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ABSTRACTS and PRIMERS NB FORENSIC PATHOLOGY SYMPOSIUM APRIL 11, 2015 SAINT JOHN REGIONAL HOSPITAL, SAINT JOHN, NEW BRUNSWICK CANADA
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CONTRIBUTORS
Cenk Acar MD Anatomic Pathologist Dept. of Laboratory Medicine, Saint John Regional Hospital, Saint John NB Alfie Ballew, MBA. Chief Deputy Coroner, Marion County Coroner’s Office, Indianapolis IN USA. Courtney E. Curtis, J.D., Assistant Supervisor-Special Victims Team, Marion County Prosecutor’s Office, Indianapolis, Indiana Robert Belliveau, Regional Coroner, Dept. of Public Safety, Govt. of New Brunswick, Saint John George Enoworock, MD. Forensic Pathologist, Dept of Pathology, Centre Hospitalier et Universitaire, Yaounde Cameroon, West Africa. Greg Forestell, BPE., Chief Coroner, Dept. of Public Safety, New Brunswick Jayantha Herath, MD, DLM, MD (Forensic) FRCPC (AP/FP), Medical Director, Provincial Forensic Pathology Service, Toronto, Ontario Forensic Pathology Service. Hossain M, Anatomic Pathologist, Department of Laboratory Medicine, Saint John Regional Hospital, St. John, New Brunswick and Dalhousie University, Halifax, Nova Scotia Dirk Huyer, MD, Chief Coroner for Ontario Mark MacSween, MD FRCPC, Dept of Radiology Saint John Regional Hospital Walt McKinney, Coroner, Department of Public Safety, Govt. of New Brunswick Anne O’Brien, MD FRCPC, Anatomic Pathologist Dept of Laboratory Medicine, Saint John Regional Hospital, Saint John NB Ken Obenson, MD FRCPC Forensic Pathologist, Dept of Laboratory Medicine Saint John Regional Hospital Thomas Sozio, DO, Forensic Pathologist, Central Indiana Forensic Services, Indianapolis IN\ Andrea L. Wiens, DO. Forensic Pathologist and Neuropathologist, Office of the Chief Medical Examiner, Tulsa, Oklahoma, USA Marnie Wood, MD FRCPC. Forensic Pathologist/Medical Examiner Nova Scotia Medical Examiner Service Claire Wright, BTech ASQ-CQA. Quality Coordinator, Dept. of Laboratory Medicine, Saint John Regional Hospital, Saint John, New Brunswick.
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CONTENTS ABSTRACTS
5. Postmortem Examination of Decomposed Bodies in Ontario: Analysis of 5 year Period from 2009 to 2015. 6. Gastric Friability & Apparent Perforation in an Infant with Fulminant Streptococcal Meningitis & Sepsis 7. Pediatric Death Investigation in Ontario: Analysis of a 6 year Period from 2005 to 2011. 8. BMI Profile of Decedents Presenting for Autopsy in Saint John 9. The Disposition of Johns and Janes Doe in New Brunswick 10. An (?) Incidental Meningioma 11. The Practice of Forensic Radiology in Saint John- A Birds eye View 13. What Challenges face Forensic Investigators (trying to work) in Resource-Limited Jurisdictions? 15. Using Post Mortem Drug Levels as a Tool in Distinguishing Non-Accidental and Accidental Fatal Drug Ingestions 16. Sufferin Succotash! Is it SIDS or Cigarette Smoke? PRIMERS 18. Dealing with the Media during a Mass Fatality Incident 20. Essentials of Child Death Prosecutions: Navigating the Minefield of the Judicial System 21. Critical Value Reporting in Forensic Pathology 23. Autopsy As A Performance Measure and Quality Improvement Tool 24. Neuropathology of Ethanol Use and Abuse 26. Creating a Cause of Death Statement 28. Moving Away from the “Shaken Baby Syndrome” Controversy
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ABSTRACTS
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POSTMORTEM EXAMINATION OF DECOMPOSED BODIES IN ONTARIO: ANALYSIS OF 5 YEAR PERIOD FROM 2009 TO 2015. Jayantha Herath, MD, DLM, MD (Forensic) FRCPC (AP/FP), Medical Director, Provincial Forensic Pathology Service, Toronto, Ontario Forensic Pathology Service.
Objectives: to analyse investigation of decomposed bodies received during 5 year period from 2009 to 2014 in the Provincial Forensic Pathology Unit, Toronto, Ontario using criteria such as: degree of decomposition, identification status at the presentation, identification status at the completion, cause and manner of death.
Material and Methods: Information from the database of Pathology Information and Management System (PIMS) of the Ontario Forensic Pathology Service (OFPS) was used in this purpose. All decomposed bodies received at the Provincial Forensic Pathology Unit (PFPU), Toronto during the five year period from October 2009 to March 2015 were tabled using Microsoft excel worksheet and analyzed.
Results: 259 cases were identified as decomposed bodies excluding skeletal remains. 202 cases were identified by the coroner. 46 cases presented with presumptive identity, and 11 cases presented as unidentified. Complete autopsy was carried out in all cases according to the Ontario Forensic Pathology Service Manual. Only one case was identified by DNA. Two cases were identified by medical, radiological comparison methods and forensic anthropology. All other cases were identified by dental comparison or fingerprint methods. Cause of death was ascertained in 217 cases but only in 131 cases cause of death was unascertained. 11 cases are still pending. Two cases of gunshot wounds were identified, and two cases were identified as blunt force injuries of the head. 25 cases were due to toxicological causes and all other cases were due to natural causes.
