Improving Public Health by Advancing the Medicolegal Death Investigation Profession

Medicolegal death investigations produce vital information on fatal illnesses and injuries in the United States, yet the system is fractured and underfunded. Less than half of deaths are reported and investigated by medicolegal death investigation agencies. In addition to providing cause and manner of death determinations, the investigations are instrumental in identifying public health trends, including early identification of the opioid epidemic and fatal fentanyl overdoses. Data from death investigations is used by over 40 federal agency programs in creating policies and regulations. Medicolegal death investigations agencies are generally underresourced, with insufficient infrastructure for data-sharing and computerized record management. These critical shortfalls are combined with a dire shortage of board-certified forensic pathologists to complete postmortem examinations and a lack of mass fatality preparedness, which can directly affect community health and well-being.

The last time medicolegal death investigation policies were reviewed by the Executive Branch was during the Obama Administration. In 2016, the National Science and Technology Council (NSTC) Committee on Science’s Medicolegal Death Investigation Working Group noted the essential role medicolegal death investigation agencies play in establishing a scientific cause and manner of death while serving public health and reporting emerging health threats. The working group outlined the importance of accrediting medicolegal death investigation offices and certifying medicolegal death investigators. In the seven years since the report, there has only been an increase of 23.7% in certified death investigators, with more jurisdictions requiring certification to maintain employment. The NSTC’s Fast-Track Action Committee found the need to improve infrastructure and support for medicolegal death investigation agencies to reinforce the integrity of public health and criminal justice systems.

Key recommendations for improving public health by advancing the medicolegal profession include:

Challenge and Opportunity

Medicolegal death investigation is at the intersection of medicine, public health, and the criminal justice system, yet it does not have a formal place in any system nationally. Public health trends, including early detection of outbreaks and emerging health threats, are found during autopsies and reported on death certificates. The data from death certificates is used in public health surveillance at a local, regional, state, and national level to determine trends and the impact of interventions, shape policy, and help recognize health disparities. The information from the death certificates is obtained through death scene investigations, evidence collection, medical record reviews, postmortem examinations, and toxicology testing, coupled with interviews of witnesses, family, and friends of the decedent. Data obtained during medicolegal death investigations not only provides an accurate cause and manner of death but also helps the living by showing the health of our communities and tracking death trends and health threats.

The coroner system in the United States stems from the English system dating to the 12th century. A physician-headed medical examiner system was created in Massachusetts in the late 1800s, leading to versions of our current systems. State statutes and local jurisdictional charters create the structure of medicolegal death investigation offices. There is no standardized medicolegal death investigation system across the United States. Coroners are typically elected officials who run for the political role through normal voting processes. Coroners can also be appointed based on the jurisdiction and are regularly non-medical professionals. In contrast, medical examiner’s offices generally have a physician leading the office, except in Wisconsin, where the appointed medical examiner can be a non-physician. The jurisdiction of a coroner or medical examiner’s office is most commonly a county, though 16 states have a centralized state medical examiner system. There are 14 states with a county or district-based coroner system, 14 states with a mixture of coroner and medical examiner offices, and six states with county or district medical examiner systems. Texas has Justice of the Peace positions where the elected role hears misdemeanor, traffic, and civil disputes in addition to holding medicolegal duties without a requirement for any legal or medical experience or education. California is unique with four different medicolegal investigation agency types, including a Sheriff-Coroner, Coroner, Medical Examiner, and Coroner-Medical Examiner. The Sheriff-Coroner’s position, which is in 48 of California’s 58 counties, is the most contentious due to concerns about the independence of investigations when the medicolegal agency head also serves as the sheriff. A 2022 attempt to separate sheriff and coroner positions was unsuccessful. Medicolegal death investigation agencies range from having one part-time elected official responsible for the entire jurisdiction to having over 100 employees, with most agencies across the nation having few full-time employees and significantly limited resources.

Medicolegal death investigation systems, by state. (Source: Centers for Disease Control and Prevention’s Death Investigation Systems.)

