Page 42 - CFDI Guide

2. Who, When and How the body was discovered.

Persons reporting the incident and discovery of the body may be involved, know who is involved,
or have no involvement or additional information. It is important to review all relevant records

and reports, and then interview these persons. All too often brief statements, oral and/or written,
given by involved persons may be lacking in detail, partially true, or mostly to completely false – a

proper interview will assist with further details.
3. Medical incidents, complaints, injuries, symptoms prior to death are important to a complete

death / SBI investigation, particularly in determining if a natural event may have contributed to
the incident or not. As has been previously detailed, it is important to obtain all relevant medical

records, EMS records, medical history, current medications, drug use, alcohol use, tobacco use,
family medical history and other information assisting with the investigation.

4. Social history is essentially the non-medical background of the person. Mental health is considered
social history, but is often under medical treatment (i.e. a psychiatrist is a MD) or similar (i.e. a

psychologist is a PhD, or therapist). These are protected under HIPAA and may include medical
history. Social history includes past suicidal ideation and attempts, alcohol and other drug

use/abuse (prescription, over-the-counter and illicit). Particular attention should be paid to proper
dispensing and use of prescription medication – abuse is illegal but easily hidden. Other social

history includes marital status, education history, employment history and both familial and social
relationships.

IV. FORENSIC AUTOPSY 6
For simplicity, all references will be to medical examiners and forensic pathologists, not on the difference
between the medical examiner and coroner systems, or a hospital autopsy and forensic autopsy. For our

purposes, the focus will be on the forensic autopsy conducted by a board certified forensic pathologist and

autopsy technician. In addition, there are exceptions to every protocol, and jurisdictional policies will
differ. Two important things to consider are:
▪ The medical examiner’s office is an independent, often law enforcement based, agency which is

supposed to be neutral as to their findings; they conduct separate investigations.
▪ These investigations are often concurrent and cooperative investigations between the medical

examiner’s office and the law enforcement agency.
▪ The CFDI should consult with the attending forensic pathologist and case investigator.

6 Adapted from ‘Reviewing and Comprehending Autopsy Reports’, Dean A. Beers, CLI, 2010 – adapted to ‘Practical
Methods for Legal Investigations: Concepts and Protocols in Civil and Criminal Cases’, CRC Press 2011
30 | P a g e