N.C. Medical Examiners

Q&A: State officials answer Observer’s questions

The Observer sent written questions to the N.C. Office of the Chief Medical Examiner (OCME). Here’s how state officials responded:

ON FUNDING

Q. How much does the state spend annually for the medical examiner system? How much additional money do the counties spend? Please provide those figures for each of the past five years.

A.

County payments for autopsies and ME fees // State appropriations for OCME

FY 2009 // $3,701,500 // $4,090,774

FY 2010 // $3,916,899 // $4,112,349

FY 2011 // $3,704,700 // $4,161,613

FY 2012 // $3,867,300 // $4,468,361

FY 2013 // $3,911,000 // $4,394,503

Q. We see from the data that the state makes many payments for medical examiner services, and that the counties also make payments. What does the state pay for and what expenses do the counties cover?

A. According to N.C.G.S. § 130A-387 (fees) and N.C.G.S. § 130A-389 (autopsies), the counties pay for deaths which occur inside the county of residence and the state pays for deaths which occur outside the county of residence. The state pays for the transportation of all cases. The amount set by statute for medical examiner services is $100 per case and $1,250 per autopsy. This amount increased August 1,2013 from $1,000 per autopsy. The increase in the autopsy fee was sought by Secretary (Aldona) Wos to stabilize our regional autopsy centers.

ON THE MEDICAL EXAMINERS’ OFFICE:

Q. How many forensic pathologists does OCME currently have?

A. Five.

Q. How many forensic pathologists did it have during its period of peak staffing in the past five years?

A. Five.

Q. When was the peak?

A. Before now, there were five forensic pathologists from July 2011 to June 2012.

It is important to note that the OCME has been historically short-staffed. For the past decade or more, OCME has experienced difficulties recruiting and retaining experienced forensic pathologists. As a result, the numbers of autopsies performed by the pathologists employed by the OCME exceeded national standards for accreditation.

Secretary Wos acted quickly to address this critical shortage of forensic pathologists in OCME. During the last legislative session, she sought and obtained authority from the General Assembly to increase the salary ranges for forensic pathologists. She directed staff to escalate recruitment for these critical positions. As a result of these efforts, OCME hired two board-certified forensic pathologists who started in January. Secretary Wos also initiated and approved the hiring of temporary forensic pathologists to provide support to the current OCME staff to reduce their caseload.

Q. Does OCME require any training for its medical examiners? Why or why not?

A. The OCME has several opportunities for training county medical examiners. The most frequent method is through OCME’s reviews of cases, which are used as a means for teaching county medical examiners. OCME staff is also available 24 hours a day, seven days a week to assist the county medical examiners.

OCME staff participates in training at the regional centers, and training is also available upon request at the OCME office in Raleigh. In the past, the OCME has held annual seminars, and they are working to continue these in the future.

County medical examiners are trained in their particular specialty (MD, nursing, etc.) before appointed.

Q. Does the state require medical examiners to have any professional experience? If so, please describe.

A. Appointments must be made in accordance with N.C.G.S. § 130A-382.

Q. Are any training or orientation materials routinely provided to newly appointed medical examiners? If so, we'd like to request them.

A. This information was provided in an email to Ames Alexander on February 21, 2014.

Q. We’d also like to request any widely distributed memos, emails, letters, newsletters or other correspondence that OCME officials have sent out to all N.C. medical examiners over the past five years.

A. This information is being gathered and will be supplemented.

Q. Have the OCME “guidelines, rules and statutes” changed since 2001?

A. The guidelines have not been updated since 2001, but there are plans to update them this year. Looking at the history, it appears that there have been statutory changes to Article 16 of Chapter 130A of the North Carolina General Statutes.

Q. If so, we'd like to request each version of the guidelines that has been in place since 2001.

A. The guidelines are available at http://www.ocme.dhhs.nc.gov/rules/index.shtml.

Q. What tools or work materials does OCME provide to medical examiners to help them do their jobs?

A. OCME staff is also available 24 hours a day, seven days a week to provide information and support the county medical examiners.

In addition to the orientation materials, the OCME provides an order form for county medical examiners to order toxicology kits to submit samples, as needed. The postage for the toxicology kits is paid by the state OCME.

Q. How many times in the past five years has the state fired, disciplined or rescinded the appointment of a medical examiner? Who were they? And what were the reasons for those actions in each case? Please send any related documents.

A. Dr. Radisch recalls that two appointed medical examiners have had their appointments rescinded in the past five years. This information is being gathered and will be supplemented. (Note: The state later revised its answer, saying that the appointments of four medical examiners had been rescinded.)

MEDICAL EXAMINERS

Q. Most N.C. medical examiners have other jobs, often full-time jobs. As we understand it, they receive $100 per case. What are the advantages of this type of ME system? What are the drawbacks? How would you like to see the system improved?

