Medicolegal
Pathology
Introduction to Forensic
Pathology.
What is Medicolegal
Pathology?
 The
branch of medicine that
produces evidence useful in the
administration of justice, public
health, and public safety by using
the medical principles derived from
the study of disease and injury.
 Forensics:
The scientific application of
methods, techniques and procedures to the
resolution of problems pertaining to the law.
What is Pathology?
 Pathology:
The scientific study of the
nature of disease and its causes,
processes, development, and
consequences.
– Subdisciplines are Clinical, Anatomical and
Forensic Pathology.
Medicolegal or Forensic
Pathology

A branch of medicine that
applies the principles and
knowledge of the medical
sciences to problems in
the field of forensics
(medicolegal).
Investigates and
deterines cause and
manner of death.

Less than 1,000 board
certified forensic
pathologists in the U.S.
History of Death Investigations
 Death
investigation techniques used
in the U.S. today originated in
England.
 A Death Investigator was given the
title of Coroner (crown)
– Elected to protect the crown’s interests
from corrupt sheriff’s.
A
Coroner could arrest suspects
including the sheriff.
– This is still the case in Missouri.
The Inquest

The coroner was
required to
assemble a group
of peers to judge a
suspect’s guilt or
innocence.

The group also
considered the
necessity of a
postmortem (after
death) examination
or autopsy.
– Antemortem (prior
to death)
History of the Medical Examiner
 New
York city established the 1st city
wide death investigations division.
 In 1939, Maryland developed the 1st
statewide death investigations
division.
 Today death investigations are
performed differently from state to
state and county to county.
Coroner/ME Jurisdiction
 Sudden
or Unexpected Death
 Violent Deaths, e.g. homicide,
suicides
 Unattended Deaths
– The person had not seen a physician for
more than 20 days prior to death
 Contagious
Diseases, e.g., AIDS
 Occupational Diseases, e.g. COPD
Coroner/ME System
 California
has Coroner/ME System
separated by county.
– We have more Coroner than ME
systems.
 Some
States have either a CO or ME
system or it is split by Region.
Coroner/ME System
 Across
the U.S., there are MORE
Coroner Systems; these are
generally represented under the
setting of the Sheriff’s Office.
– Some Coroner’s offices are also the local
Funeral Homes.
 U.S.
(Federal) Government has their
own system.
Coroner
 Usually
an elected official
 May be appointed by the Sheriff’s
department
 May be a physician
– May be a medical examiner
 It
all depends on the county/state
Medical Examiner
Must be a Pathologist who is a M.D. or
D.O.
 A doctor must have advanced training to
become an ME or Forensic Pathologist.
 To Become a Forensic Pathologist

–
–
–
–
Four years of undergraduate school
Four years of medical school
Internship and residency in pathology
Residency in Forensic pathology
Medical Examiner’s Duties
 Visits
death scene on request
– responds or has an investigator respond
to all homicide related deaths
 Reviews
field investigative information
 Performs autopsy (aka “posts”)
–Autopsy means to “see for yourself”
 Orders all ancillary tests & exams
 Provides consultation to DA
 Provides conclusions as to cause and
manner of death
What types of death need
investigating?
 Violent
Deaths (homicide, accidents,
suicide)
 Suspicious Deaths
 Sudden and unexpected
 Deaths without a physician in
attendance
 Death in custody
 Deaths during or after a medical or
surgical procedure
Death Investigator
 Works
for Coroner/ME Office
 Reports to the medical examiner or
pathologist performing the autopsy.
 Goes to the death scene and make
an evaluation.
 Gathers relevant medical history as
well as talk to witnesses and
relatives about the decedent’s last
whereabouts.
 Reports death to the next of kin.
Death Investigator
 Usually
an individual with law
enforcement training or a:
– Licensed registered nurse
– Trained mortician
 Must
attend the PC 832 course.
 Must attend the coroner’s investigations
academy after being hired by the coroner’s
office.
Crime Scene Technician
 Usually
a member of local law
enforcement.
– Typically civilian personnel
 The
technician’s expertise includes:
– Photographing and diagramming death
scene.
– Collecting all potentially important
evidence.
– Recovering fingerprints
– Recovering other prints such as shoes
and tires
Criminalist

