Certification of CAUSE and MANNER of death

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The S. C. death certificate PROCESS.

Facts, explanations, and opinions come from evidence and witnesses and are considered routinely in arriving at the cause and manner of death. Most such determinations are expeditiously made outside of any court of law, though always within some legal jurisdiction. Most are straightforward, but some situations really stretch the definitions within causes of death and the five categories of manner of death

A "fact...or ordinary...witness" is generally not allowed to state opinions or conclusions about facts of a case in a court of law. An "expert witness," however, upon being recognized by the court (the judge) as an expert for purposes of THAT particular case, is expected to give facts and draw conclusions and/or state opinions. An "expert witness" is anyone the judge will allow as an expert on that particular case.

The CAUSE of a person's death is...in the final analysis...a medical determination or finding based on evidence and opinion. The cause may be considered over several time frames: the original or underlying (proximate) cause; intermediate or intervening causes; and immediate (or dependent) causes.

For example, a 48 year old woman has a breast lump removed; following a number of years, the cancer re-appears in her bones; chemotherapy follows. She later dies with pneumonia. Breast cancer is the underlying or proximate cause of death and pneumonia is the immediate or dependent cause of death.

And scientists might also be interested in the biological mechanism (probably either hypoxia or a fatal arrhythmia) of the death.

BUT, "proximate cause" becomes a different thing when applied to civil lawsuits for medical malpractice. The South Carolina Medical Association handbook, "Physicians Guide to Malpractice Law in South Carolina" [updated March 2000, pages 59-70) indicates that the legal definition of "proximate cause" in medical malpractice is one of the trickiest legal definitions in law. In medical malpractice, proximate cause of death or injury to plaintiff is more like the "dependant cause" of death certification. It is the event (or lack of, or failure of, an event or action) that "but for" the fact that it happened or failed to happen, the injury or death would never have happened [the "responsible cause"]. Also, in the malpractice arena, expert testimony is usually required to pinpoint (assign or fix) the "proximate cause"; and the winning of a case by plaintiff usually requires 3 interconnected things:

• (1) plaintiff must have actually suffered damages or injury (or death); 
• (2) defendant physician (health-care worker) performance or nonperformance is negligent; 
• (3) the interconnection between the first two is explained to the jury's satisfaction by the "proximate cause". 


• and, the "most probable standard" indicates that plaintiff must introduce evidence that the injuries complained of "most probably" [greater than 50% probability] resulted from the alleged negligence. 
• and, negligence need not be the sole cause of an injury...it can be sufficient for the alleged negligence to be a "proximate concurring cause" or a "contributing cause". 
• and, though it might be established that a physician's conduct, or lack thereof, has in fact been one of the causes of the patient's injuries, the defendant is not necessarily liable in the absence of "foresee-ability". A defendant cannot be condemned for that which cannot be foreseen, is unpredictable, and could not be expected to happen. 
• and, some states have adopted a "loss of chance doctrine" ["increased risk of harm doctrine"] whereby the defendant can be held liable if his conduct increased the risk of harm to the patient (plaintiff).
  

Amazingly, even after a thorough autopsy, the cause of death may be uncertain or "unascertained". Most are comfortable with the designation of SIDS (sudden infant death syndrome) in infants. Society finds it difficult to accept inability to determine an exact cause of death at an age beyond infancy. But, I can personally attest that these are not rare situations (the "obscure death autopsy" rate is published as no less than 5% of autopsies). In non-natural deaths, thorough case investigation and scene analysis are EXTREMELY important to case and autopsy interpretation!

The MANNER of a person's death is...in the final analysis...a legal determination or finding based on evidence and opinion. It is usually routinely assigned, but it is always subject to dispute/challenge and might not come to a truly finalized assignment until decided after thorough discovery & disclosure of all case facts in a court of law after all appeals are exhausted. That is, if someone wants to contest a manner of death, it is ultimately decided in a court of law...court actions tending to drag along slowly. Outside of court proceedings, such findings are legally made by government-employed or elected medical examiners or coroners. Medical opinions or conclusions obtained during the case investigation are usually given great weight, whether from general doctors or pathologists trained in (and practicing) forensic pathology (remember the TV program, Quincy)? In our fast-paced society, decisive information (not yet put forward) is sometimes absent at the time that the manner of death opinion is by a coroner or medical examiner. Manner of death can have immense importance in whether people undergo intense personal investigation, go to jail, receive large lawsuit awards, or receive multiple (double or triple indemnity) payments on life insurance policies.

1. NATURAL MANNER of DEATH: the death is purely a consequence of one or a combination of natural diseases. 


2. UNINTENTIONAL, NON-NATURAL DEATHS:
    
   >accidental manner of death: unintended and essentially unavoidable death, not by a natural, suicidal or homicidal manner [also see others, below]
   
   >accidental manner of death because of failure of judgement or supervision: This mostly applies to children (small child drowns as the parents are distracted). This might also include adults with known or unknown underlying health problems who either knowingly "push the limit" or "push the limit", ignorant of the danger [FA10-160].
   
