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Back to Archives | Back to November 2007 Contents 

The Role of Medical Examiners in Law Enforcement

By J. C. Upshaw Downs, M.D., Coastal Regional Medical Examiner, Georgia Bureau of Investigation, Savannah, Georgia

he significance of modern forensic science to law enforcement is nowhere more evident than in the investigation of fatality cases. The level of cooperation between the death investigation team and police can literally make or break a case. Though generally familiar with the basics of how to deal with a dead body (certainly on an operational, local level), officers may not be cognizant of the roles and qualifications of all the various parties involved. With improved understanding of the principles and the nature of forensic pathology, law enforcement executives will be better able to maximize their investigative assets by careful allocation of limited resources.

Death Investigation Systems

One of the most important cogs in the forensic system—the investigation of sudden, unattended deaths—can often seem one of the most frustrating. The death investigation system in the United States is a hodgepodge, modified hand-me-down inherited from English common law. The lack of uniformity is evidenced by the fact that there are in excess of 2,300 different systems in the 3,137 U.S. counties. The biggest discrepancy is in the local official actually charged with operating the death investigation system. Historically, that duty has fallen to the coroner. At present, roughly half the population is served by coroners and the other half by medical examiners (MEs). Typically, MEs serve more urban populations, coroners more rural. Currently, 239 ME systems serve 31 percent of U.S. counties (960).

Although the systems vary, types of deaths commonly under medical examiner/coroner (ME/C) jurisdiction are usually similar, regardless of jurisdiction. In general, sudden, unnatural, unexpected, unexplained, and/or suspicious deaths, as well as those believed to possibly be related to physical or chemical (poisons, drugs, medicines, and so on) trauma, are considered ME/C cases. Some areas have additional specific criteria such as matters of public health or medical therapy–associated deaths, but these vary widely. In addition, fatalities for which no physician of record is available to sign a death certificate and cases where death occurred in custody require investigation. An important and sometimes forgotten precept is that the temporal association between a physical and/or chemical insult and death is not important in determining ME/C jurisdictional issues; however, it may have important ramifications in the legal realm.

Although allusions to the office of coroner date as far back as the Dark Ages, the first clear description of the office came about in 1194 under the reign of Richard the Lionheart. Among the duties of the office was to hold the pleas to the crown (in Latin, custos placitorum coronae), which became known as the “crowner” or “coroner.” Originally, the coroner was an appointed, unpaid nobleman considered above reproach. In fact, one important duty of the coroner was to keep an eye on the (at that time often corrupt) sheriff. This is a tradition in many (if not most) areas that continues to the present day: the coroner is vested with the power to serve subpoenas on and, when necessary, arrest the sheriff.

The well-entrenched traditional office of coroner migrated to North America with the colonists and continues to the present day in some 28 states. At present, the office of coroner is usually elected (though appointed in Hawaii, Kansas, and North Dakota). In general, qualifications are minimal, except in a few states where coroners are required to be physicians (Louisiana, Ohio, Kansas, and North Dakota). Implicit in such a legal requirement is an apparent belief that a medical degree confers expertise in the specialty of death investigation, which may not necessarily be the case. In other jurisdictions, the coroner serves as justice of the peace (Texas), a law enforcement official (parts of California), or a prosecutor (Nebraska and parts of Washington). Depending on the location, the coroner is quite often a part-time and poorly paid job, considered a public service. There may be minimal educational requirements (less than 1/3 of states require coroner training).

The modernization and professionalization of death investigation began in the United States in Baltimore, Maryland, in 1890, when physician MEs were required to perform autopsies for the coroner. It was not until 1918 that New York City formed the first true ME office. At present, the term medical examiner is reserved for a physician who conducts autopsy examinations on decedents in order to determine the cause and manner of death. After completing medical school, ideally, the ME is trained in the specialty of anatomic pathology and in the subspecialty of forensic pathology by an accredited institution. In the United States, baseline minimal educational and competency criteria are demonstrated by achieving certification in the subspecialty of forensic pathology through the American Board of Pathology.