Conclusion: Primary objectives in decomposed cases are to confirm identity, exclude traumatic cause of death, identify cause and manner of death and generate a medicolegal autopsy report with medicolegal opinion. Four principal methods are used for identification: fingerprint method, dental comparison, medical methods including radiology and anthropology, and DNA. After careful post-mortem examination, identity and cause of death can be ascertained in most decomposed cases.
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Gastric Friability & Apparent Perforation in an Infant with Fulminant Streptococcal Meningitis & Sepsis Hossain M. Pathologist, Department of Laboratory Medicine Saint John Regional Hospital, St. John, New Brunswick and Dalhousie University, Halifax, Nova Scotia Stomach ulcerations that are thought to be etiologically related to intracranial pathology (eg. increased intracranial pressure, trauma, surgery) are well described and often referred to by the eponym “Cushing ulcer”. Such ulcerations are not commonly reported in the infant population in recent English literature. The current case demonstrates extensive gastric friability with apparent perforation of the stomach that was detected at autopsy of an otherwise healthy infant presenting with fulminate Streptococcal meningitis and sepsis. The etiology of the gastric friability and apparent perforation is believed to be pathophysiologically related to the gastric changes seen in “Cushing ulcer”.
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PEDIATRIC DEATH INVESTIGATION IN ONTARIO: ANALYSIS OF 6 YEAR PERIOD FROM 2005 TO 2011. Dirk Huyer MD, Chief Coroner for Ontario and Jayantha Herath, MD, DLM, MD (Forensic) FRCPC (AP/FP), Medical Director, Provincial Forensic Pathology Unit, Toronto. Introduction: In Ontario, death investigation services are provided by the Office of the Chief Coroner (OCC) and the Ontario Forensic Pathology Service (OFPS). Together, they form a division within the Ministry of Community Safety and Correctional Services. To conduct the highest quality death investigations in the public interest the OCC partners with the OFPS to ensure a coordinated and collaborative approach. In Ontario, coroners are medical doctors with specialized training in the principles of death investigation. Coroners investigate approximately 15,000 deaths per year. Objectives: To analyse child and youth deaths that have been previously investigated in Ontario opposed to overall number deaths that occur in Ontario and Canadian. The main objective would focus discovering trends in the data as opposed to the overall number of deaths. Material and Methods: Information from the database of Coroners Information System (CIS) of Office of the Chief Coroner and Pathology Information and Management System (PIMS) of the Ontario Forensic Pathology Service (OFPS) and the Pediatric Death Review Committee and Deaths Under Five Committee (DU5C) Annual Report 2014 were used in this purpose. All reported child and youth deaths during this period was analysed. Results: The coroners investigate approximately 20% of all deaths that occur within the province each year. In paediatric deaths (i.e. from live birth to the nineteenth birthday), this proportion over the past five years is approximately 35%. From year 2005 to 2011 Ontario has had 1335, 1249, 1297, 1237, 1247, 1201 and 1122 deaths respectively. Average number of deaths in Canada was 3479. Between 2005 and 2011, the year to year totals have remained fairly consistent both in Canada and Ontario. Over the 6-year period studied, the OCC investigated approximately 23% of infant deaths (< 1 year), 65% of deaths of 1-4 year olds, 54% of the 5-9 year olds, 41% of 10-14 year olds and 84% of adolescent deaths (15-19 year olds). There is a change in the distribution of the manner of death provided by Ontario coroners that follows age progression from infancy to adolescence. There is a clear contrast between the manners of death provided in infancy (< 1 year) versus adolescence (14-18 years). Natural and undetermined deaths dominate investigations of children under one, gradually changing to non-natural manners (accident, homicide and suicide) which are more prevalent among adolescents. Over the past five years, the full DU5C reviewed between 92 and 108 cases, the exception being 2013 where 55 cases were reviewed by full committee. The manner of death for majority of cases for all five years was “undetermined.” Conclusion: From 2005 to 2011, the average number of pediatric deaths in Ontario was 1241, and the average number of deaths in Canada was 3479. Between 2005 and 2011, the year to year totals have remained fairly consistent both in Canada and Ontario. One of the significant changes reflected in the classification of these deaths involves the cause of death being provided as “undetermined” in cases where there is a comprehensive investigation, but no conclusive finding.
