DEATH INVESTIGATION

Fierro MF, MD, Institute of Medicine Workshop on the Medicolegal Death Investigation System, 2003
Objectives
 Main Objective: To acquire knowledge about the investigation
of death and significance of a medico-legal autopsy
 Specific Objectives:
1. To express the objectives of a death investigation
2. To identify the types of death that require investigation in the
Philippines and compare these with other countries
3. To identify the members of a death investigation team and
discuss the functions of the team
4. To explain the aspects of the death investigation process,
particularly the medico-legal autopsy
5. To describe the contents of a medico-legal report
6. To explain the use of the medico-legal autopsy to the legal
system
Death Investigation
 To identify and develop an understanding
of death (natural, unnatural, unlawful)

 Clinical death investigation

 Medico-legal investigation
Death Investigation
 Natural death, MD signs death certificate
dispose the body
 Unnatural death or no MD can complete a death
certificate
investigate and certify the death
 Deaths that cannot be certified by a MD are
examined by a variety of legal officers
 Coroners
 Procurators fiscal (inquest officer)
 Medical examiners
 Magistrates judges
 Police officers
Shepherd R., Simpson’s Forensic Medicine, 12th ed. 2003, p32-33
Cases Where Autopsy is Performed
Section 95(b), Code of Sanitation of the Phil. or PD No.856

 Whenever required by special laws

 Upon orders of a competent court, a
mayor and a provincial or city fiscal
 Upon written request of police
authorities
 Whenever the Solicitor General,
provincial or city fiscal as authorized by
existing laws, shall deem it necessary
to disinter and take possession of
remains for examination to determine
the cause of death
 Whenever the nearest kin shall request
in writing the authorities concerned to
ascertain the cause of death
Medicolegal Cases (Phil.)
1. Deaths involving persons
who have no means of being
identified
2. Persons pronounced as
“dead on arrival”
 DOA at the ER
 death within a short period (1 –
24 hours) from arrival

Sanchez, TR, MD, LLB. Forensic Medicine: Facts the Public Must Know
 Medicolegal Cases (Phil.)
3. Deaths under the following
circumstances
 Unexpected sudden death especially
when the deceased was in apparent
good health
 Death due to natural disease but
associated with physical evidence
suspicious of foul play
 Death as a result of violence,
accident, suicide or poisoning
 Death due to improper or negligent
act of another person
Sanchez, TR, MD, LLB. Forensic Medicine: Facts the Public Must Know
Deaths Which Require Investigation
(CDC Regulations, 1998)

 Types of death that fall under the jurisdiction of a

coroner/medical examiner:
 Non-natural deaths, accidents, suicides, homicides
 Suspicious deaths
 Sudden & unexpected deaths
 Unattended deaths
Deaths which occurred in custody
Deaths of persons whose bodies are to be cremated, dissected or
buried at sea
Deaths related to disease resulting from employment or to
accidents on the job
Deaths related to disease that might constitute a threat to public
health
http://www.deathinvestigator.com/introduction/
Death Investigation Team (U.S.)
 Coroner
 Medical Examiner
 Forensic autopsy technicians

 Investigate scenes
 Investigate backgrounds
 Conduct examinations in the laboratory
 Obtain evidence
 Consult with concerned parties
 Testify in court
Olarte LO. Death Investigation. Legal Medicine Vol.II. 2006
Death Investigation Team (Phil.)
 Medical Examiner
 Forensic autopsy technicians

Investigate scenes
Investigate backgrounds
Conduct examinations in the laboratory
Obtain evidence
Consult with concerned parties
 Testify in court
Death Investigation

 Aims to answer the following questions:

 Who died? (identification of the deceased)
 Where? (place of death)
 When? (time of death)
 Why? (cause of death)
 How? (manner & mechanism of death)

The Medico-legal autopsy.

