Hospital staff and the Medical Examiner

Please read carefully the sections of this manual that deal with establishing a hospital death as a Medical Examiner case, deaths in the operating room, and deaths occurring in emergency rooms. All discussion applying to the practicing physician applies equally to attending physicians, and hospital personnel whether pathologists, interns, residents, administrators, nursing supervisors, or social workers. Certain special conditions arise in relation to these people and the Medical Examiner which merit separate consideration.

Each hospital shall have a responsible medical professional (such as the Nursing Supervisor), with whom the Medical Examiner can, at any hour communicate. The procedure to follow in reporting a death to the Medical Examiner's Office is the same for hospitals as for practicing physicians. The designated hospital representative shall make the report by phone to the Medical Examiner's Office (206-731-3232, ext. 1) immediately upon determination of death. Pertinent information regarding the decedents medical history is required to be reported at that time. The hospital representative shall submit promptly the following information to the Medical Examiner:

1.	Name and age (if known);
2.	Date and time of admission;
3.	Time of death;
4.	Clinical diagnosis (if made);
5.	Place, date, time, and manner of incident or violence (if any);
6.	Name and telephone number of attending physician;
7.	Any other relevant information;
8.	If next of kin has been contacted

This will allow Medical Examiner personnel to decide disposition of each case.

In order to assist the Medical Examiner when a death is taken under jurisdiction and investigation, hospital personnel should use the following guidelines. These guidelines are designed to aid in establishing cause and manner of death.

1.	Do not clean the body or clothing after death.
2.	Special care should be used in cutting and handling of clothing so that valuable evidence such as bullet holes remain intact.
3.	All clothing of the deceased should accompany the body.
4.	Any IV lines, tubes, catheters, endotracheal tubes, dressings, splints, clamps, and orthopedic devices should be left in place. Therapeutic articles will be returned to the hospital upon request.
5.	Any needle puncture wounds to the deceased, made by hospital personnel should be circled in pen and the initials "RX" written next to the circle.
6.	Any blood, urine, gastric material, or any body fluid collected at the time of admission should be saved and accompany the body.
7.	Admitting blood and urine should be saved on all patients classified in critical condition if their death would result in jurisdiction by the Medical Examiner. This is helpful in detecting concealed homicides.
8.	It is permissible for the family to view the body before removal to the Medical Examiner's Office, provided the body is not cleaned or otherwise disturbed. In cases where there is potential criminal, investigation, (e.g., homicidal deaths), viewing should not be permitted and such requests should be referred to the Medical Examiner.
9.	Notification of the death to the family should be communicated to the Medical Examiner investigators when they arrive to remove the body. Thus, notification efforts can be initiated and/or coordinated, and not duplicated. The attending physician will be asked to complete a confidential form entitled "Physician's Summary Report". This form seeks information on location of injuries, bullets or other foreign objects, surgical procedures, laboratory and x-ray data, etc. This form is exceedingly helpful in differentiating those marks on the body that are wounds of violence from those that are the result of treatment, e.g., cases with multiple stab wounds. Hospitals will be supplied with a quantity of these forms so that they are readily available. This form must accompany the body to the Medical Examiner's Office. Cooperation with these procedures is both necessary and appreciated.

After Medical Examiner's investigators receive notification of a death, they are dispatched to take jurisdiction, investigate and transport the body to the KCMEO. A minimum of one investigator is available 24 hours per day. Occasionally, due to multiple calls in rapid succession, an investigator will not be immediately available to respond to the hospital. The person making notification of death should ask if a delay is anticipated. Residential deaths take priority over hospital deaths. This is because hospitals have the staff to care for a body, which is often not possible at a residence.

Medical Examiner investigators will, upon request by hospital personnel, delay their response for up to an hour. Hospital personnel should also inform family members that the Medical Examiner's Office would be contacting them for information necessary for death certification. To this end, whenever possible, hospital personnel should ask responsible family member to remain at the hospital until arrival of Medical Examiner investigators.

Hospital autopsy

Under no circumstances should the hospital staff request autopsy permission from the family when the death is clearly within Medical Examiner's jurisdiction.

When requested to perform an autopsy by members of the hospital staff, the hospital pathologists should ensure, from the review of the medical history, that the death does not fall under the Medical Examiner's jurisdiction. If, during the course of an autopsy, it becomes clear that the case should have properly been in the Medical Examiner's jurisdiction, the autopsy shall stop. The Medical Examiner's Office must be consulted to ascertain further direction and guidance. The Medical Examiner is authorized to perform autopsies by RCW 68.50 and King County Ordinance #2878. No permission is needed by the Medical Examiner in order to perform autopsies.

