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For the past decade, illicitly manufactured fentanyl has been a primary contributor in drug overdose deaths regardless of age. The pediatric population is particularly vulnerable to fentanyl exposure, yet there are limited case reports involving this population. Postmortem cases from 2019 to 2023 were retrospectively analyzed to determine the prevalence of fentanyl in decedents between 0 and 12 years of age. Over this time frame, the fentanyl positivity rate increased from 2.6 to 6.2% (n = 632). The most commonly reported age group was 0–4 years, with a peak around 1 year of age for toddlers. Fentanyl concentrations in blood (n = 573) ranged from 0.19 to 360 ng/mL (mean 18 ng/mL, median 6.9 ng/mL). Polydrug use was present in 428 cases; midazolam (n = 96) and methamphetamine (n = 66) were the most common drugs found concurrently in blood with fentanyl, followed by markers of illicitly manufactured fentanyl, such as xylazine (n = 23), para‐fluorofentanyl (n = 18), and acetyl fentanyl (n = 17). This report contrasts the differences in postmortem pediatric fentanyl toxicology results for three groups of case histories: likely medical intervention (n = 113), pregnancy/birth related (n = 136), and inadvertent/intentional exposure (n = 196). Overall, this study provides a retrospective review of postmortem pediatric fentanyl concentrations in a variety of biological matrices and highlights the need for comprehensive toxicology testing in postmortem pediatric casework. [ABSTRACT FROM AUTHOR]

With the escalating overdose epidemic, many surveillance efforts have appeared. In 2018, King County Medical Examiner's Office (KCMEO) initiated a fatal overdose surveillance project aimed at expediting death certification and disseminating timely information. In this project, KCMEO investigators collected items of evidence of drug use from overdose death scenes, which were tested by five in‐house methods, four using handheld devices: TruNarc Raman spectrometer, with and without the manufacture's H‐Kit, Rigaku ResQ Raman spectrometer, and MX908 mass spectrometer. The fifth in‐house method used fentanyl‐specific urine test strips. Results from in‐house testing were compared with results from Washington State Patrol (WSP) Materials Analysis Laboratory. From 2019 to 2022, there were 4244 evidence items of drugs and paraphernalia collected from 1777 deaths scenes. A total of 7526 in‐house tests were performed on collected specimens, and 2153 tests were performed by the WSP laboratory using standard analytical methods. The WSP results served as reference standards to calculate performance metrics of the in‐house methods. Sensitivities, specificities, and predictive values ranged from good to poor depending on the method, drug, and evidence type. Certain drugs were often associated with specific evidence types. Acetaminophen was frequently found in combination with fentanyl. Fentanyl test strips gave good scores for detecting fentanyl; otherwise, in‐house methods using handheld devices had poor performance scores with novel drugs and drugs diluted in mixtures. The results showed that in‐house testing of drug evidence has value for medical examiner overdose surveillance, but it is resource intensive, and success depends on collaboration with forensic laboratories. [ABSTRACT FROM AUTHOR]

Death investigation on tribal lands and of American Indian/Alaska Native (AIAN) people is complex and not well documented. An analysis of data from the 2018 Census of Medical Examiner and Coroner Offices (CMEC) provides a timely update on the extent of medicolegal death investigations (MDIs) on federal and state-recognized tribal lands. An estimated 150 MEC offices serve tribal lands, however, 44 % of these offices (i.e., 4 % of MEC offices) do not track cases from tribal lands separately. MEC offices with a population of 25,000 to 250,000 that serve tribal lands had more resources and access to information to perform MDIs than all other MEC offices. Analysis also indicates that the median number of unidentified human remains cases from MECs serving tribal lands is 6 times higher than that of jurisdictions not serving tribal lands. This analysis begins to elucidate gaps in the nation's understanding of MDI on tribal lands.

Technology uses among medical examiner and coroner (MEC) offices in the United States are not well characterized, yet technology is essential to job-performing duties. Resources, operational infrastructure, and MECs' policies and procedures that affect technology use should be better understood. MEC offices need access to technologies like internet, case management systems (CMSs), databases, and advanced imaging to perform their basic duties. A current state of the technologies MEC offices use to complete a death investigation is presented by analyzing data from the 2018 Census of Medical Examiner and Coroner Offices. This analysis shows the New England division reported the most internet and CMS access. Many offices reported limited access to, and low participation in, databases for assessing and sharing case data. Offices serving populations >250,000 have more access to the internet, CMSs, databases, and advanced imaging. Although MEC office technology use has improved over time, it is still disparate.

In the United States, medical examiners and coroners (MECs) fill critical roles within our public health and public safety systems. These professionals are primarily charged with determining the cause and manner of death as they investigate deaths and respond to associated scenes and mass fatalities and can also help identify trends in public health crises through medicolegal death investigations. Despite their instrumental role, they are organized in disparate systems with varying governing structures, functions, staffing, caseload, budget, and access to resources. This paper examines data from the 2018 Census of Medical Examiner and Coroners to evaluate MEC operations in the United States. The findings show that MEC offices’ organizational and operational governance structures greatly influence resources, workloads, and access to information and services. Standalone MEC offices were generally better resourced than those affiliated with law enforcement, public health, forensic science, district attorneys, or other agencies.1