.http://www.dundee.ac.uk/forensicmedicine/notes/autopsy.pdf
Death Investigation
 Aspects of the death investigation process:
1. Scene
 Attendance by police officers, CID, family doctor, police
surgeon, forensic pathologist, forensic scientists
 Aim: to collect the maximum of information with minimum
of disturbance
 Photography, videos, trace evidence
2. History
 Social – from relative, friends, police
 Medical – from GP, hospital notes. Often indicates the
likely cause of death
3. The medico-legal autopsy
The Medico-legal autopsy.
.http://www.dundee.ac.uk/forensicmedicine/notes/autopsy.pdf
Medico-Legal Autopsy
 Postmortem examination, necropsy
 Greek word, autopsia, “to see with one’s own eyes”
 The scientific examination of a dead body
 Performed primarily to determine the cause of death &
to identify disease states present
 Academic institutions
 Teaching and research purposes

 Forensic autopsies
 Determine if a given death was an accident, homicide, suicide or
a natural event

http://www.medicinenet.com/autopsy/article.htm
Persons Authorized to Perform Autopsy
Section 95(a), Code of Sanitation of the Phil. or PD No.856

 Health officers
 Medical officers of law enforcement
agencies
 Members of the medical staff of accredited
hospitals
Autopsy
 Can be performed by any doctor
 Ideally should be performed by a properly
trained pathologist

 Medico-legal
Medico-legal autopsies
autopsies are
are aa specialized
specialized
version
version of
of the
the standard
standard autopsy
autopsy
 Should be performed by pathologists
pathologists who
have had the necessary training & experience
in a mortuary with adequate facilities
Shepherd R., Simpson’s Forensic Medicine, 12th ed. 2003, p32-33
Medico-Legal Autopsy
 Performed on behalf of the state
 Aims:
 To identify the body
 To estimate the time of death
 To identify & document the nature & number of injuries
 To interpret the significance & effect of the injuries
 To identify the presence of any natural disease
 To interpret the significance & effect of the natural
disease present
 To identify the presence of poisons
 To interpret the effect of any medical or surgical
treatment
Shepherd R., Simpson’s Forensic Medicine, 12th ed. 2003, p32-33
Medico-Legal Autopsy
 External examination
 Examination of the outside of the body (paying close
attention to the presence of injury or stigmata of disease)
 Collection of any trace evidence which may be present
 Internal examination
 Examination & dissection of internal organs
 To identify & document injuries
 To identify & document natural disease
 Laboratory examination
 Examination of retained tissues, fluids, weapon fragments,
etc.
http://www.deathinvestigator.com/introduction
Shepherd R., Simpson’s Forensic Medicine, 12th ed. 2003, p187
Identification of Decedent
 Body must be identified
to the Pathologist as the
decedent for whom
autopsy authority has
been given.
 Identification in 2 doctor
autopsies is performed in
front of the 2 doctors
performing the autopsy
Identification of Decedent
 Initial (provisional) identification may be:
 Visual (relatives)
 Circumstantial (address, car, papers, cards,
keys, clothes)
 Medical (scars, teeth, x-rays, DNA)
 Permanent record is made of the method
of formal identification:
 Personal (name, title, address)
 Body tag (record all details)
 Accompanying documentation
Personal Effects & Clothing
 Examination of the personal effects &
clothing is an integral part of the medico-
legal autopsy
 Provides information on
 Lifestyle
 Events leading to death
 Often, actual cause of death
 List of jewelry, valuables, & personal
effects
Personal Effects & Clothing
 Listed description of the
clothing
 Type of garment, color,
fabric type
 Location, if disarranged
 Wet/moist/dry
 Stains (blood, vomit, feces,
urine, semen, dirt, oil, soot,
etc.)
 Damage (holes, cuts, tears)
Personal Effects & Clothing
 Clothing findings are correlated with
historical & scene information
 Appropriateness of clothing
 Source of stains
 Trace materials
 Clothing findings must also be correlated
with other autopsy data
 Injuries
 Source of blood stains
External Examination
 Detailed head to toe examination of the
naked body
 Documenting
 Stains & soiling
 General & specific individualistic
characteristics
 Post-mortem changes (temperature, lividity,
rigor mortis, putrefaction)
External Examination
 Location, extent & type of staining or
soiling of the body are described
 Dual flow pattern of blood from a wound
 High velocity impact blood spatter from
gunshot wound
 Coffee grounds vomitus & melena
 Antiseptic from medical intervention
External Examination
General body characteristics
 Racial group  Face (hirsute woman,
 Height, weight clean shaven, beard,
 Head hair (color, dyed, moustache)
length, style, balding)  Mouth (vomit, blood, tablet
 Eyes (color, pupil size, debris, teeth, dentures)
conjunctival congestion or  Breasts (normally
petechial hemorrhages, developed, atrophic,
jaundice, prosthesis hirsute)
 Nose & ear canals (blood,  Genitalia (pubic hair
pus) pattern, circumcised,
 Earlobes (piercing, palpable testes)
earlobe creases)  Feet (general hygiene,
bunions, ingrowing nails)
External Examination
Specific identifying characteristics
 Tattoos (location, design, color, names)
 Scars (surgical & non-surgical, needle
tracks, striae)
 Skin lesions (nevi, senile keratoses, other
skin diseases)
 Prosthesis
 Pacemaker
External Examination
Post-mortem changes
 Body temperature to touch (alternatively
state if body has been refrigerated)
 Rigor mortis (extent & degree)
 Hypostatic lividity (distribution, dual
pattern, color, contact pallor)
 Putrefactive changes
Injuries (Evidence of Injury)
 Described systematically either by
grouping them according to
 anatomical location (e.g., right arm, anterior
chest, left leg)
 numerical order (e.g., where the number of
injuries is few or where each and every injury
is particularly important as in multiple stab
wounds
 If numbered, it is stated that the order of
numbering does not imply sequence of infliction or
degree of severity
Injuries (Evidence of Injury)
 Described as to their type: e.g., abrasion,
bruise, laceration, incised wound, puncture
or stab wound, gunshot wound, burn,
fracture
 Described with regard to their location,
size, shape, and color
Injuries (Evidence of Injury)
 Location of the wound is given by
 general description (e.g., on the left side of
the face, over the rib cage, immediately below
the left breast)
 precise location in relation to fixed anatomical
landmarks (analogous to latitude & longitude)
Injuries (Evidence of Injury) orbital ridge

