Docstoc

THE OFFICE OF THE MEDICAL EXAMINER

Document Sample
THE OFFICE OF THE MEDICAL EXAMINER Powered By Docstoc
					                                                                                   24 1




THE OFFICE OF THE MEDICAL EXAMINER
     OF THE CITY OF NEW YORK*
                                  REPORT BY THE
                           COMMITTEE ON PUBLIC HEALTH
                        THE NEW YORK ACADEMY OF MEDICINE

T HE interest of the Committee on Public Health and its predecessor committee
      in *the operation of the medical examiner system in New York City covers a
period of 60 years. The present Committee began its study in 1912 of the system
for investigating criminal, suspicious, accidental, or unexplained deaths.
      It was the Committee's view that any death that may have legal implications
should be investigated immediately and properly. In criminal cases the determination
of the cause of death may involve the fixing of guilt, while in civil cases it is a
factor in the payment of death claims or damages. Thus, the Committee believed,
it is essential that all deaths of a violent, accidental, or suspicious nature-a sig-
nificant percentage of all deaths in New York City-should be investigated
promptly by competent persons of good character who would be thoroughly trained
for their duties.
      Before 1918 the determination' of the cause of death was the responsibility of
a county coroner, usually an obscure politician who was elected by the voters. Gen-
erally, the coroner was assisted by a physician appointed by the board of coroners.
This physician, more often than not, lacked special qualifications for the position
he held.
      In addition, there was no machinery for the prompt and efficient medical
examination of deaths coming within the coroner's jurisdiction. The coroner's
physician was not required to be on the case immediately, and this made it possible
for interested persons to intervene for their own purposes. Special medical exam-
ination and testimony could be obtained only by the written consent of the District
Attorney and a Justice of the Supreme Court. The law as to who was to determine
the necessity for autopsy was ambiguous.
      In 1915, the Committee on Public Health played a key role in the reform of
the prevailing system. The Committee was instrumental in drawing up and aiding
in the passage of a bill that abolished the coroner's office in New York City as of
January 1, 1918, and established the Office of the Chief Medical Examiner. Since
that time, the Committee has been in the forefront of the movement to strengthen
the operation of the present system.
      From the beginning the Committee on Public Health envisioned a larger role
for the Office of the Chief Medical Examiner. It was thought that adequate medico-
legal facilities for New York City should include an Institute of Forensic Medicine.
Such an institute is now a reality, and the Committee takes special pride in having
played a part in bringing the plan to fruition.
  *Approved by the Executive Comm~ittee of the Committee on Public Health, October 31, 1966.
Approved by the Committee on Public Health, November 7, 1966.

