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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