The varied names and jurisdictions for medicolegal death investigation offices do not change the foundation of the duties: investigating unexpected and unnatural deaths. Typically, the medicolegal death investigation agency receives a call from a law enforcement agency, medical first responder, hospital, care facility, or other medical professional to report a death. Basic demographic information, the known circumstances behind the death, medical history, and other vital information are obtained to determine jurisdiction. Based on agency practices and state law, the medicolegal death investigator may respond to the death scene to assume jurisdiction and custody of the decedent. For natural deaths where a physician will certify the death to natural causes, the medicolegal death investigator may be able to release the decedent to a funeral home or mortuary of the family’s choice. When a medicolegal death scene investigation is required, the investigation includes photography, collecting evidence, identifying the decedent, locating and notifying kin, writing an investigative report, and providing information to the forensic pathologist, who will determine the cause of death. Death certificates are commonly generated by the medicolegal office, with the manner of death determined by the chief medicolegal officer. Medicolegal death investigation offices are also tasked with identifying decedents, which may require advanced scientific testing. Less than 50% of medicolegal agencies collect DNA samples from unidentified decedents, which is essential in present-day scientific identification and adds information to national databases. Not collecting DNA can significantly delay the identification of decedents and notification to friends and family of missing and unidentified people.

Medicolegal death investigation offices also participate in specialized fatality review teams, which include multidisciplinary stakeholders from social services, public health, law enforcement, emergency medical services, and other areas to find systemic gaps in treatment and identify potential missed intervention points. Fatality review teams can be regional and can include overdose fatality review, infant and child death fatality review, domestic violence fatality review, and elder abuse fatality review. Meeting findings are summarized into actionable items to prevent future deaths. The medicolegal investigative and autopsy reports and the reviewed medical and social history provide the requisite information to allow the multidisciplinary teams to make prevention determinations. 

Medicolegal death investigation agencies report to local, state, and national organizations to assist with surveillance and injury prevention. Many states require medicolegal death investigators to report workplace injuries and deaths to the regional Occupational Safety and Health Administration branch, with death certificates reporting contagious diseases and drug toxicity-related deaths to local health departments. The United States Consumer Product Safety Commission relies on medical examiners and coroners to report consumer product-related deaths so they can further investigate products, create appropriate warning labels, and potentially prevent injuries and deaths. For deaths relating to medical misadventure, medicolegal death investigation agencies must also report deaths to the state medical board, dental board, nursing board, or county-level emergency medical services board. There are two national reporting systems, both overseen by the Centers for Disease Control and Prevention (CDC), for violent deaths and overdoses. The National Violent Death Reporting System records violent death data from medicolegal and law enforcement reports to link over 600 data points to create a context behind the death and develop violence prevention strategies. The State Unintentional Drug Overdose Reporting System oversees 49 states and Washington, DC, to obtain inclusive overdose fatality data. The data includes information on the known circumstances behind the death and identification of the substances involved to gain nearly real-time information about emerging drug threats and determine the effect of prevention efforts. Coroner and medical examiner agencies may also be required to enter unidentified persons into missing and unidentified person systems and the National Missing and Unidentified Persons System to assist with future identification efforts. Data review and entry are complicated, with limited resources, a lack of case management systems, and time constraints with part-time employee offices.

The data and information obtained from medicolegal death investigations have many uses that can assist in local, state, and national prevention efforts. The challenges for the reporting systems are that they are voluntary, and many agencies do not have the resources to provide hundreds of data sources to multiple systems. Having data organized and in a searchable database is key for access and data-sharing, though less than 50% of medicolegal offices with a population of less than 250,000 people have a computerized case management system. Only 87% of agencies with a population of over 250,000 people have a case management system, with 40% of coroner offices not having internet access outside of their personal devices. Computerized case management systems help reduce errors and lost paperwork while increasing efficiency and resource allocation. Less than 70% of coroner offices have access to fingerprint databases, compared to 91% of medical examiner agencies, and 82% of agencies have access to bloodborne pathogen training. The average budget of a medicolegal office is $470,000, with each decedent autopsy and investigation costing approximately $3000. With about 2,040 medicolegal death investigation offices nationally and almost 11,000 full-time equivalent employees, there is an average of just five full-time employees per office. A large portion of the budget is commonly spent on personnel, leaving little funding for improving infrastructure and training.

