Death Investigation Flashcards
Define Death
Death is a process not an event
Time of death is recorded as an event
No legal definition
- when doctor records it
Define taphophobia
Fear of being berried alive
Many “genuine” published accounts of premature burial
Fear peaked during cholera epidemics of 18th and 19th centenary
Features of safety coffins
Ropes of levers inside - to bell, flags or pyrotechnics Rope to church bells Window in coffin Trumpet tube Hatched with key inside Air/feeding tubes Food and water supply Shovel
Types of safety coffins
Portable death chamber
- chamber with bell and window and placed over empty grave
- watchman checked for signs of life or putrefaction over a few days
- floor opened to grave and chamber reused
Taberger Coffin design
- strings to head, hands and feet of corpse
- attached via tube to bell above ground
- housing prevented accidental ringing
- netting prevented insects entering coffin
Types of death
Apparent death - collapse, no pulse - opportunity for resuscitation - cardiac arrest, LOC Brain death - cerebral cortex - 1st - brain stem - 2nd - whole brain Somatic (clinical) death of person as whole Cellular/molecular death Putrefaction
Define resusciation
To bring someone or something back to life or consciousness
To revive from unconscious
Make active or vigorous again
Types of cardio-pulmonary resuscitation
Mouth to mouth resuscitation External cardiac massage Defibrillation Drugs - adrenaline and atropine Intubation and ventilation
Features of apparent death (suspended animation)
No or minimal signs of life Responsive to prolonged resuscitation Recognised in certain situations - electrocution - drowning - drug overdose - hypothermia - cardiac arrest in children
Clinical assessment of death
History and circumstances Signs - collapse with LOC and muscle flaccidity - cessation of heartbeat - cessation of breathing - dilated fixed pupils Physical examination Resuscitate if in doubt
Clinical triad of death
Triad of Bichat Failure of body as integrated system associated with irreversible loss of - circulation - respiration - innervation - consciousness
Stages of natural cardiac death
Disease or injury - MI Primary cardiac arrest Cerebral hypoxia - cortex in 2-3 mins - brainstem in > 4 mins - whole brain Secondary respiratory arrest - brainstem controls breathing Somatic death Cellular death
Stages of natural respiratory arrest
Disease of injury - COPD, asthma, PE Primary respiratory arrest Cerebral hypoxia - cortex in 2-3 mins - brainstem in > 4 mins - whole brain Secondary cardiac arrest Somatic death Cellular death
Causes of brain death
Cardiac arrest Other hypoxia Haemorrhage Stroke Poisoning Hypoglycaemia
Function of brain sections
Cortical - higher functions - emotions - sensation - movement Brainstem - consciousness (RAS) - respiratory centre - vasomotor centre - pulse and BP
Define whole brain death
No legal definition Brain death is nearest equivalent Necessary component is brainstem death - innervation - spontaneous respiration - heartbeat Bedside clinical diagnosis
Define persistent vegetative state
Cortical damage
- cardiac arrest, hypoxia, trauma, poisoning, hypoglycaemia
Brainstem intact
- spontaneous breathing and heartbeat
- eyes open/close cyclically, swallow, grimace intact
Awake but unaware of self or environment
No speech or purposeful movement
May live many years with nutritional support
Diagnosis of PVS
Brain damage
No awareness of self or environment
No reversible causes
Duration > 6 months
Assessment includes
- no spontaneous meaningful motor response including voice
- no language comprehension or expression
- no sustained, reproducible, purposeful or voluntary behavioural response to normal or noxious visual, auditory or tactile stimulus
Cortical death seen post-mortem
PVS vs BS Death
PVS - cortex dead - awake but unaware - spontaneous breathing - spontaneous heartbeat - moral dilemma - should they be allowed to die as no way back for higher functions BS Death - BS destroyed - unconscious - artificial ventilation - spontaneous heartbeat - no moral dilemma - stop ventilating corpse
Brainstem functions
Maintains consciousness - reticular activating system Initiates every breath - respiratory centre Controls heart rate and BP - vasomotor centre All sensory input from whole body to cortex passes through brainstem - apart from smell and vision All motor output from cortex passes through BS Medicates cranial nerve reflexes
Cranial nerves