As the overdose epidemic overwhelmed medicolegal death investigation offices and toxicology laboratories, the King County Medical Examiner's Office responded with "real‐time" fatal overdose surveillance to expedite death certification and information dissemination through assembling a team including a dedicated medicolegal death investigator, an information coordinator, and student interns. In‐house testing of blood, urine, and drug evidence from scenes was performed using equipment and supplies purchased for surveillance. Collaboration with state laboratories allowed validation. Applied forensic epidemiology accelerated data dissemination. From 2010 to 2022, the epidemic claimed 5815 lives in King County; the last 4 years accounted for 47% of those deaths. After initiating the surveillance project, in‐house testing was performed on blood from 2836 decedents, urine from 2807, and 4238 drug evidence items from 1775 death scenes. Time to complete death certificates decreased from weeks to months to hours to days. Overdose‐specific information was distributed weekly to a network of law enforcement and public health agencies. As the surveillance project tracked the epidemic, fentanyl and methamphetamine became dominant and were associated with other indicators of social deterioration. In 2022, fentanyl was involved in 68% of 1021 overdose deaths. Homeless deaths increased sixfold; in 2022, 67% of 311 homeless deaths were due to overdose; fentanyl was involved in 49% and methamphetamine in 44%. Homicides increased 250%; in 2021, methamphetamine was positive in 35% of 149 homicides. The results are relevant to the value of rapid surveillance, its impact on standard operations, selection of cases requiring autopsy, and collaboration with other agencies in overdose prevention. [ABSTRACT FROM AUTHOR]

The evolving opioid epidemic in the United States, fueled by illicit fentanyl, has greatly increased deaths from illicit drug use. These nonnatural deaths require formal death investigation. The National Association of Medical Examiners states in its Forensic Autopsy Performance Standards that autopsy remains a necessary component for proper investigation of suspected acute overdose deaths. If a death investigation office lacks adequate resources to investigate all deaths under its jurisdiction while meeting expected standards, then that office may be forced to consider altering its protocols for investigation by changing the types of deaths investigated or the extent of its investigations. Drug death investigations take longer to complete because novel illicit drugs and mixtures of drugs complicate toxicological analyses, prolonging a family's wait for completion of a death certificate and autopsy report. Public health agencies must also wait for results, but some agencies have developed mechanisms for rapid notification of preliminary results to allow timely deployment of public health resources. The increased deaths have strained the resources of medicolegal death investigation systems throughout the United States. Given the significant workforce shortage of forensic pathologists, newly trained forensic pathologists are too few to meet the demand. Nevertheless, forensic pathologists (and all pathologists) must make time to present their work and themselves to medical students and pathology trainees to encourage an understanding of the importance of quality medicolegal death investigation and autopsy pathology and to provide a model that can encourage interest in a career in forensic pathology. [ABSTRACT FROM AUTHOR]

The opioid epidemic has affected the United States (US) for decades with fentanyl and its analogs accounting for a recent surge in morbidity and mortality. Currently, there is a relative lack of information characterizing fentanyl‐related fatalities specifically in the Southern US. A retrospective study was conducted to examine all postmortem fentanyl‐related drug toxicities in Travis County, Texas, encompassing Austin (one of the fastest‐growing cities in the US), from 2020 to 2022. Fentanyl contributed to 2.6% and 12.2% of deaths submitted for toxicology between 2020 and 2022, respectively, representing a 375% increase in fentanyl‐related deaths over this 3‐year period (n = 517). Fentanyl‐related fatalities primarily occurred in males in their mid‐30s. Fentanyl and norfentanyl concentrations ranged from 0.58 to 320 ng/mL and 0.53 to 140 ng/mL with mean (median) concentrations of 17.2 ± 25.0 (11.0) and 5.6 ± 10.9 (2.9) ng/mL, respectively. Polydrug use was present in 88% of cases, with methamphetamine (or other amphetamines) (25%), benzodiazepines (21%), and cocaine (17%) representing the most frequently identified concurrent substances. Co‐positivity rates of various drugs and drug classes widely varied over time. Scene investigations reported illicit powder(s) (n = 141) and/or illicit pill(s) (n = 154) in 48% (n = 247) of fentanyl‐related deaths. Illicit oxycodone (44%, n = 67) and illicit "Xanax" (38%, n = 59) pills were frequently reported on scene; however, toxicology only identified oxycodone and alprazolam in 2 and 24 of these cases, respectively. The results of this study provide a better understanding of the fentanyl epidemic in this region creating an opportunity to promote increased awareness, shift focus to harm reduction, and aid in minimizing public health risks. [ABSTRACT FROM AUTHOR]

On March 11, 2020, the World Health Organization officially declared the SARS-CoV-2 virus (COVID-19) a worldwide pandemic. As of December 2021, there have been over 278 million cases and 5.4 million deaths reported. One area of concern regarding the pandemic was its potential impact on mental health, and it was feared that the onset of such a devastating pandemic would lead to increased suicide risks among the general population. With suicide being a leading cause of death in adolescents, it is important to assess the potential mental health consequences that the COVID-19 pandemic may impose. Aim: The aim of the study was to analyze the impact of COVID-19 on suicide deaths among adolescents in the state of Maryland from 2019 to 2021. Subjects and Methods: This was a retrospective study of adolescent suicide victims, aged 10-19 years, from January 2019 to December 2021 in the state of Maryland. De-identified data were collected from the statewide medical examiner's office which is responsible for the medicolegal death investigation in Maryland. Results: A total of 102 adolescent suicide deaths were investigated statewide by the Maryland Office of the Chief Medical Examiner during these 3 years. The number of adolescent suicide cases stayed relatively stable during the COVID-19 pandemic, with slightly more cases during the pre-COVID-19 pandemic period (2019: n = 37; 2020: n = 31; and 2022: n = 34). Looking at months of incidence, less cases were reported in March-May 2020 (n = 5), which marks the beginning of the pandemic when compared to the same period in 2019 (n = 13). The number was higher for August-November 2020 (n = 15) than for that of 2019 (n = 8) and 2021 (n = 8). The male-to-female suicide ratio was 3.7:1 (n = 80/22). However, the data exhibited a significant increase in the number of female adolescent suicides, from 8.11% in 2019 (n = 3) to 25.81% in 2020 (n = 8) and 32.35% in 2021 (n = 11). Of the cases examined, more than 50% were white and approximately 27% were African-Americans. The two leading causes of death were hanging (47%) and firearm injuries (29%). Maryland consists of 23 countries and Baltimore City. The majority of adolescent suicides occurred in county residents with only 8.8% of cases in Baltimore City. [ABSTRACT FROM AUTHOR]

Researchers use public records from deceased individuals to identify trends in manners and causes of death. Errors in the description of race and ethnicity can affect the inferences researchers draw, adversely impacting public health policies designed to eliminate health inequity. Using the New Mexico Decedent Image Database, we examine: 1) the accuracy of death investigator descriptions of race and ethnicity by comparing their reports to those from next of kin (NOK), 2) the impact of decedent age and sex on disagreement between death investigators and NOK, and 3) the relationship between investigators’ descriptions of decedent race and ethnicity and cause and manner of death from forensic pathologists (n = 1813). Results demonstrate that investigators frequently describe race and ethnicity incorrectly for Hispanic/Latino decedents, especially regarding homicide manner of death and injury and substance abuse causes of death. Inaccuracies may cause biased misperceptions of violence within specific communities and affect investigative processes.