For police agencies, these distinctions may prove significant in terms of ensuring that all appropriate deaths are examined by a competent and qualified professional. Certainly, lay coroner offices are cheaper to run than an ME office—but at what ultimate cost? Some deaths may not be quite as simple as they appear; in the following scenarios, bodies should routinely be brought in for consultation/examination: homicides, firearms deaths, bodies recovered in water (apparent drownings), bodies recovered from fires (apparent fire deaths), decomposed bodies, and child deaths—to name but a few. However, not all such bodies are examined in some jurisdictions; some death investigators may lament inadequate resources and the need to conserve in order to ensure that high-profile cases (including homicides) get the attention they merit. The cost is relatively cheap, less than $3.00 per capita for a county ME system and less than $2.00 per capita for a state system. The question for local planning becomes where to spend a jurisdiction’s limited funds.

Law enforcement should have confidence that all cases where foul play is a potential concern are adequately evaluated. This goal is best achieved when the local system measures up. In the long run, an adequately funded professional death investigation system can save tremendous resources—for multiple agencies—by getting valid answers fast and allowing other agencies to concentrate on more pressing matters.

Cause and Manner of Death

The primary duty of MEs is to determine the cause and manner of death. In certain cases, these data will be presented in court to assist the trier of fact in determining what happened and how it happened. Though seemingly straightforward, both cause and manner are opinions based on practitioner education and training. On occasion, despite the same set of facts, different MEs call the cause and/or manner of death differently. Law enforcement should be aware that the ultimate goal for MEs is to apply the same logic to the same fact set and maintain internal consistency in making a determination. In this way, concerns about arbitrary rulings may be minimized.

Cause of death is a determination of how a death came to happen—what physical event occurred to cause cessation of life at a particular point in time. Typically, MEs are concerned with the proximate or underlying cause of death, defined as the initial event which started the unbroken chain of events culminating in an individual’s demise. Note that time is not a consideration in making this determination—only that an event occurred, and following an uninterrupted sequence, a person died. In trauma and many medical settings, the cause is obvious. For example, in a motor vehicle crash the cause is often “blunt force injury,” which an ME may then further specify as to location, and in a firearm-related death, the cause would be “gunshot wound.” A heart attack might be called “arteriosclerotic coronary vascular disease” or “coronary artery disease” or one of several other synonyms. In general, the cause of death is determined medically by examination (directly via examination of the body, indirectly via records review, or a combination). In this regard, MEs are true medical detectives, and the witness is the body.

In some deaths, the findings are general and nonspecific, thus requiring additional testing. Such procedures may include toxicology testing, special chemistry (electrolytes in eye fluid), metabolic screening (for inherited disease), microscopic examination, and so on. In some instances, when no clear cause of death is immediately observable after a complete autopsy, the cause is left pending these further studies, and a final determination may take weeks or months. Likewise, an ME may have a specific concern regarding a particular organ (most commonly the brain or, less often, the heart or other organ/tissue) and may decide to preserve that specimen in fixative to allow a more detailed examination once the specimen has been properly preserved. Again, the final ruling may be deferred to the results of such testing.

The manner of death is a shorthand description of the circumstances by which the cause of death came to occur and is determined primarily by investigation. There are five accepted categories of manner: natural, accident, suicide, homicide, and undetermined. Different professionals define these terms in different ways, but in general, the following definitions hold true:

  • Natural: death where trauma or foul play is excluded

  • Accident: death associated with an unforeseen or reasonably unforeseeable event

  • Homicide: death of one at the hand of another

  • Suicide: death by one’s own hand

  • Undetermined: insufficient data exist to classify the death in another category

Note that “intent” is not explicit in any of these definitions, especially homicide and suicide. Intent is a legal construct and a matter for determination by the courts. For this reason, the act of homicide may carry with it any of several legal descriptors: criminally negligent, manslaughter, or murder, for example. Put another way, the act of homicide is not necessarily murder or even illegal. If a killing is determined to be legally justified, as in self-defense or an act of war, then there is no further criminal legal action. Police would encounter such a case most often in situations where deadly force was employed in the line of duty. This issue is discussed in more detail later.