There is no standardized oversight or required training of medicolegal death investigation personnel. Only 16 states require training for medicolegal death investigations. For example, California requires 80 hours of training for medicolegal death investigators, the highest of all state requirements. In contrast, New York requires training for the coroner and deputy coroners but does not outline the required number of hours or duration. The American Board of Medicolegal Death Investigators (ABMDI) is a national certifying board that the Forensic Specialties Accreditation Board accredits. ABMDI tests medicolegal death investigators on foundational and advanced knowledge, awarding registry and board certifications. ABMDI certification requires continuing education to maintain certification, though most medicolegal agencies do not require certification for employment. The lack of standardized training of medicolegal death investigation personnel can lead to gaps in knowledge and recognizing evidence, dramatically reducing the accuracy of death certificates and reporting. Limited budgets, personnel, and resources contribute to a lack of investigative awareness that can lead to incorrect causes and manners of death. Inaccuracies on death certificates can have a profoundly negative effect on families and the community and contribute to public mistrust.

Training is not the only constraint in accurate and timely medicolegal death investigations. There is an extreme shortage of board-certified forensic pathologists, who are the physicians conducting postmortem examinations and determining the cause of death. In 2020, there were approximately 500 practicing forensic pathologists, but the workload required 1,280 forensic pathologists. The gap is now likely even greater, with workloads having increased with the rise of the opioid epidemic, fentanyl deaths, gun violence, and COVID-19. The 2018 coroner/medical examiner census noted 890 forensic pathologists employed by medicolegal agencies, though forensic pathologists commonly work in neighboring counties or other states as a locum tenens, a temporary, per-diem physician. The shared nature of some forensic pathologists inflates the number of physicians who appear to be working, shrouding the significantly lower number of practicing physicians. In medical examiner officers, such as in Los Angeles and New York City, the department head is a forensic pathologist assigned solely to administrative work, limiting the number of available forensic pathologists to complete postmortem examinations. Some jurisdictions resort to using non-board-certified forensic pathologists for postmortem examinations, which can result in inaccurate causes and manners of death. The lack of available forensic pathologists also allows for non-qualified people to falsify credentials and autopsy reports, even in high-profile cases, defrauding grieving people and the government alike. A 2015 report on increasing the number of board-certified forensic pathologists mentioned that physicians should work in a nationally accredited office. Agency accreditation is important to ensure proper working conditions and a high standard for policies and procedures to create an environment for the best possible medicolegal death investigations. Yet the last coroner/medical examiner census showed that only 17% of medicolegal death investigation offices were accredited. Some agencies will never be able to reach accreditation, as there is a limit of 325 autopsies per year, and workload shortages restrict the number of available forensic pathologists to complete autopsies.

The medicolegal profession is highlighted in the media in high-profile deaths and mass fatality situations. A significant amount of time and effort by medicolegal administrators should be devoted to mass fatality planning to provide an efficient, effective response, coordinate with allied agencies, and safely recover and identify decedents. There is no specific number for what constitutes a mass fatality incident, as mass fatality is when the number of deaths exceeds agency resources. In some jurisdictions, a mass fatality may be three decedents from one incident, while others may request allied resources when 50 decedents are from an incident, such as in the October 1, 2017 mass shooting in Las Vegas, NV. All states have an Office of Emergency Response or similarly named emergency response commission, where medicolegal death investigation agencies should be integrated into mutual aid and planning committees. There are significant limitations with the response to and accurate handling of medicolegal death investigations without a case management system and internet access, impacting smaller and underresourced jurisdictions.  The federal-level Disaster Mortuary Operational Response Team (DMORT), run by the National Disaster Medical System, deploys to mass fatality scenes to assist with recovery, examination, identification, and collecting ante- and postmortem decedent data. DMORT responds with qualified personnel, including forensic pathologists and investigators, to set up a mobile autopsy suite and bring decedent storage facilities. With the high cost of deployment, DMORT only responds to large-scale mass fatality scenes and needs to be requested by a state Office of Emergency of Response when other mutual aid responses have been exhausted. A vast majority of medicolegal agencies lack the resources to handle a mass fatality. Less than 30% of agencies had specialized response training, and nearly half of agencies reported that they were only moderately prepared for a mass fatality.

