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140 Part 4 Records and Reports
Section 404 Investigator’s Reports and Case Files
Section 404.
Case Files
Regardless of whether you develop investigative protocols it is incumbent upon you to maintain as thorough and organized set of investigative files as possible. The investigative files should include but not be restricted to the following: all reports, investigator's notes, sketches and death scene photographs, reports of autopsy and laboratory analyses of evidence, copies of all forms completed by the coroner to include chain-of-custody forms and laboratory request forms. The major objective is to maintain as complete and proper file as possible.
Section 501
Autopsy Protocol
Section 501.1 Overview.............................................................................................................................. 115 Section 501.2 Ordering an Autopsy............................................................................................................ 115 Section 501.3 Autopsy Protocol.................................................................................................................. 117
Section 501.
Overview
Coroners may find the following definition of forensic pathology useful to their work. Forensic pathology is the branch of medical practice that produces evidence useful in the criminal justice administration, public health and public safety. Under this definition are three key elements: Cause of Death, Manner of Death and Mechanism of Death. The cause of death related to the disease, injury or abnormality that alone or together in some combination initiates the physical and biological malfunctions that eventually leads to death. The cause of death can be thought of in terms of underlying or immediate cause of death. For example, a driver of an automobile dies in a single vehicle accident. The autopsy discloses that the driver had a blood alcohol level of 0.25 and the driver's heart had been pierced by a metal rod. The underlying cause of death would be penetrating trauma to the chest, the mechanism of death would be heart failure due to the penetrating metal rod, and acute alcohol intoxication would be listed as a contributing factor. The manner of death pertains to the way the death occurred. Social relationships and personal causation are two elements involved in determining manner of death. Examples are the self-inflicted injuries of a suicide victim and the fatal injuries incurred as a result of an accidental fire in a home. The usual classifications of death are: natural, accident, suicide, homicide or undetermined. The mechanism of death refers to the process of death, in which failure of one or more vital organs due to injury, disease or natural events. For example, the mechanism of death for many diabetics is kidney failure. Other body organs, such as the liver, are adversely affected by kidney failure and death may follow. The actual cause of death may be due to heart or liver failure, but the diabetes was responsible for initiating the death process.
Section 501 Autopsy Protocol
Caution: The pathologist will, or may, offer both a cause and manner of death in his/her report of the post- mortem. However, the coroner is not bound by this report in determining manner of death. Often you will have additional information that was gathered at the death scene. This additional information and the results of the autopsy will often allow you to reach a more accurate determination of the manner of death.
Note: If there is a disagreement with the findings of the pathologist, the coroner and pathologist should strive to arrive at a consensual view. This is necessary, as such a disagreement could prove embarrassing to one or both parties, if it is brought out in court at a later date.
Note: The mechanism of death should not be noted on the death certificate. (It is unnecessary and could create confusion or doubt in non-medical personnel.)
Section 501.
Ordering an Autopsy
An autopsy is not required in every coroner's case; However, if in doubt, request an autopsy be performed. Normally, a decedent's body is the property of the next of kin (spouse, child, parent, brother or sister, nearest relative, guardian or executor of the estate). However, in deaths that are unusual, unnatural or suspicious in nature the state has an overriding interest which supersedes the interests of the family. The coroner has a responsibility to order an autopsy on cases that are of interest to the state. Coroner's are protected from liability when ordering an autopsy in good faith. In Indiana the person performing the autopsy must be a pathologist certified by the American Board of Pathology in anatomic pathology, or a physician responsible to such a person. A coroner can not cut into or remove any part of a decedent's body under your jurisdiction, unless you meet the above stated qualifications.
Exceptions to this is the aspiration (drawing or taking) of blood, urine, or other body fluid for chemical analysis if an autopsy is considered unnecessary.
Caution: Do not take any fluids if an autopsy is planned, as this will introduce artifacts; e.g. , puncture wounds on the body area from which you draw the fluids.
An autopsy is not required in every coroner's case. Whether or not to obtain an autopsy is probably the hardest decision a coroner will have to make. Financial and family pressures often go against the coroner’s desire for an autopsy. The coroner should obtain an autopsy, if required, despite these pressures. The coroner has the authority to order an autopsy by Indiana Statute. (See Section 104.3, Coroner’s Investigation of Death.) The county must provide the funds for post mortem examinations. Unnecessary autopsies also waste time and resources for everyone. Therefore, the coroner should carefully pick those cases requiring an autopsy. Veteran coroners (and pathologists) have been known to make mistakes. However, the mistake is nearly always in not obtaining an autopsy when needed. If you are unsure in a particular case, you should call a colleague or a member of the Indiana State Coroners Training Board.
