Death Investigation and Coroner's Service

Question 1

Which deaths are investigated and what are the exceptions?

Answer 1

ALL deaths are investigated unless the death occurred under a doctor’s care of known terminal illness

Question 2

What are 5 reasons for conducting an investigation?

Answer 2

1. determine if crime occurred
2. establish cause of death
3. closure for family
4. insurance issues
5. prevent future deaths

Question 3

What 5 questions need to be answered in an investigation?

Answer 3

1. Who - identity of victim
2. When - time of death
3. Where - at the death scene or else where
4. Why - medical cause of death
5. How - mechanism of death

Question 4

History of Death Investigation

Answer 4

• Coroner system in England arose in 900AD
• Coroners appointed by king to examine bodies, scene, inquests, and arrests (called Crowners)
• After Norman Conquest in England, Coroners and jury had to determine if descendent was of Norman descent
• if they were Norman everyone in the area had to pay Murdrum tax

Question 5

What is the role of the Coroner / Medical Examiner in Death Investigation?

Answer 5

• to investigate unexpected and unexplained deaths
• assist police with suspicious deaths
• attend scene, contract F. Pathologist for autopsy, contract secure body removal

Question 6

How have Coroners contributed to death investigation?

Answer 6

• administration of justice
• help the bereaved
• make findings public
• increase knowledge

Question 7

What do Coroners do at a crime scene?

Answer 7

1. broad rights to search and seizure (cannot give to police - need warrant)
2. collect evidence (drugs, suicide notes, weapons)
3. note position of body and injuries

Question 8

What additional resources are available to Coroners?

Answer 8

• Pathologist
• Toxicologist
• psychiatrists, psychologists
• friends, family, and colleagues
• WorkSafeBC

Question 9

What types of deaths are investigated?

Answer 9

1. deaths from violence, accidents, negligence, misconduct, malpractice
2. self-inflicted illness / injury
3. sudden, unexpected deaths (no Dr.)
4. illness with unknown causes (no Dr.)
5. maternal and child deaths
6. deaths in custody
7. deaths from involuntary patients

Question 10

What are the 5 categories for Manner of Death?

Answer 10

1. suicide
2. homicide
3. accidental
4. natural
5. undetermined

Question 11

What is a homicide?

Answer 11

• intentional infliction of injury to cause death
• 1st degree, 2 degree, manslaughter
• coroner does not assign blame

Question 12

What is defined as a suicide?

Answer 12

• intentional taking of one’s life
• some deaths can appear to be a suicide, but were accidental
• if there are doubts, death is ruled accidental or undetermined*

Question 13

What is an accidental death?

Answer 13

• death caused by unexpected or unintentional injury
• could have occurred earlier but eventually resulted in death
• requires detailed analysis and further investigation to ensure it’s not suicide or homicide*

Question 14

What is a natural death?

Answer 14

• can include disease and continual environmental abuse
• Ex: chronic drug and alcohol abuse
• need to conduct a further investigation into individual’s past to determine if it was natural or a suicide*

Question 15

What is an undetermined death?

Answer 15

• no obvious reason for death or insufficient evidence

Question 16

What is a delayed death?

Answer 16

• Ex: someone falls and survives, get pneumonia in hospital and dies from disease
• death is not natural but an accident due to fall*

Question 17

Compare and contrast Coroners and MEs

Answer 17

Coroner:

• can have no relevant background or many
• oversee death investigation
• attend death scene
• hire forensic path. to conduct autopsy
• have judicial powers (provide recommendations through inquests)

Medical Examiner:

• need to be doctor or GP
• oversee death investigation
• attend death scene
• hire forensic path. to conduct autopsy (can do external autopsy)
• no judicial powers

Question 18

What is a Coroner’s Report?

Answer 18

• public document that answers the 5 Qs

- Coroner signs death certificate (allowed to presume death and issue death certificate without body - missing person)

Question 19

What is a Coroner’s inquest?

Answer 19

• jury consisting of 5-7 people
• hear evidence from lay witness and expert witness
• do not assign guilt
• make circumstances surrounding death public and make recommendations to prevent further deaths

Question 20

What is a Forensic Pathologist?

Answer 20

• medical doctor that specializes in the study of disease and conducts autopsies
• rarely attends death scene
• no judicial powers
• can testify as expert witness

Question 21

What is an autopsy and who conducts it?

Answer 21

examination of the body after death

performed by forensic pathologist

Question 22

Forensic vs. Clinical autopsy

Answer 22

forensic = goal is to determine cause of death , manner of death
clinical = goal is to understand disease progression

Question 23

Cause vs. Mode of death

Answer 23

cause = medical explanation of death 
mode = mechanism or explanation of death

Question 24

What does an external examination include?

Answer 24

• physical characteristics (sex, age, identifying marks)
• time since death indicators (liver or rigor mortis, temperature)
• x-rays
• fingernail scraping, hair and pubic combing, sexual organs swabbed
• wound examination
• photography and notes

Question 25

What does an internal examination include?

Answer 25

• Y-incision
• organ removal
• examination of stomach contents (give idea of time of death)
• sample collection from each organ
• head and brain examination

Question 26

What information can wound interpretation provide?

Answer 26

• type of wound (incision, blunt trauma, thermal)
• instrument used
• location of wound (suicide or homicide)
• type of attack (frenzied or defensive)
• mode and manner of death

Question 27

Why does the NAS recommend eliminating the Coroners system and replacing it with the medical examiners system?

Answer 27

• coroners are often elected and thus do not require medical qualifications
• have two systems makes reporting difficult