Because a death occurs in the emergency room, there is no strict requirement that it be reported to the Medical Examiner. Clearly, if any reporting criteria are present (see Criteria for Reportable Deaths, pp 1:1 - 1:4), deaths should be reported for clearance or investigation by the Medical Examiner. If a firm clinical diagnosis has been established while the victim was in the emergency room and no reporting criteria are present, the attending licensed physician can certify death.

Some hospitals have the policy whereby no emergency room physician will certify death if the patient has not been under previous care by a member of the hospital staff. In such instances, the criterion for reporting is that of sudden death in a person without supportive past medical history. If there is supportive past medical history from a private physician not a member of the hospital staff, that private physician should certify death. If the physician is unavailable, the medical examiner staff will view the body and provide a means for certification.

If death is reported to the Medical Examiner's Office, it is incumbent upon emergency room personnel to supply any information to the Medical Examiner's investigator in order that the Medical Examiner can review the clinical findings and render accurate certification. An autopsy will not necessarily be performed if the investigation does not warrant it.

Deaths in the operating rooms

All deaths that occur in the operating room, whether due to surgical or anesthetic procedures, are reportable to the Medical Examiner. After reviewing the case, the Medical Examiner will make the decision to assume jurisdiction of the death based on medical history of the patient, the degree of risk associated with the surgery, and the general health of the patient. If the person is in surgery because of trauma or injury, and dies while undergoing surgery, the death must be investigated by the Medical Examiner.

In general, the Medical Examiner will assume jurisdiction and investigate any surgical death that occurs under the following conditions:

1.	Where the procedure being performed is considered by others in the profession to be relatively low risk, and the patient dies unexpectedly;
2.	Where the death of the patient occurs during the performance of a procedure, or during the immediate postoperative period, and the patient's condition was not considered to be life threatening prior to the initiation of the procedure.

In order to appropriately allocate investigative resources and at the same time serve the medical community and the family, we have developed an investigative procedure that assesses the overall condition of the patient before the anesthetic is administered and before the surgical procedure commences. The procedure which is followed in anesthetic/surgical deaths has been reported in great detail in the Journal of Forensic Sciences : 30:822-827, July 1985.

It is important that the medical community recognize that a Surgical/Anesthetic Death Committee, which utilizes anesthesiologists and surgeons to review the case after the investigation is complete, examines these deaths. The deliberations of the committee are open to physicians who are responsible for the care of the patient. It is only after the committee has deliberated that certification of death is completed.

In order to more clearly identify cases which require an in-depth investigation, the person reporting the surgical/anesthetic death should use the American Society of Anesthesiology Classification (ASA) of the physical status of the patient before the anesthetic is begun and before the surgical procedure is undertaken. The decision to actively investigate a death is largely determined by the ASA category assigned to the patient before the anesthetic is administered.

For the purposes of anesthesia, the classification of the physical status of the patient adopted by the American Society of Anesthesiology is divided into five classes: Class I being a healthy patient who is without functional or physical disability, while Class V is the patient who is moribund, or is unlikely to survive twenty-four hours with or without the surgical procedure. In between these two extremes, Classes II, III, and IV represent patients assessed to have increasing risk. All patients undergoing an anesthetic are assigned one of these risk categories.

At the time of the report of the death, the investigator at the Medical Examiner's Office will seek the ASA classification. All deaths assigned a classification of I, II, or III are identified for further investigation that ordinarily will include an autopsy with a toxicological study of the patient.

Deaths, which have an ASA classification of IV or V, will be reviewed to establish the nature and extent of the natural disease in the context of the surgical process.

Only when an unusual factor or question surfaces during review of such deaths will active jurisdiction be taken. Such deaths where there is a clear equipment malfunction or where the wrong agent was given to the patient require active investigation that will include autopsy and toxicological examination.

We recognize that the opportunity exists for gross errors to be concealed by operating room staff and physicians, but the ASA criteria provide some predictability concerning the level of investigation undertaken.