Note: Family members, initially opposed to an autopsy being performed, will normally be grateful later. (If they are not, be suspicious of them.)
When the cause and manner of death cannot be established at the death scene an autopsy is required. A death case with an obvious cause and manner of death may require an autopsy for legal documentation. In such cases, knowledge of specific mechanics of death are desired; e.g. ; determination of fatal wounds, contribution of any natural disease to the cause of death and the elapsed time between the moment of fatal injury and
Section 501 Autopsy Protocol
- Establish decedent's identity.
- Establish the cause of death.
- Determine the mechanism of death.
- Confirm the manner of death.
- Confirm medical history.
- Separate complicating medical factors.
- Rule out disease or factors harmful to public health.
- Facilitate adequate photography of wounds.
- Establish direction of force.
- Correlate wounding and object producing the wound(s).
- Determine time interval between wound(s) received and death.
- Establish sequence of events.
- Retrieve an article involved in mode of death, such as a bullet.
- Obtain and examine trace evidence such as hairs, stains, and seminal fluid.
- Obtain specimens for toxicology.
- Establish order of death in situations where more than one family member has been killed.
- To document all injuries in order to answer any future questions that are unknown at the time of the autopsy.
§ 501.2. Ordering of Autopsy by Person Other than the Coroner There are four situations in which persons other than the coroner may order an autopsy. First the county prosecuting attorney may mandate the coroner to order an autopsy, if the coroner fails to order one on his/her own volition. When this occurs, funds from the coroner's budget must be used to pay for the autopsy. Second, the county health officer may order an autopsy if the death could be a threat to public health. Third, the judge of the Circuit Court may order an autopsy, over the objection of the decedent's family or next of kin. Fourth, the family or next of kin always have the right to order an autopsy.
Note : In the latter case the cost of the autopsy may be borne by the family if the coroner does not justify the legal need.
Section 501.
Autopsy Protocol
The autopsy is an important tool in establishing the manner of death and cause of death.
Note: Negative findings are, or may be, more important than positive findings. You should call the pathologist for explanations regarding the autopsy findings.
Coroners should wait on a pathologist's report before rendering a cause of death. The following Autopsy Protocol is included as an information resource for the lay person. It is not as comprehensive in detail as an Autopsy Protocol for pathologists or medical personnel. However, it should be of assistance to the lay person in interpreting and understanding data contained in an autopsy report.
Note: The pathologist will generally note a cause of death and manner of death. The coroner may record a manner of death that is independent, and different, from that of the pathologist. However, any disagreement between a pathologist's and coroner's determination of the manner of death should be based on material fact and data not available to the pathologist. This information must be able to withstand the scrutiny of judicial review.
Section 501 Autopsy Protocol
Note : Any board certified pathologist may conduct coroner’s autopsies in Indiana. However, in death cases with obvious or suspected legal ramifications it may be desirable to obtain the services of a Forensic Pathologist (See Part 2, Section 201.4 and Section 202.4.) The forensic pathologist is familiar with the medicolegal issues incurred in the criminal justice process. Also, they are normally qualified and willing to provide expert testimony at a judicial trial or hearing. It is suggested that coroners check with local pathologists as to their willingness to participate in the criminal justice process. If they are not willing, death cases of potential or actual interest to criminal justice agencies should be handled by forensic pathologists.
Autopsy Protocol
- Preliminary Procedures
- Summary of Known Circumstances
- Documents Reviewed And/or Evidence Examined
- External Examination of Body
- Victim Identification Procedures
- Internal Examination of Body
- General Description of Body Organs
- Specific Description of Wounds or Injuries
- Establish Evidential Chain-of-custody
- Record of Specimens Retained and Examinations Performed
Step 1: Preliminary Procedures. This includes the taking of detailed notes of the post-mortem. The date, time, location and circumstances of the autopsy are recorded. The prosector(s), witnesses and other personnel are identified. Also, any special item, such as embalming information is noted.
Step 2: Summary of Known Circumstances. This a short, concise version of the known facts about the decedent. It will generally contain the victim's age, race and sex. It will have a brief description of the death scene and the circumstances in which the victim's body was found. Also, it may contain information pertaining to the victim's last known activities or plans if known.
Step 3: Documents Reviewed And/or Evidence Examined. At a minimum the pathologist may review reports of investigation or conversations with official personnel that pertain to the victim's death. Evidence obtained at the death scene involving a known, or potential interest, to criminal justice agencies is generally beneficial to the pathologist. For example, a knife recovered from the body of a stabbing victim would be of interest to the pathologist. It would be instrumental in determining if wounds and injuries found on the body could have been made by the suspect knife.
