME
www.ocme.unc.edu
• Death Certificates are also public records, but copies
must be obtained through vital records at the state
or county level
OCME as Medical Examiner
• OCME serves as the primary medical examiner
for Wake, Franklin, and Durham counties,
regular back-up for several close-by counties,
and potential back-up for any county or
regional pathology center
Death Investigation Realities
• CONTRARY TO THE PUBLIC IMPRESSION OF HOW DEATH
INVESTIGATIONS ARE CONDUCTED – the “CSI EFFECT”
• Crime scene processing is conducted by crime scene
technicians
• Evidence is analyzed by crime lab technicians
• Crimes are investigated by law enforcement officers and
they identify interrogate and arrest suspects
• The court system decides matters of guilt and innocence
• The role of the Medical Examiner in criminal matters is to
provide sound, medically based evidence in regard to the
cause (and manner) of death of the victim
The role of the ME is to determine WHAT DID IT, NOT WHO
Case Flow
Law Enforcement, first responders (EMS, Rescue, Fire
Departments), medical personnel
County Medical Examiners
Regional Pathologists
OCME
Regional Centers
• Brody School of Medicine-Greenville
– 4 Forensic Pathologists
• WFU School of Medicine-Winston-Salem
– 3 Forensic Pathologists
• Mecklenburg County-Charlotte
– 3 Forensic Pathologists
• Other
– Jacksonville*, Clinton, Hickory, Sylva, Lumberton
(no ABP certified FPs)
Medical Examiner Autopsies in North Carolina
Current centers
Current pathologists
Future regional offices ??
Medicolegal Autopsy
• Not every death that comes under medical examiner jurisdiction requires
an autopsy
• An autopsy is “ordered” when it is deemed “advisable and in the public
interest” as defined by guidelines promulgated by the OCME
• ME autopsies do not require the consent of the next of kin and an
objection by the NOK is not a bar to the exam
• All ME autopsies are complete autopsies
• Medicolegal autopsies are performed by designated regional pathologists
or by the OCME Pathology Branch
• A little over 40% of ME cases in NC are autopsied. Not all trauma deaths
have an autopsy
Medicolegal Autopsy
Purposes :
•
•
•
•
•
•
Identification
Collect evidence
Document injuries and natural disease
Collect samples for special testing
Try to narrow down where and when injured/died
Opinion as to cause and manner of death
Central Office Functions
• Administrative
– Case Management
• Assemble case files for all ME cases in NC except
Mecklenburg county
• Public interface
• Subpoena management
• Case coding and data entry
• Budget
• Purchasing
• IT
Central Office Functions
• Pathology Support
– Transcription
– Histology: includes Mecklenburg, for ~2000 cases per year,
average of 6 glass slides per case
– Morgue technician staff
– Radiology
– Photography
– Investigation
– Ancillary:
•
•
•
•
Anthropology
Odontology
Neuropathology
Laboratory
Central Office Functions
• Six forensic pathologists and one fellow
(training)
– Autopsies
– Review all ME cases in NC = QA, before public
record
– Consultation
– Testify
– Teaching
– Mass fatality planning and management
Central Office Functions
Court Testimony
• In 2011, OCME pathologists testified in court
39 times, a fraction of the subpoenas they
received and for which they were on
telephone stand-by. The total time, travel and
court (testimony and waiting), was 190 hours.
• Toxicologists are being subpoenaed to appear
more frequently (Melendez-Diaz).
Central Office Functions
• Teaching
– Forensic Pathology Fellowship
• Program Director
– Pathology Residents (1 month required)
• UNC, Duke
– Medical Students
• Second year (all) and elective rotation
– Pathology Assistant Students (Duke)
– Miscellaneous presentations
Central Office Functions
• Toxicology
– All ME testing in NC
– More than 10,000 cases per year, with more than
twice that many analyses
– Screen, then confirm and quantitate
Central Office Functions
• Child Fatality Prevention Team
– 2 (-1)
– Investigator/Trainer
– Researcher
Funding
• Appropriations
• Receipts
• Grants
63%
23%
14%
Major Stakeholders
•
•
•
•
•
•
•
•
•
•
•
Families
Law Enforcement
District attorneys, defense attorneys, plaintiff’s attorneys
Vital Records
Funeral Directors
Legislators
EMS
Medical practitioners, including VA
Public Health professionals
Transporters
Media
Statutes, Rules, and Guidelines
•
NC OCME Guidelines, Rules, and Statutes
– http://www.ocme.unc.edu/rules/index.shtml
• Administrative Code
• General Statutes
• Guidelines for Medical Examiners
Priorities
•
•
•
•
•
National accreditation
Medical Examiner training
Improved communication
Appropriate death certification
Regionalization
Mission Statement
The North Carolina Office of the Chief Medical
Examiner will ensure consistent and
competent medicolegal death investigation by
utilizing training, consultation, quality
assurance, and the appropriate use of
resources.