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A Guide to Death Scene Investigation: Establishing and Recording Decedent Profile Information

After an investigator has documented, evaluated, and processed the body, he or she must record the decedent's profile information. He or she should follow these steps:

• Document the Discovery History
• Determine Terminal Episode History
• Document Decedent Medical History
• Document Decedent Mental Health History
• Document Social History

Document the Discovery History

Principle: Establishing a decedent profile includes documenting a discovery history and circumstances surrounding the discovery. The basic profile will dictate subsequent levels of investigation, jurisdiction and authority. The focus (breadth/depth) of further investigation is dependent on this information.

Authorization: Medical Examiner/Coroner Official Office Policy Manual; State or Federal Statutory Authority.

Policy: The investigator shall document the discovery history, available witnesses and apparent circumstances leading to death.

Procedure: For an investigator to correctly document the discovery history, he/she should:

1. Establish and record person(s) who discovered the body and when.
2. Document the circumstances surrounding the discovery (who, what, where, when, how).

Summary: The investigator must produce clear, concise, documented information concerning who discovered the body, what the circumstances of discovery were, where the discovery occurred, when the discovery was made and how the discovery was made.

Determine Terminal Episode History

Principle: Preterminal circumstances play a significant role in determining cause and manner of death. Documentation of medical intervention and/or procurement of antemortem specimens help to establish the decedent's condition prior to death.

Authorization: Medical Examiner/Coroner Official Office Policy Manual; State or Federal Statutory Authority.

Policy: The investigator shall document known circumstances and medical intervention preceding death.

Procedure: In order for the investigator to determine terminal episode history, he/she should:

1. Document when, where, how and by whom decedent was last known to be alive.
2. Document the incidents prior to the death.
3. Document complaints/symptoms prior to the death.
4. Document and review complete EMS records
5. Obtain relevant medical and pharmacy records.
6. Obtain relevant antemortem specimens.

Summary: Obtaining records of pre-terminal circumstances and medical history distinguishes medical treatment from trauma. The history, relevant antemortem specimens, and electronic data collected and/or transmitted may assist the medical examiner/coroner in determining cause and manner of death.

Document Decedent Medical History

Principle: The majority of deaths referred to the medical examiner/coroner are natural deaths. Establishing the decedent's medical history helps to focus the investigation. Documenting the decedent's medical signs or symptoms prior to death determines the need for subsequent examinations. The relationship between disease and injury may play a role in the cause, manner and circumstances of death.

Authorization: Medical Examiner/Coroner Official Office Policy Manual; State or Federal Statutory Authority.

Policy: The investigator shall obtain the decedent's past medical history.

Procedure: Through interviews and review of the written records, the investigator should:

1. Document medical history, including medications obtained and taken, alcohol and drug use, and family medical history, including alternative practices.
2. Document information from treating physicians and/or hospitals to confirm history and treatment.
3. Document physical characteristics and traits (e.g., left-/right-handedness, missing appendages, tattoos, implanted/indwelling devices, etc.).

Summary: Obtaining a thorough medical history focuses the investigation, aids in disposition of the case, and helps determine the need for a post-mortem examination or other laboratory tests or studies. Potential sources of medical information should include but are not limited to nursing homes, hospice agencies, intermediate care and assisted living facilities. Electronic media can be a valuable source of information for obtaining a decedent's medical history.

Document Decedent Mental Health History

Principle: The decedent's mental health history can provide insight into the behavior/state of mind of the individual. That insight may produce clues that will aid in establishing the cause, manner and circumstances of the death.

Authorization: Medical Examiner/Coroner Official Office Policy Manual; State or Federal Statutory Authority.

Policy: The investigator shall obtain information from sources familiar with the decedent pertaining to the decedent's mental health history.

Procedure: The investigator should attempt to:

1. Document the decedent's mental health history, including behavioral issues, hospitalizations and medications.
2. Document the history of suicidal ideations, gestures and/or attempts.
3. Document mental health professionals (e.g., psychiatrists, psychologists, counselors) who treated the decedent.
4. Document family mental health history.
5. Obtain relevant records.

Summary: Knowledge of the mental health history allows the investigator to properly evaluate the decedent's state of mind and contributes to the determination of cause, manner and circumstances of death.

Document Social History

Principle: Social history includes marital, family, sexual, educational, employment and financial information. Daily routines, habits and activities, and friends and associates of the decedent help in developing the decedent's profile. This information will aid in establishing the cause, manner and circumstances of death.

Authorization: Medical Examiner/Coroner Official Office Policy Manual; State or Federal Statutory Authority.

Policy: The investigator shall obtain social history information from sources familiar with the decedent.

Procedure: When collecting relevant social history information, the investigator should:

1. Document marital/domestic history.
2. Document family history (similar deaths, significant dates).
3. Document sexual history.
4. Document employment history.
5. Document financial history.
6. Document daily routines, habits, activities, hobbies and unusual behavioral patterns.
7. Document internet activity (e.g., social media sites).
8. Document relationships, friends, caregivers and associates.
9. Document religious, ethnic or other pertinent information (e.g., religious objection to autopsy).
10. Document educational background.
11. Document criminal history and obtain relevant records.

Summary: Information from sources familiar with the decedent pertaining to the decedent's social history assists in the determination of cause, manner and circumstances of death. Special attention may be required in dependent populations (e.g., infants, special needs and the elderly).