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BMI Profile of Decedents Presenting for Autopsy in Saint John Ken Obenson MD FRCPC Dept of Laboratory Medicine Saint John Regional Hospital
Introduction: Obesity has been associated with increased morbidity and rate of death. Postmortem examinations are required to determine the cause of death, to detect clinically unsuspected disease entities, and consequently to determine what impact obesity may have on patient mortality. The provincial government is already under significant pressure to reduce health care expenditure; obesity and related diseases are most likely a significant contributor.. Methods: A total of 90 sequential coroners autopsies performed in 2014 (~50% of total) were retrospectively reviewed. Children aged 16 and younger were excluded. Obese (BMI >/= 30 kg/m2) and non-obese patients were studied. The primary cause of death in each group was categorized into into non-cardial natural disease, ischemic heart disease, drug toxicities, homicidal injuries, accidental injuries and asphyxias (due to hanging, drowning or chemicals). Results: Of 90 autopsies, 36 (40%) were obese of whom 23 were males. There were a total of 59 males and 31 females. The men were aged from 18 to 88 years, the females 17 to 85 years. The leading causes of death in the obese population were non-cardiac natural disease (30%), ischemic heart disease (27.7%) of which there was a single female, drug toxicities (16.7%), homicidal injuries (11.0%) accidental injuries (11.0%) and asphyxias (4%). Eight were morbidly obese (BMI 40 or more) of whom 2 died from ischemic heart disease (25%). By comparison, in the non-obese group, the leading causes of death are non-cardiac natural causes (24%), ischemic heart disease (16.6%), homicidal trauma (16.7%) and drug toxicities (15%). Asphyxias, accidental injuries and undetermined causes accounted for the remaining 28%. Conclusion: Although this survey is limited to coroner’s cases which have their own selection biases, obesity does increase the risk of death both due to ischemic heart disease and other noncardiac causes, particularly in males. With two-thirds of adults in New Brunswick deemed obese and among the heaviest in Canada, it is likely that this unfortunate pattern of mortality will continue unless there is a concerted effort at provincial level to facilitate life style changes and reduce the burden of this disease.
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The Disposition of Johns and Janes Doe in New Brunswick Ken Obenson MD FRCPC, Dept of Laboratory Medicine Saint John Regional Hospital Introduction: Bodies that present to the morgue for post mortem examination may not be immediately identified. Such bodies are by convention typically designated John or Jane Doe. Other jurisdictions use the term Male X or Female X. The purpose of this study was to determine how these cases are ultimately disposed. Methods: The coroner’s autopsy records at Saint John Regional Hospital, for the 19 year period 1994-2012 were reviewed for the names “John” or “Jane Doe”, “Male X” or “Female X”. These were subsequently sorted for gender, race, whether adult or child, location found (indoors versus outdoors), whether ultimately identified and the cause of death. The study period corresponds to the period for which data is available. Results: In total, 32 consecutive cases were recovered. Five were found indoors. Twenty three decedents were males, 8 females and 1 body was of undetermined gender. Twenty nine decedents were adults, 2 were children and one of unknown age. In 15 cases the race was unknown, 1 was first nations while the rest were White. All decedents underwent radiologic examination. The majority of decedents were ultimately identified (22) by either DNA studies or in consultation with the forensic odontologist. In 15 cases the cause of death was undetermined, 7 were determined to have drowned, 5 died by thermal injury or smoke inhalation, 4 due to blunt force trauma and 1 due to drug toxicity. Bodies were most commonly discovered in June (6 decedents), April and December (5 decedents each). Conclusions: Unknown decedents presenting for post-mortem examination in Saint John are often adults and male. Most are ultimately identified. However the cause of death is undetermined in almost half of cases.
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An (?) Incidental Meningioma Ken Obenson MD FRCPC, Cenk Acar MD; Department of Pathology, Saint John Regional Hospital; Walt McKinney (Coroner), Greg Forestell BPE, (Chief Coroner) Dept. of Public Safety, Govt. of New Brunswick Introduction: Meningiomas are benign tumors of the meninges that may be found incidentally at autopsy. Depending on their location in the skull, size, pattern of growth and what structures they compress, they may not be a direct or a contributory factor to death. We present autopsy findings of a decedent presenting with a meningioma. Case summary: As per Coroner’s investigative report, the decedent is an 87-year-old female found at foot of stairs to basement. She was last seen in bed around 5 a.m on the morning she was found deceased. She had a history of being unstable on her feet and a medical history of diabetes, hypertension, chronic obstructive pulmonary disease, and hypothyroidism. She also had a tumor on the left side of the foramen magnum. The tumor pressed on the spinal cord, the basilar and vertebral arteries. Significant non brain findings: Left ventricular hypertrophy (weight of 320 g and left ventricle muscle wall up to 2 cm thick in areas) Adrenal cortical adenomas Mild bronchiectasis
The brain weighed 1,225 g was mildly atrophic and showed no contusions. There was no intracranial hemorrhage or cerebral edema. The off-white firm left foraminal mass measured 2.3 cm in maximum dimension. The cut sections of the mass show homogeneous fairly well delimited white-tan, tissue without evidence of hemorrhage or necrosis. Histologically the spindled/whorled pattern was characteristic of a meningioma. There was no evidence of the mass infiltrating the surrounding brain stem. Neither the basilar artery nor the distal vertebral arteries showed any evidence of thrombosis. Discussion: Foramen magnum meningioma represents 2% of all meningiomas. The clinical symptomatology is usually insidious and consists of headache, neck pain and hypoesthesia in C2 dermatome. In one study, the most common symptoms of the 19 women and six men (mean age, 59.2 yr) was cervico-occipital pain (72%) and gait disturbance (32%). Clinical examination revealed gait ataxia in 48% of patients. This decedent did not have vascular or parenchymal changes to the brain stem or spinal cord that would have caused immediate death, although the location of the mass may have contributed to her fall. Conclusion: The presence of a meningioma in the foramen magnum does not necessarily lead to sudden death. Where there is concern that it is a direct cause or significant contributory factor, it is important to thoroughly review the circumstances, especially in a patient with multiple comorbidities.