Vol. 43, No. 3, March 1967
  24 2                 COMMITTEE ON PUBLIC HEALTH


     In more recent years, the Committee has endeavored to enhance the quality of
the services of the Office of the Medical Examiner by encouraging harmonious
relationships between that facility and other agencies that may become involved
when death occurs in a hospital. In 1950 the Committee issued a carefully prepared
Autopsy Manual with a chart in the form of a plaque to be hung on the walls of
autopsy rooms. The Manual and the chart were distributed to hospitals with a letter
indicating the need to acquaint new interns and other hospital personnel with pro-
cedures at the time of death. Many hospitals in New York City and elsewhere
requested copies of the Manual for each new class of interns and residents and the
booklet has gone through several editions since its initial publication.
     A very important section of the Autopsy Manual defines a medical examiner's
case and outlines the procedures to be followed when a person dies in a hospital
  " from criminal violence; by casualty; by suicide; suddenly when in apparent
health; when unattended by a physician; or in any suspicious or unusual manner.
... Accordingly, a responsible agent of the hospital must report the case promptly
to the Office of the Chief Medical Examiner in the borough in which the death has
occurred.
      Once a case has been accepted as a Medical Examiner's case, its status never
changes except on decision of the Medical Examiner, the Manual points out. The
present laws and regulations concerning Medical Examiner's cases provide that the
Medical Examiner will certify the cause of death in all Medical Examiner's cases.
      In 1959 Dr. Milton Helpern, Chief Medical Examiner, prompted a survey of
the agency by the City Administrator. One consequence of the survey was the
partial centralization of the structure of the Office of the Chief Medical Examiner.
Borough offices in Brooklyn, Queens, and The Bronx were closed. Dispatching and
record-keeping functions of the three borough offices were transferred to a central
office in Manhattan. Postmortem examinations and autopsies continued to be per-
formed in morgue facilities in the several boroughs.
      In December 1965, just at the close of the previous administration in New
York City, there appeared a report of the results of a survey made to determine
what further steps might be taken in order to improve the organization of the
Office of the Chief Medical Examiner. In a letter accompanying the report, Dr. John
Connorton, erstwhile Deputy Mayor, indicated that he had conducted the survey
at the request of Dr. Milton Helpern, Chief Medical Examiner.
      Because it describes the present situation in some detail, the Committee on
Public Health believes it would be helpful to quote from the Connorton report at
length:
         During the reporting year ending June 30, 1964, a total of 30,249 cases
   were reported to the medical examiner for investigation. This number includes
   2,847 cremations and 4,045 "No Cases," where investigation has shown that no
   further action is required by the Office of the Chief Medical Examiner. While
   these two categories do not always result in elaborate examinations, procedures
   require a report from the field medical examiner as in all other cases.
      On the subject of Medical Examiner Field Response, the Connorton survey
shows that, "generally speaking, field visits are either not being made at all or are
being made after considerable lapse of time. Study of a sample of some 300 medical
examiner cases covering the period from June 1963 through June 1964 indicates
that delays of four to six hours, between time of notification and time of arrival on
the scene, are not unusual. Intervals as long as eight hours have been reported. In
                                                                    Bull. N. Y. Acad. Med.
                       THE OFFICE OF THE MEDICAL EXAMINER                      2   43

60 per cent of the reports studied arrival time was not recorded by the field medical
examiner-in 34 per cent not even the date of arrival was recorded. In only 15 per
cent of all cases reviewed was full information available regarding the time of
notification of the field medical examiner and his arrival on the scene." Further:
         If he does not visit the scene, the medical examiner must order the body to
   be brought into the morgue, if any doubt exists as to the cause of death. Informa-
   tion which he should gather in the field must be sought subsequently. As a result,
   some of the medical examiners have made unauthorized use of the clerical staff,
   which may include typists and stenographers, to telephone the police and others
   for needed information with which to fill out their reports.
      The survey notes that the procedure followed by some field medical examiners
is undesirable for several reasons:
          1) Observations made by others at the scene are not those of trained med-
   ical examiners. Opportunities to question certain witnesses may be lost. The
   completeness of the information obtained over the telephone is limited to the
   ability of the clerical personnel to ask questions sufficient for filling out a form.
   Such questions obviously lack the breadth and depth necessary to establish or con-
   firm essential facts related to the death.
          2) The time the clerical personnel must spend in making telephone inquiries
   to complete the medical examiner's report results in damage to other activities.
   As one conspicuous result, the number of untranscribed cases continues to rise at
   a fast rate.
          3) Bodies are ordered unnecessarily into the morgue and released to families
   only after examination. These could have been released immediately if the
   medical examiner had visited the scene. The families might have been saved
   some additional delays and emotional stress perhaps some needless expense.
   The City would have been saved the cost of transporting the body unnecessarily.
          The unduly delayed visit also is unsatisfactory because opportunities may be
   lost to make immediate and essential observations concerning the condition of the
   body and circumstances surrounding the death.
       Dr. Connorton's survey describes the procedures followed in reporting field
investigations:
          Handwritten reports of field investigations are prepared by medical exam-
   iners. Reports of examinations made in the morgue are dictated to stenographers.
   Reports of autopsies are dictated to recording equipment in Manhattan. In the
   other boroughs, a stenographer is present to take the report. The field reports are
   made part of the case record in their hand-written state. The other reports are
   transcribed. The chief medical examiner is required to deliver to the appropriate
    district attorney copies of all records relating to every death in which, in the
    judgment of the medical examiner, there is any suspicion of criminality. Such
   records are not open to public inspection. Requests for copies of reports of other
   cases are received from insurance companies, lawyers, government agencies and
  others.
         Priority in transcribing records is given to cases of criminality. The "re-
   quested" cases receive next consideration. At the end of 1963, there were over
   1,100 requests for cases not yet transcribed. But this figure is miniscule compared
   to the total of 27,000 cases, in all, which were awaiting transcription at that
   time.
Vol. 43, No. 3, March 1967
--
     24 4                COMMITTEE ON PUBLIC HEALTH