Location crown

 Suitable vertical
suprasternal notch
landmarks
 Crown
 Orbitalridge
anterior iliac
 Suprasternal notch crest
 Superior anterior iliac symphysis pubis
crest
 Superior margin of the heel
pubic symphysis
 Heel
Injuries (Evidence of Injury)
Location
 Suitable horizontal
landmarks: any
midline structures
 Glabella
 Midlineof the sternum
 Umbilicus
Injuries (Evidence of Injury)
 Internal injuries
 Described in continuity
with the related
apparent injuries
 Bruising & abrasion to
the chest, then the
fractured ribs, then the
lacerated lung and
hemothorax
Signs of Medical Intervention
 Described under a different subheading
 Includes all medical equipment attached
to, or accompanying, the body
 Urinary catheters
 Endotracheal tube

 Rods for external fixation of fractures

 External surgical incisions

 Described in continuity with the internal
evidence of surgery
Internal Examination
 Systematic description of natural disease
 Does not include recent injuries which
have been previously described under the
appropriate heading
 Negative observations are included
 No pulmonary thrombo-emboli
 No significant coronary artery atherosclerosis

 No skull fracture
Other Examinations
 Special dissections are described
 Neck dissections
 Further examination of organs, e.g., brain
after formalin fixation
 Microscopic studies
 Biochemical studies
 Toxicological studies
Autopsy Report
 Autopsy procedure & microscopic findings
 List of diagnosis
 Summary of the case
 Opinion (Conclusion or Commentary)
 Emphasizes the relationship or correlation between
clinical findings (the MD’s examination, laboratory
tests, radiology findings, etc.) and pathologic findings
(those made from the autopsy)

http://www.medterms.com/script/main/art.asp?articlekey=2404
Opinion (Conclusion or Commentary)
 Interpretative and subjective
 Representing the opinion of the author
 Includes the cause of death as appearing
on the death certificate
 Brings together all the relevant information
obtained from
 Examination of the body
 Scene of death
 History of the decedent
Opinion (Conclusion or Commentary)
 Information obtained second-hand (hearsay)
may be included
 Police reports
 Medical records
 Fire investigation reports
 Relevant issues are addressed
 What happened
 To who
 When
 Where
 Why
 How
Opinion (Conclusion or Commentary)

 Cause of death
 the disease process or injury responsible for
initiating the train of events, brief or
prolonged, which produces the fatal end result

The Medico-legal autopsy.

.http://www.dundee.ac.uk/forensicmedicine/notes/autopsy.pdf
Opinion (Conclusion or Commentary)
 Mechanism of death
 thephysiologic or biochemical derangement
produced by the above cause, which is
incompatible with life, i.e., how the disease or
injury leads to death

The Medico-legal autopsy.