The challenges of advancing mass fatality planning and improving medicolegal infrastructure are restricted by agency budgets and limited grant funding. Due to the specialty of the field and because it crosses the medicine, public health, and the criminal justice systems, there are few federal grant opportunities. The Bureau of Justice Assistance’s Strengthening the Medical Examiner-Coroner System Program helps with accreditation, including purchasing supplies and upgrades to meet standards and assisting with funding for forensic pathology fellowships. There were 14 awards in 2023 totaling over $2 million, with funding ranging from $53,878 to $300,000. Most of the awards were to larger agencies, including Los Angeles and New York City, where there are resources for grant writing and administration. The competitive Paul Coverdell Forensic Science Improvement Grant Program is offered to forensic science and medicolegal agencies with forensic science laboratories. In 2023, more than $4.6 million was awarded to 15 agencies, with only one grant awarded to a medicolegal death investigation agency. The National Network of Public Health Institutes funded $200,000 to 10 medicolegal death investigation agencies in 2023 to improve data collection from medicolegal agencies for surveillance of overdose-related mortality reporting. Nationwide, there are more than 2,000 medicolegal death investigation agencies, but in 2023 just 25 received federal or national-level grant funding.

Plan of Action

A multi-stage, multi-agency approach is needed to improve medicolegal death investigations in the United States to provide accurate mortality data to shape prevention and policy efforts. In addition to increasing minimum medicolegal death investigation operating budgets, funding is needed to improve training, attract physicians to forensic pathology, and advance infrastructure upgrades for timely and accurate mortality data reporting. National standards for medicolegal death investigation should be established and integrated into state systems for reliable, reproducible, and scientifically valid investigative results and analysis.

United States AgencyRole
Department of Commerce (DOC)The DOC oversees the National Institute of Standards and Technology (NIST), which advances science by creating standards to support innovation and promote inclusivity.
NIST should be the principal agency to create nationally recommended standards for medicolegal death investigators and agencies. Once standards are created, they should undergo review by a standards-developing organization (SDO) to build consensus and disseminate the technical work.
Department of Health and Human Services (HHS)HHS houses the Centers for Disease Control and Prevention (CDC), the nation’s health protection and preventative agency, and collects and analyzes vital data to save lives and protect people from health threats.

The Collaborating Office for Medical Examiners and Coroners (COMEC) is a new office with the CDC, established in 2022, to support medicolegal death investigations in a public health context.
HHS’s National Disaster Medical System oversees the Disaster Mortuary Operational Response Teams (DMORT), which responds to mass fatality scenes to support local coroners and medical examiners in recovering, identifying, examining, and processing decedents.
Department of Justice (DOJ)The DOJ is responsible for upholding the law to ensure safety in our country while protecting civil rights. The DOJ houses the Office of Justice Programs, the organization’s funding and evaluation department.
The Bureau of Justice Assistance (BJA) is the primary federal funding source for medicolegal death investigation grants.
The Bureau of Justice Statistics (BJS) funded a census of medicolegal death investigation agencies in 2018 and 2023, with the 2018 census being the first since 2004.
The National Institute of Justice (NIJ) created a research report in 2011 as a technical update for Death Investigation: A Guide for the Scene Investigator created by a multidisciplinary National Medicolegal Review Panel.
Department of Labor (DOL)The DOL is the primary agency for concerns about labor and the workforce. The DOL should provide input on national medicolegal training standards and training programs for medicolegal death investigators.

Recommendation 1. Create national foundational training standards.

Building from the National Institute of Justice’s 2011 Death Investigation: A Guide for the Scene Investigator Technical Update and fundamental tasks of medicolegal death investigation from the American Board of Medicolegal Death Investigators, the NIST should convene a multidisciplinary group of subject matter experts to develop foundational training standards guided by NIST’s Organized Scientific Area Committees for Forensic Science best practices and standards. The DOL should be involved in reviewing and structuring training standards and programming from a labor and workforce perspective. Subject matter experts should determine a continuing education structure to allow for continuous training for contemporary topics in the field, similar to requirements for maintaining medical licensure. Although NIST is not an enforcing agency, the created standards should be made widely available to state legislation and the medicolegal community. States that adopt the standards should have access to additional NIJ funding to improve medicolegal offices. Similar to NIJ funding requiring credentials for discretionary funding for law enforcement agencies for use-of-force policies and the prohibition of chokeholds, the discretionary funding can be limited to agencies that have adopted the NIST standards.   

Funding for training should be available through grants and legislation for funding from burial permits. Since 1991, California has designated $1 from each burial permit to fund medicolegal death investigation training. Creating similar legislation for every state can allow for sustainable funding for continued training, alleviating the need for continued federal funding.