If an autopsy is clearly required for statutory purposes, it will be performed by the Medical Examiner and the physician will be denied the request to seek autopsy permission. Interested attending physicians may request to attend a Medical Examiner's autopsy and/or receive a copy of the autopsy diagnosis and opinion. Release of this information is restricted.

Except in those few instances when there is genuine error, asking the family for autopsy permission is tacit recognition that the death is not in the Medical Examiner's jurisdiction. If it is later decided that it is a Medical Examiner case and the family has refused autopsy permission, this will create needless difficulties.

Instances may arise where the Medical Examiner has jurisdiction in a death, (e.g., hospitalized patient with a fractured femur sustained in a fall at home), but clinicians desire an autopsy authorized by the next of kin to be performed by the hospital pathologist. This can be accomplished only if the following procedure is followed:

Notify the Medical Examiner's Office of the death immediately with a clear statement of events, which caused the injury.

Inform the investigator taking the call that an autopsy is desired at the hospital for clinical interest. Do not request autopsy permission from the family until assessment has been made by the Medical Examiner that a hospital autopsy can be performed.

If the death has been assessed by the Medical Examiner and approval given to seek autopsy permission from the surviving next of kin, the physician can then proceed. A medical examiner case number will be assigned.

Once an autopsy is completed, a copy of the report will be forwarded to the Medical Examiner's Office to complete the record. Similarly, a copy of the death certificate with the identifying KCME case number should be submitted to the Medical Examiner's Office for file.

If all prior steps are completed but the surviving next of kin denies autopsy permission, an autopsy may not be authorized by the Medical Examiner over the objections of the family. In some cases, a clinician may wish to perform an autopsy in a case where the deceased has no known next of kin. The Medical Examiner has the authority to authorize autopsies under such circumstances according to RCW 68.50.010 and RCW 68.50.101. If the Medical Examiner agrees to give autopsy authorization, the physician must sign a Medical Examiner Autopsy Authorization form agreeing to certain conditions.

SIDS deaths

Beginning in 1984, there has been a change in the handling and processing of SIDS deaths. Before 1994, infants who were suspected of dying of SIDS were routinely released to Children's Hospital and Medical Center for autopsy. Since 1994, all sudden deaths in infancy are now routinely investigated and examined by the Medical Examiner. This includes scene investigation and recreation, family history, family interviews, routine radiology, autopsy (including histology), and toxicological analysis of body fluids.

Every effort is made by a Medical Examiner Investigator to visit the scene where the death occurred. Additionally, a standard SIDS Scene and Circumstance Protocol is completed on each death so that there is maximum collection of information surrounding these deaths.

After the autopsy examination is completed, and the cause of death is determined to be SIDS, the King County Department of Public Health is contacted so a visiting nurse can have an opportunity for a follow-up visit with the family. At that time, information regarding the local SIDS support group is provided and access to counseling for the families of SIDS's death is made available.

Additionally when a death involves an infant or child under the age of 18, the Washington State Department of Social and Health Services is immediately contacted to assess whether or not the individual or family of the child has ever had a Child Protective Service, Family Reconciliation Service, or Child Welfare Service referral. This information becomes an essential part of the investigative report. If the infant or child has had contact with CPS, than a closing case conference is held on a quarterly basis. This interagency agreement is designed to share information on infants and children who come under the jurisdiction of the Medical Examiner and who likewise have had referral to CPS.

Property disposition

Next of kin is known

Under no circumstances should the hospital staff take it upon themselves to notify any hotel operator, apartment, or rooming house owner, of the hospital death of any tenant. So doing may lead to the property of the deceased being disturbed, misplaced, or lost to the rightful heirs.

If on admission to the hospital, the patient listed the next of kin, he or she may be notified and will likely take charge of property.

Next of kin is NOT known

In cases where no next of kin or legal representative is known or indicated, the hospital staff or representative should make every effort to locate any next of kin. If after due diligence by the hospital staff or representative, and no next of kin can be located, the Medical Examiner should be notified.

Any attempts by the hospital to locate next of kin should be documented and presented to the Medical Examiner Investigator.

The Medical Examiner's Office will assume jurisdiction of the death, dispatch investigative staff to the residence, and in the presence of witnesses, take charge of property or the residence, search for next of kin, and arrange for burial as required.

Adherence to the above procedure assures that a properly authorized person, in the presence of witnesses, will be the first to enter and search the premises of the deceased.