A. North Carolina’s Medical Examiner System is structured from Article 16 of Chapter 130A of the North Carolina General Statutes.

Under Secretary Wos, improvements have already been made to the state's Medical Examiner system. North Carolina’s medical examiner system relies heavily on three regional autopsy centers, including the Mecklenburg County’s Medical Examiner Office, the Office of the Chief Medical Examiner (OCME) in Raleigh, and five hospitals.

In April 2013, the State was in danger of losing the services of the regional centers due to a lack of funding needed to cover their costs. Secretary Wos secured this funding, which included an increase in the autopsy fee from the General Assembly, a federal grant and additional state funds. As a result, DHHS was able to ensure the continuation of the critical services provided by all three regional centers that perform nearly 50% of the State's autopsies.

Secretary Wos has also been focused on enhancing operations of our State's medical examiner system. In May 2013, she directed OCME leadership to develop a plan for enhancing the system based on the recommendations included in the Strategic Plan for Improving the Medical Examiner System - a plan largely ignored since 2001 -and benchmarking current processes against those utilized by other states. Some enhancements already have been implemented, such as requiring pathologists to include an incident history along with any specimen submitted for toxicology testing and re-enforcing the availability of expedited carbon monoxide testing. Additional efforts are underway, including pursuing national accreditation.

Secretary Wos has been a champion for improving North Carolina’s medical examiner system. She has already addressed several critical issues in a very short period of time.

Q. Some local medical examiners we've interviewed said the $100 per case is not enough money to do a thorough job. Is that a concern? What are your thoughts on that?

A. The appointment as a county medical examiner is a vital public service, and the OCME expects all county medical examiners to do a thorough and professional job.

Q. Compare the state's system to Mecklenburg County's system? What does one do better than the other? Which system do you find more desirable? Why?

A. As stated above, the Medical Examiner system relies on three regional autopsy centers, which are comprised of two academic medical centers and Mecklenburg County's Medical Examiner Office, and five hospitals. These regional centers and hospitals are all important parts of the state's Medical Examiner system.

Q. We're hearing from some current and former medical examiners that it is difficult for doctors and nurses with full-time jobs to do all the work that is involved in investigating medical examiner cases -traveling to far-away scenes, making phone calls to collect information, etc. What are your thoughts? Can full-time professionals be expected to do thorough death investigations?

A. As stated above, the appointment as a county medical examiner is a vital public service, and the OCME expects all county medical examiners to do a thorough and professional job.

Q. We understand that some medical examiners have delegated the work of drawing blood from bodies to funeral homes. Does the state find that practice acceptable?

A. This practice is acceptable if performed under the supervision of the medical examiner.

Q. Data show medical examiners in Wake County hardly ever attend death scenes - less than one percent of the time. Why is that? Are there special circumstances in Wake?

A. While state law does not require a medical examiner to visit the scene of a death, state law does require law enforcement to notify the medical examiner before releasing the scene. Wake County has excellent crime scene investigators, and OCME staff has a comprehensive dialogue with law enforcement to ensure that a thorough death investigation is conducted.

Q. Do OCME pathologists serve as Wake's MEs?

A. Yes, this has been the practice since 2008.

ON OBSERVER’S FINDINGS:

OCME: OCME has not undertaken the effort to confirm these statistics. Every death investigation is different and must be reviewed on a case-by-case basis.

Q. We reviewed the MEIS data from 2001 through mid 2013 and found:

Statewide, medical examiners have not viewed bodies in about 10 percent of cases. Some medical examiners failed to view bodies in more than 70 percent of their cases. Also, some medical examiners have collected thousands of dollars for cases in which they didn't view bodies. What are your thoughts about that? Does any of that raise concerns for you? If so, what concerns?

A. The guidelines require medical examiners to personally view every dead body over which he/she assumes jurisdiction. As stated above, the OCME expects all county medical examiners to do a thorough and professional job.

In some instances a medical examiner may be asked to investigate a death after a body has been buried or cremated. Viewing of the body will, of course, be impossible and the investigation will be limited to a historical review of the circumstances of death and whatever observations about the body were made at the time.

Q. In some states, medical examiners almost always go to death scenes. In N.C., they have gone to death scenes about 10 percent of the time. Again, what are your thoughts about that? Does any of that raise concerns for you? If so, what concerns?

A. Each state has its own jurisdictional requirements. The North Carolina Medical Examiner system is governed by Article 16 of Chapter 130A of the North Carolina General Statutes.

There are many cases where the means and manner of death are apparent from: (1) information provided by law enforcement, (2) obtained by viewing the body, (3) testing by our Tox (toxicology) Lab, or (4) any combination of these.

Keep in mind, North Carolina law allows law enforcement to release a scene without the presence of a county medical examiner. However, law enforcement must inform the medical examiner that there is a body, which presents the opportunity to discuss the facts and circumstances of the case, as well as whether the scene should be held for a medical examiner to visit the scene.