Decomposition studies have been conducted in several regions of the world, but relatively few have investigated taphonomy in tropical environments. Even fewer have explored carcass decomposition during multiple tropical seasons, leaving the relationships between season and decomposition in tropical environments poorly understood. Ten decomposition studies using 30 carcasses were conducted in Honolulu, Hawaii, USA to start addressing this knowledge gap. These studies show that some postmortem processes were observed regardless of season. Carcass temperature and chemistry were spatiotemporally variable. Fly larval masses were consistently observed within 3 days (∼75 ADD) postmortem and carcasses lost 60%–90% of mass by 10 days (∼250 ADD) postmortem (Total Body Score ∼26). Season had a significant effect on decomposition, yet the warmest and most humid seasons did not always result in the most rapid and extensive decomposition. Seasonal variation appears to be less pronounced than at other tropical decomposition sites.

Ligature strangulation is more common in homicides and is rarely seen in suicides and sexual asphyxia involving neck compression. We report a rare case of a dentist found dead of ligature strangulation next to a dental unit. The ligature was attached to the window frame, wrapped tightly around the neck once with a noose, and tied at the midpoint of the neck and at the head of the dental chair. A death scene and medicolegal investigation suggested suicidal ligature strangulation. The victim was squatting next to the dental unit with the control panel within reach. Pressing Button 1 (the recline button) would have tightened the ligature around the neck. A container containing pink nylon ribbon was found near the victim. The position of the knot at the front of the neck was consistent with suicide. Bloodstain pattern analysis confirmed the longitudinal flow pattern. No other remarkable findings were observed. Nobody had visited the clinic, autopsy found no drugs in his system, and the environment was undisturbed. Homicide was ruled out. According to witnesses, the victim had been in litigation with the owner of the building where his clinic was located. There were no reports of the victim having engaged in any unusual sexual or autoerotic activity. He had not received any death threats. Approximately 1 h before his death, he sent a suicide text message to his wife. Our case highlights the importance of distinguishing between suicide and homicide, especially in cases of ligature strangulation. [ABSTRACT FROM AUTHOR]

Background: There is a striking geographic variation in drug overdose deaths without a specific drug recorded, many of which likely involve opioids. Knowledge of the reasons underlying this variation is limited. Objectives: We sought to understand the role of medicolegal death investigation (MDI) systems in unclassified drug overdose mortality. Methods: This is an observational study of 2014 and 2018 fatal drug overdoses and U.S. county-level MDI system type (coroner vs medical examiner). Mortality data are from the CDC's National Center for Health Statistics. We estimated multivariable logistic regressions to quantify associations between MDI system type and several outcome variables: whether the drug overdose was unclassified and whether involvement of any opioid, synthetic opioid, methadone, and heroin was recorded (vs unclassified), for 2014 (N = 46,996) and 2018 (N = 67,359). Results: In 2018, drug overdose deaths occurring in coroner counties were almost four times more likely to be unclassified (OR 3.87, 95% CI 2.32, 6.46) compared to medical examiner counties. These odds ratios are twice as large as in 2014 (difference statistically significant, P <.001), indicating that medical examiner counties are improving identification of opioids in drug overdoses faster than coroner counties. Conclusions: Accurate reporting of drug overdose deaths depends on MDI systems. When developing state policies and local interventions aimed to decrease opioid overdose mortality, decision-makers should understand the role their MDI system is playing in underestimating the extent of the opioid overdose crisis. Improvements to state and county MDI systems are desirable if accurate reporting and appropriate policy response are to be achieved. [ABSTRACT FROM AUTHOR]

Like their counterparts in healthcare, workers in medical examiner and coroners' offices are considered essential workers. The frequency and urgency of their work during the coronavirus disease 2019 (COVID-19) pandemic have only become of greater importance. Because of the increased mortality in the general population due to SARS-CoV-2, the virus that causes COVID-19, it is reasonable to assume that the workload and risk of occupational exposure to SARS-CoV-2 have increased for these workers who are required by state law to investigate deaths known or suspected to be due to a contagious disease that constitutes a public hazard. Studies investigating the impact of the COVID-19 pandemic on these workers and their operations have been limited. The objective of this study was to conduct an assessment of routine medical examiner and coroners' office duties (e.g., infectious disease testing and decedent transport) by surveying the 67 county medical examiner and coroners' offices in Pennsylvania to characterize how the rise in infectious disease cases from COVID-19 influenced workload and resource needs. Quantitative results demonstrated an increase in workload and use of personal protective equipment (PPE) while engineering control usage remained the same. Qualitative results revealed various challenges experienced by the offices during the pandemic including limitations in access to PPE, insufficient storage space for increased numbers of decedents, personnel shortage/burnout, and limited or no engagement at the state level for emergency response planning and implementation. These data are valuable to inform the need for additional guidance or supplies and may be used to optimize resource planning and implementation (e.g., personnel, facilities, and supplies) for both routine and surge demand scenarios. [ABSTRACT FROM AUTHOR]