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The Practice of Forensic Radiology in Saint John- A Birds eye View Ken Obenson MD FRCPC. Dept of Laboratory Medicine Saint John Regional Hospital Mark MacSween MD FRCPC. Dept of Radiology Saint John Regional Hospital
Introduction: Radiologic imaging has long been recognized as a critical additional tool in the investigation of death, from "routine" hospital and coroner’s cases to the investigation of mass disasters. Free standing Coroners or Medical Examiners offices often have their own equipment and radiology staff. In contrast, the practice in Saint John a small city in New Brunswick is hospital based. Background: Approximately 200 post mortem examinations are performed in Saint John each year. These include both hospital cases and forensic cases ie so called type 1s (sudden and unexpected) and type 2 deaths (criminally sudden and suspicious). Imaging is requested on virtually all type 2s and on selected type 1s. Except for patients who arrive in the emergency room, infants and fetuses, images are almost never requested on decedents admitted to hospital. Types of studies: In Adults-The most commonly requested study in adults are routine plain xrays, typically of the skull, neck or chest. So called "whole body" xrays may be obtained in cases of advanced decomposition or on burn victims. Rarely CT scans have been requested to document soft tissue injury. In at least 1 case, post mortem MRI was useful in excluding bony trauma to the cervical spine. Post mortem angiography has been rarely performed to document (successfully) vertebral artery dissection. In Infants-Obtaining skeletal surveys in deceased infants is standard practice. Occasionally CT scans have been performed on in search of congenital anomalies. Very occasionally MRIs have been used to document complex cerebral anomalies. Image Acquisition: Digital images are obtained in the morgue by a portable machine operated by certified radiographers. In cases where CTs or MRIs are indicated, an appointment is scheduled with the radiology department which is usually on the same day. Interpretation: The pathologist has the option of reviewing images on a computer in the morgue or discussing findings with a qualified radiologist. Turn-around time from image acquisition to uploading for viewing is typically within 15 minutes.
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Comment: The fact that the practice of post mortem radiology is hospital based is no handicap to the provision of a high quality service in Saint John. Indeed, there are a wide variety of tests available for post mortem imaging in Saint John relative to many other facilities in North America. For instance, except for a few large volume facilities (Miami, Baltimore, Dover Delaware) located in much larger metropolitan areas, most free standing forensic centers do not have on-site access to the more sophisticated imaging modalities such as CT, MRI. Turn-around times are reasonable and rapid reporting is especially valuable when the pathologist needs to exclude projectiles or foreign bodies. The volume and variety of cases also helps radiologists maintain competence in interpreting post mortem radiology. Radiographers also maintain skills required to properly acquire post-mortem images.
Conclusion: Radiologic imaging is a useful and important part of most post mortem examinations. Notwithstanding the fact that the practice is hospital based or the relatively small population served, the capacities for post-mortem imaging in Saint John Regional Hospital meet or exceed international norms.
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What Challenges face Forensic Investigators (trying to work) in ResourceLimited Jurisdictions? Ken Obenson MD FRCP, Dept of Laboratory Medicine, Saint John Regional Hospital. George Enoworock MD. Dept of Pathology, Centre Hospitalier et Universitaire, Yaounde Cameroon, West Africa.
Maintaining a modern death investigation system (DIS) requires a constant investment of money. Even in Western societies and particularly in Canada, the recent economic downturn has forced sharp cut backs in public services that have not spared the local DIS. Nevertheless there are expectations of a certain minimum standard that might still be considered a luxury by those working in so called “resource limited” jurisdictions. From the death scene to the judicial system, the effects of the lack of funding are pervasive. The challenges vary from jurisdiction to jurisdiction and very broadly can be ascribed to the economic costs of infectious disease, the lack of qualified staff, grossly inadequate basic equipment or infrastructure, lack of or poor enforcement of enabling legislation, or a combination of all of the above. Burden of infectious disease: In low resource settings typical of developing countries, the health systems are overwhelmed by infectious diseases and malnutrition. The practice of post mortem examinations tends to be culturally restricted and is not considered a priority. In some areas, it is even considered a taboo. Staff: Qualified staff are either not available or are poorly paid. Tanzania with a population of 37.5 has 2 forensic pathologists while Canada with a population of 33 million has more than 30. Some jurisdictions may rely on medical officers to provide an autopsy service. This is fraught with risks of a miscarriage of justice. Many jurisdictions lack access to the specialists taken for granted in Canada. The majority lack access to forensic anthropologists, forensic entomologists or forensic artists. For instance the shortage of qualified toxicologists in one country has lead to backlogs that are measured in years! Autopsy facilities: facilities are quite basic and generally lack air flow pumps and space concessions required in Canadian based facilities. Consequently autopsies on decomposed bodies are generally not performed in them. X-ray support is frequently lacking. The lack of running water is a particularly vexing problem. Power supply may be erratic and unreliable which complicates efforts to refrigerate bodies. Judicial proceedings: The legal system may not be developed sufficiently to adequately test the conclusions by the pathologist. Defense attorneys are generally not as comprehensive in their cross examination to the extent that the typical forensic pathologist practicing in Canada would
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expect. Complicating matters is that at trial in many jurisdictions, the burden of proof is often placed on the accused. Conclusion: The quality of death investigation in these jurisdictions will only improve when there is a local political will to do so. There have to be changes in cultural awareness of the need to perform autopsies in certain circumstances. Proper purpose built facilities are needed with adequately trained and compensated staff. Unfortunately given the myriad problems many of these countries face such changes appear unlikely for the foreseeable future.