           In recent years, use of modern recording devices has brought changes in
    legal definitions of required record keeping. The Corporation Counsel has given
    his opinion that filing of reports in the form of voice dictation of autopsies and
     examinations conducted by the medical examiner is not in conflict with the
    requirements of the Charter or Administrative Code.
           Because of delays in providing copies of "requested" cases, many individuals
    seeking information go to the Office of the Chief Medical Examiner to review the
     case record and make their own notes. Clerks are available to locate the record
    and return it to the files after it has been read. No charge is made for this service.
        In the matter of autopsies, the survey says that "the Office of the Chief Med-
 ical Examiner offers generally excellent medical examiner services to the City of
 New York. The Chief Medical Examiner has steadily moved toward reducing the
 incidence or possibility of error but standards of performance are not uniformly
 high. In no other borough is the level of performance consistently as high as in
 Manhattan." Moreover:
           Lack of proper supervision in a borough office may sometimes permit hasty,
     superficial autopsy performance. Limited experience may also lead to errors. The
     medical examiner may not recognize an unusual condition or lack someone with
     greater experience to consult.
           X-ray equipment, highly important to the work of the medical examiner, is
     available only in Manhattan. Installation of such equipment, with trained oper-
     ators, is not economically justifiable in the borough offices.
        In the light of its findings, the survey by Dr. Connorton recommends greater
 centralization of the operation of the Office of the Chief Medical Examiner and
 indicates the following specific steps to implement the recommendation:
           A. All services of the Office of the Chief Medical Examiner should be cen-
     tralized at its Manhattan office. The consolidation of services is essential to permit
     the Chief Medical Examiner to utilize to the utmost the professional capabilities
     within the organization as well as the modern resources and technical equipment
     of the new Manhattan headquarters building. Better supervision, closer review,
     and increased availability of experienced professional consultation will result from
     centralization.
           B. To advance the professional potential of the medical examiners through
     training, research, and consultation as well as to promote higher quality of pro-
     fessional services, the Office of the Chief Medical Examiner should be reorganized
     with the duties and responsibilities of the Deputy Chiefs clearly specified.
           C. To assure proper transcription of necessary reports, priorities for tran-
      scribing case records should be established by the Chief Medical Exmainer.
           D. Fees for providing information on case records should be adjusted to
     cover transcribing costs. The fees should include a charge for examination of
     records in the Chief Medical Examiner's Office.
         The Committee on Public Health believes that the survey by Dr. Connorton
  fails to deal with a number of questions that are pertinent to a serious review of
  the operation of the Office of Chief Medical Examiner.
        Among these questions are the following:
            1) How many Assistant Medical Examiners are qualified pathologists cer-
  tified by the American Board of Pathology?
                                                                         Bull. N. Y. Acad. Med.
                      THE OFFICE OF THE MEDICAL EXAMINER                      2   45