Foundational training standards will create a minimum and standardized training nationally to improve medicolegal death investigations and utilize best practices to best serve communities. The training will also allow medicolegal death investigation agencies to provide more accurate and timely data for public health surveillance and participate in multidisciplinary task forces, which can potentially reduce future deaths. Requirements for foundational and continued training can be shared widely by COMEC, with virtual training programs created by COMEC and available for continuing education credit. COMEC currently hosts virtual training for sudden unexpected infant death investigation, the investigation and certification of drug toxicity-related deaths, and death investigation after natural disasters and radiation emergencies. Existing training and structure can be used to create and distribute foundational training and continuing education at a national level without reinventing a new nationally available website and training structure.

Recommendation 2. Fund data infrastructure modernization and enhanced surveillance efforts.

The health of communities lies in early recognition and timely reporting of causes of death. With less than 50% of medicolegal death investigation agencies having a computerized case management system and under 40% of coroner offices having business-related internet access, the field cannot progress without a significant investment in infrastructure. The lack of computerized case management will continue to severely limit timely data-sharing with local, state, and federal public health agencies, restricting near real-time analysis of death trends and disease tracking. Public health surveillance of mortality data assists in recognition, intervention, and preventive efforts, which cannot be accurately completed without timely and complete data from medicolegal death investigation agencies.

With the current state of the opioid epidemic and fentanyl drug toxicity-related deaths, rapid and accurate toxicology testing is needed for public health surveillance. Advanced toxicology panels, including the ever-growing novel psychoactive substances, are expensive, and agencies need to make difficult budgetary decisions around personnel and toxicology testing. Funding is needed to subsidize advanced, rapid toxicology testing to provide the most accurate types of drugs involved with the death. Additional funding, awarded through a cooperative agreement by the CDC, should be allocated to advanced panel toxicology testing and the purchase of rapid toxicology screening machines that can be housed in the medicolegal office. Rapid toxicology screening machines do not quantify all drug levels, which commonly requires secondary toxicology testing through an accredited laboratory. But the screening does allow for nearly immediate identification of fatal drug trends, allowing for early notification to public health officials. The NIJ should specifically request research and development of a rapid toxicology testing process with an accuracy level that does not require secondary testing in their research grant for forensic science for criminal justice purposes to provide additional options for medicolegal agencies. The precise cause of death, involved drugs, and thorough investigations significantly contribute to multidisciplinary overdose fatality review teams. The fatality review teams can use the information to identify timely intervention strategies and strengthen services to reduce future drug toxicity-related deaths in near real-time.

Recommendation 3. Research the current efficacy of mass fatality response policies and efforts to create standardized procedures.

In the focus on current caseload and office needs, mass fatality preparedness and training tend to be overlooked. This deprioritization is dangerous for medicolegal death investigation personnel responding to scenes and is concerning for the community with underprepared and underresourced investigators working to navigate a mass fatality incident. The declaration of a federal state of emergency does not always provide funding for medicolegal death investigation agencies for fatality management operations, and the nature of the mass fatality may limit mutual aid response to assist jurisdictions, such as in the case of earthquakes, biological acts of terrorism, and other large-scale natural disasters. Research is needed to determine best practices in mass fatality planning and resourcing for all jurisdictional sizes, including determining the current state of planning and available resources. DOJ should fund the research through BJA or BJS via a grant process to find the most qualified and knowledgeable researchers. Findings should be shared widely via open-source academic journals, at national and regional medicolegal conferences, and via webinars to ensure the information is readily available. The findings should also be published in a guide on the DOJ website to assist agencies in creating personalized mass fatality plans and practical exercises.

Recommendation 4. Increase certification and accreditation to enhance professionalism, knowledge, and skills.

The National Commission on Forensic Science supported recommendations for the accreditation of medicolegal death investigation offices and the certification of medicolegal death investigators in 2015. Despite these recommendations, only 17% of medicolegal death investigation offices were accredited in 2018. In November 2023, there were 2,049 actively certified diplomates with the American Board of Medicolegal Death Investigators, from an approximate 11,000 full-time equivalent positions,  totaling approximately 19% of full-time equivalent medicolegal death investigators. Increasing the number of accredited offices and certified medicolegal death investigators can provide consistency in practice, improve data quality, enhance facilities, incorporate evidence-based best practices, and elevate surveillance efforts. 

Recommendation 5. Support forensic pathologist pathways and debt reduction.

