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Using a 2004 population-based survey of all US medical examiner and coroner offices, we examined the characteristics of offices accepting an infant death case and calculated the percentage of offices that had death scene investigation or autopsy policies for the investigation of sudden unexpected infant death (SUID). We also calculated the percentage of offices that used and did not use sudden infant death syndrome (SIDS) as a cause of death, and we compared differences in characteristics among those offices.Of medical examiner and coroner offices, 52% did not report an infant death in 2004. Of the 7957 infant deaths reported, 43% occurred in jurisdictions that experienced 1 or 2 infant deaths. Of the offices that used SIDS as a classification, 34% did not have policies for conducting death scene investigations and autopsies for SUID. At least 5% of offices that reported an infant death did not use SIDS as a cause of death classification. These findings have important implications for understanding recent trends in SIDS and SUID. Supporting the implementation of national standards for investigating and certifying infant deaths could provide guidelines for consistent practices in medical examiner and coroner offices.

In the past few years, a number of publications and other resources have appeared concerning the management of mass fatality incidents. Some are geared toward the general management of incidents while others cover more specific topics such as decontamination procedures. Still others cover selected agents, including chemical, biologic, or radiologic ones. Few publications have been written specifically for medical examiners and coroners. The Medical Examiner and Coroner's Guide for Contaminated Deceased Body Management is written specifically for the medical examiner or coroner who will be in charge of investigations of fatalities that result from terrorism or other events that result in contaminated remains. In some such cases, agents may be used that will require mitigation of environmental hazards and decontamination of human bodies. To that end, this Guide provides information and suggestions that may be useful in understanding the principles involved in decontamination procedures, recognizing that it may not be the medical examiner or coroner staff who actually conducts decontamination procedures. The suggestions in this guide may differ slightly from those in other publications. However, those who have contributed to this guide believe that the recommendations are practical, workable, have a scientific basis, and do not differ much in substance when compared with other relevant publications. The contents of this Guide may be reproduced for practical use but the Guide may not be sold and it may not be cited for advertisement purposes. Reference to specific commercial products is for informational purposes only and does not constitute endorsement of the product or company which produces the product. The recommendations contained in this Guide are not mandated nor are they required by federal, state, or local law. Rather, the recommendations are intended to assist medical examiners and coroners for the purposes of planning and providing a set of reasonable practice guidelines for incident response.

To assess the quality of manner of death (MOD) certification among medical examiners/coroners (ME/Cs) in Taiwan, death certificates issued in 2002 for which the final MOD was suicide or undetermined were extracted for analysis. Indicators of the quality of MOD certification included (1) MOD not given by the ME/Cs; (2) MOD assigned by the ME/Cs was changed by the coder; (3) ratio between undetermined and suicide deaths (U/S ratio). There were 450 death certificates for which the ME/Cs did not assign the MOD in the original certificate. Three fifths (285/450) of them were issued by 4 ME/Cs. The same 4 ME/Cs also had extremely high U/S ratios (1.25-1.84) compared with the average (0.31). The overall quality of MOD certification among ME/Cs in Taiwan was fair; only a small number of ME/Cs had poor quality in MOD certification. The high U/S ratio among the 4 ME/Cs would certainly affect the suicide mortality rates of the counties the 4 ME/Cs were in charge of. Actions should be taken to improve the certification quality of these 4 ME/Cs.

