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Richard Griffith , Senior Lecturer in Health Law at Swansea University, considers the reforms to the death certification process and discusses the statutory examination of all deaths not referred to the coroner by a medical examiner.

Objectives: To demonstrate the severity of undercounting opioid-involved deaths in a local jurisdiction with a high proportion of unspecified accidental poisoning deaths., Methods: We matched toxicology data to vital records for all accidental poisoning deaths (n = 1238) in Marion County, Indiana, from January 2011 to December 2016. From vital records, we coded cases as opioid involved, specified other substance, or unspecified. We extracted toxicology data on opioid substances for unspecified cases, and we have reported corrected estimates of opioid-involved deaths after accounting for toxicology findings., Results: Over a 6-year period, 57.7% of accidental overdose deaths were unspecified and 34.2% involved opioids. Toxicology data showed that 86.8% of unspecified cases tested positive for an opioid. Inclusion of toxicology results more than doubled the proportion of opioid-involved deaths, from 34.2% to 86.0%., Conclusions: Local jurisdictions may be undercounting opioid-involved overdose deaths to a considerable degree. Toxicology data can improve accuracy in identifying opioid-involved overdose deaths. Public Health Implications. Mandatory toxicology testing and enhanced training for local coroners on standards for death certificate reporting are needed to improve the accuracy of local monitoring of opioid-involved accidental overdose deaths.

Sudden unexpected death of an individual with epilepsy can pose a challenge to death investigators, as most deaths are unwitnessed, and the individual is commonly found dead in bed. Anatomic findings (eg, tongue/lip bite) are commonly absent and of varying specificity, thereby limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention constituted an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden unexpected death in a person with epilepsy is encountered., (© 2018 National Association of Medical Examiners. This paper has been simultaneously published in Epilepsia. Volume 59, #3 and Academic Forensic Pathology: The Official Publication of the National Association of Medical Examiners, Volume 8, #1.)

This article continues the series of previous publications of the authors based on the analysis of the detailed report of the experts of the National Confidential Enquiry into Patient Outcome and Death program (NCEPOD) designed to evaluate the quality of autopsies carried out by the coroners in the Great Britain. It was shown that only in 13 to 55% of the 1,691 case the operators had an opportunity to refer the necropsy materials for the pathological study. The problems encountered in association with histological and toxicological analysis arose from the misunderstanding between the coroners and the pathologists as regard the organizational aspects of autopsy studies as swell as the financial and economic considerations. The Coroner Rules that had been adopted in 1984 and remained in force in the country until 2005 needed to be radically revised, corrected, and amended to facilitate the solution of a number of problems and eliminate the formal organizational and technical contradictions that hampered the further improvement of the quality of autopsies that must be performed by the corners at the national rather than the local level. The maximum number of the unacceptable results were revealed in the protocols of autopsires carried out by the forensic medical experts. All pathologists in the Great Britain are recommended to pay special attention to all cases of sudden death of the adult subjects and the deceased epileptic patients. The detailed investigations are mandatory in all cases of death following medical manipulations, such as surgical interventions, and complications.

This article extends the previous publication of the authors based on the analysis of the detailed report of the experts of the National Confidential Enquiry into Patient Outcome and Death program (NCEPOD) issued in the Great Britain in 2006. The analysis has demonstrated that all autopsy studies should invariably involve measurement of the corpse length and weight (including body mass index) as well as the detailed description of all injuries to the body (or references to their absence). All autopsy studies should be carried out only by a medical professional (e.g. a pathologist, histologist, forensic medical expert, etc.). The thorough examination of the cadaver is mandatory prior to evisceration. The maximum scope of the examination of all body cavities with the comprehensive description of all internal organs and systems is compulsory. Putrefaction and decomposition of the corpse can not be regarded as a justification for its perfunctory ('restricted') inspection; on the contrary, these dictate the necessity of a more careful examination with the compulsory description of all organs and body systems as well as harvesting biological fluids and tissues for the laboratory analyses (including histological, toxicological, and other relevant studies).