Many would argue that intent is requisite to committing suicide; however, the explicit intent dies with the perpetrator. In some instances, someone may take a drug overdose in an effort to get attention and then call someone on the telephone hoping to be “rescued.” If the rescue never occurs or is unsuccessful, the manner of death is still suicide. Many MEs argue that intent is implicit in the act of an overdose or a gunshot wound to the head. Although there is no way to disprove such a belief, there is also little need to invoke the necessity of requisite intent in such cases. In fact, suicide cases can be some of the most time consuming for detectives. Family members frequently want to meet with investigators to discuss their understanding of events and their conviction that the decedent did not “intend” to die. Law enforcement officers may find it advantageous to remove discussion about perceived or vicarious intent in such conversations. This tactic serves multiple purposes, including setting aside the largely unknowable matter of a decedent’s terminal thoughts and emotions while focusing attention on demonstrable physical facts.

For an example of a more complex interaction of cause and manner, an ME examines a body and determines the manner of death to be coronary artery disease. Although the death appears to be natural, the circumstances paint a different picture. The victim, a long-term cardiac patient, is staffing a liquor store late at night when a robber brandishes a gun and threatens to shoot him unless given money. The decedent is stressed by the events and collapses from a “heart attack.” Very clearly, the illegal act of the robber is the event precipitating death, and equally clearly, the robber was responsible for his act. The perpetrator does not have the luxury of choosing the health status of the victim. In short, the victim was alive before it started and deceased afterwards. In this case, the cause may be certified as stress cardiomyopathy and the manner as homicide—despite the fact that the assailant never laid a finger on the victim and despite the chronic nature of the natural disease.

Another caution is that typically, commentary on adequacy and/or appropriateness of medical care is not considered in the determination of cause and manner of death. This principle is illustrated by a scenario wherein an individual sustains a gunshot wound to the buttocks, severing the femoral artery. The ambulance is delayed in arriving on the scene, and it takes 90 minutes to transport the individual to the hospital room, where he arrives without vital signs. With aggressive efforts, the patient is resuscitated and stabilized. Three days later, while still in the hospital, the victim begins to ooze blood from his wound and several intravenous and tube sites resulting from a medical loss of clotting factors. The patient’s eventual death directly resulted from the original gunshot wound, although it took a somewhat circuitous route. The perpetrator is responsible for the ultimate outcome, as the criminal act necessitated the medical treatment in the first place. Medical care is not a guarantee of a desired outcome; therefore, attackers bear the responsibility of their actions.

Death Scene

An old investigative pearl of wisdom is that cases are won or lost at the scene. Numerous parties may be part of a death scene, including family, patrol officers, emergency medical services (EMS), fire department staff, ME/C staff, and detectives. The most effective scene processing takes place when all parties understand and respect the needs and duties of the others.

The ME/C has jurisdiction over the body; however, the law enforcement agency in whose jurisdiction the body is found has ultimate responsibility for the scene. If necessary, access to the body may be restricted until such time as any potential evidence in the area is properly documented and secured. A competing concern may be determination of the time of death by the ME/C. Although there is no precise way to determine a specific time of death other than having a witness with a watch, the professional death investigator may make certain observations regarding classic postmortem changes such as rigor mortis (muscle stiffening), livor mortis (skin blood pooling), and algor mortis (cooling). By placing these facts in context, MEs may be invaluable to investigators in helping to narrow the window of potential time since onset of death.

MEs can also serve as resources at the scene by recognizing specific pattern injuries that others may miss. Such analyses are most commonly performed at autopsy, as scene lighting conditions and space are seldom suited to detailed exams; however, if performed at the scene, such an examination may allow crime scene specialists to secure certain specific evidence items immediately, before the scene is released, which would necessitate another search, and would avoid the risk of the suspect destroying physical evidence.

