Presentation on theme: "Deborah Radisch, MD, MPH January 24, 2014"— Presentation transcript:
1 Deborah Radisch, MD, MPH January 24, 2014 North Carolina Medical Examiner System and the Office of the Chief Medical ExaminerDeborah Radisch, MD, MPHJanuary 24, 2014
2 Organization of Death Investigation Systems in the US Coroner – elected, usually lay official. County centered and funded. A few jurisdictions require that candidates be physicians and/or provide sufficient funding to obtain medical expertise. May hire pathologists to conduct exams but final decisions about/certification of cause and manner of death in individual cases may be made by the coroner.Medical Examiner – appointed, physician / medical knowledge. May have county or statewide jurisdiction. May be a forensic pathologist or not. County centered systems, county systems with central oversight, district systems.Justice of the peace, district attorneySystems can be mixed and vary from state to state and in some states from county to countyTHERE IS NO STANDARDIZED NATIONAL DEATH INVESTIGATION SYSTEM
4 North Carolina ME System Based on model legislation similar to that already in place in Maryland and Virginia. It was intended to utilize the pre-existing facilities and personnel that comprised the medical health care delivery system, local hospitals and physicians, to provide county medicolegal death investigation servicesCentral oversight and professional support for the local MEs would be provided by the Office of the Chief Medical Examiner which would be a state functionWhile it was originally intended that only MDs would serve as MEs the original statute allowed the coroner to serve as “acting” ME until a physician could be found and over the years PAs and RNs have also served as “acting” MEsIt can be seen as a public/private cooperative enterprise with the current funding ~ 60% state dollars and 40% county
5 Major Program Areas Medicolegal Death Investigation State County Medical Examiners“de facto” Regional Centers /PathologistsCentral OfficeAdministrativeSupportPathologistsToxicologistsITChild Fatality Prevention Team
6 ME Cases in NC ~ 11,000 cases investigated per year Of those, ~ 4500 are autopsied2013 estimate:OCME autopsiesOCME externals
7 Deaths Requiring Medicolegal Investigation Unattended natural deathsNo physicianPhysician but no life-threatening illnessBreak in medical care, but no specific time limit since last visitVisitors to NC, stranger from afar, non attendance by virtue of geographySudden, unexpected, apparently natural deathsDeaths due to external causes = unnaturalManner: accident, suicide, homicide, undeterminedInjury can be due to physical, chemical, thermal, electrical forces or radiationThe injury may be the sole cause of death or contributoryThere is no time limit between the time of injury and death as long as the two can be linked causally, even if years have passed (proximate cause)
8 Deaths Requiring Medicolegal Investigation Other Cases Deaths possibly due to contagious disease – public health threat when a diagnosis must be established in order to determine whether others have been exposed and might need prophylactic treatment Bioterrorism Deaths in jail, prison or other correctional facility, under police custody or control Suspicious deaths Deaths in certain state institutions (Divisions of Mental Health, Developmental Disabilities and Substance Abuse Services)
9 County Medical Examiners PhysiciansPhysician Extenders (PA, FNP)NursesEMT-ParamedicsLay
10 ME Records and Payments ME Report of InvestigationMust be sent to the OCME within 14 daysServes as an invoice ($100)ME Death Certificate - medical certification must be completed within 3 days and the DC filed with the health department within 5 days. The health dept. sends a copy to the OCMEAutopsy ReportTo the OCME by 180 days$1250
11 ME RecordsME Reports, ME Autopsy Reports, and results of toxicology tests become public records available to any requester after receipt and review at the OCMEDeath Certificates are also public records, but copies must be obtained through vital records at the state or county level
12 OCME as Medical Examiner OCME serves as the primary medical examiner for Wake, Franklin, and Durham counties, regular back-up for several close-by counties, and potential back-up for any county or regional pathology center
13 Death Investigation Realities CONTRARY TO THE PUBLIC IMPRESSION OF HOW DEATH INVESTIGATIONS ARE CONDUCTED – the “CSI EFFECT”Crime scene processing is conducted by crime scene techniciansEvidence is analyzed by crime lab techniciansCrimes are investigated by law enforcement officers and they identify interrogate and arrest suspectsThe court system decides matters of guilt and innocenceThe role of the Medical Examiner in criminal matters is to provide sound, medically based evidence in regard to the cause (and manner) of death of the victimThe role of the ME is to determine WHAT DID IT, NOT WHO
14 Case FlowLaw Enforcement, first responders (EMS, Rescue, Fire Departments), medical personnelCounty Medical ExaminersRegional PathologistsOCME
15 Regional Centers Brody School of Medicine-Greenville 4 Forensic PathologistsWFU School of Medicine-Winston-Salem3 Forensic PathologistsMecklenburg County-CharlotteOtherJacksonville*, Clinton, Hickory, Sylva, Lumberton (no ABP certified FPs)