Background: Recent government inquiries in several countries have identified the length of time it takes coroners to investigate deaths due to injury and other unnatural causes as a major problem. Delays undermine the integrity of vital statistics and adversely affect the deceased's family and others with interests in coroners' findings. Little is publicly known about the extent, nature and causes of these delays., Methods: We used Kaplan-Meier estimates and multivariable regression analysis to decompose the timelines of nearly all inquest cases (n=5096) closed in coroners' courts in Australia between 1 January 2007 and 31 December 2013., Results: The cases had a median closure period of 19.0 months (95% CI 18.4 to 19.6). Overall, 70% of cases were open at 1 year, 40% at 2 years and 22% at 3 years, but there was substantial variation by jurisdiction. Adjusted analyses showed a difference of 22 months in the average closure time between the fastest and slowest jurisdictions. Cases involving deaths due to assault (+12.2 months, 95% CI 7.8 to 17.0) and complications of medical care (+9.0 months, 95% CI 5.5 to 12.3) had significantly longer closure periods than other types of death. Cases that produced public health recommendations also had relatively long closure periods (+8.9 months, 95% CI 7.6 to 10.3)., Conclusions: Nearly a quarter of inquests in Australia run for more than 3 years. The size of this caseload tail varies dramatically by jurisdiction and case characteristics. Interventions to reduce timelines should be tried and carefully evaluated., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

The investigation and classification of deaths in England and Wales relies upon the application by medical practitioners of diverse reporting standards set locally by coroners and thereafter upon the effectively unconstrained decision process of those same coroners. The author has conducted extensive comparative analysis of Ministry of Justice data on reports to the coroner and their inquest and verdict returns alongside Office of National Statistics data pertaining to the numbers of registered deaths in equivalent local jurisdictions. Here, he analyses 10 jurisdictions characterised by almost identical inquest return numbers in 2011. Substantial variation was found in reporting rates to the coroner and in the profile of inquest verdicts. The range of deaths reported varied from 34% to 62% of all registered deaths. Likewise only 2 of the 10 jurisdictions shared the same ranking of proportions in which the six common verdicts were reached. Individual jurisdictions tended to be consistent over time in their use of verdicts. In all cases, proportionately more male deaths were reported to the coroner. Coroners generally seemed prima facie to be 'gendered' in their approach to verdicts; that is, they were consistently more likely to favour a particular verdict when dealing with a death, according to the sex of the deceased. The extent to which coroners seemed gendered varied widely. While similar services such as the criminal courts or the Crown Prosecution Service are subject to extensive national guidance in an attempt to constrain idiosyncratic decision making, there seems no reason why this should apply less to the process of death investigation and classification. Further analysis of coroners' local practices and their determinants seems necessary., (© International Headache Society 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Several countries of the British Commonwealth, including Australia and the United Kingdom, vest in coroners the power to issue recommendations for protecting public health and safety. Little is known about whether and how organisations that receive recommendations act on them. Concerns that recommendations are frequently ignored prompted the government of Victoria, Australia, to introduce a requirement in 2008 compelling organisations that receive recommendations to provide a written statement of action., Methods: We conducted a prospective study of organisations that received recommendations from Victorian coroners over a 33-month period. Using an online survey, we asked representatives of "recipient organisations" what action (if any) their organisations took, and what factors influenced their decision. We also probed views of the quality of the recommendations and the mandatory response regime in general. Responses were analysed at the recommendation- and recipient organisation-level by calculating counts and proportions and using chi-square analyses to test for sub-group differences., Results: Ninety of 153 recipient organisations surveyed responded (59% response rate); they received 164 recommendations (mean = 1.9; range, 1-7) from 74 cases. A total of 37% (60/164) of the recommendations were accepted and implemented, 27% (45/164) were rejected, and for 36% (59/164) the recommended action was "supplanted" (i.e., action had already been taken). In nearly half of rejected recommendations (18/45), recipient organisations indicated implementation was not logistically viable. In half of supplanted recommendations, an internal investigation had prompted the action. Three quarters (67/90) of recipient organisations believed the introduction of a mandatory response regime was a good idea, but fewer regarded the recommendations they received as appropriate (52/90) or likely to be effective in preventing death and injury (45/90)., Conclusions: Only a third of coroners' recommendations were implemented by the organisations to which they were directed. In drawing policy lessons, it is important to separate recommendations that were rejected from those in which action had already been taken. Rejected recommendations raise questions about the quality of the recommendations, the reasonableness of the organisation's response, or both. Supplanted recommendations focus attention on the adequacy of consultation between coroners and affected organisations and the length of time it takes for recommendations to be issued.