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Using Post Mortem Drug Levels as a Tool in Distinguishing Between NonAccidental and Accidental Fatal Drug Ingestions Thomas Sozio DO Forensic Pathologist, Central Indiana Forensic Services Prescription drug abuse has risen to epidemic proportions in the United States. This shift has caused an increase in both the number of accidental and non-accidental drug related deaths. The distinction between an accidental and suicidal overdose has always been a challenge in America’s medicolegal death certification system. In addition to the standard scene investigation, medical history, and past psychological history, the toxicology report has become paramount in distinguishing a non-intentional overdose from an intentional overdose. This retrospective study looked at the postmortem drug concentrations as an additional tool to help in the decision making process between a suicide and an accidental drug overdose. A 4 year (2009-2012) review of drug concentrations in suicides, accidental overdoses, and undetermined deaths from the Marion County Coroner’s Office in Indianapolis was compiled and compared to standard therapeutic drug ranges. A significant number of suicides showed a statistically significant highly elevated drug concentration(s) when compared to accidental drug overdoses.
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Sufferin Succotash! Is it SIDS or Cigarette Smoke? Ken Obenson MD FRCPC Forensic Pathologist, Dept of Laboratory Medicine Saint John Regional Hospital Robert Belliveau, Regional Coroner, Dept. of Public Safety, Saint John The Sudden Infant Death Syndrome, better known by its acronym SIDS is a diagnosis of exclusion. Research into the causation of SIDs has led to the discovery of several associated risk factors which have been mitigated through public education. One of those risk factors, maternal smoking is probably the single most preventable risk factor. Nicotine contained in cigarettes crosses the placental barrier easily, and there is evidence for accumulation of nicotine in fetal serum and amnionic fluid in slightly higher concentrations than in maternal serum. Published studies also indicate that there is a relationship between involuntary environmental tobacco smoke exposure and respiratory illness in older children. However in studies of SIDs cases many infants die with lower than lethal nicotine levels, which unfortunately are still higher than in non SIDs controls. The dilemma is that many of these cases may have no other risk factors for SIDs but are still classified as such. A typical scenario is of a child sleeping in its own crib in its own room without any other scene or historical concerns. The parents may admit to tobacco use or the investigator may find other stigmata of its use (scent of tobacco, ashtrays containing cigarette stubs or packets of cigarettes). Physical examination of the body, radiologic and microbiological studies are negative. Toxicologic analysis may reveal only elevated but not toxic levels of cotinine, a nicotine metabolite. However cigarette smoke may also contain other substances such as carbon monoxide which compete with oxygen for receptors on red blood cells and may therefore interfere with oxygenation. Since nicotine levels in SIDs cases are less than fatal it is not implausible to suggest that a hypoxic mechanism is instrumental in causing death. Therefore the investigation of a SIDS scene where cigarette consumption is suspected should prompt collection of a sample for carbon monoxide analysis. A prospective study with known non-cigarette exposed controls is likely to yield useful information.
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PRIMERS
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Dealing with the Media during a Mass Fatality Incident Alfie Ballew MBA Chief Deputy Coroner Marion County Coroners Office, Indianapolis Marion County is home to the largest city in Indiana, the state capital of Indianapolis. Catastrophic incidents due to natural or man-made causes are possible and therefore plans must be in place for the management of large numbers of fatalities. In a mass fatality incident, the primary goal of the operation is to identify the deceased so that they may be returned to loved ones. The purpose of this media plan is to define response objectives as well as operational guidelines when faced with a mass fatality incident in Marion County. A significant number of deaths occurring in the United States must be investigated and certified by a medical-legal officer. Under Indiana Law, a death that has been caused by something other than natural causes must be investigated by the County Coroner or his/her designee. In a catastrophic event where there are large numbers of fatalities, it is reasonable to believe that the deaths were caused by an unnatural event. Therefore, in instances when there are large number of fatalities, the County Coroner or his/her designee has the responsibility and authority to investigate each death. In cases of potential terrorism or plane crashes, Marion County response agencies shall work in cooperation with Federal Response Agencies, such as the FBI, Federal Department of Homeland Security, National Transportation Safety Board (NTSB), and others as deemed necessary. By definition a mass fatality incident is one where there are more human remains at one time than the county can reasonably handle from a storage, identification, and investigation perspective. The Marion County Coroner’s Office has limited morgue storage space for short or long term storage, as well as limited numbers of personnel to respond. The Marion County Coroner shall review the specifics of an incident to determine projected number of deceased, and make the determination at that time as to whether or not to activate the Mass Fatality plan.
After determination has been made as to whether the agency is dealing with a mass fatality, the Coroner will work with many local partner agencies. One of the major players to be utilized for the purpose of dissemination of information is the Consolidated City of Indianapolis (Marion County) Division of Homeland Security. The responsibility of this agency involves being responsible for activation of the Marion County Emergency Operations Center, to include all Emergency Support Functions (ESF) as required to support field response to the incident.