.http://www.dundee.ac.uk/forensicmedicine/notes/autopsy.pdf
Opinion (Conclusion or Commentary)
 Manner of death – the fashion or mode in
which the cause of death came into being:
 Natural

 Accident

 Suicide

 Homicide

 Undetermined

Forensic Pathology: Cause, manner and mechanism of death.

http://www.pathologyoutlines.com/topic/forensicscauses.html
Opinion (Conclusion or
Commentary)
Cause Mechanism Manner

Atherosclerotic coronary Electrical arrhythmia or Natural

artery disease Heart failure
Stab wounds Internal or external blood Homicide, Suicide or
loss Accident

Hanging Asphyxia Suicide

Strangulation Aspyxia Homicide

http://www.dundee.ac.uk/forensicmedicine/llb/autopsy.htm
Opinion (Conclusion or Commentary)

 May be as brief or as detailed as the need

dictates
 Directed to the law officer investigating the
death and any other legally interested
parties who may obtain access to the
report subsequently
Author/Medical Examiner
 Original signature
 May include relevant degrees and other
qualifications
System of Death Investigation
Friday, September 23, 2005
Editorials: Flawed system of death investigation

Dr. Raquel B. Rosario-Fortun, a forensic expert from the University of the Philippines in Quezon City,
talked the other day at a forum in Cebu for news reporters and photographers.

Her lecture, one of the highlights of the celebration of Cebu Press Freedom Week, dealt mainly with the
behavior of journalists at the crime scene.

Yet it could also serve very well as a crash course for the police in handling crime investigations.

Most striking in her observations of police practice is the "defective" system of investigating murders and
homicides.

Rosario-Fortun noted the probes to be not science-based and hobbled by the policy of "no-aggressive-
complainant-no-case" and the practice of relying mostly on witnesses.

Flaws of the investigation system are clearly demonstrated in police handling of the vigilante or vigilante-
style killings in Cebu City (more than 80 murders as of the last count).

The police claim that their inability to solve the "salvaging" cases is due to lack of witnesses, as if it were
the only means to solve the crimes.

Rosario-Fortun even deplored the police habit of picking up suspects on the basis of cartographic sketch
made from description of witnesses.

On the serial murders in Cebu City, since the police are unable to get witnesses, there are no cartographic
sketches and there are no suspects as well. Crime solution is zero for police investigators who do not or
cannot use forensic evidence to solve the crimes.
Case
 2 year old girl, C.A., died on a Monday morning

 Apparently well 4 days prior to her death. The following day she didn’t
feel well and complained of vague abdominal pain. She stayed in
bed, ate what was fed to her. Two days before she died, she refused
to eat. She continued to complain of abdominal pain. Her mother
noted her abdomen to become distended. Still refusing to eat the next
day, her mother’s live-in boyfriend beat her with a piece of doubled-
over electric wire. The child died the following day.

 Mother’s live-in boyfriend was arrested and imprisoned. He was

charged for violating R.A. 7610.

 The autopsy report concluded that the child died of pneumonia.

 Manner of death: No report
Death Investigation
 Competent law enforcement
 Competent medical death investigation and
forensic pathology
 Competent forensic science
 Competent public health system

POOR PERFORMANCE BY ANY ONE

OF THESE ELEMENTS ABSOLUTELY
IMPAIRS DEATH INVESTIGATION
Fierro MF, MD, Institute of Medicine Workshop on the Medicolegal Death Investigation System, 2003
 IT IS ONLY THE
PATHOLOGIST WHO HAS
THE FORMAL TRAINING AND
EXPERIENCE IN
PERFORMING AN AUTOPSY.
References
 Death Investigation: A Guideline for the Scene Investigator,
Technical Update, US Department of Justice, June 2011.
https://ncjrs.gov/pdffiles1/nij/234457.pdf
 Sanchez, TR. Medico-legal cases in. Forensic Medicine:
Facts the Public Must Know
 The Medico-legal autopsy.
.http://www.dundee.ac.uk/forensicmedicine/notes/autopsy.pdf
 Shepherd R., Simpson’s Forensic Medicine, 12th ed. 2003,
p32-33
 Forensic Pathology: Cause, manner and mechanism of death.
http://www.pathologyoutlines.com/topic/forensicscauses.html