The cause of death statement is the core of the death certification process for the physician certifier. The World Health Organization defines the cause of death as the disease or injury that initiates a chain of events leading to death. This cause of death needs to be listed at the bottom of the cause of death statement with the events the cause of death initiated (mechanisms of death) listed above in a direct causal relationship (cause of death 'A,' initiated process 'B,' that in turn caused process 'C,' that in turn produced 'D,' that directly led to the death). In addition to the cause of death and its attendant mechanism(s) of death, the death certificate also includes an area for other significant conditions. This area is to be used for significant medical conditions that are not part of the chain of event leading from the cause of death. An example of an, other significant condition, would be metastatic breast carcinoma in an individual dying of a ruptured aortic aneurysm. The manner of death is restricted to either natural or unnatural (accident, homicide and suicide). Physicians, unless they are also acting as a coroner, are only allowed to certify natural deaths.

Aims: In England and Wales, doctors are charged with a responsibility either to report a death to the coroner or issue a medical certificate specifying cause of death. A lack of formal prescriptive or presumptive oversight has resulted in the promulgation by individual coroners of local reporting regimes. The study reported here identified overall and gendered variations in local reporting rates to coroners across the jurisdictions of England and Wales, consistent over time., Methods: Analysis was performed on Ministry of Justice (MOJ) data pertaining to the numbers and proportions of deaths reported to the coroner by jurisdiction over a 10-year period (2001-2010). Office of National Statistics (ONS) data provided the numbers of deaths registered in England and Wales over the same period to serve as a denominator for the calculation of proportions. Where coroner jurisdictions (and local authorities) had been amalgamated during this period, the combined reported and registered death figures have been included in line with the current jurisdiction areas., Results: While reporting rates for individual jurisdictions were found to be stable over the 10-year period, wide local variations in reporting deaths to coroners were found with no obvious demographic explanation. The gender of the deceased was identified as a major factor in local variation., Conclusions: The decision to report a death to the coroner varies across jurisdictions. Implications for coronial investigations are discussed and the need for wider research into coroners' decision-making is proposed.

The completion of the medical certificate of cause of death is required for registration of a death, and this data helps plan healthcare services for the country. Many audits have shown them to be inaccurately completed by junior doctors, but the authors examined whether advice from consultant pathologists could improve this. Using the Office for National Statistics guidelines, the authors found that only 56% of the certificates were appropriately completed. The planned introduction of medical examiners to England and Wales is aimed at improving this situation, but consultant pathologists will still issue causes of death following postmortems, and it would seem prudent to train pathologists as well.

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.

The National Academy of Sciences recommends that states assess the performance of medicolegal death investigation agencies. To aid in performance assessment, we adapted an instrument based on the CDC's 10 Essential Public Health Services by translating the terminology to that of essential medicolegal death investigation services. This produced a survey that could be used to standardize reporting practices and services of agencies. To validate the instrument, a stratified random sample of 12 death investigation chiefs in 12 states was interviewed. This sample represented both medical examiner and coroner jurisdictions within the varying medicolegal structures. A cognitive testing process elicited how well participants could respond to and interpret the survey questions. The response was favorable in that the respondents agreed that given specific revisions toward question clarification, the instrument would be a useful and relevant tool for assessing system performance., (© 2011 American Academy of Forensic Sciences.)

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.

Traditionally in England and Wales it has been in the domain of doctors to pronounce 'life extinct'. The recent implementation of recognition of life extinct (ROLE) procedure in England and Wales has permitted other health care workers undertake this role in selective cases. A momentous case that changed a medico-legal role is presented.

Medicolegal autopsies are a vital tool for obtaining reliable injury mortality data. In Finland, medicolegal autopsies have increased from 13.6% of all deaths in 1970 to 23.8% in 2004. In fact, medicolegal autopsies are performed in 87.2% of all unintentional injury deaths, 98.3% of homicides and 99.5% of suicides. Finland has exceedingly high medicolegal autopsy rates compared with other countries. Autopsy rates should be appropriately considered when performing international comparisons of injury-related deaths.

