Key messages

• Medicolegal death investigations in the United States are carried out by elected or appointed officials possessing various degrees of expertise.

• The major responsibility of the medicolegal official is to certify the cause and manner of death of those persons falling under his or her jurisdiction.

• Only the medicolegal official can certify a death in which the cause or circumstances of death are not entirely natural.

Although medicolegal death investigation in the United States can trace its origins, for the most part, to the British coroner system, there are currently many significant differences in the structures of the systems, the qualifications of the personnel, and their responsibilities.

There is not a uniform system for death investigation in the United States. Some jurisdictions use the coroner system, whereas others use the medical examiner system. Coroners are elected officials whose requirements for office vary by jurisdiction. Some jurisdictions have only age, residency, and non-felon requirements, whereas others specify that the coroner must be a physician. Medical examiners are appointed officials who are required to be physicians. In some jurisdictions further requirements may specify that the medical examiner be a pathologist and, in some places, that he or she must be a forensic pathologist.

The role of the medicolegal official in the United States, whether the coroner or the medical examiner, is primarily to determine and certify the cause and manner of death of the decedents falling under medicolegal jurisdiction as specified by statute and regulation. In general, these deaths include those which are sudden, unexpected, or unattended, occur while in legal custody, are work related, affect the general welfare of the community, or involve trauma (including chemical trauma such as drug overdoses). The medicolegal verdict may be the outcome of an inquest (most commonly in the coroner system) or may be the opinion of the medicolegal official charged with investigating the death (most commonly in the medical examiner system). For death certification purposes, the cause and manner of death are based on the preponderance of the evidence. If significant doubt exists about their true nature, the cause and/or the manner of death may be designated as 'undetermined'. In the United States, only the mediocolegal official is permitted to certify the cause and manner of a death for a case in which jurisdiction has been accepted. The medicolegal investigation of deaths under the jurisdiction of the medicolegal office is not subject to cessation by the police department or the prosecuting attorney. Similar to the British coroner system, it is not the role of the medicolegal official in the United States to assess criminal culpability or civil liability. The cause of death is defined as the disease or injury that starts the lethal train of events resulting in death. The determination of the cause of death is based on medical (antemortem and postmortem) and non-medical (investigative) information.

The medicolegal official is also responsible for certifying the manner of death, which is a determination of how death came about—natural or otherwise. Non-natural deaths include those occurring by accident, homicide, and suicide. Some jurisdictions have an 'unclassified' category which is often used for deaths related to substance abuse or therapeutic complications. If the manner of death cannot reasonably be determined, it is certified as 'undetermined'. For death certification purposes, homicide is the killing of one person through a volitional act of another person. A manner of death of homicide does not imply intent to kill, infer legal culpability, or require a higher standard of proof than other manners of death. If any aspect of a death (cause or manner) is unnatural, the death must be certified by a medicolegal official. Rarity of a disease process does not equate with it being unnatural. A natural cause of death may arise in an unnatural manner (e.g. stress-induced dysrhythmia precipitated by armed robbery) and thus fall under the jurisdiction of the medicolegal official. In contrast, what may appear to be an unnatural component of a death may by custom not remove the death from the 'natural' category. This applies to certification of deaths where therapy may have caused or contributed to death. Modern medical diagnostic and therapeutic techniques have become progressively more aggressive and invasive. Predictably, even in the best of hands some patients will die as a result of medical intervention. Since some of these iatrogenic complications are 'injuries', particularly those related to mechanical procedures, some medicolegal officials certify deaths due to these types of injuries as accidents, whereas others consider reasonably foreseeable complications as an extension of the disease process and thus certify such deaths as natural. Unforeseeable mechanical complications (e.g. explosion of a respirator) lead to unnatural manners of death. Such determinations do not reflect an opinion regarding liability or deviation/adherence to the standard of care.

The foregoing discussion shows that, although there are similarities between death investigation practices in the United States and the United Kingdom, significant differences exist. The clinical practitioner must be familiar with the medicolegal practices in the location in which he or she practices to fulfill the legal requirements. As a general rule, if there is doubt as to whether or not the medicolegal official has jurisdiction in a particular death, the death should be reported to the medicolegal official for an official ruling.

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