Carbon monoxide (CO) toxicity associated with exposure to an environmental, exogenous source, is routinely investigated in the field of forensics. Paramedics responded to the home of a 60‐year‐old woman who complained of persistent nausea, dizziness, and fatigue. Her initial carboxyhemoglobin (COHb) saturation was 25% as measured by paramedics in the field via pulse CO‐oximetry (SpCO) and was, 2 hours later, confirmed by hospital laboratory spectrophotometric analysis to be 16% after initial treatment in the emergency department. The clinical presentation of environmental CO exposure and subsequent death notification to the North Carolina Office of the Chief Medical Examiner prompted an extensive investigation into the suspected residential source of CO, which ultimately ruled out all exogenous sources. The medicolegal death investigator later discovered an updated hematology consultation note, which determined the actual source of the CO to be endogenously produced from disease. Herein, we report an unusual fatality involving enhanced endogenous CO production caused by warm autoimmune hemolytic anemia. This unique case report and brief literature review of disease‐related elevation of endogenous CO will shed light on this lesser‐known phenomenon alerting the forensic community to its potential occurrence and need for consideration when sources of environmental exposure have been exhausted. [ABSTRACT FROM AUTHOR]

This paper examines a pediatric hyperthermia homicide in which the decedent was placed into a room with only a diaper on and left unattended overnight. There were no furnishings in the room except for a 1500‐W space heater and a stroller. The following morning, emergency personnel were summoned to the residence. A caretaker said the decedent was playing normally 5 min before making the 911 call. The decedent's initial rectal temperature was 42.2°C. Law enforcement asked how long the child had to be exposed to a high temperature in order to induce fatal hyperthermia in an empty bedroom. The scene was reconstructed using the child's residence and the same heater. Environmental data were gathered over a 16‐h period. The thermal parameters of the room and environment were analyzed using a lumped‐element thermal model. These parameters were then fed into an adapted Gagge's two‐node model of human thermal regulation, which provided a time‐window of exposure necessary to elicit hyperthermia, which in this case, depending on certain variables, ranged from 45 min to 4 h. [ABSTRACT FROM AUTHOR]

In the United States, the governance of unnatural death certification varies greatly by state. Although cross-sectional research has linked mortality data quality with variation in medicolegal death investigation systems across states-especially with regards to drug-related deaths-this relationship has not be sufficiently tested using longitudinal data. This research assesses the impact of system governance reform on the quality of drug mortality data by assessing the impact of transitioning from a coroner system to a medical examiner system on data quality. The research finds no evidence that system-level reform is associated with improved drug-related mortality data quality. These findings suggest that alternative methods should be examined for improving public health data concerning drug-related mortality. These likely include focusing on individual-level characteristics and practices of officials and offices, rather than system-level variables. • Past research shows cross-sectional link between MDI system and mortality data. • We examine system reform impact on drug-related mortality data quality. • Change to medical examiner system did not improve drug-related mortality data. • Individual practices likely influence data quality more than system characteristics. [ABSTRACT FROM AUTHOR]

Death investigation on tribal lands and of American Indian/Alaska Native (AIAN) people is complex and not well documented. An analysis of data from the 2018 Census of Medical Examiner and Coroner Offices (CMEC) provides a timely update on the extent of medicolegal death investigations (MDIs) on federal and state-recognized tribal lands. An estimated 150 MEC offices serve tribal lands, however, 44 % of these offices (i.e., 4 % of MEC offices) do not track cases from tribal lands separately. MEC offices with a population of 25,000 to 250,000 that serve tribal lands had more resources and access to information to perform MDIs than all other MEC offices. Analysis also indicates that the median number of unidentified human remains cases from MECs serving tribal lands is 6 times higher than that of jurisdictions not serving tribal lands. This analysis begins to elucidate gaps in the nation's understanding of MDI on tribal lands., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Technology uses among medical examiner and coroner (MEC) offices in the United States are not well characterized, yet technology is essential to job-performing duties. Resources, operational infrastructure, and MECs' policies and procedures that affect technology use should be better understood. MEC offices need access to technologies like internet, case management systems (CMSs), databases, and advanced imaging to perform their basic duties. A current state of the technologies MEC offices use to complete a death investigation is presented by analyzing data from the 2018 Census of Medical Examiner and Coroner Offices. This analysis shows the New England division reported the most internet and CMS access. Many offices reported limited access to, and low participation in, databases for assessing and sharing case data. Offices serving populations >250,000 have more access to the internet, CMSs, databases, and advanced imaging. Although MEC office technology use has improved over time, it is still disparate., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

In the United States, medical examiners and coroners (MECs) fill critical roles within our public health and public safety systems. These professionals are primarily charged with determining the cause and manner of death as they investigate deaths and respond to associated scenes and mass fatalities and can also help identify trends in public health crises through medicolegal death investigations. Despite their instrumental role, they are organized in disparate systems with varying governing structures, functions, staffing, caseload, budget, and access to resources. This paper examines data from the 2018 Census of Medical Examiner and Coroners to evaluate MEC operations in the United States. The findings show that MEC offices' organizational and operational governance structures greatly influence resources, workloads, and access to information and services. Standalone MEC offices were generally better resourced than those affiliated with law enforcement, public health, forensic science, district attorneys, or other agencies. 1 ., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier B.V.)

This review covers previous and current literature on the impact of forensic anthropologists on the positive scientific identification of human remains and aims to provide an understanding of what information a forensic anthropologist can contribute to an investigation. Forensic anthropologists looking to identify human remains study traits of the skeleton and any orthopedic devices present. In order to obtain a positive scientific identification, evidence that is both sufficiently unique to the individual and comparable to available antemortem data from that individual must be found. The increased availability of radiographs, scans and implants in recent decades has facilitated the identification process. When these records are unavailable, other techniques, such as craniofacial superimposition and facial approximation, can be employed. While these methods may assist the identification process, they are most useful for exclusion of certain individuals and gathering leads from the public. Forensic anthropologists have heavily relied on the skull and its complexities for identification – typically focusing on the frontal sinus and other unique traits. Post-cranial remains can provide important information about bone density, possible disease and other characteristics that may also be utilized. Techniques used to positively identify individuals are not limited to medicolegal death investigations, and have been useful in other legal contexts. In the future, a team approach, utilizing all the information gathered by multiple forensic scientists – including forensic anthropologists – will most likely become more common.