      2) In as much as the medical examiners' responsibilities concern medicolegal
matters, how many members of the Office of Chief Medical Examiner are certified
in the subspecialty of forensic pathology?
      3) What percentage of cases referred to the medical examiner are autopsied
in New York City?
     4) How many cases are studied microscopically? How many are studied toxi-
cologically, bacteriologically, and virally?
      5) How thorough is the record-keeping? It would be revealing to evaluate the
quality of performance in the recording of findings from a random selection of
records from all the boroughs. How far behind now are the records on autopsy
cases from reaching completion in typed form?
      6) How many full-time medical examiners are there? Most assistant medical
examiners do not consider themselves engaged in a career service. What has been
done to make the position a career service?
      7) How many assistant medical examiners have appointments on medical
school faculties? Why aren't there more affiliations with medical schools?
      8) How many assistant medical examiners are teaching, thus using the in-
valuable material that clears through the Office of the Chief Medical Examiner to
advance medical education?
     9) How many research projects are now under way in the Office of the Chief
Medical Examiner? How many assistant medical examiners are doing research?
How much of the research space is being used currently by medical examiners?
      10) How much training in forensic pathology is being made available to
fellows and residents in the medical schools and other departments of pathology
in New York City?
      11) Why does not the Office of the Chief Medical Examiner make use of the
abundant talent in pathology that is available in the voluntary hospitals of New
York City? Such pathologists could be appointed assistant medical examiners and
upon assignment by the Chief Medical Examiner, would handle those cases orig-
inating in their hospitals, specifically those cases in which the hospital is not a
potential litigant. The hospital pathologist would be responsible for the quality and
thoroughness of the autopsy and be required to file a full report of these cases
promptly with the Office of the Chief Medical Examiner. This would avoid delay
for all concerned and help solve the problem of overlapping jurisdiction which
presently causes much friction and ill-will.
      12) Why does not the Office of the Chief Medical Examiner give serious con-
sideration to the creation of one central office for the reporting and certification of
all deaths?
      13) Why cannot the present statute be amended so that it will not require that
a qualified medical examiner-a physician or pathologist-visit each and every
scene of death immediately upon the report of a case? This requirement is not
being met adequately in any case.
      In the opinion of the Committee on Public Health, these are questions that
require serious study. But the report by Dr. Connorton has failed to take any of
them into account.
      And whereas Dr. Connorton's report presents one view of the problem, there
is a directly opposite point of view which has been brought to the Committee's
attention. At the heart of this opposing view is the belief that decentralization,
together with other changes, not greater centralization, is the way to achieve im-
Vol. 43, No. 3, March 1967
  2   46               COMMITTEE ON PUBLIC HEALTH

proved services, greater economy, and a higher level of efficiency in the medical
examiner system.
     A number of persons familiar with the functions of the Office of the Medical
Examiner have suggested that a plan of decentralization should be designed to
strengthen the borough offices of the medical examiner.
     The present policy of centralizing all services in Manhattan is creating a num-
ber of very serious problems, according to the proponents of decentralization:
     1) Histologic studies, often an important part of the examination, take many
weeks before the slides are returned.
     2) In the matter of toxicological studies, organs are left standing around for
24 to 48 hours (or longer) before being taken to the central office in Manhattan.
Much of this time, tissues are not refrigerated. Further, the results of the proce-
dures that are performed are not made available for a period that may extend from
months to years.
     3) Bacteriological studies are not done at all in the borough offices at the
present time.
     4) Serological specimens are sent to Manhattan but not preserved in a fitting
manner.
     The proposal to perform all autopsies in Manhattan is impractical and works
an unnecessary hardship on families and funeral directors. At the present time, both
parties must wait an overlong time to obtain bodies of Manhattan cases and the
situation will surely become worse if the cases from the other boroughs are added
to the workload. In addition, there are other factors: the public would be put to
great inconvenience and needless expense and effort to make the journey to Man-
hattan from the other boroughs for the purpose of identifying bodies and to give
information of a routine nature. Finally, the District Attorney in each borough out-
side Manhattan would be put to the needless problem of having to get the Medical
Examiner from Manhattan to travel to the site of the Grand Jury or homicide trial
to give testimony.
     Decentralization, the proponents of this point of view hold, would have the
virtue of improving the quality of the work performed in the borough offices. A
qualified Deputy Medical Examiner should be assigned to each of the boroughs to
serve mainly in an administrative capacity and only to a much lesser extent in pro-
fessional activities.
     It is suggested that the borough offices should seek affiliation with medical
schools-two boroughs in addition to Manhattan have schools in their areas. Pro-
vision should be made to have hospital laboratories in the respective boroughs per-
form the Medical Examiner's histology, serology, bacteriology, and routine toxicol-
ogy; the more difficult procedures may -still be done in Manhattan. Rapid tests for
alcohol, barbiturates, arsenic, lead, phenothiazines, and salicylates could be done in
the hospital laboratories within the boroughs. This arrangement would yield data
immediately, or in one to two weeks at the maximum, and the case then could be
closed quickly instead of its being delayed, as at present, from 3 to 30 months.
     In addition to decentralization there are two other changes that would help to
meet the need for skilled manpower not only by augmenting the numbers but also
by utilizing them more selectively, appropriately, and therefore efficiently. One
category would be assigned mostly to deaths occurring outside the hospital for in-
vestigation on the scene. The other would cover deaths occurring in the hospital.
                                                                    Bull. N. Y. Acad. Med.
                       THE OFFICE OF THE MEDICAL EXAMINER                       247

