Priority Action Report

Medicolegal Death Investigation 

Subcommittee

Crime Scene / Death Investigation SAC

J. Keith Pinckard, MD PhD

February 13, 2017
Subcommittee Leadership

Position Name Organization Term Email

Chair Keith Pinckard Travis County 

Medical 

Examiner

drkpinckard@yahoo.com

Vice Chair Laura Crandall NYU Langone 

Medical Center

laura.crandall@

nyumc.org

Executive 

Secretary

Kelly Keyes Orange County 

Sheriff’s Coroner

Office

kakeyes@ocsd.org

2
Subcommittee Members

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# Name Organization Email

1 Baker, Andy Hennepin County Medical Examiner’s Office Andrew.Baker@co.hennepin.mn.us

2 Carter, David

Chaminade University of Honolulu david.carter@chaminade.edu

3 Fowler, David Maryland Office of the Chief Medical Examiner fowlerd@ocmemd.org

4 Fudenberg, John Clark County Office of the Coroner Medical Examiner FUD@clarkcountyNV.gov

5 Hensley, Tom Jackson County (Missouri) Medical Examiner's Office mo_reb@yahoo.com

6 Howe, Julie Franklin, Jefferson, and St. Charles Counties (Missouri) 

Medical Examiner Offices howej@slu.edu

7 Lunn, Matthew Arapahoe (Colorado) County Coroner's Office mlunn@arapahoegov.com

8 McGivern, Lauri Vermont Office of the Chief Medical Examiner lauri.mcgivern@state.vt.us

9 Nashelsky, Marcus University of Iowa Carver College of Medicine 

Department of Pathology and Johnson County (Iowa) 

Medical Examiner marcus-nashelsky@uiowa.edu

10 Oliver, William Brody School of Medicine at East Carolina University 

(North Carolina) oliverw@ecu.edu

11 Sampson, Barbara Office of the Chief Medical Examiner, New York City bsampson@ocme.nyc.gov

12 Thomas, Lindsey Hennepin County (Minnesota) Medical Examiner ‘s 

Office lindsey.thomas@hennepin.us

13 Warner, Margaret U.S. Centers for Disease Control and Prevention, 

National Center for Health Statistics mwarner@cdc.gov
Resource Committee Liaisons

Name FSSB Committee

William Oliver Human Factors Committee

Lindsey Thomas Legal Resource Committee

? Quality Infrastructure Committee

Kelly Keyes Kavi Liaison

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Discipline Description

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Medicolegal Death Investigation: 

The Subcommittee on Medicolegal

Death Investigation will focus on

standards and guidelines related to

deaths reportable to coroners and

medical examiners including

sudden, unattended, unexpected, or

suspicious deaths and deaths due

to violence (accidents, suicides and

homicides). This subcommittee will

also focus on education, research,

certification, accreditation, systems

administration, and the value of

medicolegal death investigation to

public health.
Subcommittee Core Values

•Values shared by all stakeholders on 

Subcommittee

• Medical Examiners

• Coroners

• Medicolegal Death Investigators

•FORENSIC PATHOLOGY IS THE PRACTICE 

OF MEDICINE

•Issue of “cognitive bias”

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Summary of Priority Projects

Priority OSAC 

Process Working Title of Document

1 With SAC prior to 

SDO (RA-300) Competent Medicolegal Death Investigation

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Standards/Guidelines Development

Priority 1 Document

Document Title: SDO-1- Competent Medicolegal Death 

Investigation

Scope: Broad

Objective/rationale: Define the components of all aspects of 

competent death investigation, including organizational/structural 

independence, and from scene through autopsy

Issues/Concerns: applicability of field to standards development

Task Group Name: Entire subcommittee

Task Group Chair Name: Keith Pinckard MD PhD

Task Group Chair Contact Information: 

drkpinckard@yahoo.com

Date of Last Task Group Meeting: July 2016

8
Standards/Guidelines Development

Priority 1 Document

Key Components of Standard: 

• Independence

• Inspection/Accreditation of offices

• Certification of personnel

• Adherence to existing guidelines and standards

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Task Group/Subcommittee Action 

Plan

Planned Actions

OSAC Process 

Stage (e.g., 

SDO 100) 

Assignee Estimated

Completion Date

Review by SAC prior to SDO RA-300 Greg Davis MD ?

Priority 1: 

Competent Medicolegal Death Investigation 

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Summary of Standards/Guidelines 

Priority Actions

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Repeat of the Priority 

Actions Summary slide

Priority OSAC 

Process Working Title of Document

1 With SAC prior to 

SDO (RA-300) Competent Medicolegal Death Investigation
Standards/Guidelines Reviewed For 

Technical Merit

Title Developing 

Organization Status*

OSAC Process 

Stage (e.g., RA 

100)

A Guide to Death Scene Investigation NIJ pending RA-100

Forensic Autopsy Performance Standards NAME pending RA-100

Sudden, Unexplained Infant Death 

Investigation: Guidelines for the Scene 

Investigator

CDC pending RA-100

Guidelines for Communication with Next of 

Kin During Medicolegal Death Investigation

SWGMDI pending RA-100

Standards for Interactions Between Medical 

Examiner/Coroner Offices and Organ and 

Tissue Procurement Organizations and Eye 

Banks 

SWGMDI pending RA-100

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Research Needs Identified

•Improved surveillance of drug-related deaths by 

medical examiners and coroners

•Detection and surveillance of fentanyl and 

fentanyl analogue related deaths 

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Research Needs Identified

•Postmortem naloxone testing to provide 

valuable insight into the prevalence and 

geographic distribution of lay naloxone rescue 

attempts as well as help characterize its utility 

as distributed to the public and help guide 

public health toward overdose death 

prevention 

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Research Needs Identified

•Obstacles to accreditation in medicolegal death 

Investigation offices, especially in rural areas 

•Obstacles to certification of medicolegal death 

investigators, especially in rural areas 

•Formally submitted; status pending

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Additional Items of Interest

•Issues in cognitive bias in Medicolegal Death 

Investigation

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Additional Items of Interest

•Draft Recommendations for Medical 

Examiner/Coroner Drug-related Death 

Investigations 

•Strategy Statement for Medical 

Examiner/Coroner Drug Death Investigations 

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Priority Action Report

Medicolegal Death Investigation 

Subcommittee

Crime Scene / Death Investigation SAC

J. Keith Pinckard, MD PhD

February 13, 2017