Three examples follow.
Case 1
Case 1: An infant victim of multiple blunt force injuries. The illustrated wound is a pattern burn on the abdomen caused by a disposable lighter. Although recognized at autopsy, the assailant’s disposable lighters had been thrown away before being secured for a potential comparison.

Case 2
Case 2: A middle-aged homicide victim, who was beaten multiple times with a pair of channel-lock pliers. The front of the decedent’s neck had three overlapping patterns of the neck being grabbed with the teeth of the pliers, confirming that strangulation had also occurred.

Case 3
Case 3: A young child whose abandoned body was recovered from the woods. Multiple pattern injuries on the body led law enforcement officers to secure belts and a portion of PVC pipe, which were matched back to the wounds.

Experts and Differences of Opinion

A particularly frustrating, though fortunately uncommon, situation for police is when an investigation ends with an ME and investigators reaching different opinions about a cause or, more commonly, a manner of death. Problems can be avoided in such situations by communication. Different perceptions of events and/or a misunderstanding of terms used can cause confusion. In some criminal cases, despite a thorough and complete investigation by qualified individuals, the defense may retain an expert with a different opinion regarding the same set of facts. The ME’s decision should not reflect on personal views or on remuneration regarding a case but on the facts as known when the decision is rendered—and may be revisited if additional investigative information is forthcoming.

A seemingly self-evident cause of death may not appear as straightforward when put into context. In a high-speed pursuit, a police cruiser forces a fleeing vehicle off the road and into a tree, killing the driver. The cause of death would be blunt-force injury from the crash. Determination of the manner of death would require careful consideration of all the case facts. An ME would typically have little knowledge regarding use-of-force issues and would instead rely on an overview of the situation. Clearly, the officers involved in the chase were making a decision to stop a speeding vehicle they recognized as a threat. In order to achieve that end, the officers used the lone available effective weapon at their disposal at the time: their cruiser. Despite the relative safety of appropriately applied precision intervention technique (PIT) maneuvers, such maneuvers are not without risk and carry no assurance of a good outcome. In such a case, the manner is appropriately certified as homicide. One way to avoid controversy in such cases is to remove the law enforcement element from the scenario—what would the results be if this were a criminal-on-citizen activity?

A recent area of apparent controversy in death certification is in cases involving a condition formerly called “shaken baby syndrome” but now known by numerous appellations, including shaken/impact syndrome, nonaccidental trauma, closed-head injury, inflicted head trauma, and others. The media have publicized several cases over the last few years suggesting that medical professionals differ widely on this diagnosis. The reality is that such claims make for good stories but have little basis in substantive fact. The typical case involves an infant or young toddler who sustains a severe head injury with a reported history of minor trauma. A complete autopsy reveals certain specific physical findings that fit the clinical picture of multiple inflicted blunt-force injuries. At trial, the defense will often retain an expert who will point out that several of the findings may be seen in other nontraumatic medical conditions, in an attempt to raise doubt. Law enforcement consultation with the ME and other medical professionals before trial is essential to ensure that clever attempts at obfuscation do not jeopardize a complex police investigation and that justice is served. The ME may assist by anticipating questions and providing investigative leads in following the investigation.

In addition, MEs may be able to assist investigators of nonlethal trauma events. As experts in the examination of wounds, MEs may be consulted in appropriate trauma cases. Unfortunately, due to the stigma associated with using resources located in the morgue, many agencies do not take advantage of such a tremendous asset usually close at hand.

Suggestions for Improved Cooperation

To maximize understanding among the disparate stakeholders involved in the professional death investigation process and foster improved communication, law enforcement agencies and ME/Cs should increase their exposure to each other’s area of expertise.