      Currently, the Medical Examiner is obliged to go to the scene of every death
that is reported. About 50 per cent of these deaths, it has been noted, are clearly
the result of natural causes; frequently the case is an elderly person who dies at
home and has not been attended by a physician during the week preceding death.
The critics of this system argue that it is both unrealistic and wasteful to require
that a highly trained forensic pathologist should visit the scene of death in such
cases. Indeed, they think it is wasteful to require a physician investigate the case.
      In their opinion, the City Charter should be amended to permit the Medical
Examiner to engage the services of trained lay investigators-they could be police
detectives-who would go to the scene of death and make the preliminary investiga-
tion. Then, if the investigation shows no evidence of trauma, crime, etc., the
family physician or the physician who pronounced the death should be empowered
to issue a death certificate stating the most likely diagnosis from his examination
of the body and history from the family.
      Such a procedure, it is believed, would correct the present situation in which
bodies may remain in the home for many hours-especially if the death occurs
between midnight and 7:00 a.m.-till the Medical Examiner arrives to issue a death
certificate.
      The use of trained lay investigators would eliminate another problem arising
from the fact that physicians are very reluctant to work as medical examiners
because of the low salaries: $25 per day. This appears to be reflected in the undue
turnover of physicians in the system. Also in this connection it is noted that the
present staff of investigators, even if they are physicians, are no better qualified for
investigative work than trained lay investigators would be.
      Under the present law, the assistant medical examiner is required to be "a
skilled pathologist and microscopist." But the Office of the Chief Medical Examiner
is not complying either with the letter or the spirit of the law. An examination of
the qualifications of the current complement of assistant medical examiners reveals
that only 20 to 25 per cent of them are qualified pathologists. And this situation,
the critics believe, results in part from the fact that the pathologists must visit every
scene of death.
      If the law were amended as suggested, then a lay investigator who suspects
that a death has legal implications would call the forensic pathologist medical
examiner on duty for the day, and the latter then would go to the scene of the case
himself. This procedure would help to cut down on the work load of the Office of
the Medical Examiner, save money for the city, and serve the public better by
achieving a more rapid removal of the deceased from homes in cases of natural
death.
      Given the present scale of salaries, it should be easier to recruit lay investi-
gators who would be trained to a high degree of expertise and would remain in
their positions for many years. This system is used in London with maximum
effectiveness.
      For deaths occurring in a hospital, skilled manpower could also be augmented
and used more effectively. The critics of the present system suggest that the Chief
Medical Examiner should make use of qualified hospital pathologists. It is proposed
that a number of qualified hospital pathologists should be named assistant medical
examiners and be authorized to issue death certificates in cases of death in which
the hospital is not a potential litigant. Certainly these experienced pathologists
would be highly competent to evaluate the cause of death. It would greatly
Vol. 43, No. 3, March 1967
  248                   COMMITTEE ON PUBLIC HEALTH

