Answers to Frequently Asked Questions

Issuing a death certificate (pending or otherwise) is the responsibility of the person in charge of interment, usually the family's chosen funeral home.  The law requires that the death certificate be filed "not later than the 10^th day after the date of death" (Texas Health and Safety Code Sections 193.002-193.003).

"Pending" is a temporary classification of the cause and manner of death that is assigned by the medical examiner when further information or testing is required to classify the cause and manner of death. Once the cause and manner of death are determined, the medical examiner's office will file an amendment to the pending death certificate with the state registrar. The family can then order a certified copy of the amended death certificate through their selected funeral home or directly from the Texas Department of State Health Services Vital Statistics Unit.

However, in the meantime, as the investigation is progressing, a "pending" death certificate will be available.  The "pending" death certificate is still legal proof of death. Some insurance companies and financial institutions may accept a pending death certificate for the purposes of paying benefits or handling other accounts, but this varies based on each family's specific institution, account/s or circumstance/s.

In many cases the cause of death is evident at the time of autopsy. In these cases the death certificate is generated immediately. In other cases the cause of death may not be apparent from anatomic (grossly visible) findings. In these instances the pathologist must await additional studies. For example, in some cases the pathologist may realize that the person has an infection (pneumonia for example) but he may wait for the results of cultures to find which microorganism(s) is involved. In other instances drug toxicity may be suspected and so the pathologist must await results from the toxicology laboratory. In some instances, the cause of death may be readily apparent at the time of autopsy, but the manner of death is not known. An example of the latter is a person dying in a house fire from smoke inhalation and burns. We can see soot in the airway, and we can see burns. However, we cannot tell from autopsy what started the fire. That answer must come from the arson investigation (which is outside the purview of the medical examiner). As manner of death (homicide, suicide or accident) will then hinge on that determination, we must await conclusion of the investigation. Other examples of the latter are head injuries where nobody saw the traumatic incident, and some close range gunshot wounds (where gunshot residue analysis, range determination, firearms examination, and police investigation may all be necessary to arrive at a determination between suicide, homicide or accident).

The need for toxicology studies is one of the most frequent reasons for delay in death certificate completion. Toxicology in the medical examiner setting is different than drug testing that is done in the hospitals. Hospitals will simply do screening tests for types and categories of drugs ("opiates" for example). Because clinicians have the advantage of a living patient with symptoms to evaluate, they do not need to know quantities (if a sedative toxicity is suspected from clinical symptoms and opiates are detected on a drug screen, then the person is treated for opiate toxicity). The medical examiner however will need to know which specific drug(s) within the drug class or category (for example, whether "opiates" is morphine, heroin, hydrocodone, etc) are involved. Also, the medical examiner will need to know the quantity of those drugs in multiple biological samples (blood, liver, gastric contents, etc) in order to put the death into perspective. In other words, postmortem levels must be interpreted in light of tissue distribution/redistribution of drugs, gastric quantity and so forth in order to know 1) is this a toxic level? and 2) is this an accident or suicide? Furthermore, in order for accredited forensic toxicology laboratory results to be considered legally valid the results must be confirmed by two types of tests. Toxicology tests will take longer if multiple drugs are involved, if unusual drugs are involved, or if the person is decomposed.

Finally, one must consider the possibility that the pathologist's initial suspicions are not confirmed. For example, if the pathologist suspects drug toxicity but the initial toxicology report reveals only low levels of drugs or no drugs at all. In these cases, the pathologist may submit additional tissues to reevaluate specific parts of the heart muscle or brain, while at the same time consulting with the toxicologist to pursue testing for more unusual or exotic drugs that weren't originally analyzed, while at the same time asking the police to return to the scene of death to ascertain more information, or perhaps to interview additional witnesses. Each death is different, and the findings in each case are different. Additional follow-up is determined as results are obtained. Obviously in such multi-step investigations the process may be lengthy, and the requisite time necessary may not be entirely under the control of the pathologist.

In general, a medical examiner is a physician, trained in death investigation, typically sub-specialized in Forensic Pathology. When one refers to a "medical examiner system" one is usually referring to a system in which the physicians (Forensic Pathologists) are the death investigation authorities for a specified geographic jurisdiction. Within that jurisdiction, the medical examiners review deaths, decide which cases meet their criteria for further investigation, and perform autopsies when indicated.