Step 4: External Examination of Body. Space precludes a comprehensive list of everything involved in the external examination. However, the following is generally examined, or noted, during this phase of the autopsy: The victim's clothing; and inventory of jewelry, valuables and evidence recovered; body weight and length; presence of algor, rigor or livor mortis; general condition of the body; description of the color and condition of head and body hair, examination of the nose and mouth to include dental examination; external condition of body areas to include the breasts, genitalia, ears and skin; any scars or incisions; any puncture marks to include those of needles; and, specific injuries noted, such as stab wounds, gunshot wounds or blunt instrument injuries.
Section 501 Autopsy Protocol Section 404 Investigator’s Reports and Case Files
depending on the nature of the death and whether the case is of interest to criminal justice agencies. However, specimens retained could include clothing, bullets or bullet fragments, and suspected gun powder residue from the victim's skin or clothing. Toxicological specimens could include blood, urine or body tissues. Generally, some specimens are collected for storage. This is so additional examinations or tests can be conducted at a future date. Finally, items to include hair exemplars, fingernail scrapings, fingerprints, blood, vaginal or anal swabs and other evidence may be collected as necessary.
Caution: If any doubt exists as to the need to collect specimens of whatever type, do it during this phase of the autopsy. It is better to collect specimens and not use them, then to need them and not have them.
Note Pertinent Negatives: In an autopsy report, there will be numerous items that state a certain finding is not present. These statements are as important as the positive findings which are present, and are present in the autopsy report to confirm that a particular part of the anatomy was examined and found to be normal.
Section 502 Sample Autopsy Report
Section 502
Sample Autopsy Report
NEW CITY REGIONAL HOSPITAL
DEPARTMENT OF PATHOLOGY
AUTOPSY REPORT
NAME: xxxxxxxxxxxxxxxx AUTOPSY NO: NCxxxxxx
AGE: 74 DATE: xxxxxxxxxxx
SEX: M TIME: 9:00 am
PROSECUTOR: xxxx PHYSICIAN: XXX County Coroner ASSISTANT: xxxx
ANATOMIC FINDINGS
- Decomposed white male with early insect activity
- Left ventricular hypertrophy (580 gm)
- Atherosclerosis, moderate, coronary arteries and aorta [ Note: If applicable, toxicological findings will be placed here.]
CAUSE OF DEATH
Ventricular arrhythmia
MANNER OF DEATH
Natural
________________Pathologist XxxxxxXXxxxxx, M.D.
Completed:______________
CIRCUMSTANTIAL SUMMARY
XXXX XXXX was a 74 year old white male who had left his home at approximately 5:30 pm on XX XX to
Section 502 Sample Autopsy Report
for explanations regarding the autopsy findings.]
SIGNS OF DEATH: Rigor mortis is absent and post mortem lividity cannot be assessed.
ARTIFACTS: No artifacts of medical or post mortem care are present.
The following artifacts of putrefaction are present: Skin slippage, green discoloration of the abdominal wall, marbling of the skin by intravascular hemolysis, purging hemolyzed fluid from the mouth and nose, malodorous gas bloating, air drying of the lips and fingers, fly eggs, and insect larvae.
[ Note: This section will document what changes are present, and is vital in correlating the time of death with other investigative findings.]
INJURIES
No external or internal injuries are identified.
[ Note: This section should document the presence or absence of injuries in a thorough and complete manner.]
INTERNAL EXAMINATION
SEROUS CAVITIES: The body cavities are opened with a standard Y-shaped incision. The cranial cavity is opened with a coronal incision of the scalp and removal of the calvarium. An odor like alcohol is not apparent in the body cavities. The lungs are well aerated and fill the pleural cavities. There is no evidence of pneumothorax. There is no blood or effusion in either pleural cavity. There are no pleural adhesions. There is no blood or excess fluid in the pericardial sac. There is no evidence of pericarditis. There is no evidence of peritonitis. There is no blood in the peritoneal cavity. There is no ascitic fluid. After removal of the organs from the body, inspection of the serous cavities reveals no evidence of fracture of the ribs, sternum, clavicles, vertebral column or pelvic walls. Contusion hemorrhage is not present in the body walls.
NECK ORGANS: The larynx and trachea are in the midline. No significant hemorrhage is present in the skin, fat or sternoclei-domastoid muscles of the anterior neck. The thyroid gland is symmetrical and composed of reddish-brown parenchyma.