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1. Operate utilizing the NIMS and Incident Command System. 2. Efficient and coordinated mobilization and deployment of local, District, State, and National resources at the request of the Incident Commander, to rapidly respond to a mass fatality incident. 3. Disseminate warnings, emergency public information and instructions to citizens of the Consolidated City of Indianapolis, Marion County, and other counties and jurisdictions as needed. 4. Coordinate with the Coroner about the transition into recovery operations to ensure a return to pre-disaster conditions. All of the above efforts will be coordinated in conjunction with the Coroner’s Office. Additionally, a Public Information Officer will work directly with the Coroner and Chief Deputy Coroner to assure that all information shared with the public thru the media are accurate and up to date regarding the dead. The Command center will serve as the centralized location for information sharing regarding the incident. The PIO will be responsible for frequent updates with the media regarding identification of the dead after notification has been made to the family, the number of dead, and the status of locating remains of the dead. If the case should arise that the Coroner is having difficulty finding the family, the media will be used to broadcast specific information about locating a family. The media will be given one centralized phone number and a direct point of contact to call regarding additional information and updates. The PIO will utilize a variety of social media methods to share and update information. Methods currently identified are email, Facebook, and Twitter and well as periodic on camera news briefings. These methods have been used in the past and work well as frequent updates are being added. 1. After initial response to the incident, respond to the Marion County EOC to represent the ESF 16. 2. Initiate Missing Persons Response Team to a pre-determined location (location to be the same or close to where the Mental Health Response Team is staging) to set up operations for family members of the deceased (or presumed deceased or missing) to make a missing persons report. Ultimately, the goal is to make sure that the community has been kept up to date on the incident at hand.
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Essentials of Child Death Prosecutions: Navigating the Minefield of the Judicial System Courtney E. Curtis, J.D., Indiana University Maurer School of Law, 2004 Assistant Supervisor-Special Victims Team Marion County Prosecutor’s Office, Indianapolis, Indiana
Child death cases are inherently different from most other death investigations. When a child is killed, the average person wants to believe that this is a mistake or accident of some kind. It is difficult to fathom the evil that is required to kill a child, and so the brain, in order to protect us from a truth we may as human beings be too fragile to accept, seeks out other options first. As a pathologist, it can be difficult to step away from the idiom, “Don’t go looking for zebras,” and yet when approaching a child death investigation, the ideal forensic pathologist must do just that. The reason is simple: to juries, anything that kills a child is a zebra and not your standard horse. The pathologist must be able to state clearly why the cause of death is not any number of naturally occurring causes. If a particular cause was not considered, he or she must be able to state clearly why it was not considered. The best response is not just that a particular cause of death is not likely, but why this particular constellation of injuries does not fit that diagnosis. A forensic pathologist must be able to explain to the jury differential diagnosis, both what it is and why it matters. Defense attorneys will propose maladies in a vacuum that rarely, if ever, account for the totality of symptoms the pathologist was presented with. The most successful courtroom testimony is calm, ordered, and shows a considered analysis of why that diagnosis can only be correct if the pathologist ignores the other symptoms he or she was presented with. Prepare your prosecutor in advance, so that he or she is familiar with the types of diseases and/or injuries you may be questioned about during cross examination. This arms your prosecutor with the tools he or she needs to ask questions on redirect that shore up your original findings. Remember, you are the expert!
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Critical Value Reporting in Forensic Pathology Ken Obenson MD FRCPC Forensic Pathologist; Claire M Wright B.Tech ASQ-CQA, Quality Coordinator, Dept of Laboratory Medicine Saint John Regional Hospital
Although critical value reporting is well developed in anatomic pathology, formulated criteria are relatively new to forensic pathology. A properly implemented quality management system requires that critical values in forensic pathology be defined on parameters that ensure public health, safety and the integrity of the justice system are protected. In anatomic pathology, the impact of a critical value is determined by how it affects the individual patient while in forensic pathology the impact is measured based on how it affects relatives, members of the public and the accused in a criminal process. Critical values can therefore be defined as follows: Any fact or finding in a death investigation that 1. Is an immediate danger to public safety such as a highly infectious disease 2. May require urgent testing /monitoring of a decedent's relatives for unconfirmed or unexpected natural disease such as a cardiac channelopathy 3. May substantially alter the nature of a death investigation or 4. May impact the outcome in a judicial process such as unexpected toxicology results or trauma Once identified, there must be a system in place to provide for proper communication of a critical value, the means by which the notification is made, the party notified and the time frame for notification. These would be determined by what party would be impacted by the result i.e. relatives in cases of unexpected natural disease, departments of public safety and public health in cases of a highly infectious organism or recovery of explosives, and the local court officers in criminal prosecutions. Obviously time frames will be defined by need and local policy. Any dangers to public health or safety must by necessity receive high priority. Where unexpected natural diseases are discovered the family should be notified as soon as possible to facilitate genetic or other clinical testing as needed. Immediate notification of the prosecution service may be required where a process is ongoing. A written record of notifications must be maintained in accordance with institutional policies and procedures.
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In sum, critical value reporting is an important part of a quality management system designed to protect relatives, the public and the judicial process. Such a system must be designed in consultation with users of the service to be effective.