Q. On average, since 2001, autopsies have been performed on about 40 percent of ME cases. Many states do autopsies on a larger percentage of cases. Why doesn't N.C. do more autopsies? Is the state's medical examiner system doing enough autopsies? Why?

A. Every death investigation is different, and other states may have different requirements governing the performance of an autopsy. In North Carolina, autopsies are conducted in accordance with N.C.G.S. § 130A-389.

Q. How much does limited funding play into the state's decision about what cases to autopsy?

A. None.

Q. According to the data, state pathologists have performed autopsies on about 28 percent of completed ME cases from January through September 2013. That's a large reduction from the previous year. What accounts for that drop off? (Note: A subsequent Observer analysis found the percentage to be 34 percent rather than 28 percent, but there was still sharp drop-off from the previous year.)

A. Every death investigation is different and must be reviewed on a case-by-case basis.

Q. Our analysis of medical examiner data shows large county-to-county variations in N.C. death investigations. For instance: Deaths that become ME cases range from 8 percent in one county to 27 percent in another. Who ultimately decides whether to take a case - the local ME or OCME?

A. The jurisdictional requirements are defined in Article 16 of Chapter 130A of the North Carolina General Statutes. The law provides the medical examiner with discretion as to whether he/she believes a given death is within his/her jurisdiction. If here is any question as to whether or not a given death should be investigated by the medical examiner, we encourage the medical examiners to call the Office of the Chief Medical Examiner (OCME) for consultation.

Q. ME cases in which an autopsy is performed range from 19 percent in one county to 73 percent in another.

- Deaths deemed natural range from 25 percent to 65 percent.

- Deaths deemed chronic ischemic heart disease range from less than one percent in one county to 44 percent in another.

- ME cases in which the body was not viewed by the local ME range from less than one percent in one county to nearly 60 percent in another.

Why are their such large variations from county to county? What, if any concerns, do such disparities raise?

A. Every death investigation is different and must be reviewed on a case-by-case basis.

Q. With so much variation from county to county, how much faith should citizens have in the system?

A. Medical examiners are health care professionals who are well-respected in their communities. Together, the efforts of law enforcement and medical examiners are critical parts of a death investigation.

Q. How satisfied are you in the system as a whole? Why?

A. No system is perfect, but Secretary Wos has been focused on enhancing the operations of our state's Medical Examiner system. In May, she directed OCME leadership to develop a plan for enhancing the system based on the recommendations included in the Strategic Plan/or Improving the Medical Examiner System from 2001 and benchmarking its processes against those utilized by other states.

Q. Elderly decedents are autopsied and viewed at a much lower rate than other ME cases. Since 2001, autopsies on those 75 and older are performed on about 8 percent of cases. Meanwhile, their bodies are not viewed about 22 percent of the time by the local ME. What, if any, concerns does that create for you? Has the state been conducting enough autopsies on elderly victims?

A. This is a large group and, as stated above, every death investigation is different and must be reviewed on a case-by-case basis.

Q. Autopsies on elderly decedents have declined steadily in the past decade, ME data show. In 2002, 12 percent of people 75 and older were autopsied. That number dropped to 4 percent in 2011 and 3.5 percent in 2013. What accounts for the drop off? Is it a concern?

A. As stated above, every death investigation is different and must be reviewed on a case-by-case basis.

Q. OCME guidelines call for autopsies on all cases involving charred, decomposed or skeletonized bodies and natural deaths of known addicts. But we found many cases in which such bodies were not autopsied. Cases with no autopsy include charred bodies (about 30 cases), decomposed or skeletonized bodies (about 340 cases) and apparent natural deaths of known alcoholics and drug abusers (about 3,900 cases).

What are your thoughts about that? What, if any, concerns does it raise?

A. As stated above, every death investigation is different and must be reviewed on a case-by-case basis.

Q. We found roughly 1,800 cases (not including cases marked as pending) in which the manner of death was changed following the original "report of investigation by medical examiner." What are some of the most common reasons the manner is changed?

A. This makes sense. Cases are usually marked pending because evidence is pending. In any case where new evidence is discovered, the OCME takes it into consideration. New evidence can be presented from a variety of sources, including local law enforcement, the SBI crime lab, or the OCME’s Toxicology Lab. The OCME also reviews medical records, conducts microscopic examinations, etc.

Q. National standards call for 100 percent of cases to be closed within 60 days. Since 2001 in N.C., about 4 percent of cases didn't meet that standard. What are your thoughts about that? What are your concerns about that? What are the most common reasons some cases aren't closed on time?

A. As The Charlotte Observer has previously reported, the OCME has been historically short staffed. Secretary Wos obtained the authority from the General Assembly to increase the salary ranges for forensic pathologists, and the OCME hired two experienced, board certified forensic pathologists who started in January 2014.

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