The expert who works
in the forensic lab.
– Has a Master’s degree in
criminalistics/forensic
sciene
– Most criminalists work
with one particular type
of evidence, such as:
 Blood
 Bullets
 Ammunitions
 Fibers
 Hair
 Impressions
Other Medico-legal
Investigators (Specialists)

Other specialists include:
–
–
–
–
–
–
–
–
–
Serologists
Questioned Document Examiner
Toxicologist
Anthropologist
Odontologist
Radiologist
Entomologist
Botanist
Meteorologist
 Forensic
Pathologist
– At scene of death controls body
– Performs autopsies
– Determines cause of death
 Death
Investigator
– Works for the CO/ME office
– Investigates cause of death
 Crime
Scene Investigator
– Works for law enforcement
– Collects evidence
– Takes photographs
 Criminalistic
Specialist
– Processes evidence in the laboratory
Forensic Evidence
 Evidence:
Anything that can be
used to determine whether a crime
has been committed.
– May exonerate the innocent
– Corroborate or refute an alibi or
statement of a witness
– Identify a perpetrator or victim
– Induce a confession
Forensic Evidence

Direct Evidence: Establishes a fact
– Eyewitness testimony
– Confession

Circumstantial Evidence: Requires that
a judge and/or jury make an indirect
judgment or inference about what
happened. No absolute proof; provides a
general idea of what happened. Often
much more reliable than Direct Evidence.
– Fingerprints
– Hair
– Fibers
Forensic Evidence


Forensic evidence
can’t find and convict
the criminal unaided.
It provides an
additional weapon in
the detective’s
armory.
– It can offer clues to
help the detectives
track down the criminal
and
– It can help detectives
prove a suspect was
present at the crime
scene or committed a
particular act of
violence.
Medico-legal Investigations

Duties of the medico-legal system
– Determine cause, manner and mechanism and
time of death
 Four
important medicolegal elements of death
investigation.
–
–
–
–
–
Identify the deceased if unknown
Collect evidence from body
Document injuries or lack thereof
Deduce how injuries occurred
Provide expert testimony if case goes to trial
Definition of Death
 In
1968 Black’s Law Dictionary
defined Death as: the cessation of
life; the ceasing to exist; defined by
physicians as the total stoppage of
the circulation of the blood, and
cessation of vital functions
consequent thereon, such as
respiration, pulsation, etc.
What is Death?
 Cellular
Death
– The tissues and their constituent cells
are dead.
 No
longer function or have metabolic
activity, primarily aerobic respiration
 From cardiorespiratory failure
 Different tissues die at different rates
Definition of Death
 Clinical
Death
– The cessation of respiration and
circulation functioning. Resuscitation
may or may not be possible.
 Anoxia
and hypothermia
– May live for more than 5 minutes after cessation
of respiration and circulation.
What is Death?
 Somatic
Death
– Irreversible loss of personality, being
unconscious, unable to be aware of or
communicate with one’s environment, unable
to appreciate any sensory stimuli or to
initiate any voluntary movement.
– Reflex nervous activity may persist and
circulatory and respiratory functions continue
either spontaneously or with artificial support
so that the tissues and cells of the body,
other than those already damaged in the
central nervous system, are alive and
functioning.
Definition of Death

Brain Death
– An irreversible
process.
– Irreversible cessation
of all brain functions,
including brain stem.
– PVS – Persistent
Vegetative State =
permanent damage to
frontal lobe function
and not brain stem.
Definition of Death

Brain Death is determined by:
–
–
–
–
–
Coma and cerebral responsiveness
Apnea
Fixed and Dilated Pupils
Absence of Cephalic Reflexes (brainstem)
Absence of Electrical Impulses in the
Cerebrum(no EEG pattern)
 Two
physicians required to pronounce brain death;
one must be a neurologist in California.
Death Certificate
 Medico-legal
requirement of the
death certificate
– Cause and
– Manner of Death
Cause of Death

The “original” underlying medical condition
which initiates a lethal chain of events
culminating in death.
– i.e.. a shotgun blast to the head, stab wound
to the chest or coronary atherosclerosis.

Proximate
– The legal synonym for “original” in the
definition above.