Olfactory - smell Optic - sight Oculomotor - eye movement Trochlear - eye movement Trigeminal - face sensory Abducens- eye movement Facial - muscular control of face Vestibulo-cochlear - balance and hearing Glossopharyngeal - swallow, breathing Vagus - swallow, breathing, heart rate, intestines Accessory - muscles of shoulders Hypoglossal - muscles of tongue 2-10 can be tested at the bedside - 1, 11 and 12 cannot
Brainstem death UK code
Tests performed by 2 senior Drs (>5yrs)
Appropriate specialist
Tests repeated
Signs of BS activity
Epileptic fit - sign of cortical activity - motor nerves intact Decorticate rigidity Doll's eye reflex - eyes remain fixed on moving head
Diagnosis of BS Death
Preconditions
- deeply comatosed, requiring artificial ventilation
- cause of coma known
- reversible causes excluded
- drugs
- alcohol
- hypothermia
- diabetes
- hypothyroidism
- hypoxia
- hypotension
- SOL
Clinical tests
- pupils do not react to light - 2,3
- no corneal reflex - 3,5,7
- no nystagmus upon ear irrigation - 3,4,6,8
- no grimace to pain - 5,7
- no gag reflex - 9,10Features of the apnoea test
100% O2 for 10 mins
5% CO2 for 5 mins
Disconnect from ventilator for 10 mins
Rising CO2 fails to stimulate spontaneous breathing
Features of cellular death
Selective vulnerability to cessation of circulation - CNS - 4 mins - peripheral NS - 5 mins - muscle - 3 hours - blood cells - 6 hours - skin - 24 hours - bone, cornea - 48 hours Cells die and degenerate due to autolysis - by intracellular enzymes
Pros/cons of organ transplants
Better than mechanical devices Rejection - host antibody attacks donor antigens Tissue typing for compatibility Immuno-suppression - rejection vs infection
Types of transplant
Homologous - same patient - skin graft - bone graft - own blood Live donor - blood - bone marrow - kidney - part liver Cadaveric - heart and lungs - kidneys, liver - cornea - bone - sources - BS death due to RTA, SAH
Key points of the Human Tissue Act 2004
Regulates removal, storage and use of human tissue
Creates new offense of DNA theft
Makes it lawful to preserve organs of deceased for transplantation
Authorises museums to move human remains
Key points of Human Tissue (Scotland ) Act 2004
Transplantation
- use of parts of deceased body for transplantation, research etc
- prohibits commercial dealings in human body parts for transplantation
Post-mortem examinations
- allows for authorisation of hospital post-mortems when alive or by family - non-legal cases for medical interest
Tissue or organs no longer required for Procurator Fiscal purposes
Defines nearest relative
Key features of Anatomy Act 1832
Passed to stamp out body-snatching
Anatomists needed a licence - issued by Home Secretary
Responsibility for the proper treatment of all bodies dissected in the building
Med schools had legal access to unclaimed bodies - deaths in prison and workhouses
Purposes of Death Certificate
Information
- relatives, statistics, epidemiology, research
Disposal of body
- official recognition, registration and funeral
Proof of death
- grieving, insurance, litigation, benefits
Death certification in Scotland
Any Dr who knows cause of death Need not have attended in last illness Need not view body after death Whole death certificate given to informant (relative) 7 days to register death
Death certification in England and Wales
Dr who attended during last illness (<14 days) or Dr who attended regularly during last illness and have viewed body
Dr seeing body for first time may not certify
Slip given to informant
5 days to register death
Key points for completion of death certification
Use precise pathological terms - infarction, atherosclerosis, carcinoma Avoid imprecise terms - cardiorespiratory arrest, failure, come, old age Avoid abbreviations No need to fill every line 1a = immediate cause, due to 1b = antecedent cause due to 1c = antecedent cause due to 1d = underlying cause 2 = other influencing factors
Define stillbirth
A child that has issued forth from its mother after 20th week of pregnancy and which did not at any time after being completely expelled from its mother breath or show any signs of life
Less than 20 weeks = miscarriage and does not need a death certificate
Things need to dispose of body
Death certificate Death registered Issued certificate of disposal Funeral arrangements - burial cremation Notification of disposal back to registrar
Cremation forms needed
Application for cremation - issued by funeral directors - completed by relative in charge - countersigned by person in authority Medical certificate - completed by dr who issued death certificate Confirmatory medical certificate - completed by doctor registered > 5 years Authority from registrar Authority form PF/coroner Authority to cremate - issued by medical referee to crematorium