Although nonhuman remains constitute a significant portion of forensic anthropological casework, the potential use of bone metrics to assess the human origin and to classify species of skeletal remains has not been thoroughly investigated. This study aimed to assess the utility of quantitative methods in distinguishing human from nonhuman remains and present additional resources for species identification. Over 50,000 measurements were compiled from humans and 27 nonhuman (mostly North American) species. Decision trees developed from the long bone data can differentiate human from nonhuman remains with over 90% accuracy (>98% accuracy for the human sample), even if all long bones are pooled. Stepwise discriminant function results were slightly lower (>87.4% overall accuracy). The quantitative models can be used to support visual identifications or preliminarily assess forensic significance at scenes. For species classification, bone-specific discriminant functions returned accuracies between 77.7% and 89.1%, but classification results varied highly across species. From the study data, we developed a web tool, OsteoID, for users who can input measurements and be shown photographs of potential bones/species to aid in visual identification. OsteoID also includes supplementary images (e.g., 3D scans), creating an additional resource for forensic anthropologists and others involved in skeletal species identification and comparative osteology.

In 2007, the Bureau of Justice Statistics reported on 2004 data collected from the Census of Medical Examiner and Coroner Offices (CMEC). The CMEC was one of the first comprehensive reports on the state of the medicolegal death investigation system in the United States and included information on administration, expenditure, workload, specialized death investigations, records and evidence retention, and resources. However, the report did not include responses on questions that were related to toxicology such as specimen retention and type of testing. The purpose of this publication is to provide the community with toxicology laboratory‐specific responses from nearly 2000 medical examiner and coroner (MEC) offices. Data obtained from a BJS CMEC public use dataset for any remaining information that was not reported in the 2007 BJS report were evaluated specific to the operation of toxicology laboratories within a MEC office or specific to toxicology testing. The CMEC includes information on average operating budget for MEC offices with internal or external toxicology services, budget for toxicology/microbiology services, respondents' routine uses of toxicology analysis, toxicology specimen retention time, average turnaround times, use of computerized information management systems, and participation in federal data collections. These historical data begin to address the present state of our nation's toxicology laboratories within the medicolegal death investigation system and their preparedness for the current drug overdose epidemic. [ABSTRACT FROM AUTHOR]

Pig (Sus scrofa domesticus) carcasses were decomposed on the soil surface of a terrestrial habitat on the island of Oahu, Hawaii to begin characterizing the decomposer community. Results showed that carcasses can decompose rapidly on Oahu, primarily due to the activity of fly larvae, with ~80% of mass lost by 8 days (~220 ADD) postmortem. Scavenging was conducted exclusively by the small Indian mongoose (Herpestes javanicus), first feeding on larvae then feeding on the remains. Carcasses were habitats of warm temperature, little to no oxygen, slightly acidic/neutral pH, and high sodium concentration. Larval masses selected for a microbial community comprised of multiple bacterial taxa from phyla Firmicutes and Proteobacteria, particularly genera Clostridium, Proteus, and Providencia. These larval masses were well established from 3 to 8 days (~90 to ~220 ADD) postmortem. These data provide helpful, novel insight into the structure and activity of carcass decomposer communities on Oahu. [ABSTRACT FROM AUTHOR]

Social media (SM) represent a global consumer phenomenon with an exponential rise in usage within the last few years. The various applications and websites are relatively easy and fast to access, and the number of users increases continuously. SM are an incredible source of freely available, public information about their users. The purpose of this study is to provide information about the usefulness of SM in forensic practice. The electronic database of the Cook County of Medical Examiner's Office ("CCMEO") in Illinois was searched for investigative narratives that included specific SM keywords, in the period from August 2014 to January 2018. A total of 48 cases met the study's criteria. Among these, "Facebook" has been found to be the most helpful SM for medicolegal investigation purposes. Information obtained by SM can play an important role in forensic practice since it can be used to clarify certain aspects of the medicolegal death investigation, with particular regard to time and manner of death. [ABSTRACT FROM AUTHOR]

Microbes can be used effectively as trace evidence, at least in research settings. However, it is unknown whether skin microbiomes change prior to autopsy and, if so, whether these changes interfere with linking objects to decedents. The current study included microbiomes from 16 scenes of death in the City and County of Honolulu and tested whether objects at the scenes can be linked to individual decedents. Postmortem skin microbiomes were stable during repeated sampling up to 60 h postmortem and were similar to microbiomes of an antemortem population. Objects could be traced to decedents approximately 75% of the time, with smoking pipes and medical devices being especially accurate (100% match), house and car keys being poor (0%), and other objects like phones intermediate (~80%). These results show that microbes from objects at death scenes can be matched to individual decedents, opening up a new method of establishing associations and identifications. [ABSTRACT FROM AUTHOR]

This review covers previous and current literature on the impact of forensic anthropologists on the positive scientific identification of human remains and aims to provide an understanding of what information a forensic anthropologist can contribute to an investigation. Forensic anthropologists looking to identify human remains study traits of the skeleton and any orthopedic devices present. In order to obtain a positive scientific identification, evidence that is both sufficiently unique to the individual and comparable to available antemortem data from that individual must be found. The increased availability of radiographs, scans and implants in recent decades has facilitated the identification process. When these records are unavailable, other techniques, such as craniofacial superimposition and facial approximation, can be employed. While these methods may assist the identification process, they are most useful for exclusion of certain individuals and gathering leads from the public. Forensic anthropologists have heavily relied on the skull and its complexities for identification - typically focusing on the frontal sinus and other unique traits. Post-cranial remains can provide important information about bone density, possible disease and other characteristics that may also be utilized. Techniques used to positively identify individuals are not limited to medicolegal death investigations, and have been useful in other legal contexts. In the future, a team approach, utilizing all the information gathered by multiple forensic scientists - including forensic anthropologists - will most likely become more common. [ABSTRACT FROM AUTHOR]