Immediate
– What kills a person now, but was originally
precipitated by something else (proximate)
Mechanism or Mode of Death
 An
abnormal physiological state that
pertained at the time of death
– i.e. coma, congestive heart failure,
cardiac arrest, pulmonary edema,
septicemia and hemorrhage
Manner of Death
 The
circumstances surrounding a
death or how the cause of death
came about.
 Circumstantial events or manner of
death may be:
– Natural due to disease or
– Unnatural due to: Accident, Suicide,
Homicide, Questionable/Undetermined.
 NASH/Q
Certification of Death
Five Classifications of Death (NASH/Q)
 Referred to Manner of Death

–
–
–
–
–
Natural: pathology; death caused by disease.
Accident: not intentional or by a criminal act.
Suicide: death by one’s own hand.
Homicide: death by another.
Questionable: cause and/or motive is not
known; generally when other classifications
are not used. Also “Undetermined” death is
used. “Equivocal” has also been used as well.
Death Certificate
 Cause
of death:
– Primary or Immediate
– Secondary
Death Certificate
 Primary
cause of death
– Subdivided into a three-link sequential
chain, eg.
 Hypoxemic
necrosis of brain (brain death)
– Due to
 Exsanguination
– Due to
 Gunshot
wound
Death Certificate
 Secondary
cause of death
– Includes conditions which are not
related to the primary cause of death
but are substantially contributory to the
individual’s demise
 Emphysema
of lungs,
 Hypothermia
 Arteriosclerotic
cardiovascular disease
Autopsy Reports



Cause of death: Heart
failure with cardiac
arrhythmia due to a
pulmonary emboli.
Contributing cause:
Intestinal dismobility, on
chronic pain
management.
Manner of Death Undetermined.
Autopsy Report

A Psychological Autopsy may have to
be done if manner of death is thought to
be suicide.
– An investigation of a decedent’s mental state
prior to death.
Autopsy

Final photo of the
King.
Autopsy

Autopsy Photo of
Marilyn Monroe
Identification of the Deceased
 Physical
Description
– Height
– Weight
– Color of eyes, hair and skin
 Scars
and Marks
– Birthmarks, scars, etc.
– Tattoos
 Fingerprints
Identification of Deceased
Identification of Deceased
Identification of the Deceased
 Photographs
– The entire body should be
photographed.
 Radiological
Features
– X-rays should be taken of the body.
Identification of the Deceased
 Age
Determination
– Age may be roughly estimated by the
teeth
– Joining of the bones (epiphysis)
– Ossification center
 Dental
Features
– The pattern of dental work may be
determined by an Odontologist.
– Eruption of Teeth
Identification of Deceased
 Blood
Factors
– ABO groupings, Rh factors, DNA testing.
 Medical
Indications
– Postmortem may reveal preexisting
diseases.
 Any
Other Means Available
– Clues may be found at the scene or in
the personal effects.
Definition of Murder

P.C. 187: Unlawful killing of human
being, or fetus, with malice aforethought.
– 1st Degree: by any of the destructive devices
or explosive, use of ammo designed primarily
to penetrate metal or armor, poison, lying in
wait, torture, other willful, deliberate,
premeditated killing, committed or attempted
during a burglary, arson, rape, robbery,
mayhem, carjacking, kidnapping, train
wrecking or a drive-by shooting with intent to
kill.
First-Degree Murder in California Law

California law, there are three ways to be
convicted of first-degree murder:
– By committing the murder using:
a
dsetructive device or explosive, weapon of mass
destruction, ammunition primarily designed to
penetrate metal or armor or poison, or
 by lying in wait or by inflicting torture,
– By killing in a way that is willful, deliberate and
premediated, OR
– By way of the felony-murder rule (that is
committing a specifically enumerated
felony that automatically turns any logically
relate death into first-degree murder).
Second Degree Murder

Willful murder but is not deliberate
and premeditated.
– Second-degree murder is any murder
that isn't defined as first-degree
murder.
 Shooting
a gun into a crowded room and
killing someone, even if that wasn't your
intention
 Vehicle Manslaughter; intoxicated driver.
Degrees of Murder
– Manslaughter: Unlawful killing of a
human being, without malice.
 Voluntary:
A sudden quarrel or in the heat
of passion.
 Involuntary: While committing an unlawful
act, not a felony; or while committing a
lawful act that might produce death, done in
an unlawful manner; or without due caution
and circumspection; provided that this
subdivision shall not apply to acts
committed in driving of a vehicle.
 Vehicular: Drives in an unlawful way that
produces death
Murder