There is no end in sight to the critical shortage of forensic pathologists, who are neutral scientists specializing in determining the cause of death while providing valuable data for public health surveillance. A federal grant is available to provide a stipend for forensic pathology fellows in training, including limited loan repayment and travel for fellowship recruitment. Funding is limited and requires medicolegal death investigation agencies to be knowledgeable about the grants and be awarded funding. A more grassroots approach to creating more forensic pathologists should begin earlier, both in medical school and in offering scholarships for current medicolegal investigative personnel to attend medical school to become forensic pathologists. The field should be highlighted during the early years of medical school, requiring a rotation through a local medicolegal death investigation office, and increasing residency and fellowship pay to encourage physicians to enter the field and become board-certified. Similar to other loan repayment programs, loan forgiveness for forensic pathologists should be reduced to five years in public practice as a board-certified forensic pathologist. Funding should be provided to medical schools, residency, and fellowship programs and not dependent on a limited competitive federal grant funding process.

Budget Proposal

A budget of $90 million is proposed to create national medicolegal death investigation training standards, fund data infrastructure modernization and enhance surveillance efforts, research the current efficacy of mass fatality response, increase medicolegal certification and accreditation, and support forensic pathologist career pathways. NIST should receive $2.5 million to hire and support subject matter experts to create the national foundational medicolegal death investigation training standards. The DOL should be awarded $500,000 to support standards development with a focus on the workforce and labor. Circulating the standards through a standards-developing agency, such as the American Academy of Forensic Science’s Academy Standards Board, should occur at no cost.

The CDC should be provided with $32 million to create and manage low-barrier infrastructure improvement grants focusing on smaller and medium medicolegal jurisdictions to ensure agencies have computerized case management systems and basic internet connection at a minimum. Medicolegal death investigation data elements for reporting and information exchange have been outlined by the Medicolegal Death Investigation Subcommittee of NIST’s Organization of Scientific Area Committees, providing a baseline of data needs for a computerized case management system. At least $1 million of the funding should focus on low-barrier scholarship-type funding for individual medicolegal death investigator certification, with the certifying agency accredited by the Forensic Specialties Accreditation Board for monitoring professional board certification. At least $5 million should be available for low-barrier grants to assist medicolegal agencies in achieving accreditation through one of the two medicolegal death investigation agency accreditation boards. Annual reporting on the number of agencies and individuals funded for infrastructure improvements, accreditation, and certification should be transparently listed on the CDC funding website.

The DOJ should receive $4 million for nationwide research on the efficacy of mass fatality response policies and the creation of standardized procedures. Portions of the funding should be dedicated to open-source publishing to allow broad access to the research findings, with a guide on best practices and standards made available on a federal government website to help agencies create and hone their policies. The information should also be presented at national, state, and regional medicolegal and forensic science conferences with at least one recorded webinar to provide data and support to the most agencies possible. 

Similar to providing grants for physicians and healthcare professionals to work in health professional shortage areas, medically underserved areas, or primary care shortage areas, funding should be provided to state Departments of Health Care Access and Information or similarly positioned state-level departments. Each state and the District of Columbia should receive $1 million for scholarships, loan forgiveness, and fellowship reimbursement for physicians on track to become board-certified forensic pathologists. State funding should also be used to introduce forensic pathology as a subspecialty during medical school rotations to provide exposure to the career.  


The current state of medicolegal death investigations in the United States is plagued with significant variations in practices, budgets, and training across jurisdictions. The heterogeneity creates disparities in the quality of investigations, data reporting, participation in fatality review teams, and overall professionalism in the field. The continued shortage of board-certified forensic pathologists to complete postmortem examinations and the lack of standardized training exacerbates the challenges. Increased federal funding to support medicolegal death investigation efforts can lead to more accurate and timely data reporting, improved public health surveillance, better-informed policy creation, and enhanced capabilities to respond to mass fatality incidents. Ultimately, these measures will contribute to the well-being of communities and assist public health prevention efforts.