The purpose of this brief is to present several case vignettes that illustrate omissions in the investigation of elder deaths. These vignettes demonstrate the need for a standardized approach in the conduct of medicolegal investigations of fatal elder abuse. For each of the described oversights, a recommendation is offered to address the gap in investigation processes, which in turn could improve the determination of cause and manner of elder death. Inherent limitations of resources and practical realities of death investigation are discussed and recommendations are made for future research. Viewed broadly, deficiencies in elder death investigations can lead to the underreporting of elder abuse and the reduction of legal options for victims, which may reflect a systemic pattern of social injustice. [ABSTRACT FROM AUTHOR]

Decomposition studies have been conducted in several regions of the world, but relatively few have investigated taphonomy in tropical environments. Even fewer have explored carcass decomposition during multiple tropical seasons, leaving the relationships between season and decomposition in tropical environments poorly understood. Ten decomposition studies using 30 carcasses were conducted in Honolulu, Hawaii, USA to start addressing this knowledge gap. These studies show that some postmortem processes were observed regardless of season. Carcass temperature and chemistry were spatiotemporally variable. Fly larval masses were consistently observed within 3 days (∼75 ADD) postmortem and carcasses lost 60%-90% of mass by 10 days (∼250 ADD) postmortem (Total Body Score ∼26). Season had a significant effect on decomposition, yet the warmest and most humid seasons did not always result in the most rapid and extensive decomposition. Seasonal variation appears to be less pronounced than at other tropical decomposition sites., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Estimating postmortem interval is an important goal in medicolegal death investigations. Although several methods have been developed to achieve this goal, many of these require significant time and advanced expertise to generate a reliable estimate. Unfortunately these techniques do not provide much insight during the early stages of an investigation when critical decisions must be made regarding the allocation of investigative resources. An equation was recently developed to address this problem: provide a preliminary estimate of postmortem interval to initiate an investigation while more advanced techniques are conducted. To evaluate this equation, we used it to estimate postmortem interval at multiple indoor death scenes with known PMI in Nebraska and Hawai'i. This equation allowed us to accurately estimate PMI at 15 of 19 (79%) indoor death scenes. In Nebraska, this equation was accurate at 100% of the scenes. In Hawai'i, this equation was accurate at 60% of the scenes. All inaccurate estimates of postmortem interval were associated with at least 20% mass loss and a postmortem interval of ≥4 days. Although this equation was accurate at the majority of the death scenes attended, we conclude that more research is warranted, particularly the effect of climate on decomposition and the investigators' ability to accurately estimate soft tissue mass loss. [ABSTRACT FROM AUTHOR]

Researchers use public records from deceased individuals to identify trends in manners and causes of death. Errors in the description of race and ethnicity can affect the inferences researchers draw, adversely impacting public health policies designed to eliminate health inequity. Using the New Mexico Decedent Image Database, we examine: 1) the accuracy of death investigator descriptions of race and ethnicity by comparing their reports to those from next of kin (NOK), 2) the impact of decedent age and sex on disagreement between death investigators and NOK, and 3) the relationship between investigators' descriptions of decedent race and ethnicity and cause and manner of death from forensic pathologists (n = 1813). Results demonstrate that investigators frequently describe race and ethnicity incorrectly for Hispanic/Latino decedents, especially regarding homicide manner of death and injury and substance abuse causes of death. Inaccuracies may cause biased misperceptions of violence within specific communities and affect investigative processes., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

In postmortem cases where the cause of death is hanging, toxicological analyses may be considered unnecessary by some medical examiners, toxicologists, and other persons involved in medico-legal investigations because the cause of death seems "obvious." To ascertain if toxicological analyses are necessary when the cause of death is hanging, all 102 hanging cases (25 females; 77 males) from 2011 to 2013 that came under the jurisdiction of the San Francisco Office of the Chief Medical Examiner were examined from a total of 3912 sudden, unexpected, or violent death cases in the same period. Suicide was the manner of death in 99 of these cases, with two accidental and one undetermined death. The average age of decedents was 43.9 years (median 41), the youngest was an 11-year old male and the oldest was an 86-year old female. Of the 102 cases, 33 had negative toxicology while 69 cases had at least one positive toxicology result. Females were equally likely to have negative or positive results (12 and 13 cases respectively), but males were 37.5% more likely to have positive toxicology (n=56) rather than negative toxicology (n=21). For females, alcohol, mirtazapine, venlafaxine, and trazodone were the top psychoactive substances in peripheral blood while THC, cocaine, hydrocodone, bupropion, olanzapine, doxylamine, quetiapine and dextromethorphan were also reported. For males, alcohol, THC, cocaine, amphetamine, methamphetamine, bupropion, and diphenhydramine were the top psychoactive substances in blood, but several other drugs were also found in individual cases. Our study of hanging cases over a 3-year period support the idea that complete postmortem toxicology investigation of hangings should be performed, even when the "obvious" cause of death is asphyxia due to hanging. Many of these cases involved psychoactive substances (most often alcohol and cannabis), and having such knowledge provides a better understanding of the circumstances surrounding the decedent's death, their possible state of impairment, including the possibility of a staged suicide if the decedent was too impaired to perform a self-hanging. [ABSTRACT FROM AUTHOR]

Florida's climate is suitable for many potentially hazardous animals, including both indigenous and exotic species, which are frequently kept as in zoos or as pets. This has resulted in many unforeseen fatal encounters between animals and the ever expanding human population. While the literature and knowledge pool for more common types of deaths referred to medical examiner/coroner's offices is abundant, the appreciation of wildlife and exotic pet-related deaths is far less widespread. We report seven animal attack-related deaths that occurred in Florida. The inflicted injuries included blunt and sharp force injuries, asphyxia, drowning, and envenomation. The underlying cause of death, however, was always a result of the human/animal interaction and in many cases related to human error and failure to appreciate the potentially dangerous behavior of nondomesticated species. These cases illustrate the varied circumstances and pathophysiologies associated with deaths due to indigenous and exotic species and the importance of the multidisciplinary approach in the medicolegal investigation of these cases. [ABSTRACT FROM AUTHOR]

