2004 Spring, 14. The New Hampshire Office Of Chief Medical Examiner: Medicolegal Death Investigation in the Granite State.

AuthorBy Dr. Thomas A. Andrew, Chief Medical Examiner

New Hampshire Bar Journal

2004.

2004 Spring, 14.

The New Hampshire Office Of Chief Medical Examiner: Medicolegal Death Investigation in the Granite State

New Hampshire Bar Journal Spring 2004, Volume 45, Number 1 The New Hampshire Office Of Chief Medical Examiner: Medicolegal Death Investigation in the Granite State By Dr. Thomas A. Andrew, Chief Medical Examiner I. INTRODUCTION: GENERAL HISTORY OF DEATH INVESTIGATION

Systematic death investigation dates back to the 12th Century. In 1194 the British Parliament passed legislation establishing an elective office called "Keepers of the Pleas of the Crown." Three knights and one civilian were to be elected from each shire to serve as "Crowner." The focus of their investigation was not so much on cause of death as it was determining who was responsible for the death. The individual deemed responsible generally forfeited his money, land and livestock, or a large portion thereof to the King. Murder paid the crown twice; once by the perpetrator and a second hefty fine was assessed on the village that was so lax as to allow such a disturbance within its confines.

While the opportunities for corruption were both abundant and exuberantly exploited, this was the system transported to the colonies in the 17th century. Across the Atlantic, "Crowner" became "Coroner"; and death investigations in what was to become the United States were carried out primarily by elected coroners. It was not until after the Civil War that state legislatures began to consider the value of having death investigations conducted in a more scientific fashion; and in 1868 Maryland passed a law specifying that a physician shall serve as coroner. Massachusetts took the issue a step further in 1877, supplanting the coroner with a physician bestowed with the title of "Medical Examiner." The first modern, public health oriented system, and the model for all medical examiner systems since, was established in 1915 in New York City. Not only was the coroner replaced by a physician medical examiner, but the Medical Examiner was to be a non-political appointee and the scope of the Medical Examiner's jurisdiction was expanded beyond deaths of a criminal nature to include deaths in the workplace, public health hazards stemming from overcrowding in the face of the burgeoning Industrial Revolution, transportation and product safety concerns and others.

This was the template applied as medical examiner systems were established around the nation. A National Research Council study published in 1932 referred to the superior functioning of the medical examiner system as "startling when compared with the poorly functioning coroner system." The NRC stated, "Dollar for dollar, the office of medical examiner does more work and better work for its community than does the office of coroner." Momentum gradually slowed in the latter half of the twentieth century; however, and the coroner's system remains in place in 55% of medicolegal jurisdictions in the United States in 2004. Twenty-eight states are served exclusively by coroners. Of the states with a centralized state medical examiner's office, six still have coroners serving in remote rural locales. Only 953 Of the 3,137 counties in the U.S (30%) are served by a medical examiner. Ten of those counties comprise the state of New Hampshire.

Formal medical examiner systems are typically headed by a board certified forensic pathologist appointed on the basis of his or her training and experience. Given that there are less than 400 full time, board certified forensic pathologists in the U.S, it is no mystery why coroner systems continue to flourish. At the current rate of 40 trainees in forensic pathology each year it would take over thirty years to fully meet the demographic need for forensic pathologists in this country. Even well functioning medical examiner systems remain resource-starved. Quoting once more from the National Research Council study published 71 years ago, ". . . the medical examiner system does not function as well as it should, because the same public indifference which retains the coroner system results in inadequate financial support that does not permit the well-trained medical examiner to use the scientific procedures which he knows to exist and which he knows how to employ." Given the impact that the quality of death investigation has on personal liberty and freedom, public health and safety, injury prevention and control, mortality analysis and objective assessment of medical care, the issue is neither small nor trivial.

Taking the long view, there are substantial fiscal advantages to be realized in a smoothly running medical examiner system. There are economies of scale in purchasing with less cost per capita. The state medical examiner is well positioned for federal contracts and grants to provide and support staff and activities of the office. The obstacle for the short-sighted is the start-up cost, however, once capitalized, maintenance is usually manageable and as the budget becomes institutionalized it becomes more predictable.

II. NEW HAMPSHIRE CENTRALIZES

New Hampshire did not have a centralized State Medical Examiner office until 1986 when late Roger Fossum was appointed New Hampshire's first Chief Medical Examiner (NH RSA 611). Dr. Fossum essentially built a full service medical examiner system from the ground up. Legislation further defining the Office of Chief Medical Examiner (OCME), its scope, authority and responsibilities (NH RSA 611-A) was passed in 1996. Unfortunately, this was two years after Dr. Fossum's untimely death at the age of 46. Then Deputy Chief, Dr. James Kaplan, served as Acting Chief Medical Examiner until September, 1997 when Dr. Thomas Andrew was named New Hampshire's second Chief Medical Examiner. Dr. Thomas Gilson served as Deputy Chief from April 1998 through October 2001 and Dr. Jennie Duval, a New Hampshire native, began work as Deputy Chief in January 2002.

OCME's place on the state's organizational chart (Fig. 1) differs compared to other jurisdictions where the medical examiner's office is within the Department of Health. Location in the Department of Justice is certainly not unusual and, in fact, may be the most common. A west coast phenomenon has some coroner's offices within Safety.

OCME ORGANIZATIONAL CHART

Governor and Executive Council

Department of Justice Attorney General

OCME Chief Medical Examiner OCME Deputy Chief Medical Examiner

Chief Forensic Investigator

Field Investigators - Assistant Deputy

Medical Examiners (ADME's)

Fig. 1

Despite the late arrival of a formal medical examiner system, New Hampshire is on the leading edge as far as the utilization of non-physician death investigators to perform field investigations. OCME has a talented and dedicated group of nurses, paramedics, physician assistants and others to respond to all "untimely deaths" as outlined in NH RSA 611-A. These individuals assess the scene and circumstances surrounding the death, confer with family members of the deceased and/or witnesses to the fatal event and other agency responders such as law enforcement and emergency medical personnel. They then present the case to the Chief or Deputy Chief Medical...

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