Background: On 1 June 2005, amendments to the Coroners Rules 1984 were introduced in England and Wales. These principally cover the retention of tissues from autopsies and their subsequent disposal. This study assesses regional variations in the interpretations of the amendments, and their impact on local autopsy practice in Oxford., Methods: A questionnaire was circulated to pathologists in 120 coronial jurisdictions, addressing conditions under which histological material could be retained. A local review of autopsy practice was conducted before and after the introduction of the amendments., Results: Questionnaires were returned from 71 coronial jurisdictions. 35 (49%) coroners provided written guidelines on their interpretation of the amendments. In 52 (73%) jurisdictions, pathologists are authorised to retain material to confirm/refine causes of death from natural causes. In 77% of jurisdictions, coroner's officers are responsible for obtaining instructions from the next of kin on subsequent retention, use or disposal of retained tissues. In Oxford, there has been a reduction in the proportion of cases in which histology is taken, but an increase in the proportion of cases in which a histology report is issued., Conclusions: There is considerable regional variation in the interpretation of the 2005 Coroners Rules Amendments. These variations have potentially important implications for clinical practice.

In the U.S. today, the pathologists, both hospital-based and forensic, are regularly involved in quality assurance (QA) programs, the evaluation of patient safety at all levels of medical care, including treatments in walk-in clinics and medical offices. In the United States, official death investigations are conducted by the Medical Examiner's Office. The Medical Examiner's Office is aided in its work by a network of coordinating agencies to provide complete, comprehensive reporting and investigation of deaths placed under its jurisdiction. Those agencies are the Health Department, the Registrar of Vital Statistics on Births and Deaths, Division of Health Facilities, the Hospital Office of Decedent Affairs and the State medical licensing agencies, as well as the various law enforcement and regulatory agencies and the prosecuting attorney's office. Forensic pathologists are witnesses to the fatal results of often avoidable untoward events. They need to use their experiences to address and emphasize overall prevention programs to improve the quality of life in the community, to publicize the avoidable actions which can lead to untoward results. In the current growing atmosphere of threatening chemical, biological and radiation terrorist attacks, the health care system, especially hospitals, including emergency services, are mobilizing to develop plans to meet possible anticipated need for disaster preparedness.

Safety in health care has increasingly become a key focus of health care providers. Data on "patient outcomes" and evidence-based clinical decision-making have led to real changes in health care policy and care provision. Specialist groups such as the National Patient Safety Agency which operates the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in the United Kingdom are reliant on good information in order to identify factors that lead to poor patient care. In a recent study the NCEPOD reviewed the quality of coroners' autopsy reports on which they rely for much of their core data. The study found that just over half of the reports (52%) were considered satisfactory by the reviewers, 19% were good and 4% were excellent. However, over a quarter of autopsies were marked as poor or of an unacceptable standard. While analysing the factors associated with poor-quality autopsies, comments and recommendations were made with regard to the processes of death investigation and the degree to which the coroner's death investigation meets the needs of health care services.

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.

Purpose: The aim of the study is to examine the validity of manner of death (MOD) certification of unnatural adult deaths by Ontario coroners., Methods: A census of 306 active coroners practicing in Ontario was performed, with data collection occurring in 2002. Mailed self-administered questionnaires contained 14 fictitious clinicopathologic scenarios and questions regarding demographic information of the coroner. Crude and adjusted odds ratios of correct MOD certification were calculated by using responses of two deputy chief coroners as the gold standard., Results: Nearly 74% of coroners responded to the survey. Deaths from hanging, drowning, and carbon monoxide had better odds of being certified correctly; whereas deaths from heroin, over-the-counter medication, and injuries from a descent had decreased odds of being certified correctly. Scenarios including a prior suicide attempt or a note had greater odds of correct MOD certification than those with only depression. Accidental deaths were underreported when injury resulted in a "natural" lethal complication and when there was a delay between injury and death., Conclusions: In detailing which deaths are likely to be misclassified and how they may be misclassified, this study will allow future research to more accurately assess suicidal and accidental deaths.