   >accidental manner of death because impulsive suicidal display/threat gone bad: a young male gang member, in a verbal battle with his mother, brandishes his loaded and cocked pistol against his own head as he tries to get his own way. In the excitement and tension of the situation, the pistol accidentally is set off and kills him.
   
   >accidental manner of death because sham suicide went bad: a distraught young man who was unable to get a job returned home to live with his parents. Wanting to be able to live without responsibility, a long-running conflict had developed between him and the parents. Hoping to gain sympathy and get his way long term, he set up a rope and noose in his closet and slipped it around his neck as he sat on a stool and pretended unconsciousness, hoping to set up a sham suicide that would shock his parents into yielding to his demands. But, somehow, the stool tipped over. Before, he could loosen the strangling noose, he blacked out and slumped enough to fatally tighten the choke hold of the noose around his death.
   
   >homicidal manner of death:
   
   by good deed: if one human is responsible for the death of another but in an involuntary way & without legally negligent behavior, the death may be legally called "involuntary manslaughter". Were you in the right-hand lane of a 4-lane road & were to wave a driver waiting at a parking lot exit to come across in front of your stopped lane and the driver's intent (known or unknown) was to LEFT turn and he/she gets T-boned & killed by an unseen moving  driver in the other lane on your side, you MAY be guilty of involuntary manslaughter (though society may not yet be ready to label it as such)!
   
   by sustaining sympathetic attention: an episode (30 May 2011, "The Unreal World") of the TV series, Body of Proof, is about the mother of a girl with a disease requiring treatment. Mom substituted sugar pills for the real medicine to keep daughter sick so that Mom would not lose the constant sympathy that she craved from her circle of friends. The daughter dies, having other complicating diseases, too. HERE is the written story. Though I am not aware of it yet leading to a death there are supposedly very rare instances of victimization of the perpetrator that were alleged to be true but were actually falsified to gain attention or to exploit or manipulate others called Falsely Alleged Victimization Syndrome or FAVS. An excellent 30 minute example of this is Forensic Files TV show episode 23 first shown in season 2, "Sealed with a Kiss", concerning school teachers Joanne Chambers and Paula Nawrocki.
   
   
3. INTENTIONAL, NON-NATURAL DEATHS:
   
   suicidal: Death caused by self, with some degree of conscious intent. A permanent solution to what could be a temporary problem! One should always be very skeptical on hearing of a multi-injury death (multiple gunshot wounds; multiple stab wounds) being ruled as a suicidal manner of death [FA09-40]! While Munchausen syndrome deaths are self-caused by the deceased, society does not...by convention...count these as suicidal. There are a few recognized instances of secret set-ups for suicidal death by another (such as suicide by cop); and there are others less conventionally recognized types of suicidal degrees of recklessly indifferent risky behavior (FA11-110; also drunken speeding death of Jackass member Ryan Dunn June 2011). Society also does not count self-caused deaths as suicide (1) due to calculated (society sometimes even celebrating such deaths when happening under celebrated & advertised challenges) deaths in high risk activities (remember lucky Evel Knievel but not-so-fortunate Mt. Everest climbers?), (2) ignorant (alcohol binge drinking) & reckless behavior as one often sees among teenagers, (3) poor lifestyle habits, or (4) known self-destructive habits...when the deceased unequivocally knew that he/she was putting his/her life in danger. And, homicides can be made to look like a suicide (faked suicide [see CBS's 48 Hours episode about 2008 of a Baptist preacher faking his wife's suicide), or wife shoots husband in head to fake suicide & importance of blood spatter patterns and powder patterns (Forensic Files season 16, #68 "Second Shot at Love", video HERE)),or an accident (faked accident).
   
   homicidal: death caused by another human [check out types & degrees] in a (1) conscious way & to now include (2) such unconscious &/or mentally ill or deranged way as Munchausen by proxy deaths or include cases where the killer was in a frantic "survival mode", essentially unconscious acts which result in the death of another.
   
   
4. UNDETERMINED: not enough evidence, yet or ever, to choose the manner of death. A startling example of such is the case of spontaneous combustion in 1951, Mary Reeser (I think it was a murder). I saw the episode in June 2015. The video of this true case is available on line via The Travel Channel (I saw the episode on The Discovery life Channel, Direct TV), as an episode of Mysteries at the Museum with the title, "A Pile of Ashes and Bones". 


5. UNCLASSIFIED: too complex to classify; it either stays in that category or has to be clarified and declared legally with action in a coroner system or medical examiner system or rarely in a court of law.
   