REFERENCES: Institute for Quality Management in Healthcare Accreditation Requirements (2013) Version 6.0 VIII.5 ISO 15159:2012 (3rd Ed). Medical Laboratories, Requirements for Quality and Competence ISO. 5.8.2(c);5.9.1 Riechard RR. A Quality Assurance Strategy for Forensic Pathology. Academic Forensic Pathology 2001 1(1):8-13
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Autopsy As A Performance Measure and Quality Improvement Tool Anne O’Brien MD FRCPC Anatomic Pathologist Dept of Laboratory Medicine Saint John Regional Hospital Saint John NB
Horizon Health Network has recently implemented a Medical Quality Improvement process. One element of this process consists of a standardized format for Morbidity and Mortality reviews which includes correlating autopsy findings with clinical events and diagnosis. The autopsy results are critical to maximizing the benefit of the mortality review. To this end ii is important that pathologists have a process in place to monitor the quality and timeliness of the autopsy and report.
Universally, autopsy rates that used to hover well above the 20% range for in-hospital deaths have fallen over the last half century. This decline is based on a number of factors, including the utility of the autopsy, given the impressive advances in diagnostic and imaging modalities over the last several decades. Despite these advances autopsies identify diagnostic discrepancies in up to 20% of cases and evidence suggests that clinicians have difficulty identifying which autopsies are likely to produce significant results.
Current statistics show that inpatient autopsy rates at the Saint John Regional Hospital have followed this general downward trend with non-coroner autopsy rates of approximately 3%. In the interest of medical quality improvement and education it is recommended that this number be increased. This will require a concerted effort directed towards clinicians, house staff and the general public.
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NEUROPATHOLOGY OF ETHANOL USE AND ABUSE By Andrea L. Wiens, DO Forensic Pathologist and Neuropathologist Office of the Chief Medical Examiner, Tulsa, Oklahoma, USA Ethanol (ethyl alcohol; “alcohol”) is a commonly abused intoxicant that is associated with approximately 3.3 million deaths per year worldwide1, the majority of which are related to complications of chronic abuse. Neuropathologic changes are frequently identified in patients who use/abuse ethanol. Ethanol concussion syndrome refers to sudden death of an acutely intoxicated patient soon after a moderate to severe blunt head impact which in and of itself is not severe enough to cause sudden death.2 Ethanol concussion syndrome is a diagnosis of exclusion. Postmortem findings may include soft tissue injuries to the face and scalp, facial fractures, and possibly petechiae in the corpus callosum or periventricular regions of the brain. Neck and spinal cord injuries are absent, as is intracranial hemorrhage. Chronic ethanol abuse may lead to alcohol related brain damage (ARBD) characterized by brain atrophy largely due to loss of cerebral hemispheric white matter volume and frontal lobe cortical volume.3 Behavioral disinhibition is related to selective loss of neurons from the superior frontal cortex. Atrophy of the superior cerebellar vermis due to loss of Purkinje and granule neurons may result in gait ataxia. Wernicke’s encephalopathy develops with thiamine deficiency due to malnutrition and is represented at neuropathologic examination as petechial hemorrhages in the mammillary bodies. Clinical symptoms may include ataxia, confusion, and ophthalmoplegia. Hepatic encephalopathy ensues in patients with severe liver disease. Clinical symptoms vary from mild (e.g. confusion) to severe (e.g. coma). The associated neuropathology includes diffuse brain edema and Alzheimer type II astrogliosis in the basal ganglia, thalamus, and deep cerebral cortex. Alzheimer type II astrogliosis is a nonspecific functional disorder of astrocytes that can be seen with hyperammonemia, uremia, hypercapnia, and hypoglycemia. Central pontine myelinolysis (CPM), or osmotic demyelination syndrome, is a neurologic entity resulting from rapid correction of hyponatremia or hypophosphatemia in markedly malnourished patients. Clinically, patients demonstrate encephalopathy and seizures, followed by correction of the electrolyte imbalance, then rapid deterioration several days later which may end in death. The neuropathology is typically centered in the basis pontis which shows loss of myelin with relative preservation of axons. Approximately half of cases also demonstrate extrapontine
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involvement (cerebellum, lateral geniculate body, external capsule, hippocampus, putamen, cerebral cortex).3 Marchiafava-Bignami Disease (MBD) is an extremely rare demyelination syndrome related to chronic ethanol abuse and vitamin deficiencies.4 Patients with MBD may demonstrate variable T2-hyperintense corpus callosum lesions on magnetic-resonance imaging and clinically demonstrate altered consciousness, including coma. Neuropathologic features include thinning, discoloration, or cavitation of the corpus callosum due to demyelination with preservation of axons, necrosis, and cystic cavitation. Delirium tremens is an acute delirium with associated autonomic nervous system hyperactivity that can follow sudden withdrawal from ethanol in a chronic abuser. The peak incidence occurs 48-72 hours after the last ethanol ingestion, and may precipitate a fatal seizure.5 Treatment with benzodiazepines has greatly reduced the mortality of delirium tremens. Neuropathologic findings are nonspecific and generally are related to ARBD, CPM, and rarely MBD. References 1)World Health Organization. Global status report on alcohol and health 2014. http://www.who.int/substance_abuse/publications/global_alcohol_report/msb_gsr_2014_1.pdf. Accessed 15 March 2015. 2)Milovanovic AV and DiMaio VJ. Death due to concussion and alcohol. Am J Forensic Med Pathol 1999;20:6-9. 3)Büttner A. Neuropathology of chronic alcohol abuse. Acad Forensic Pathol 2014;4:180-187. 4)Hillborn M, Saloheimo P, Fujioka S, Wszolek ZK, Juvela S, Leone MA. Diagnosis and management of Marchiafava-Bignami disease: A review of CT/MRI confirmed cases. J Neurol Neurosurg Psychiatry 2014;85:168-173. 5)Milroy CM. Sudden death and chronic alcoholism. Acad Forensic Pathol 2014;4:168-171.
