1. Manner: Natural – Natural disease presenting as unexpected death Marnie Wood MD FRCPC (Anatomic and Forensic Pathology) ABP March 20, 2012

2. Objectives Gain better understanding of natural deaths over which the Nova Scotia Medical Examiner Service (NSMES) assumes jurisdiction Have an appreciation of the spectrum of natural disease seen by MES as unexpected deaths View case examples of ME investigation of natural deaths

3. Introduction May think violent/suspicious deaths are the majority of Medical Examiner cases

4. Introduction Anecdotally Natural deaths compose 56% of autopsied NSMES cases (Accident 29%, Suicide 12%, Homicide 3%, Undetermined <1%) The cause of death in majority is some variety of ASCVD or chronic ethanol abuse

5. Introduction Natural deaths are reportable to Medical Examiner under several subsections of Fatality Investigations Act May or may not assume jurisdiction over the reported death

6. Duty to notify Medical Examiner Service: – Death result of violence, accident or suicide – Unexpectedly when in good health – Where person not under care of a physician – Where cause of death is undetermined – Result of improper or suspected negligent treatment by a person

7. Definition of unexpected varies markedly depending on perspective Tragic does not equal unexpected Cause of death need not be determined with 100% certainty – Opinion based on reasonable interpretation of data

8. Notify ME where person dies in health-care facility and there is reason to believe: – Death result of violence, suspected suicide or accident – Death result of suspected misadventure, negligence or accident on part of attending physician or staff – Cause of death is undetermined – Stillbirth or neonatal death where maternal injury before admission or during delivery – Within 10 days of surgery, or during anaesthesia

9. Death in Health Care Facility Threshold for taking jurisdiction over deaths during medical intervention tends to be high – Accidental or intentional overdose of medication – Injury from malfunction of equipment (eg electrocution) – Procedure outside of scope of licensed practice – Complication beyond reasonable/foreseeable – Consider any allegations being made

10. Death in Health Care Facility Tragic does not equal unexpected, accidental or negligent Cause of death need not be determined with 100% certainty – May be able to determine cause without knowing exact mechanism

11. Notify of deaths in custody Death while detained, or in custody in a correctional institution While an inmate is in Hospital While in custody under Children and Family Services Act While detained by, or in custody of peace officer

12. Notify of death related to employment or occupation Where person dies as result of: – Disease or ill health – An injury sustained by the person – A toxic substance introduced into the person Probably caused by or connected with the person’s employment

13. Typically do not take jurisdiction: Natural Manner when sufficient clinical information with which to form reasonable opinion of cause of death Natural Manner where mechanism of death was a reasonable/foreseeable complication of appropriate medical therapy Deaths during surgery/treatment for natural disease Natural Manner where occupational disease did not contribute in any way

14. Of reportable, typically take jurisdiction over: All accidents, homicides, suicides All possible accidents, homicides, suicides Where negligence is alleged All in custody, regardless apparent manner All possibly related to occupation Where insufficient clinical information to determine cause of death

15. Introduction Deaths occurring under these circumstances are investigated by the Medical Examiner, through review of scene and history information, +/- autopsy to determine – Identity of deceased – Time and place of death – Cause and manner of death

17. Case 1 64 year old woman Found deceased in bed, no recent complaints Recent long flight No known medical history

19. At autopsy: – Abundant pulmonary edema – Subarachnoid hemorrhage concentrated at base of brain

21. Case 2 55 year old woman Found collapsed in bedroom, unresponsive with labored breathing, arrest prior to EHS Death declared at scene Six month history increasing shortness of breath, palpitations following flu-like illness

22. At autopsy: – Serous pleural and pericardial effusions – Abnormal texture of organs