In Harris County, the Commissioners Court appoint the Chief Medical Examiner. The Chief Medical Examiner must be a physician, licensed to practice medicine in the State of Texas and be certified by the American Board of Pathology in Anatomic and Forensic Pathology. The Chief Medical Examiner serves continuously and can only be removed for cause.

In contrast, a Coroner typically refers to an elected official, who serves as the authority for death investigation, but may not have any medical training. Thus, a coroner typically has to have a contract with some forensic pathologist, or medical examiner office in some nearby jurisdiction to perform autopsies when an autopsy is required. In Texas, some counties rely on Justices of the Peace to fulfill the role of coroner.

Over the years, the terminology has become blurred, in part because of ignorance, and in part because of system evolution issues. So, for example, in Los Angeles, CA the Coroner's Office is, in fact, a medical examiner's office, for all practical purposes.

Each state has different laws and each jurisdiction operates differently, but these are the basic differences between a medical examiner and a coroner.

Death investigation always begins at the scene. The scene investigation may give clues as to drugs or toxins which may be related to the cause of death. Some poisonous agents are not detected on routine drug screens therefore the pathologist must have knowledge of medications and toxins in order to request the specific analytical tests needed to detect them. An example would include the "sniffing" or "huffing" of aerosol propellants, a risky activity which has been frequently reported in teenagers. Sniffing of propellant substances can cause sudden death by precipitating lethal cardiac arrhythmias. A special analysis (gas chromatography by head space analysis) is required to detect the chemicals in the blood. In other cases there may be sufficient natural disease to account for death but the individual may in fact have died of a drug overdose or other subtle cause. In the case of drowning and suffocation the autopsy findings are not specific and police investigation is critical to the understanding of the death.

In the examination of skeletal or severely decomposed remains, the forensic pathologist will frequently consult another doctor with special expertise in analysis of bones, a physical anthropologist. If sufficient skeletal parts remain, the pathologist or anthropologist may be able to determine the age, race and sex of the individual and sometimes estimate the length of time since death. Occasionally, specific markings on the bones may enable the pathologist to come to a conclusion as to the cause of death.

An autopsy is an examination of a dead body. In the course of an autopsy the body is examined multiple times; first as it is received, then again after it is unclothed, and yet again after being cleaned (any loose dirt, blood or other foreign substances are removed). At each step, identifying features, injuries or other unusual features are documented with multiple modalities (i.e. photographs, verbal and/or diagram). The body is then opened, and each organ is examined, in turn, for the presence of injuries or pre-existing natural disease.

In the course of an autopsy, samples of various organs, tissues and body fluids are retained for additional ancillary studies, if warranted. The ancillary studies include microscopic examination (Histology), drug testing (Toxicology), and microbiology (bacterial and viral culture). Additionally, depending on the type of case, other items of evidence may also be retained: foreign objects (bullets, knife blades or tips, ligatures, etc.), scalp hair (for comparison to hair on a suspect weapon or vehicle), fingernail scrapings (for analysis of blood and/or foreign DNA), sexual assault swabs, gunshot residue test swabs, and so on. The HCIFS is also very active in the collection of trace evidence from dead bodies (collected under visible and alternate light sources).

The medical examiner law in Texas (Texas Code of Criminal Procedures section 49.25) is very clear with respect to which deaths fall under the jurisdiction of the medical examiner i.e. in which cases the medical examiner has the duty and responsibility of determining cause and manner of death. However, the law does not specify what elements must be included in that death investigation. In many cases, a medical examiner will be satisfied that an autopsy is not necessary, after discussion with police at the scene, with family, and/or with the decedent's personal physician and that adequate medical information exists to explain the cause, mechanism and circumstances of the person's demise and that injury or foul play have been ruled out. In such cases, a medical examiner may elect to perform an "external examination" rather than a complete autopsy.

An external examination will include photography of the body as it is received; photography of the body unclothed and cleaned, documentation (photography, diagram and verbal description) of any identifying features, etc., collection of samples for potential toxicology analysis and potential DNA analysis. Most traumatic deaths are autopsied; however, in some instances where the decedent has been hospitalized for a substantial time prior to death and where injuries, cause and mechanism of death, and circumstances are clear (and there is no suspicion of homicide), the person may not be autopsied. The latter category primarily consists of victims of motor vehicle crashes who have been hospitalized for weeks or months. Certain types of cases, especially homicide and suicide, are typically autopsied regardless of the duration of post-injury survival. Importantly, the medical examiner retains final discretion in all cases within medical examiner jurisdiction, and each case is decided on a "case-by-case" basis. 