ME/Cs could provide in-service trainings, tailored to specific community/law enforcement needs. Local death investigators would be invited to present an overview of local laws and preferences. Such opportunities would be tiered to reach different levels of the command structure, such as patrol officers, detectives, and command staff. Ideally, patrol officers would learn the basics of how to proceed in a broad variety of general cases, most importantly when to secure the scene for potential evidence and when to call in investigative assistance. Detectives would understand how pathology evidence can facilitate a specific type of investigation. Command staff would become familiar with resources and availability of ME/C staff to better formulate strategic plans.

Police agencies could have staff rotate through the ME office as interns in order to increase exposure to how the office operates and what procedures are employed. In addition, staff would have the opportunity to examine bodies in various states of decomposition and with various injuries and natural diseases in order to become more familiar with the information that might be available from an autopsy exam. In addition, MEs should be readily available to explain pertinent findings and answer questions.

Some jurisdictions have found significant benefit in establishing interoffice liaisons with the ME office. In large jurisdictions, this may go as far as assigning staff directly to the morgue.

One area in need of major attention in most regions is mass disaster planning. A typical jurisdiction has one or at most very few MEs available. Morgue facilities are usually borderline sufficient to handle routine daily caseloads. In the event of a major event such as a terrorist act, ME/Cs may lack the physical plant or other resources to adequately assist other first responders. Law enforcement agencies should aggressively work with their death investigation system to understand and anticipate limitations and to ensure that operations can continue in a worst-case scenario.

Different MEs have different comfort levels. There is no “one-size-fits-all” answer. The better the investigation on the front end, the better the result on the back end and the less chance that investigators will be left without answers.

The U.S. National Institute of Justice has created a protocol for death scene investigation with the motto “every scene, every time,” which may be of assistance in creating a strategic response plan.1 In addition, the U.S. Centers for Disease Control have recently developed a standard protocol for the investigation of sudden child deaths.2

In all deaths, especially suspicious and child fatalities, the following suggestions may assist an ME’s investigation:

  • Take copious photos (high-quality digital photos are preferred) of the scene and bring them to the autopsy

  • Collect suspect weapons and allow the ME to examine and compare them to wounds

  • Collect all containers of prescription and over-the-counter medications administered or prescribed for decedent

  • Collect water sample if pertinent

  • Check for/document potential environmental issues (possibility of electrocution, heat/cold, gases, and so on)

  • Obtain history from the very last person to see the decedent alive

  • Obtain history from the very first person to find the person dead

  • Obtain the 9-1-1 recording if available (digital copy preferred)

  • Obtain EMS records, emergency room records, and hospital records

  • Obtain past medical records (birth to death in a child case)

  • Check social services and other agency history

  • Collect the decedent’s clothing (leave on body, if possible)

  • Collect other objects of potential significance in the victim’s immediate environment (in child deaths, this includes bedding, pillows, parents’ clothing, and so on)

  • For cases of child death, collect bottles, cups, foods, and other items to which the child was recently exposed

  • Measure thicknesses of fabrics, bedding, and so forth

  • Measure heights, water temperatures, times to fill bathtubs, and so forth

  • Check/photograph water heater in burn cases, including documenting if any action (such as flushing a toilet) makes the water hot/cold

  • Reconstruct events in child deaths: have the individuals who found the body and/or last saw the child alive use a doll or stuffed animal to show exactly what they saw or did and photograph it (this may involve the use of bedding and so forth to show how the child was positioned)

An essential bonus: have officers show up for the autopsy with someone who has as many of the above materials as possible and who knows the details of the case.

This list, while not all-inclusive, is a good start for anyone investigating a suspicious or child death.■


1U.S. Department of Justice, Office of Justice Programs, National Institute of Justice, Death Investigation: A Guide for the Scene Investigator, November 1999, (accessed September 24, 2007).
2U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, “Sudden, Unexplained Infant Death Initiative (SUIDI): How to Use the SUIDI Reporting Form,” (accessed September 24, 2007).



From The Police Chief, vol. 74, no. 11, November 2007. Copyright held by the International Association of Chiefs of Police, 515 North Washington Street, Alexandria, VA 22314 USA.

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