(1) By common convention/custom, an unavoidable killing of another person by a sober person responsibly going about his/her business is considered to be an accidental manner of death...not homicide. Sadly, too often the declaration of "unavoidable" is made too quickly because of the human-nature discomfort over the distress of the killer and his/her family (who are still alive). My partner, Dr. John Carter, and I (he has discovered, defined, and best articulated the problem with this common convention; and I agree) think that any and all deaths should undergo a thorough, essentially check-listed investigation, hammering at the issue of avoidability. Example:  auto-pedestrian deaths...(1) what is the evidence for or against "visibility" (was location such that intense sunlight was in the driver's eyes...and was the windshield visor up or down?)? (2) was there any posted sign declaring a pedestrian crossing? (3) was a car phone in the vehicle? If so, what was the exact time of calls about the time of the killing? (4) what was the emotional state of the killer and of the deceased just prior to the killing event...the sobriety of each? (5) what human distractions were available to killer and deceased (driver distracted by crying infant?)...deceased distracted by an ongoing argument? We have seen at least one instance where the driver was alcohol-intoxicated and the sober lover switched & claimed to be the driver prior to arrival of anyone else on the scene. When Dr. Carter assigned "homicide" as the manner of death, the stories quickly changed and the case clarified. As you can imagine, it could take some real questioning investigation...even lie detector testing...to truly settle the question of "unavoidable".

"Crib death" or SIDS (sudden infant death syndrome) cases are especially delicate. When a baby or infant is found dead sleeping in the bed with other older persons, the issue of "avoidable death" is problematic. Were the others in the bed knowledgeable of such as "death by overlying" or were they ignorant? Were they sober...if not, it may be a homicide [FA08-23]?

(2) By common convention/custom, an accidental killing of oneself is an accidental manner of death...not suicide.

(3) By nearly common convention/custom, those found dead of a disease or abnormality known to be associated with unexpected sudden death [see listing] are declared dead by natural manner unless [a] complicated by an obvious accidental component (then reasonably declared an accidental manner of death) or [b] death happening during an abduction (homicide).

For example #1, epileptics may be found dead...an accepted, though sad and disappointing outcome. If found face down in the pillow, one might propose asphyxia as the dependent cause = accidental manner of death. But such asphyxia in an adult (as opposed to an infant) is more of a speculation; most would certify the manner as natural (possibly...not surely...proximately asphyxiating). But, an epileptic found dead in the bath-tub, head submerged, would be certified as accidental manner (probably...essentially surely...dependently ly drowning).

For example #2, a 60+ year old man [FA10-160] has become determined to lose weight and decides to do it by working out in the heat of the day and/or in the gym and at home and sweating the weight off. The autopsy was without evidence of disease. An arrhythmogenic electrolyte abnormality...accidentally induced by extreme exercise to sweat weight off was left as the presumed cause of death...making it an accidental death. The above examples assume autopsy absence of medication overdose & failure to detect other over-riding causes or manners.

For example #3, a 70+ year old man [FA14-68] After tennis the previous afternoon, he went to bed. He had moved during the night and apparently returned to the bed & collapsed there while spouse showered. Breathing funny, the spouse called 911. EMS arrived about 24 minutes later to the rural location & transport to ER [total elapsed time of abouty an hour]. Autopsy found some severe chest injury associated with the combination of the CPR transport "thumper" which included posterior heart injury by an anterior projecting intervertebral osteophyte. This appeared initially to be a death with a significant element of unintentional accidental manner due to resuscitative efforts. However, microscopic exam of the high interventricular septal myocardium found impressive scarring and some fresh change, this being in the whole area of the AV node. So, final forensic autopsy interpretation was that his arrhythia causing collapse onto the bed was lethal and that the traumatic injuries were agonal and/or postmortem. The initial presumed manner of accidental death was innaccurate...the full findings making it an natural manner of death.

The above examples assume autopsy absence of medication overdose & failure to detect other over-riding causes or manners.

Autopsies often provide critical information in determination of THE TRUTH of the cause and manner of death!

The "system"...law enforcement agencies, coroner's staff, or those in the medical examiner's office...only "knows" what it finds out (or what comes to light) by the point in time when preliminary, updated, or "final" determinations of cause and manner of death need to be made. Depending on a large number of factors, the urgency and pressure to "finalize" a case can vary from intense to mild. Though it may require legal action to do so, it is always possible to attempt a change in cause or manner of death based on new information. Barring any apparent controversy or high-profile factors in a case, deaths which appear to have straightforward cause and manner are fairly quickly classified as what they appear to be. With or without postmortem or autopsy exam or other special tests or procedures, the classification is...simply...whatever the medical examiner or coroner says it is.
The system may need your help!

If you have clear information which might have a bearing on the correct determination of cause & manner of death in a case...especially if you have reason to believe that a miscarriage of justice has happened or is happening...contact the coroner's office or medical examiner's office having  jurisdiction over the case.

Should you find yourself in the situation of a victim, in that you are sure of a miscarriage of justice and don't seem to be able to get anywhere, victims assistance programs may help you wedge into the system and correct a wrong or otherwise seek justice. My friend, Laura Hudson, is a founding visionary of such aid (South Carolina Victims Assistance Network).

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(posted 29 July 1998; latest addition or adjustment 31 December 2015)