N.C. OCME Annual Report 1993
Chapter 1: Who We Are and What We Do
In North Carolina, most deaths occur under non-suspicious circumstances from natural causes. The deceased individual usually has a history of life-threatening illness and dies under the care of a physician who, having provided treatment for that illness, is able to certify both the fact and cause of death. Most of these deaths occur in hospitals or other terminal care facilities, though some may occur in homes or other places. Under the laws of the State of North Carolina, a physician is obligated to certify the death of his patient if that patient dies of the disease or illness for which the physician provided treatment, and the death does not fall under medical examiner jurisdiction.
Problems arise, however, when someone who has no physician dies and thus, no one who can sign the death certificate. Likewise, when death occurs under suspicious circumstances or as a result of violence, the medical examiner system becomes involved. Societies have a special interest in violent, unnatural deaths and have evolved mechanisms to see that they are properly investigated. The problem of unattended deaths must also be solved since there is always, in the absence of confirmed medical history, the possibility that these deaths might be due to violence or external causes.
Deaths in North Carolina that are unattended, suspicious, or the result of violence (homicide, suicide, and accident) are investigated and certified by our State Medical Examiner System. Despite several attempts to improve the quality of medicolegal death investigation, prior to the passage of legislation in 1967, these deaths were, for the most part, investigated by an elected lay coroner. These county officials often lacked medical expertise and worked in isolation, dependent solely upon the resources within their individual counties to obtain medical input into death investigations.
In 1955, the North Carolina General Assembly passed legislation to allow individual counties to appoint medical examiners and to identify pathologists who were willing and able to perform autopsies when the medical examiners or coroners needed them. Legislation passed in 1965 allowed individual counties to abolish the office of coroner and to appoint a medical doctor to investigate deaths within their counties. Only a few counties acted upon this legislation. The Statewide Medical Examiner Act of 1967 further insured that medical input into death investigations would be rapid. By 1972, all the counties of the state either had physicians acting as county medical examiners or the coroner had been appointed acting medical examiner (and operated under the medical examiner statute with assistance and medical input from the Chief Medical Examiner's Office). Since that time, the medical examiner system has annually certified approximately 1/6 of all deaths that occur in North Carolina.
The North Carolina Medical Examiner System is a network of over 600 medical doctors throughout North Carolina who voluntarily devote their time, energy, and medical expertise to see that deaths of a suspicious, unusual or unnatural nature are adequately investigated. At the county level, medical practitioners are appointed by the Chief Medical Examiner for three-year terms as county medical examiners. In counties where there are no physicians willing or able to serve, non-physicians may be appointed to serve as acting medical examiners. By law, medical examiners must be notified when a death occurs in their county that falls within the statutorily defined categories. The county medical examiners take charge of the body of the deceased and conduct such examination as is necessary to properly determine the cause and manner of death. These duties are all in addition to their normal roles as private practitioners.
In evaluating a case, they must consult with law enforcement officers, relatives, and/or other individuals who may have knowledge of the circumstances surrounding the death. They conduct a physical examination of the body to detect or rule out signs of violence. On many occasions, they visit the place where the death occurred or where the body was found in order to gather more data. In some instances, in order to properly complete their investigation, they may decide that an autopsy is necessary. The law gives them the authority to order an autopsy should they deem it advisable. Such an autopsy is performed by a pathologist who has been designated by the Chief Medical Examiner as competent and capable of performing the examination. Most of these pathologists are in private practice, like the medical examiners, and participate on a voluntary basis. They report their findings to the county medical examiners, who must consider them when they render their opinion as to the cause and manner of death.
Specimens for toxicological testing obtained by the medical examiners and the pathologists are all sent to the Office of the Chief Medical Examiner, where the toxicology laboratory performs a wide variety of analyses. In most instances, the medical examiners and pathologists have the results of toxicology tests within a few days after the death occurs, although in cases where more complex analyses are required, some delay is common.
All reports generated by the medical examiners and regional pathologists are forwarded to the Office of the Chief Medical Examiner, where they are assembled and kept on file. Much of the material on file is computerized and can be retrieved for epidemiological studies. A great strength of the NC medical examiner system is the assemblage of data that allows surveillance of deaths in the state, often leading to the discovery of existing and potential public health hazards.
One significant difference between the old coroner system and the modern medical examiner system is that the latter has a much broader charge in regard to death investigation. The coroner's main concern was to "rule out foul play." This was usually construed to mean homicide. Medical Examiners are charged to uncover all forms of violence or trauma, homicidal or otherwise, and to be alert for all public health hazards.
Within the Office of the Chief Medical Examiner, five pathologists perform medicolegal autopsies for counties surrounding Chapel Hill and counties that have no regional pathologists. Cases are also referred to the central office when field pathologists are not available to do an autopsy or when additional expertise is required to assess a case. As a result, more than one fourth of all autopsies in the medical examiner system are performed at the Office of the Chief Medical Examiner. Each of the five pathologists is also responsible for providing consultation to county medical examiners and field pathologists as well as reviewing medical examiner investigative reports for a region within the state.
In addition to the pathology and toxicology staff, the central office has an administrative section which assembles information from multiple sources, performs the mechanical aspects of filing and generating reports, and coordinates the numerous other activities involved in operating the system across the state. For example, each medical examiner investigation generates a number of documents. These public documents are regularly requested by law enforcement, insurance, and other agencies. The office mails an average of four copies of the medical examiner’s report (including toxicological and autopsy results, if done) per case.
The central office is responsible for a number of activities related to death investigation, including payment for the transportation of deceased individuals throughout the state when such transportation is ordered by the medical examiners and pathologists. Hundreds of individual transporters--funeral homes, rescue squads, and independent transporters--aid the Medical Examiner System and the citizens of North Carolina by providing this service.
In addition to case investigation and management, the central office has a broad educational function. The medical examiners and regional pathologists must be kept abreast of happenings within the system, requiring continuing medical education sessions. Education of law enforcement personnel for optimal interaction between the medical examiner and law enforcement systems is also an ongoing concern. Located within the UNC Medical School complex, the central office staff also instructs medical and dental students and participates in programs and courses with the NC Justice Academy, State Bureau of Investigation, and many other institutions.
An efficiently functioning Medical Examiner System helps to insure that all suspicious deaths are adequately investigated and that the actual illness or injury that caused death is identified. This protects innocent individuals from prosecution and aids in the conviction of the guilty. It allows the speedy settlement of insurance claims and other survivor benefits. By bringing public attention to many cases of death that are in theory preventable, the toll of such premature deaths may be decreased.