If the medical examiner determines that an autopsy is necessary, a complete autopsy (including examination of all internal organs and brain), will be undertaken. Limited autopsies (e.g., "chest only," "head only," "chest and abdomen only") are common in hospital pathology, but are inadequate in medical examiner practice.

Of course, the specifics of a particular anatomical and/or toxicological examination will vary depending on the nature of the case. In other words, the specifics of an examination are tailored to the question(s) being answered.

These popular TV series certainly glamorize all aspects of forensics. (Come to think of it, the TV series even glamorize the crimes the forensic personnel are setting out to solve). Our job is really much more mundane, smelly and adversarial than what's portrayed on TV. Further, technical inaccuracies abound in the TV shows, particularly with regard to the time frame in which tests are ran. The TV shows all also take liberties with character development, where single characters assume the roles of multiple police detectives, crime scene analysts, and pathologists. More disturbing is the mindset portrayed on Crossing Jordan, in which the pathologist sets out to "prove" somebody's innocence or guilt…our role is neutral (the latter philosophy is more accurately presented on the original CSI).

Having said that though, the interest generated from those shows have been terrific for the forensic community. We have seen a deluge of bright young folks interested in our field who probably would otherwise have no idea of what we do. The fact that you're reading this is an example of that. The TV shows are also worth watching from another standpoint as well: entertainment. After all, the story lines are generally pretty good, even if some of the details are bogus.

There is no typical day. Obviously we spend much of our time performing autopsies. But that's just the beginning. We frequently attend death scenes, testify in court, lecture to medical students and residents, give hands-on training to physicians-in-training, meet one-on-one with families, meet with lawyers on civil and criminal matters, give depositions, and the list goes on.

The variety extends to cases as well. Many of the cases that find their way to the newspapers are homicides…gunshots, stabbings, beatings, etc. But then there are natural deaths: sudden unexpected deaths in babies for example, where mourning parents are desperately awaiting answers (is there an underlying genetic or metabolic abnormality?) or simply closure; natural deaths in adults (is there an infectious or hereditary disease that the rest of the family should be worried about?); motor vehicle crash victims (is there an underlying reason for the crash: heart disease, brain abnormality, drug or alcohol impairment?), and again the list goes on.

1. After high school the future forensic pathologist attends undergraduate college for 4 years and receives a bachelors degree.
2. After undergraduate college the aspiring forensic pathologist spends 4 years in medical school, earning an M.D. or D.O. degree.
3. After medical school there are several routes by which one may become a forensic pathologist. 
   • One may spend 4 years training in anatomic & clinical pathology followed by 1 year of fellowship in forensic pathology.
   • A second option is to train for 3 years in anatomic pathology and train for 1 year in forensic pathology. The fellowship training in forensic pathology involves practical (on-the-job) experience supervised by trained forensic pathologists. The forensic pathology fellow actually performs autopsies and participates in death investigation. To become certified, one then must pass an examination given by the American Board of Pathology certifying special competence in forensic pathology.

No. The HCIFS has no jurisdiction over deaths due to documented, diagnosed natural disease (such as deaths due to infectious disease like COVID-19). Individuals who are in the hospital for more than 24 hours before death, and who succumb to the effects of COVID-19, are not reportable to the medical examiner. Therefore, HCIFS would have no way of tracking those deaths.

In cases where no diagnosis was made by a physician, and we may suspect the death was caused by COVID-19, we determine jurisdiction based on the details of the circumstances, the decedent's history and the medical examiner law (Texas Code of Criminal Procedure, 49.25). When warranted, we are following the guidance of the CDC, and our local health departments to collect samples and submit for testing. Testing is not done at the HCIFS. When we do identify a death caused by COVID-19, that information is provided to the respective health department, and the cause of death would be public, as in any other case.

We average 4,500 autopsies every year. Contrast that with 29,877 Harris County death certificates filed in 2019. To get data on all Harris County deaths, contact https://dshs.texas.gov/ They have death data from all 254 Texas counties.