Justifiable Homicide:
– Public Officer: Homicide justifiable when
committed by public officer, and those acting
by their command in their aid and assistance.
– Other Persons: (Including Peace Officers):
When committed by a person in the following
cases.
 Resisting
an attempted murder or felony.
 In defense of habitation, property or person.
 In lawful defense of persons such as wife, husband,
child or parent.
 In attempt to apprehend a person for committing a
felony, lawfully suppressing a riot or lawfully keeping
or preserving the peace.
Case 1
A 25 year old man was shot in the abdomen
with a handgun. He was taken to the
hospital where he underwent an
emergency exploratory laparotomy. All
life-threatening injuries were repaired.
His postoperative course, however, was
complicated by peritonitis which led to
sepsis and eventually death two weeks
after surgery. An autopsy revealed an
extensive abdominal infection. The
medical examiner ruled the cause of death
as a gunshot wound to the abdomen and
the manner of death as a homicide.
Case 1
During the trial, the pathologist was
questioned about the cause of death.
The pathologist reiterated his opinion
that the decedent died from a
gunshot wound. A fierce crossexamination followed. The defense
attorney contended the man died as
a result of an abdominal infection.
Consequently, it was the physician,
not his client, who was to blame for
the death.
Case 1
Who should the jury believe?
Would the victim have died if the
infection had been discovered
sooner?
Should the physician be responsible
for the man’s death?
Case Discussion
Case 1
This man died as a result of a gunshot
wound to the abdomen and the manner of
death was homicide. It was a lifethreatening injury which would have
caused his death within hours if he had
not been treated. A well-recognized risk
of abdominal surgery is peritonitis. If he
had been admitted with a non-lethal
injury, and the physician made an error in
judgment which caused his death, then
the manner of death would have been an
accident, not homicide.
Case Discussion
Case 1
In this case, however, the
pathologist correctly stated that the
sequence of events was continuous
from the time the man was shot until
he died.
In the state of California the statute of
limitations for this type of crime
leading to the person’s death is one
year
Case 2
A woman in her seventies was walking to a
grocery store. An assailant pushed her
onto the sidewalk as he grabbed her
purse. She was apparently unharmed but
obviously shaken by the experience.
Within 10 to 15 minutes she developed
shortness of breath, increased chest pain
and was taken to a nearby emergency
room. During her evaluation she
developed an arrhythmia and died.
Case 2
An autopsy revealed severe
atherosclerotic disease in all
coronary arteries and numerous
infarcts of the left ventricle. There
were no signs of injury from the fall.
The medical examiner ruled the
cause and manner of her death as
heart disease and homicide,
respectively.
Case 2
During the trial, the defense attorney
disagreed with the cause and manner of
death. He stated this was not a homicide
because the woman died of heart disease,
and the fall to the sidewalk caused by his
client was not a contributing factor. Was
the pathologist correct? Should he have
called the death a homicide? Did the man
who took her purse actually cause her
death?
Case Discussion
Case 2
This case is more complex than Case
1. The manner, not the cause, of
this woman’s death is in dispute.
Since there was no significant
trauma, the cause of death had to be
the heart disease. He was more
concerned with the sequence of
events and how the pathologist
believed the robbery was directly
related to the death.
Case Discussion
Case 2
There was only a 10-15 minute interval
from the time the woman was knocked to
the ground to when she experienced signs
and symptoms of a heart attack or angina.
Since the time period was short, the
pathologist believed that the woman was
still under stress and correctly interpreted
the manner of her death as a homicide.
The longer the time frame, however,
between the incident and heart attack, the
more difficult it would be to make this
interpretation.
Case Discussion
Case 2
If, for example, the woman had gone
home, had not been seen for a few
hours, and then complained of chest
pain, the same interpretation could
not have been made. She would
have been unwitnessed during that
time and some other incident could
have triggered a fatal arrhythmia.
Consequently, in such a situation,
her death could not be ruled a
homicide.