Context: Alcohol can contribute to various manners of death by acute intoxication that places a person at risk for fatal injury, acute fatal alcohol poisoning, or the various fatal complications of chronic abuse with or without superimposed acute intoxication. The reporting of alcohol use on the death certificate may vary with office policy or procedure, certifier judgment, and the timing of information received during investigation., Objective: To determine the number of deaths including mention of alcohol use in the investigative case file, the number of death certificates on which alcohol use is reported, the number of discrepancies between the 2, and the possible reasons for observed discrepancies., Design, Setting, and Participants: Retrospective case review of all deaths where alcohol use was mentioned in the investigative case file and/or on the death certificate for deaths investigated by the Fulton County Medical Examiner in Atlanta, Georgia, during a 1-year period between January 1, 2004, and December 31, 2004., Main Outcome Measures: Percentage of deaths with alcohol use reported on the death certificate, tabulation of where and how alcohol use is reported on the death certificate, and tabulation of the differences between the investigative case file and death certificate regarding alcohol's possible role in causing death., Results: Among the 1324 deaths certified by the office, 105 (8%) had alcohol use reported on the death certificate. The majority (67%) of these cases were natural deaths. Sixty-nine (5%) deaths had mention of alcohol use in the investigative case notes but did not include it on the death certificate. Twenty-five (2%) deaths had mention of alcohol on the death certificate but did not have mention of it in the investigative case file based on our search criteria. However, subsequent review of additional case follow-up information disclosed a history of alcohol use or acute intoxication in each case., Conclusions: The data show that more natural deaths are considered to be directly caused by alcohol than other manners of death. For the unnatural manners of death (excluding acute alcohol poisoning), alcohol use is often viewed by medical examiners as an incidental, associated finding or risk factor surrounding the circumstances of death rather than being an actual cause of death. In such cases, alcohol use is often omitted from the death certificate. For deaths directly caused by alcohol, the proportion of cases involving possible underreporting or overreporting of alcohol involvement was relatively small and usually involved the omission of chronic alcohol use from the death certificate. Researchers need to be aware of potential limitations of death certificate data for studying alcohol-related deaths.

The National Association of Medical Examiners Committee on Cocaine-related Deaths recommends that the following guidelines be applied in the process of documenting, interpreting, and certifying potential cocaine-related fatalities. The committee cautions that the investigation of any drug-related death requires a complete investigation of the circumstances of death, the death scene, and past medical history. It is also necessary to have the results of the forensic toxicological analysis and those of a complete forensic autopsy examination prior to formulating an opinion as to the cause and manner of death. Cocaine should be considered the underlying cause of the death when 1 or more of the following is true: (1). the circumstances surrounding the death can be associated with an acute cocaine exposure and there are no supervening causes of death; (2). the immediate cause of death is directly due to a readily identifiable mechanism or disease such as a gunshot wound or a stroke, yet the acute use of cocaine was the direct underlying cause of the trauma or the disease process; and (3). chronic cocaine use leads to a disease that results in an ultimately fatal pathologic process leading to organ injury and death. The committee further cautions that reported drug levels may not directly relate to the toxic or lethal effects of the drug upon the patient. These guidelines are intended for use by practicing medical examiners and physicians who certify drug deaths, as well as providing education tools for students.

In 1995, a questionnaire was distributed to the > 700 physician medical examiner/coroners (ME/Cs) who are members of the National Association of Medical Examiners (NAME, St. Louis, MO, U.S.A.). The questionnaire consisted of 23 death scenarios for which individual responders were asked to assign a manner of death (homicide, suicide, accident, natural, or undetermined); 198 questionnaires were completed and analyzed. The distribution of manner of death responses was tabulated. In addition, a nosologist from the National Center for Health Statistics was provided with a cause-of-death statement based on each scenario and was asked to assign an International Classification of Diseases (ICD) code for the underlying cause of death, from which a manner of death was inferred from the ICD code's literal text description. Overall, agreement on a given manner of death in a single scenario was > 90% in only 4 of 23 scenarios and > 70% in only 12 of 23 scenarios. However, in 21 scenarios, the most common response comprised a majority. The manner of death inferred from the ICD code that was assigned by the National Center for Health Statistics (NCHS) matched the most common response of participants in 18 of the 23 scenarios. The questionnaire results show that there is substantial disagreement among experienced MEs concerning the manner of death classification that is preferred for selected types of death. Encouraging, however, is the fact that the manner of death coded for statistical purposes generally agreed with the most common classification of manner made by ME/Cs. Highlights from the discussion of each scenario that occurred during the NAME interim meeting (Nashville, Tennessee, February 1996) are also included. Other portions of the program including history of manner of death concepts and results of questions regarding responder training and characteristics are published separately in this issue of the Journal. Information derived from the questionnaire should be useful to those planning strategies to improve the consistency of manner of death classifications by ME/Cs.