Academic Forensic Pathology

The American Board of Medicolegal Death Investigators (ABMDI) was created and developed in 1998 by veteran, practicing medicolegal death investigators who were involved in the development of the National Institutes of Justice December 1997 publication National Guidelines for Death Investigation that was later renamed Death Investigation: A Guide for the Scene Investigator. The creation of the ABMDI allowed for the establishment of uniform criteria, ethical conduct and standardized practices for individuals investigating deaths that fall under the jurisdiction of the medical examiner/coroner. There are two levels of ABMDI certification: Registry Certification and Board Certification.

A survey was deployed to ABMDI certificants in 2005 and 2011 to determine how the profession has changed with respect to job title, systems employing certificants, educational level and the overall benefits and requirements of ABMDI certification. Results of the survey will be discussed.

The NAS report released in 2009 recommends professional certification for all forensic personnel, including medicolegal death investigators. Achievement of this recommendation requires legislative action, implementation strategy, and adequate time and budget. The Subcommittee on Forensic Science (SoFS) has established an Interagency Working Group (IWG) that is examining these recommendations. A Scientific Working Group on Medicolegal Death Investigation (SWGMDI) was developed in March 2011 to recommend best practices and standards, including a committee on Accreditation, Certification, Education and Training. The ABMDI is participating in the efforts to promote standardized medicolegal death investigation.

This manuscript will discuss Best Practices for Death Investigation when conducting Infant Death Scene Investigations. The autopsy starts at the scene, a thorough investigation cannot be done without completing a scene recreation. During the infant death scene investigation, the Death Investigator will gather information concerning all potential causes of the sudden unexpected infant death. The Pathologist will use this information to interpret autopsy findings, and determine cause and manner of death. One goal of the death scene recreation is to be able to accurately depict the sleep environment and sleep position in which the infant was last placed down to sleep, how the infant was last known to be alive and the position the infant was found unresponsive. Another goal of the scene recreation is to be able to provide the family with an explanation of what happened to their infant. Best Practice for the Death Investigator is to follow the Centers for Disease Control and Prevention's (CDC) Sudden Unexplained Infant Death Investigation (SUIDI) Training guidelines. This includes the use of the Sudden Unexpected Infant Death reporting form. The SUIDI reporting form is an essential tool designed to standardize and improve the data collected at infant death scenes. Inaccurate classification of cause and manner of death hampers prevention efforts and researchers are unable to adequately monitor national trends, identify risk factors, or evaluate prevention programs. Valid and consistent data is needed to support research and prevention efforts if we want to reduce infant deaths.

The Air Force Office of Special Investigations (AFOSI) has repeatedly shown that all of its specialists can play a role in the investigation of death. The key to its successes has been its ability to “think outside the box” and use its specialists’ expertise in non-traditional manners.

In 2008 a sixty-two year old male was detained by United States Customs and Immigration officials when attempting to enter the United States because his fingerprints were not detectable thus preventing his identify from being verified. It was later reported by his physician in Singapore that the individual suffered from Hand and Foot Syndrome (palmar-plantar erythrodysaesthesia) as a result of his cancer treatment of capecitabine (N4-pentyloxycarbonyl-5-deoxy-5-fluorocytidine) which causes interruptions to the normal growth of keratinocytes in the friction skin. Capecitabine is a recently developed, orally administered fluoropyrimidine prodrug designed to generate 5-fluorouracil through a three step enzymatic process giving it antineoplastic properties to combat cancerous tumor growth in a number of different cancers, including adjuvant colon cancer, metastatic colorectal cancer, and metastatic breast cancer. This study consisted of a 253 day evaluation of the physiological effects to the friction ridge skin from an individual undergoing capecitabine chemotherapy treatment. The results indicate the quality of the friction ridge skin impressions decreased by 32% and to a degree which may impair the ability to positively identify individuals using friction skin impressions alone while undergoing this type of treatment and experiencing hand and foot syndrome. Following cessation of capecitabine treatment, normal growth of keratinocytes resumed returning the skin to a normal state with no indication of damage thus demonstrating the persistency of the friction ridge skin despite the temporary toxicity of capecitabine.

Fibromuscular dysplasia is a non-atherosclerotic, non-inflammatory vascular disease that is most commonly found in the renal arteries of pre-menopausal women. However, this disease entity has rarely been described in the coronary arteries and small cardiac conduction arteries. To our knowledge, there is no recorded case of fibromuscular dysplasia in small cardiac conduction arteries in infants/children. In this report, we present a case of unexplained death of a 14 month old wherein routine histologic examination failed to reveal a cause of death, but subsequent submission of the cardiac conduction system (atrioventricular [AV] and sinoatrial [SA] node regions) demonstrated the presence of isolated AV nodal artery fibromuscular dysplasia, which was considered the cause of death. The case serves to emphasize the potential importance of evaluating the cardiac conduction system in cases where routine gross and microscopic autopsy fails to reveal an adequate explanation for death.

The purpose of an investigation is to determine something; to find out what, why, and who. A researcher searches for something new, an advance in the field of study. A doctor determines a diagnosis, a form of investigation. A police officer, at the scene of a motor vehicle traffic crash, or a burglary, or a suspicious death similarly investigates in order to determine what happened, what laws were violated and who was responsible. All these have one thing in common—the necessity to gather facts (data), assess their relevance and integrate them into a sensible and reasonable and correct conclusion. This requires expertise.

In 1956 Dr. Alan Moritz wrote a timeless manuscript entitled “classical mistakes in forensic pathology”. This treatise on the common personal and systemic failings within death investigation is considered by many to be a seminal work within the field, and all medical examiners would benefit by reviewing it annually. This brief manuscript reviews case examples where pathologists fail by substituting intuition for scientifically defensible fact, or by jumping to conclusions based on a limited data set. Without a doubt, forensic pathologists err, but it is when those pathologists refuse to accept or learn from their mistakes that they become a danger to the cause of justice.

Forensic pathology is not simply autopsy pathology. Rather, the determination of why someone died is dependent upon the findings of a competent autopsy interpreted within the context of an excellent investigation of the circumstances of death. It is important that medical examiners remember the critical distinction between “dying with” and “dying of” something. Furthermore, our determination of “the” cause of death may not explain “why” someone died; identifying the underlying cause of death may not explain the mechanism through which the person died.

A natural death is one which is not caused by accident, by suicide, or by homicide. Natural deaths are those caused by disease. Diseases may be infectious, metabolic, degenerative, congenital, or neoplastic. The number of diseases causing death are innumerable. Coding manuals used by vital statisticians cover thousands of subcategories of diseases which are known to cause or accelerate death.

Natural diseases investigated by police are relatively few in number and likewise involve limited subsets of our society. There are also geographic and ethnic variations in different parts of the world.

Forensic pathology, as a scientific discipline, must depend upon generally accepted procedural standards in order to be useful in court. Procedural standards should assist investigations and determination of proper decisions necessary for the administration of justice.