Simple Summary: Forensic anthropologists are commonly asked to determine whether bones are of human origin and, if not, to which species they belong. Current practice usually relies on visual assessments rather than quantitative analyses. This study aimed to test the utility of basic bone metrics in discriminating human from nonhuman elements and assigning faunal species. A database of more than 50,000 skeletal measurements was compiled from humans and 27 nonhuman species. Equations and classification trees were developed that can differentiate human from nonhuman species with upwards of 90% accuracy, even when the bone type is not first identified. Classification trees return accuracy rates greater than 98% for the human sample. These quantitative models provide statistical support to visual assessments and can be used for preliminary assessment of a bone's forensic significance at a scene. The statistical models, however, could not classify species at acceptable rates. For species identification, a freely available web tool (OsteoID) was created from the study data, where users can filter photographs of potential bones/species using a few basic measurements and access 3D scans and additional resources to facilitate identification. OsteoID provides an important resource for forensic anthropologists lacking access to large comparative skeletal collections, as well as other disciplines where comparative osteological training is necessary. Although nonhuman remains constitute a significant portion of forensic anthropological casework, the potential use of bone metrics to assess the human origin and to classify species of skeletal remains has not been thoroughly investigated. This study aimed to assess the utility of quantitative methods in distinguishing human from nonhuman remains and present additional resources for species identification. Over 50,000 measurements were compiled from humans and 27 nonhuman (mostly North American) species. Decision trees developed from the long bone data can differentiate human from nonhuman remains with over 90% accuracy (>98% accuracy for the human sample), even if all long bones are pooled. Stepwise discriminant function results were slightly lower (>87.4% overall accuracy). The quantitative models can be used to support visual identifications or preliminarily assess forensic significance at scenes. For species classification, bone-specific discriminant functions returned accuracies between 77.7% and 89.1%, but classification results varied highly across species. From the study data, we developed a web tool, OsteoID, for users who can input measurements and be shown photographs of potential bones/species to aid in visual identification. OsteoID also includes supplementary images (e.g., 3D scans), creating an additional resource for forensic anthropologists and others involved in skeletal species identification and comparative osteology. [ABSTRACT FROM AUTHOR]

Background: Legal systems for medicolegal death investigation in the United States are varied. A 1954 model medical examiner law was initially embraced by a few states but did not gain widespread support and was woefully inadequate. The 2009 National Commission on Forensic Science recommended the creation of an updated model medical examiner legislation., Methods: Various considerations for policymakers are explored., Results: A model law is proposed., Competing Interests: Disclosures & Declaration of Conflicts of Interest: The authors, reviewers, editors, and publication staff do not report any relevant conflicts of interest., (© The Author(s) 2022.)

The potential for the injury or death of a child resulting from the tip-over of a piece of household furniture or a domestic appliance has not been previously well recognized. We reviewed nine accidental deaths of young children that resulted from avoidable residential hazards and ⁄ or lapses in supervision of the children by their caregivers. The offending household items included televisions, bedroom dressers, a kitchen stove, and a lounge chair. The causes of death were mechanical asphyxia, blunt trauma, and combined blunt head trauma and asphyxia. All of the deaths could have been prevented by appropriate anchoring of the piece of furniture and ⁄ or closer supervision of the child. A thorough multi disciplinary investigation is essential in establishing the cause and manner of death in such cases and in identifying risk factors that may aid in the prevention of future childhood deaths. [ABSTRACT FROM AUTHOR]

The National Academy of Sciences recommends that states assess the performance of medico legal 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 medico legal 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 medico legal 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. [ABSTRACT FROM AUTHOR]

Although nonhuman remains constitute a significant portion of forensic anthropological casework, the potential use of bone metrics to assess the human origin and to classify species of skeletal remains has not been thoroughly investigated. This study aimed to assess the utility of quantitative methods in distinguishing human from nonhuman remains and present additional resources for species identification. Over 50,000 measurements were compiled from humans and 27 nonhuman (mostly North American) species. Decision trees developed from the long bone data can differentiate human from nonhuman remains with over 90% accuracy (>98% accuracy for the human sample), even if all long bones are pooled. Stepwise discriminant function results were slightly lower (>87.4% overall accuracy). The quantitative models can be used to support visual identifications or preliminarily assess forensic significance at scenes. For species classification, bone-specific discriminant functions returned accuracies between 77.7% and 89.1%, but classification results varied highly across species. From the study data, we developed a web tool, OsteoID, for users who can input measurements and be shown photographs of potential bones/species to aid in visual identification. OsteoID also includes supplementary images (e.g., 3D scans), creating an additional resource for forensic anthropologists and others involved in skeletal species identification and comparative osteology.

Coronial investigations of post-operative deaths can play an important role in improving the quality and safety of patient care. Correctly identifying reportable deaths in the post-operative period and reporting them to the coroner is a key responsibility of medical practitioners but may be challenging, particularly when determination of unexpectedness is problematic. Patient-reported outcome measures (PROMs) have a potential role to play in assisting clinicians with better identification of these reportable deaths. Moreover, the inclusion of PROMs within coronial investigations can assist in identifying systemic failures and result in recommendations on public health and safety. In particular, PROMs could be effective in addressing the overuse of surgery which remains a major public health concern. While the role of PROMs in clinical practice has undergone extensive research, their potential use in death investigations has been overlooked. As medicine continues to transition towards a patient-centred model of care, the use of frameworks such as PROMs will become increasingly important and may also provide benefit to the process of medicolegal death investigations.