strengthen and elevate the Office of the Medical Examiner to utilize these trained
and skilled specialists at any time. At this juncture with prevailing shortage of
pathologists their acquisition would be doubly beneficial.
      The benefits to be derived from the use of hospital pathologists would become
evident to all the parties concerned, proponents of the proposal assert. Deputizing
of hospital pathologists would expedite cases in which the hospital is not a poten-
tial litigant, the work load of the Office of the Medical Examiner would be cut
through the use of a heretofore untapped source of highly qualified professionals.
      It should be reiterated that the hospital pathologists serving as assistant medical
examiners would perform autopsies on Medical Examiner cases only on order and
assignment by the Chief Medical Examiner. In deaths in a hospital in which the
institution may be a possible litigant, the hospital pathologist should not serve in
the capacity of an assistant medical examiner. Also in deaths that are not medical
examiner cases or are released by the Medical Examiner, the hospital pathologist
would follow the usual procedure of seeking consent for autopsy from the family.
      Another activity of the medical examiner system that involves a waste of time
and effort, some observers find, concerns requests for cremation. According to the
present procedures, all such requests are forwarded to the Office of the Chief
Medical Examiner for clearance by the Department of Health. These requests then
are made medical examiner's cases and assigned to the tour assistant medical exam-
iner for investigation.
      A more efficient way to handle cremation requests, it is believed, would be to
have a lay investigator contact both the doctor who signed the death certificate and
the member of the family who authorized the cremation. Then the investigator
should decide if there is any reason contraindicating cremation, such as poisoning,
abortion, or past accident. If the lay investigator discovers a reason for suspicion,
he would be required to notify the forensic assistant medical examiner and have
the body sent for autopsy to the appropriate mortuary in the borough.
      Mindful of the fact that as many as 50,000 cases, some of them many years
old, still remain untyped in stenographers' notebooks, critics of the present system
suggest the situation cries out for a remedy. Accordingly, it is proposed that the
Medical Examiner should dictate the appropriate material into a machine for record-
ing on a disc. These discs, in turn, would be sent either downtown or to the
borough office where a pool of typists would be available to transcribe the material
and return it to the assistant medical examiner within one week for checking and
signature.
      Finally, there is one other matter that demands improvement: certification of
death. At the present time certification is dealt with by several deparments of the
city government: Health, Hospitals, and the Office of the Chief Medical Examiner.
This results in wasteful duplication of paper work. Overlapping and indeterminate
jurisdiction causes needless time-consuming effort. A more efficient procedure, the
Committee on Public Health suggests, is a central office for the reporting and
certification of all deaths.
      The Committee has devoted considerable time and attention to its study of the
medical examiner system. And while the Committee has high esteem for the pro-
fessional qualifications of the present Chief Medical Examiner, it believes that the
best interest of the people of New York City are more adequately served by an
objective examination of both points of view regarding the problem. This, the
Committee has attempted to do in the present instance.
                                                                       Bull. N. Y. Acad. Med.
                       THE OFFICE OF' THE MEDICAL EXAMINER                    2- 4 9


                                     CONCLUSIONS
      After careful study of the opposing points of view regarding the operation of
the medical examiner system, the Committee on Public Health has reached the
following conclusions:
      1) The Medical Examiner's department should take steps to strengthen the
borough offices organizationally and administratively, with provision of necessary
facilities and equipment. For special tests, existing facilities outside the department
should be utilized. In all boroughs the medical examiner system should be linked
more closely with existing medical institutions.
      2) The Office of the Medical Examiner should use trained lay investigators to
make the on-the-scene examinations in cases of death outside the hospitals and
certain deaths inside the hospitals.
      3) The Office of the Medical Examiner should utilize heretofore untapped
sources of manpower by deputizing qualified hospital pathologists as assistant
medical examiners. In that capacity they would perform their functions in all
medical examiner cases of deaths occurring in the hospital in which the institution
is not a potential litigant.
      4) More expeditious methods of record-keeping need to be instituted. To
achieve this objective, more extensive use of mechanical and more efficient use
of human resources should be made.
      5) A central office for the certification of all deaths should be established to
facilitate the reporting of deaths and issuance of burial permits.
      In the judgment of the Committee on Public Health, these changes give most
promise of furthering expedition and of simultaneously raising the level of com-
petence in the operation of the Office of the Medical Examiner. They would mini-
mize delay and inconvenience. But most of all they would bring greater savings to
the city, insure a higher level of efficiency in operation, and provide improved
quality of services to the people of New York City.




Vol. 43, No. 3, March 1967

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:3
posted:4/2/2012
language:
pages:9