OVERVIEW OF THE MEDICOLEGAL DEATH INVESTIGATION SYSTEM IN THE UNITED STATES
Randy Hanzlick
The medicolegal death investigation system is responsible for conducting death investigations and certifying the cause and manner of unnatural and unexplained deaths. Unnatural and unexplained deaths include homicides, suicides, unintentional injuries, drug-related deaths, and other deaths that are sudden or unexpected. Approximately 20% of the 2.4 million deaths in the US each year are investigated by medical examiners and coroners, accounting for approximately 450,000 medicolegal death investigations annually.
Death investigations carry broad societal importance for criminal justice and public health. Death investigations provide evidence to convict the guilty and protect the innocent, whether they are accused of murder, child maltreatment, neglect, or other crimes. Death investigations aid civil litigation, such as in malpractice, personal injury, or life insurance claims. Death investigations are critical for many aspects of public health practice and research, including surveillance, epidemiology, and prevention programs, most often in injury prevention and control but also in prevention of suicide, violence, or substance abuse. And death investigations are emerging as critically important in evaluating the quality of health care and the nation’s response to bioterrorism.
The term medicolegal death investigation system is something of a misnomer. It is an umbrella term for a patchwork of highly varied state and local systems for investigating deaths. Death investigations are carried out by coroners or medical examiners. Their role is to decide the scope and course of a death investigation.
Qualifications For a Death Investigator – No Consistency
The quality of a death investigation system is difficult to assess, but it can be measured with several indicators. One is accreditation by NAME, the professional organization of physician medical examiners. Only 42 of the nation’s medical examiner offices, serving 23% of the population have been accredited by NAME in recent years. Most of the population (77%) are served by offices lacking accreditation. Another indicator of quality is statutory requirements for training: about 36% of the US population lives where minimal or no special training is required of those responsible for death investigations (Hanzlick, 1996). In Georgia, for example, the typical requirements for serving as a coroner are being a registered voter at least 25 years old, not having any felony convictions, having a high-school diploma or the equivalent, and receiving annual training of 1 week.
Funding levels also vary greatly. County systems range from $0.62 to $5.54 per capita, with a mean of $2.6 per capita. Statewide systems are generally funded at lower levels: $0.32-$3.20 per capita, with a mean of $1.41 per capita. Third-party payers generally do not support the costs of operations, nor are there medical billing systems. Funding is almost exclusively from tax revenues. Because of insufficient funding, salaries of medical examiners are much lower than those of other physicians. Lower salaries lead to difficulty in recruiting and retaining skilled personnel.
What are your thoughts?
It is interesting that many jurisdictions require ABMDI certification of Investigators 12 months to 24 months AFTER being hired. Yet the ABMDI certification is spoken of as an ultimate goal that signifies compliance within a jurisdiction to some standard, and it shows due diligence that an investigator has some level of training verifiable by a standard setting organization. This is great!
But it also tells me that there are investigators being hired that are NOT ABMDI certified, yet an investigator cannot become ABMDI certified unless they are affiliated with a jurisdiction with 240 hours of documented skills and experience signed off. So who are these investigators being hired who are not ABMDI certified? Are they all new to the field? What about potential investigators, who check all the boxes to pass the ABMDI testing, yet haven’t or cannot get hired? Why is there not an educational program accredited by the ABMDI that would allow certification based on a training program at standard?
In my profession, dental assistants go to trade or community college programs and become certified by their state dental licensing board, as well as the national DANB (Dental Assisting National Board), without having to FIRST be hired by a dentist and prove 240 hours of checkboxes. The training comes FIRST, and the x-ray, sealant, polishing, and anesthesia monitoring training are in place first, not OTJ and signed off by just any supervisor.
I question the credibility coroner/medical examiner offices give to the true intent of the ABMDI established standards. Money is what allows compliance, and at this time, the ABMDI has no legal authority to get ME jurisdictions to comply with standards. As long as hiring of Medicolegal Death Investigators continues to be a Good Ol’ Boy system, there will never be a standard of investigative practices.
The application of standards to investigations, as well as investigators, will not come to pass without some way to become educated before being hired. The OTJ system “stuffs the ballot box” with favoritism and lack of best practices. And who wants to go to two years of community college training in a Death Investigation certificate program (if one existed) for $12.00/hr? That is why so many urban/metro ME offices have stacks of applications from applicants with Masters and higher degrees in fields not necessarily related to Death Investigations, yet they hire from within, amongst a pool of applicants that can get hired because they do not need a degree of certificate at the time of application – they can get it 12-24 months later! What a waste of talent and ideas to make the system parity across the country.
I see current training and requirements for MDIs as weak in skills, and impossible without connections. It is appalling that the skills necessary to perform MDI duties are not available in a university based curriculum, either as a degree or certificate program. It sure made it impossible for me to get a toe in the door.
All counties within a 200-mile radius here have Coroners with little more than high school degrees but have some political affiliation and thus are the counties Medical Examiners. I applied in four different counties with a Biocultural Anthropology degree (Forensic and Medical Sciences) in which I received training and worked two internships to gain experience studying human remains as it relates to explaining the circumstances of an accident or solving a crime. I also worked as an EMT many years ago, and I have done Legal Research (including death investigation) as an LLC in New Orleans for close to ten years. Here you have someone with legit and high-quality training in death investigation, and I cannot even get a callback! It’s not as if I feel I’m above working for $12/hour. I am passionate about bringing closure to families in grief regardless of the pay. Now I realize, it has nothing to do with qualifications, family and friends fill the positions. The people in this community deserve high-quality investigations. If they only knew that the investigators have little to no formal education or training.
Conspiracy or bad politics, it doesn’t matter, either way, …it’s sad. On a side note, the other trend I find is that big city Coroners & Medical examiner offices utilize medical students for a lot of their needs. I understand this circumstance. They are using students so they can allocate funds to other necessary areas.
Lauren I am sorry you are experiencing these issues in trying to find work in this area. I agree it is a problem and I am dedicating my work to improving standards. For too many years it has been “okay” to have less than qualified investigators working death cases. I do believe strongly that a locally elected Coroner can do a fantastic job in this area. However, some standards need to be set. Most police are local people who have chosen that field, but the state requires some basic and continuing education. Why not in the C/ME field consistently?
I think Graham nails the main issues square on the head.
There is no training to get an entry level position. You are either moving from within the medical examiners office (clerk, autopsy tech etc), in law enforcement or sometimes some have a medical background of some kind. None of these areas fully prepare(train) you for the MDI job. A specific curriculum designed around the MDI’s duties would be interesting to see come to form. Much like the current MDI Validation Survey that is going around right now. It would be interesting to have a curriculum partially-constructed by this small community of MDI’s. I find the question of the article interesting; I am curious as to how this question came about in the first place.
Thank you for the insights. This is worth the time to read this article.