Suicide pacts usually result in simultaneous deaths by mutual arrangement. While nitrogen and helium gas inhalation are being increasingly used in solitary suicide attempts, for some reason they have been rarely utilised in suicide pacts. A search of autopsy files at Forensic Science SA over a 15-year period (2003-2017) was undertaken to determine how often this method of joint suicide occurs. Only two cases were found. Case 1 comprised a 64-year-old husband and wife (who had a history of multiple sclerosis). They were found deceased in a vehicle with two empty cylinders of nitrogen gas. Case 2 comprised an 87-year-old man (who had a history of ischaemic heart disease) and his 81-year-old wife who were found deceased with plastic bags over their heads, with plastic tubes connecting the bags to opened cylinders of nitrogen. The deaths in all cases were due to nitrogen-induced asphyxiation, in the latter instance augmenting plastic-bag asphyxia. Although suicide pacts have previously usually involved carbon-monoxide toxicity or drug overdose, it is possible that dissemination of information on the use of inert gases in individual suicide attempts may alter the methods used in future.

This review covers previous and current literature on the impact of forensic anthropologists on the positive scientific identification of human remains and aims to provide an understanding of what information a forensic anthropologist can contribute to an investigation. Forensic anthropologists looking to identify human remains study traits of the skeleton and any orthopedic devices present. In order to obtain a positive scientific identification, evidence that is both sufficiently unique to the individual and comparable to available antemortem data from that individual must be found. The increased availability of radiographs, scans and implants in recent decades has facilitated the identification process. When these records are unavailable, other techniques, such as craniofacial superimposition and facial approximation, can be employed. While these methods may assist the identification process, they are most useful for exclusion of certain individuals and gathering leads from the public. Forensic anthropologists have heavily relied on the skull and its complexities for identification - typically focusing on the frontal sinus and other unique traits. Post-cranial remains can provide important information about bone density, possible disease and other characteristics that may also be utilized. Techniques used to positively identify individuals are not limited to medicolegal death investigations, and have been useful in other legal contexts. In the future, a team approach, utilizing all the information gathered by multiple forensic scientists - including forensic anthropologists - will most likely become more common.

The people of Cambodia were subjected to widespread forced migration and labor, disease, starvation, torture, murder, and indeed, genocide over a period of four years during the control of the country by Pol Pot and the Khmer Rouge in the 1970s. While the country awaits some form of justice from the hybrid tribunal hearing cases against a few of the perpetrators of these crimes, it has undertaken to memorialize the dead in visible monuments in order that the people remember and never allow it to happen again. This paper outlines the few forensic investigations which have been undertaken on the remains of the deceased from this period in Cambodia's history. The current status of the legal proceedings and the current death investigation system in Cambodia are also presented. There is a wealth of objective forensic information that can be gathered from analyzing the remains that have been disturbed and placed in monuments (stupas), and also in the undisturbed graves across the country. This information cannot only assist in any legal proceedings, but can aide in training medicolegal experts in Cambodia for the future good of the country and its rule of law., Competing Interests: DISCLOSURES & DECLARATION OF CONFLICTS OF INTEREST The authors, reviewers, editors, and publication staff do not report any relevant conflicts of interest

Background: The number of disaster-related deaths recorded by vital statistics departments often differs from that reported by other agencies, including the National Oceanic and Atmospheric Administration-National Weather Service storm database and the American Red Cross. The Centers for Disease Control and Prevention (CDC) has launched an effort to improve disaster-related death scene investigation reporting practices to make data more comparable across jurisdictions, improve accuracy of reporting disaster-related deaths, and enhance identification of risk and protective factors. We conducted a literature review to examine how death scene data are collected and how such data are used to determine disaster relatedness., Methods: Two analysts conducted a parallel search using Google and Google Scholar. We reviewed published peer-reviewed articles and unpublished documents including relevant forms, protocols, and worksheets from coroners, medical examiners, and death scene investigators., Results: We identified 177 documents: 32 published peer-reviewed articles and 145 other documents (grey literature). Published articles suggested no consistent approach for attributing deaths to a disaster. Researchers generally depended on death certificates to identify disaster-related deaths; several studies also drew on supplemental sources, including medical examiner, coroner, and active surveillance reports., Conclusions: These results highlight the critical importance of consistent, accurate data collection during a death investigation. Review of the grey literature found variation in use of death scene data collection tools, indicating the potential for widespread inconsistency in data captured for routine reporting and public health surveillance. Findings from this review will be used to develop guidelines and tools for capturing disaster-related death investigation data., Competing Interests: Disclosures: The authors, reviewers, editors, and publication staff do not report any relevant conflicts of interest. The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Over the last two decades, a diagnostic shift in regards to the certification of sudden deaths in infancy has emerged with reassignment of deaths previously certified as sudden infant death syndrome (SIDS) to a trend utilizing the classification of undetermined or asphyxia. The consequences of this shift outside the medicolegal death investigation (MDI) community is unknown. We surveyed US organizations working in the field of sudden infant death as well as bereaved parents to understand their perceptions of the current diagnostic trends. Two online anonymous surveys were utilized. Sixty-seven organizations and 55 parents with an infant death diagnosis of SIDS, sudden unexplained infant death (SUID), undetermined, or asphyxia participated. Just over 50% (34/67) of the organizations perceived the shift had an effect on their organization including barriers to bereavement support and education. Forty percent (22/55) of parent respondents stated they did not understand the final diagnosis of their infant's death. The highest frequency of themes elicited from parents were frustration that the diagnosis (regardless of terminology) did not fully explain the death, detrimental mental health effects, and negative perceptions towards the medical and public health communities. However, parents of children whose death was classified as SIDS were spared from negative perceptions towards the medical field, described the least amount of confusion, and reported the most instances of positives effects. Legal implications, perceived social stigmas, and research obstacles were also described. Recommendations from this study include the integration of collaborative efforts to combat sudden infant death with all stakeholders, in and outside of MDI, to achieve better understanding and eradication of these tragedies, improved public education, and effective care of all bereaved., Competing Interests: DISCLOSURES & DECLARATION OF CONFLICTS OF INTEREST The authors, reviewers, editors, and publication staff do not report any relevant conflicts of interest