The medical examiner and deaths in the hospital setting.

In a recent study,[1] 24 percent of families indicated that they filed a claim because physicians had failed to be completely honest and to inform them of the facts surrounding the death or, in some cases, intentionally misled them. In another 20 per cent of cases, families indicated that they could not understand the facts of the case and that no one took the time to adequately explain them. This study highlights the fact that open communication between families, treating physicians, hospitals, and the investigative aspects of the death greatly decrease the number of medical neglisence claims. The medical examiner typically serves as an impartial, neutral conveyor of information in this process.

The nationwide decrease in the quantity of autopsies being performed by local hospital-based general pathologists has placed an additional burden on medical examiners. The reasons for this decline include reliance on advanced diagnostic technology by clinicians, fear of litigation, clinician discomfort in seeking permission, reimbursement, and general pathologists' feeling that the autopsy has become unpleasant, time-consuming, and professionally unrewarding and unappreciated by their clinical peers. Presently, it is estimated that less than 10 per cent of hospital deaths undergo an autopsy examination. Recent studies have indicated that, in approximately 30 percent of deaths, autopsies may reveal major pathological discrepancies that were not detected or anticipated prior to autopsy and that contributed to death.[2] This increased involvement by the medical examiner has also come at a time when there is pressure of public and financial scrutiny requiring prudent use of public financial resources.

The modern metropolitan medical examiner is a trained forensic pathologist and an unbiased, neutral observer of fact. As a result, the medical examiner is frequently involved in criminal, as well as civil and legal investigations in homicidal, suicidal, and accidental deaths. The medical examiner also deals with difficult medical and social problems that occur during the investigation of sudden and unexpected deaths. The medical examiner is experienced in dealing with plaintiffs and their attorneys and in anticipating questions and issues with which the practitioner may have little to no exposure.[3,4]

The hospital pathologist may be understandably reluctant to be accuser and surgical quality control advocate in regard to medical and surgical colleagues. The surgeon or clinician often feels wrongfully challenged when an unexpected death occurs in the perioperative period. Hospital administrators may often feel unduly restrained in an investigation into these deaths. They also often fail to understand the role of the medical examiner as an intermediary among families, physicians, and hospital staff, frequently facilitating communication and exchange of information. As in any medical specialty, the medical examiner is required to render opinions restricted to his or her certified specialty. In many cases, the medical examiner or coroner is compelled by the nature of the incident to obtain outside expert consultants to assist in the investigation and interpretation of specific medical issues.

The medical examiner's role is limited, in that there is no determination of the presence or the absence of medical negligence, nor is there an interpretation of the standards of practice of any particular medical speciality except his or her own. The medical examiner is not concerned with legal negligence or culpability; this is an issue for the court system. The medical examiner's office is required to cooperate with investigating authorities of both plaintiff and defense and to provide legally defensible and unbiased information to the court system upon request.

Hospital administrators should be encouraged to facilitate the timely reporting of potentially natural and sudden unexpected deaths occurring in the course of diagnostic, therapeutic, surgical, and anesthetic procedures. By doing so, the hospital stands to protect the interests of patients, physicians, and the hospital; to improve and maintain the hospital's leadership role in the community; and to avoid potentially embarrassing legal conflicts when all the facts are available for public scrutiny.

The hospital administrator should:

* Provide protocols for timely and immediate reporting of deaths to the local medical examiner or coroner's office. All supervising staff, as well as frontline practitioners, should be cognizant of reporting requirements. These protocols should be posted at nursing stations and in the emergency department and should be reviewed on a regular basis by supervising staff.

* Facilitate the recovery, preservation, and exchange of reports, equipment, biological samples, and information by the hospital staff. These items must be maintained in a strict chain of custody, unused until reviewed by the medical examiner. Hospital administrative staff should insist on being present during any examination of potentially malfunctioning equipment and should request that hospital staff be continually apprised of any investigative developments in drug testing, autopsy findings, etc.

* Encourage and train employees to understand the medical examiner role and to cooperate with local medicolegal authorities. The staff should request to meet with the local medical examiner, who should provide formalized educational seminars in discussing the role of the medical examiner and his or her department's protocol for reporting cases. This should typically be part of a medical staff meeting, with involvement by nursing staff.

* Develop an open administration of risk management in dealing with sudden therapy-related deaths. Involvement of the medical examiner should be encouraged from top management down, with administrators encouraging cooperation.

* Encourage the involvement of clinicians and pathologists in autopsies. In cases of potential litigation, the pathologist should seek peer consultation and, if necessary, request that the local medical examiner or coroner view the findings at the autopsy table. Clinicians involved in the care of the patient should also be requested to view the autopsy findings and to provide immediate clinical correlation and consultation as requested.

* Review reimbursement policies to encourage the performance of autopsies. Local hospital pathologists and medical examiners should be provided with adequate financial resources to encourage the performance of necessary autopsies. Administrators should work through local medical societies to educate local politicians, physicians, and staff in the importance of autopsies in the identification, documentation, and appropriate certification of sudden and unexpected deaths in the hospital setting.

* Have personal contact with the family of a deceased patient and facilitate the release of information. The hospital public relations director should be involved in any sudden unexpected death, communicating with family members and local authorities. The public relations director should be comfortable dealing with media and family questions and should provide detailed follow-up and updates to hospital staff, family, and news media.

References

[1.] Hickson, G., and others. "Factors that Prompted Families to File Medical Malpractice Claims Following Perinatal Injuries." JAMA 267(10):1359-63, March 11, 1992.

[2.] Anderson, R., and Hill, R. Pathologists and the Decline of the Autopsy, Advances in Pathology and Laboratory Medicine. St. Louis, Mo.: Year Book Medical Publishing, Inc., 1991, pp. 1-12.

[3.] Smialek, J. "Investigation of Deaths due to Medical Treatment." In Handbook of Forensic Pathology. Northfield, Ill.: College of American Pathologists, 1990, pp. 256-60.

[4.] DiMaio, J., and DiMaio, V. Forensic Pathology. New York, N.Y.: Elsevier Publishers, 1989, pp. 489-94.