There is no hemorrhage in the intrinsic muscles of the larynx. There is no obstruction of the respiratory tract in the nasopharynx, larynx or trachea. There is scant mucus in the larynx. The mucosa of the hypopharynx, larynx and trachea is smooth and glistening without ulceration or tumor. Cervical lymph nodes are appropriate for age. No fractures or discolorations of the cervical vertebrae are detected.
HEART: The 580 gram heart is in usual position with respect to the great vessels and chest cavity. The left ventricle is significantly hypertrophied and the cardiac chambers are not dilated. On opening the aorta and pulmonary trunk, there is no evidence of air embolism and there is no evidence of pulmonary thromboembolism. There is no evidence of pericarditis. The circumflex coronary artery arises from the left main coronary. The coronary arteries are examined by multiple cross sections. There is no significant atherosclerotic plaque in the major coronary arteries. The left main coronary artery is 20% narrowed by plaque. The left anterior descending coronary artery is 30% narrowed by plaque. The circumflex coronary artery is 10% narrowed by plaque. The right coronary artery is 20% narrowed by plaque.
Section 502 Sample Autopsy Report
Thrombosis of the coronary arteries is not present. The cardiac valve leaflets are delicate. The circumferences of the cardiac valves are within normal limits for age and heart size. There is autolytic softening of the myocardium, without evidence of recent myocardial infarction or necrosis. There is no myocardial fibrosis. There is no myocardial contusion. There are no defects in the atrial or ventricular septae. The ductus arteriosus is not patent. Autolysis is advanced.
VASCULAR SYSTEM: The aorta and its main branches show mild yellow streak atherosclerosis. There is no evidence of aneurysm, coarctation, dissection or laceration of the aorta. The renal arteries are not stenotic.
LUNGS: The combined weight of the lungs is 850 grams. The trachea is complete, without malformation, from the larynx to the carina. There is no aspirated gastric material and no aspirated blood in the trachea. The distal bronchi contain scant mucus. The pleural surfaces are smooth and glistening. No petechiae are visible. The lungs and hilar nodes are not significantly anthracotic and there is no bullous emphysema. On cut section, there is no aspirated blood apparent in alveoli. Bronchopneumonia is not recognized. There is mild passive congestion of the lungs. There is no evidence of pulmonary edema. There is pulmonary contusion. Pulmonary thromboemboli are not present. There is no putrid gas cavitation.
LIVER: The 1650 gram liver has a smooth capsular surface. On cut section, the parenchyma is green-black and has a lobular architecture. The liver is mildly passively congested. Metastatic tumor is not present. The hepatic duct is patent. The gallbladder is present. There are no gallstones. Autolysis of the liver is advanced.
PANCREAS: The pancreas is appropriate in shape and size with respect to total body fat stores. On cut surface, it is lobular with interspersed fat without focal calcification, fibrosis, hemorrhage or fat necrosis. Autolysis is advanced.
GASTROINTESTINAL SYSTEM: The esophagus is lined with glistening white mucosa. The stomach is coarsely rugated. The stomach contains 50 ml of partially digested food. There is no odor like alcohol in the stomach. There are no erosions or ulcers in the stomach or duodenum. The small bowel and colon are intact without perforation, diverticula or palpable tumors. The vermiform appendix is present.
SPLEEN: The 180 gram spleen is composed of red and white trabecular pulp. There is no laceration of the splenic capsule. Autolysis is significant.
ADRENALS: Two adrenals are present with golden brown cortex and white medulla. No cortical nodules are present in either adrenal. Autolysis is advanced.
URINARY TRACT: The right kidney weighs 150 grams, the left kidney 170 grams. The two kidneys, ureters and bladder are present in their usual positions without dilatation. The kidneys are symmetrical in shape and size. The capsules strip from the cortices with ease and the cortical surfaces are smooth. On cut section, the cortex appears of ample thickness and the medulla appears ample. The kidneys are congested. There are no stones or tumors in the kidneys, pelves, ureters or bladder. Autolysis of the kidneys is advanced.
REPRODUCTIVE SYSTEM: The prostate is moderately enlarged.
CENTRAL NERVOUS SYSTEM: There is no hemorrhage in the scalp or galea. The dura, removed by stripping from the calvarium and base of the skull, shows no epidural or subdural hemorrhage. The cerebral and cerebellar hemispheres of the 1375 gram brain are symmetrical. The leptomeninges are transparent and can be stripped with ease. There is no subarachnoid hemorrhage. There is no flattening of the gyri and no
