Manner: Natural – Natural disease
presenting as unexpected death
Marnie Wood MD FRCPC (Anatomic
and Forensic Pathology) ABP
March 20, 2012
Objectives
• Gain better understanding of natural deaths
over which the Nova Scotia Medical Examiner
Service (NSMES) assumes jurisdiction
• Have an appreciation of the spectrum of
natural disease seen by MES as unexpected
deaths
• View case examples of ME investigation of
natural deaths
Introduction
• May think violent/suspicious deaths are the
majority of Medical Examiner cases
Introduction
• Anecdotally Natural deaths compose 56% of
autopsied NSMES cases (Accident 29%, Suicide
12%, Homicide 3%, Undetermined <1%)
• The cause of death in majority is some variety
of ASCVD or chronic ethanol abuse
Introduction
• Natural deaths are reportable to Medical
Examiner under several subsections of Fatality
Investigations Act
• May or may not assume jurisdiction over the
reported death
Duty to notify Medical Examiner Service:
– Death result of violence, accident or suicide
– Unexpectedly when in good health
– Where person not under care of a physician
– Where cause of death is undetermined
– Result of improper or suspected negligent
treatment by a person
• Definition of unexpected varies markedly
depending on perspective
• Tragic does not equal unexpected
• Cause of death need not be determined with
100% certainty
– Opinion based on reasonable interpretation of
data
Notify ME where person dies in health-care facility
and there is reason to believe:
– Death result of violence, suspected suicide or
accident
– Death result of suspected misadventure,
negligence or accident on part of attending
physician or staff
– Cause of death is undetermined
– Stillbirth or neonatal death where maternal injury
before admission or during delivery
– Within 10 days of surgery, or during anaesthesia
Death in Health Care Facility
• Threshold for taking jurisdiction over deaths
during medical intervention tends to be high
– Accidental or intentional overdose of medication
– Injury from malfunction of equipment (eg
electrocution)
– Procedure outside of scope of licensed practice
– Complication beyond reasonable/foreseeable
– Consider any allegations being made
Death in Health Care Facility
• Tragic does not equal unexpected, accidental
or negligent
• Cause of death need not be determined with
100% certainty
– May be able to determine cause without knowing
exact mechanism
Notify of deaths in custody
• Death while detained, or in custody in a
correctional institution
• While an inmate is in Hospital
• While in custody under Children and Family
Services Act
• While detained by, or in custody of peace
officer
Notify of death related to employment or
occupation
• Where person dies as result of:
– Disease or ill health
– An injury sustained by the person
– A toxic substance introduced into the person
Probably caused by or connected with the
person’s employment
Typically do not take jurisdiction:
• Natural Manner when sufficient clinical
information with which to form reasonable
opinion of cause of death
• Natural Manner where mechanism of death was
a reasonable/foreseeable complication of
appropriate medical therapy
• Deaths during surgery/treatment for natural
disease
• Natural Manner where occupational disease did
not contribute in any way
Of reportable, typically take
jurisdiction over:
•
•
•
•
•
•
All accidents, homicides, suicides
All possible accidents, homicides, suicides
Where negligence is alleged
All in custody, regardless apparent manner
All possibly related to occupation
Where insufficient clinical information to
determine cause of death
Introduction
• Deaths occurring under these circumstances
are investigated by the Medical Examiner,
through review of scene and history
information, +/- autopsy to determine
– Identity of deceased
– Time and place of death
– Cause and manner of death
Case 1
•
•
•
•
64 year old woman
Found deceased in bed, no recent complaints
Recent long flight
No known medical history
• At autopsy:
– Abundant pulmonary edema
– Subarachnoid hemorrhage concentrated at base
of brain
Case 2
• 55 year old woman
• Found collapsed in bedroom, unresponsive
with labored breathing, arrest prior to EHS
• Death declared at scene
• Six month history increasing shortness of
breath, palpitations following flu-like illness
• At autopsy:
– Serous pleural and pericardial effusions
– Abnormal texture of organs