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Creating a Cause of Death Statement Marnie Wood MD FRCPC Forensic Pathologist/Medical Examiner Nova Scotia Medical Examiner Service
The cause of death statement is the story of how a death came about, which may take place over seconds or years. The brevity and frequent simplicity of the statement belie the expertise and ability to consolidate complex data required of the certifier of death (Attending Physician, Coroner or Medical Examiner). The Registration of Death is legal proof of the death of an individual, which informs family, policy makers, researchers and many other agencies. It is thus imperative the cause of death statement be carefully and thoughtfully constructed. The cause of death statement begins with the immediate cause of death. This is the final complication, which is closest in time to death and the least physiologically specific of the processes listed. One must, however, be more specific than “cardiorespiratory arrest”, as that is simply a synonym for death. The statement continues with the antecedent causes, which are the links in an uninterrupted chain leading back in time from death. The last line is the underlying cause of death. The underlying cause is the pathologically specific disease or injury, which set into motion all the complications leading to death. Use of all lines on the Registration of Death is not required. A single line stating the underlying cause of death, without listing immediate or antecedent causes, is acceptable, especially if the complications of a particular disease or injury are well known. For other diseases or injuries, many physiologic processes contribute in a complex and not easily demonstrated way during the terminal period. In such cases, a single line stating “complications of” the underlying cause of death is acceptable. The cause of death is the opinion of the certifier based on interpretation of available data. Information about the history of the individual, the scene of death, and sometimes autopsy findings must be considered in determining the cause of death. Any one of these areas may be key in determining the cause of death, as opposed to a cause of death. It is well accepted that absolute certainty is not required to choose the underlying cause of death, and that the degree of certainty varies case by case. Terms such as “probable” or “possible” may precede any component of the cause of death statement. If new information arises, which changes the opinion of the certifier, the cause of death may be amended at any time. The goal is the most complete and accurate cause of death statement possible.
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REFERENCES “A Guide for Manner of Death Classification” 1st Hanzlick R. www.thename.org 2002 Handbook of Forensic Pathology 2nd Chap 4. Froed R. 2003
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Moving Away from the “Shaken Baby Syndrome” Controversy Marnie Wood MD FRCPC Forensic Pathologist/Medical Examiner
Nova Scotia Medical Examiner Service It is unlikely “Shaken Baby Syndrome” will ever disappear completely from the forensic pathology vernacular. Terms such as Non-Accidental Trauma and Inflicted Head Injury have been proposed as replacements, and have been debated in turn. The controversy arising from terminology detracts from the more important questions of whether the diagnosis of injury can be made in a particular case, and whether the injury is explained by the reported mechanism. “Shaken Baby Syndrome” arose to address cases of severe brain injury in infants without gross evidence of impact to the head. It was assumed if impact occurred, an injury of the scalp would be visible. This assumption is incorrect, especially in infants, whose healthy tissues bruise less easily. It has been suggested “Shaken Baby Syndrome” was supported by perpetrator confessions of shaking as the only inflicted injury on an infant. The assumption that confessions are entirely truthful is also incorrect. Shaking of an infant may be much more palatable to admit than the actual actions of the perpetrator. In the years since “Shaken Baby Syndrome” was introduced, there has been much controversy over whether shaking alone, without impact, can produce enough force to cause fatal head injury. This is most likely a vain attempt to over simplify complex and diverse injurious scenarios. What is not controversial is that injuries are inflicted on infants, in a variety of ways, and can be fatal. The resulting damage in the brain is similar, regardless of how the injury occurred. Thus the exact mechanism of injury cannot be determined based on autopsy findings alone. The term “Shaken Baby Syndrome” expresses more certainty about the mechanism of injury than it is possible to have, and thus can mislead an investigation and introduce unnecessary debate. While it is not possible to determine with certainty the mechanism of injury based on autopsy findings, it is possible to determine if injury exists. Granted, there is also significant controversy over the specificity of the “Triad” (subdural hemorrhage, encephalopathy and retinal hemorrhages) for inflicted injury. However, an open-minded, objective consideration of the differential diagnosis for each finding in the context of scene and history information can allow the correct diagnosis (injury vs. disease process, accidental vs. inflicted) to be made with reasonable confidence. It may also be possible to determine whether a proposed scenario explains the injuries present. There is no need to fabricate a sequence of events inspired by autopsy findings, a la television. It
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is unlikely most of us could imagine the ways in which injuries have been inflicted on an infant. However, providing an expert opinion regarding a specific proposed scenario is reasonable and valuable. It is the professional responsibility of a forensic pathologist to make a diagnosis based on a reasonable interpretation of all available facts, and to not to let the diagnosis get lost in controversy.
REFERENCES Squire, W. Shaken baby syndrome: the quest for evidence. Develop Med Child Neurol 2008;50:10-14. Squire, W. The “Shaken Baby” syndrome: pathology and mechanisms. Acta Neuropathol. 2011;122:519542. Chiesa, A., Duhaime, A. Abusive Head Trauma. Pediatr Clin N Am 2009;56:317-331.
Byard, R. “Shaken baby syndrome” and forensic pathology: an uneasy interface. And comments. Forensic Sci Med Pathol. 2014;10:239-258.