16 Medical Examiner Autopsies in North Carolina Current centersCurrent pathologistsFuture regional offices ??
17 Medicolegal AutopsyNot every death that comes under medical examiner jurisdiction requires an autopsyAn autopsy is “ordered” when it is deemed “advisable and in the public interest” as defined by guidelines promulgated by the OCMEME autopsies do not require the consent of the next of kin and an objection by the NOK is not a bar to the examAll ME autopsies are complete autopsiesMedicolegal autopsies are performed by designated regional pathologists or by the OCME Pathology BranchA little over 40% of ME cases in NC are autopsied. Not all trauma deaths have an autopsy
18 Medicolegal Autopsy Purposes : Identification Collect evidence Document injuries and natural diseaseCollect samples for special testingTry to narrow down where and when injured/diedOpinion as to cause and manner of death
19 Central Office Functions AdministrativeCase ManagementAssemble case files for all ME cases in NC except Mecklenburg countyPublic interfaceSubpoena managementCase coding and data entryBudgetPurchasingIT
20 Central Office Functions Pathology SupportTranscriptionHistology: includes Mecklenburg, for ~2000 cases per year, average of 6 glass slides per caseMorgue technician staffRadiologyPhotographyInvestigationAncillary:AnthropologyOdontologyNeuropathologyLaboratory
21 Central Office Functions Six forensic pathologists and one fellow (training)AutopsiesReview all ME cases in NC = QA, before public recordConsultationTestifyTeachingMass fatality planning and management
22 Central Office Functions Court TestimonyIn 2011, OCME pathologists testified in court 39 times, a fraction of the subpoenas they received and for which they were on telephone stand-by. The total time, travel and court (testimony and waiting), was 190 hours.Toxicologists are being subpoenaed to appear more frequently (Melendez-Diaz).
23 Central Office Functions TeachingForensic Pathology FellowshipProgram DirectorPathology Residents (1 month required)UNC, DukeMedical StudentsSecond year (all) and elective rotationPathology Assistant Students (Duke)Miscellaneous presentations
24 Central Office Functions ToxicologyAll ME testing in NCMore than 10,000 cases per year, with more than twice that many analysesScreen, then confirm and quantitate
25 Central Office Functions Child Fatality Prevention Team2 (-1)Investigator/TrainerResearcher
27 Major Stakeholders Families Law Enforcement District attorneys, defense attorneys, plaintiff’s attorneysVital RecordsFuneral DirectorsLegislatorsEMSMedical practitioners, including VAPublic Health professionalsTransportersMedia
28 Statutes, Rules, and Guidelines NC OCME Guidelines, Rules, and StatutesAdministrative CodeGeneral StatutesGuidelines for Medical Examiners
29 Priorities National accreditation Medical Examiner training Improved communicationAppropriate death certificationRegionalization
30 Mission StatementThe North Carolina Office of the Chief Medical Examiner will ensure consistent and competent medicolegal death investigation by utilizing training, consultation, quality assurance, and the appropriate use of resources.
Your consent to our cookies if you continue to use this website.