The Cause of Death is the disease or injury responsible for the lethal sequence of events. A competent cause of death should be etiologically specific.
The Underlying or Proximate Cause of Death is that which, in a continuous sequence, unbroken by an efficient intervening cause, produces the fatality and without which the end result would not have occurred. Immediate causes of death are complications and sequelae of the underlying cause. There may be one or more immediate causes, and they may occur over a prolonged interval, but none absolves the underlying cause of its ultimate responsibility. For example, a man sustains a transabdominal gunshot wound with perforation of the colon. In spite of multiple operations and other treatment, over a period of three months, he develops generalized peritonitis, septicemia, disseminated intravascular coagulation and adult respiratory distress syndrome. The abdominal gunshot wound is the proximate or underlying cause of death and all of the complications listed are the immediate causes of death.
All available information must be used in determining the cause and manner of death
Mechanisms of Death are alterations of physiology and biochemistry whereby the cause exerts its lethal effect. Mechanisms of death are never etiologically specific and are unacceptable as substitutes for the underlying cause of death. Common fatal mechanisms of death include congestive heart failure, cardiac arrhythmias, septicemia, disseminated intravascular coagulation, hepatic failure and anoxic encephalopathy. When completing a death certificate or when analyzing a fatality in an attempt to ascertain why a person died, mechanisms of death and immediate causes of death can be used interchangeably, but the “bottom line” underlying cause of death must be an etiologically specific disease or injury. The term “cardiorespiratory arrest” is a description of being dead, not a cause of death.
In most cases an autopsy is necessary. By Texas Law, (CCP Art. 49.25) the medical examiner is mandated to determine the cause and manner of death in all cases of accident, suicide, homicide, and undetermined death. In cases of natural death, when the person is NOT under a doctor’s care, or the person passes away in less than 24 hours after admission to a hospital, the medical examiner must be notified, as an autopsy may be required.
The medical examiner must use all information available to make a determination about the death. This may include information from his/her own investigation, police reports, staff investigations, and discussion with the family and friends of the decedent.
The Manner of Death explains how the cause of death arose: a natural vs. violent death. Natural deaths are caused exclusively by disease. If an injury of any sort (mechanical, chemical, electrical, etc.) causes or contributes to death, the fatality is classified as non-natural and then is sub-classified as Accident, Homicide, Suicide or Undetermined.
Inquests are natural deaths, absent any visible trauma or history of trauma either at a residence or or admitted to a medical facility less than 24 hours, that are reported to HCIFS, but the body is not brought to HCIFS if the decedent's private physician is willing to sign the death certificate based on a well documented medical history.
Trauma Inquests are deaths that are reported to HCIFS, usually after interment, when a private physician includes any type of trauma on the death certificate and Vital Statistics rejects the death certificate due to the inclusion of trauma as contributory to the death.
An Autopsy is a careful external and internal examination of the decedent, which is used to determine or confirm the cause of death.
An External Examination of the decedent, is used to determine or confirm the cause of death.
Natural – “due solely or nearly totally to disease and/or the aging process.” If natural death is hastened by injury (such as a fall or drowning in the bathtub), then the manner of death is not natural. Some examples of Natural death are: heart disease, SIDS, chronic alcohol abuse, etc.
Accident – “there is little or no evidence that the injury or poisoning occurred with intent to harm or cause death. In essence, the fatal outcome was unintentional”. Some examples of Accidental death are: accidental overdose, falls, motor vehicle accidents, etc.
Homicide is when a person is killed by one or more persons.
Homicide – “occurs when death results from… an injury or poisoning or from “…a volitional act committed by another person to cause fear, harm, or death. Intent to cause death is a common element but is not required for classification as homicide.” Homicide is when a person is killed by one or more persons. This is different than murder. Murder is the unlawful taking of a human life by another, especially with premeditated malice. For example, if a police officer kills someone in the line of duty, it is considered a homicide, but not necessarily a murder. All murders are homicides, but not all homicides are murders.
Suicide – “results from an injury or poisoning as a result of an intentional, self-inflected act committed to do self-harm or cause death of one’s self.” Some examples of Suicide are: drug overdose, gunshot hanging, etc.
Undetermined – “used when the information pointing to one manner of death is no more compelling than one or more other competing manners of death when all available information is considered.” Undetermined is intended for cases in which it is impossible to establish, with reasonable medical certainty, the circumstances of death after thorough investigation.
Pending Investigation - when determination of manner of death depends on further information, usually prior to autopsy, external examination or test results. This is an interim classification that indicates a level of uncertainty about the circumstances surrounding the death. This classification is changed once the investigation is complete.
A Fetal death is a death in utero. This encompasses both stillborns, as well as deaths of mother and fetus (i.e., car crash in which a pregnant woman dies). A fetal death certificate differs from that of a live born infant, baby or adult death certificate in that the fetal death certificate does not include a manner of death.
Skeletal remains is a body that has decomposed to the point that all or nearly all that is left is bones. in those instances, the challenge to the Medical Examiner is twofold: First, the identity the decedent must be found. Second, the cause and manner of death must be identified.
DNA may be used to confirm an identity for skeletal remains
There are several possible resources for the identification. The decedent's teeth may be compared with antemortem dental records/charts; old skeletal injuries may be correlated, i.e. a specific pattern of rib fractures, with antemortem X-rays; characteristic surgically implanted items (i.e. pacemakers, orthopedic hardware, sternotomy wires, etc.) may be compared with known items from medical records/X-rays. Frequently, DNA may be used to confirm identity. DNA can be extracted from most of the bones, including teeth, which can then be compared to the putative parents or offspring of the tentatively-identified decedent.
Sometimes, no characteristic findings are available on the skeletal remains to compare to antemortem characteristics. In order to proceed, an analysis of demographic characteristics will be used. In those instances, the assistance of a physical anthropologist (specialist in the analysis of skeletal remains) is required. The anthropologist will be able to give a range for the decedent's height (i.e. as determined from the length of the femur bone) and a range for the decedent's age. Furthermore, the anthropologist may be able to tell, from characteristics on the skull, for example, certain racial features. This is the "profile": i.e. white male, age 35-50, 5-foot-6-inches to 5-foot-9-inches. That information, combined with any clothing, the location the remains were discovered at, etc., are entered into a national database of missing persons. The assistance of a forensic artist may also be used to recreate a face for the decedent. Either a 3-D sculpture or a 2-D drawing. Such drawings, along with the demographic data, are then disseminated, with the assistance of the police department to the media.
As to cause and manner of death, skeletal remains may reveal: evidence of significant trauma of a body may be reflected as only small irregularities of the bones, or as obvious fractures. In cases of fatal stabbing for example, only small knife marks on a rib may be seen. Similarly, gunshot wounds may traverse a bony structure. Blunt trauma frequently produces fractures, some of which can be fairly characteristic of certain types of weapons/objects. However, natural disease, drug related deaths, and many types of trauma will not leave marks on the bones. If the cause of death is not readily apparent (and frequently, even if it is apparent), consultation with an anthropologist will be used. As a specialist in bone analysis, the anthropologist is attuned to the detection of subtle abnormalities, and may offer the pathologist assistance with the interpretation of injury patterns.