1. Death Investigation in Wisconsin and The United States Michael A. Stier, MD Assoc. Prof. of Forensic Pathology UW School of Medicine & Public Health

2. What Happens When Death Occurs? Death is defined by the presence of irreversible brain injury incompatible with sustaining life. Cultural death rituals follow (funeral, etc) A death certificate is issued.

3. Purpose of Certifying Death Investigate the death on limited basis. Issue a statement of Cause of Death. Issue a statement of Manner of Death. Create proof of death for legal purposes. Register lethal processes for public health and epidemiological purposes.

4. Cause and Manner of Death Cause – The specific principle event or process resulting in loss of life (not mechanism). Manner – Attempts to assign responsibility of the death to “man,” “God,” or neither. – Natural – a death due to natural processes – Accident – a spontaneous act of “God” – Homicide – intentional actions of another human – Suicide – intentionally ending one’s own life – Undetermined – Not otherwise classifiable

5. Who Issues Death Certificates? Physicians – In Wisconsin, only natural deaths Coroners – Elected persons Medical Examiners – Appointed persons District Attorneys Justice of the Peace Sherriff and other law enforcement

6. Death Investigation Myth #1 All physicians are good death investigators. FALSE: Despite death always being a medical event, current medical education does not teach certification of death and autopsy.

7. For unnatural deaths in Wisconsin One-third of counties are ME – Legal Requirements - none The other two-thirds are Coroners – Legal requirements – must be 18, a non- felon, be a resident of the county, and win county election

8. Forensic Pathologist The Gold Standard for Death Investigation Has an MD and specialty training in anatomic and forensic pathology Is employed in an ME Office, an academic institution, or privately Standards of practice are not set

9. Death Investigation Myth #2 Only true and suspect homicide victims need autopsy. FALSE: Any potentially un-natural death should have an autopsy, and unexpected probable natural deaths. Criteria in Wisconsin are non-uniform and county dependent.

10. Authorization for the Autopsy Local Coroner or “Medical Examiner” Federally mandated autopsies Families for natural deaths District attorneys and law enforcement agencies have input.

11. General Outline for the Procedure Gathering appropriate historical information Scheduling pre-autopsy procedures i.e. X-ray Performing an external exam and collecting case appropriate evidence & photography Exploring the internal morbid anatomy Sampling for toxicologic testing Performing organ specific dissection Interpreting histology and other test data

12. Death Investigation Myth #3 The medicolegal autopsy/investigation is criminally or prosecution oriented. FALSE: The comprehensive forensic autopsy is a fact finding, evidence gathering, and documentation oriented procedure.

13. Items to Have at the Autopsy All clothing items Scene photography (digital) In questionable suicides – Any possible suicide note – Any potential weapon – The ligature in hangings In probable homicides – The probable weapon (s)

14. Death Investigation Myth #4 Poisons are always detected by the toxicologist. FALSE: In the era of cost savings, broad spectrum toxicologic testing is a thing of the past.... And some toxins require specific non-routine testing procedures.

15. Death Investigation Myth #5 Cause and manner of death are the only results of autopsy. FALSE: Other routinely identified findings include relevant diseases or heritable conditions.

16. Death Investigation Myth #6 The autopsy is over when the body leaves the room. FALSE: Additional investigation is ongoing after the main procedure and the pathologist continues to correlate case information.

17. Livor mortis & Timing of Death Livor develops over time after death. At about 8-12 hours after death, redistributed blood coagulates & the livor becomes fixed. Before this time, livor can be blanched by firm digital pressure on the skin. Livor won’t form in areas of pressure on skin.