Death investigation purposes
Detection of homicide
Investigation of other unnatural deaths
Protection of citizen’s rights
Statistics and audit
Death investigation principles
Expedient Thorough Impartial Respectful of relative's rights E&W - 20% population autopsy rate - 33% of deaths referred - 60% have autopsy Scotland - 10% population autopsy rate - 24% deaths referred - 40% have autopsy
Key features of Scottish Legal System
Developed independently of E&W until union in 1707 then developed in parallel
Duty of PF to inquire into sudden, suspicious, accidental, unexpected and unexplained death occurring in their jurisdiction
In pursuance of public interest to eradicate dangers to health and life, allay public anxiety and ensure full and accurate statistics
Decision to issue DC or refer to PF
Was death primarily natural or unnatural Any unnatural factors - assault - RTC - accident - fall Do not refer to PF because relative refuse permission for hospital autopsy
Deaths to refer to PF
Uncertified death Outdoor death, residence unknown Violent, suspicious or unexplained Sudden and unexpected Accident involving a vehicle Any other accident Death at work Industrial accident, disease or poisoning Circumstances suggest suicide Poisoning - accidental or deliberate Death under medical care Defect in medicinal product Food poisoning or infectious disease Neglect or fault of another Abortion/attempted abortion Newborn child whose body is found Cot death - SIDS Suffocation or overlaying Death of foster child Death in legal custody - prison, police custody Drowning Fire, explosion, burns or scalds
Features of referred deaths under medical care
Clinically unexplained Unexpected with regard to condition Attributable to diagnostic or therapeutic hazard Negligence suggested Death during anaesthesia Complication of anaesthetic or surgery
Features/investigations of deaths under medical care PF specific interest
Was patient properly examined
Were all due precautions followed
Were there any special risks which should have been discovered
Deaths PF primary interests
Criminal involvement - assault - RTA Unnatural - suicide - homicide - accident Medical mishap - accident - negligence
Types of medical mishap
Delay in treatment Breakdown in communication Inappropriate medication Equipment failure Surgical mishap - accident - unusual difficulties
Define negligence
Breach of duty of care as a result of which there is damage to another
Legal duty of care owed
Breach of duty by omission or commission
Provable causal link between action and harm
Appropriate standard of care judged against body of opinion in filed
Types of authority for autopsy from PF
2 doctor autopsy - homicide - suspicious - RTA 1 doctor autopsy - suicide - accident - some natural disease 1 doctor or view and grant - natural View and grant preferred - family objection All can be +/- toxicology
PF further options
Make further inquires and precognition Involve other offices - health and safety executives - public health Close case on own authority Refer to Crown Office
Deaths PF must refer to Crown Office
Suspicious death Criminality involved Suicide Represents danger to public safety Medical mishap Where FAI (fatal accident inquiry) is mandatory - fatal accident at work - death in custody Where FAI have been requested by family Death of police officer Death due to fire or explosion Any other death causing concern
Features of fatal accident inquiry
Mandatory under 1976 act - fatal accident in course of employment - death in legal custody At discretion of LA - gives rise to public concern - hospital negligence - public transport accident Determines who, when, where, how and why death occurred Does not apportion blame
Deaths requiring coroners inquest in E&W
Death in prison Death in police custody Death notifiable to government department Circumstances prejudicial to public Some RTAs
Coroners inquests are adjourned for
Murder Manslaughter Infanticide Death by dangerous driving Suicide with abetment May resume after clinical proceedings
Coroner inquest verdicts
Died from natural causes
Died from industrial disease
Died from dependence on drugs / non-dependent abuse of drugs
Killed themselves - whilst in the balance of mind was disturbed
Died as a result of accident/misadventure
Was killed lawfully
Was killed unlawfully - murder, manslaughter, infanticide
Died as a result of attempted/self-induced abortion
Was stillborn
Died from want of attention at birth
Open verdict