Context: Traditionally, the emphasis of work done by medical examiners, coroners, and the death investigation community has been viewed as serving the criminal justice system. During the last several decades, however, an important role for these 3 groups has emerged within public health., Objective: To provide important background information on death investigation systems, the evolution and framework of public health entities that rely on information gathered by medical examiners and coroners, and the role of medical examiners and coroners in epidemiologic research, surveillance, and existing public health programs and activities., Data Sources: Previous articles on epidemiologic aspects of forensic pathology and the role of medical examiners and coroners in epidemiologic research and surveillance; a review of the Web sites of public health and safety agencies, organizations, and programs that rely on medical examiner and coroner data collected during medicolegal investigations; and a review of recent public health reports and other publications of relevance to medical examiner and coroner activities., Conclusions: The role of medical examiners and coroners has evolved from a criminal justice service focus to a broader involvement that now significantly benefits the public safety, medical, and public health communities. It is foreseeable that the public health role of medical examiners and coroners may continue to grow and that, perhaps in the not-too-distant future, public health impact will surpass criminal justice as the major focus of medicolegal death investigation in the United States.

This force-wide study in the Northumbria Police area provides an audit of the quality and quantity of work carried out by Forensic Medical Examiners (FMEs) over a three month period. Approximately 25% of all arrests during the period of the audit resulted in a request for FME assessment of the detainee. About 79% of consultations were performed to establish fitness to detain, in which over 30% of detainees were intoxicated and over 40% addicted to drugs and/or alcohol. Over 30% of those queried for fitness to detain also required advice and occasionally prescription for medication, both for the management of addiction and the treatment of chronic illness. In comparison to prior work this study found lower rates of mental illness in alcohol and drug dependent populations (13% and 6%, respectively). It is hoped this study will provide information in respect of the specific competencies not only required by future FMEs but also nurses working with detainees within the custody suites.

Purpose: Approximately 4,500 Americans die from asthma each year. Our objective was to determine the feasibility of creating a national fatal asthma registry to better understand this problem.Methods. Using a standard questionnaire, 18 state vital statistics departments and 22 medical examiners offices were contacted in 2001 to assess availability of fatal asthma data. Funding was obtained in 2002 to implement a fatal asthma registry. During 2003, the project was put on hold due to uncertainty about the impact of the Health Insurance Portability and Accountability Act (HIPAA). The project was revived in 2004 when a standard protocol was submitted to Institutional Review Boards (IRBs) in four different states., Results: All vital statistics departments reported that they were able to identify the decedent's name and demographic characteristics. Contact information for a relative or doctor was available in all states. Demographic characteristics and autopsy findings were available from 100% of the medical examiners offices. However, IRBs at the four institutions required major protocol modifications, including language and approach for contacting next of kin., Conclusion: Availability of demographic and clinical data across states is consistent. The creation of a national fatal asthma registry appears feasible, but different IRB interpretations of what is permissible preclude a standard approach across states.

The certification of deaths and their investigation is flawed and has not been subject to comprehensive revision for many decades; the current system is fragmented. Despite its historical 'stability', it is poorly understood by many who have to use it and the lack of supervisory structures within the system means that there is no leadership, accountability or quality assurance. No formal linkage to or communication with other public health services and systems exists, minimising its epidemiological value. There is a lack of clear participation rights in these processes for bereaved families. The standards for the treatment and support of the bereaved are woefully inadequate and have contributed in a major way to certain causes celebres. A report in 2003 suggested that death investigation should be a service that is consistent and professional, able to deal effectively with legal and health issues, work across the full range of concerns about public health and public safety and support, and audit the death certification process. The role of those supporting the current system must be properly established in a framework of accountability.

According to law a medicolegal autopsy can in practice be carried out by every physician. Strict cooperation between the physician and the prosecutor must guarantee the carrying out of all formal and medical procedures and in the meantime without overstepping the competence of the expert. The lack of precise regulations concerning all medicolegal procedures during the autopsy (like those from 1928) cause conflicting situations which in turn may not allow for all essential procedures to be undertaken in order to solve a specific case.