Frequently Asked Questions
What is the best type of medicolegal death investigation agency?
There are benefits and drawbacks to the various types of medicolegal death investigation agencies. Statewide medical examiner systems can benefit from increased funding and resources, although services may be limited in more remote areas, potentially requiring significant travel for investigators to respond to scenes. A Sheriff-Coroner or Prosecutor-Coroner system poses concerns with conflicts of interest with investigations and charging of cases, although they can be cost-effective and may have separate medicolegal death investigation bureaus. Medical examiner’s offices are commonly led by appointed physicians, although not all department heads are board-certified forensic pathologists. Coroners are conventionally elected positions with elected officials not required to have medical or investigative backgrounds. The medicolegal structure is generally built into county charters, which can be challenging to change. No matter the agency type, investigations must be conducted impartially, thoroughly, and professionally while supporting decedent families and public health surveillance efforts.
Why is nationally standardized foundational training necessary?
Currently, only 16 states require training of medicolegal death investigators. Standardized foundational training provides a baseline of medicolegal death investigation training to all associated professionals across the nation. Training can help improve the accuracy, consistency, and reliability of death investigations, ethical and legal compliance, proper evidence collection and preservation, and maintaining public trust. As the quality of investigations improves, data from the cause and manner of death can more accurately track fatal trends, guide prevention efforts, and assist in policy creation. Continuing education can provide valuable investigative updates for contemporary issues and changes in legal standards and best practices.
How can the medicolegal death investigation system be standardized at a national level?

The Model Postmortem Examinations Act, created by the National Conference of Commissioners on Uniform State Laws in 1954, outlined a state medical examiner system, allowing states to modify the model to fit its jurisdictional needs, though most states have not followed the Act’s suggestions. The overseeing body is now referred to as the Uniform Laws Commission, and no changes have been made despite multiple attempts for review requested by the National Association of Medical Examiners. The National Commission on Forensic Science recommended drafting a new model of medicolegal death investigation legislation to support states in improving their medicolegal death investigation frameworks and death investigations themselves. The Commission voted overwhelmingly to adopt the recommendation in January 2017, though no action has been taken by the Attorney General to date. While it is unlikely a national framework will be adopted by all states, model legislation for medicolegal death investigation systems can allow states to adjust the legislation to best fit their needs while maintaining a minimum standard.

Excited Delirium: A Fatal Term Laid to Rest

Excited delirium, a diagnosis generally characterized by a severely agitated state, made headlines in some of the most contentious deaths in custody, including being mentioned by an officer as a concern when George Floyd was in a prolonged prone position. Law enforcement officers have been trained to recognize excited delirium as a medical emergency requiring immediate medical intervention when someone shows extreme agitation, incoherent speech, increased pain with decreased sensitivity to pain, confusion or rapid changes in emotion, and muscle rigidity. Once the person is in custody or restrained, training outlined putting the person into the recovery position to avoid positional asphyxiation and awareness that sudden death can occur after a violent struggle. Autopsies in excited delirium cases generally reveal lung and brain swelling coupled with heart disease and recent cocaine use without providing a direct cause of death. The lack of clear signs of death during an autopsy requires forensic pathologists to relate known circumstances to the cardiovascular collapse.

History of a Controversial Term

The controversy around the use of excited delirium as a cause of death is that it was not formally recognized as a distinct medical diagnosis by many of the top medical associations, including the World Health Organization, the American Medical Association (AMA), and the American Psychiatric Association. The disputable cause of death has never been formally recognized in the Diagnostic and Statistical Manual (DSM), a guide to symptom diagnosis for mental health conditions, or the International Classification of Diseases (ICD), a guide to diseases and conditions to assist with classification and statistics tracking published by the World Health Organization. The lack of an ICD code dramatically reduces the ability to track the diagnosis in fatal and non-fatal circumstances. The American College of Emergency Physicians was the only medical organization that formally supported the diagnosis of excited delirium and its clinical use. The ACEP confirmed their support for the excited delirium diagnosis in 2021 and formally retracted their support for using the terminology in April 2023. The National Association of Medical Examiners does not endorse the use of excited delirium as a cause of death and recommends using underlying causes of the suspected delirium as the cause of death.

The history of excited delirium was first noted in the 19th century with the term delirious mania, with someone suffering from hyperactivity, psychosis, and sudden collapse. Other psychiatrists across the world added to the body of research and changed the mania phraseology, with excited delirium being coined in 1985 by an American forensic pathologist and psychiatrist to describe a person with superhuman strength, extreme fear and paranoia, hyperthermia, agitation, and generally involving recent cocaine use. Through the eyes of a forensic pathologist, there was no specific anatomic cause of death but a process of ruling out causes of death, such as in sudden unidentified infant death syndrome. In their seminal work, Drs. Welti and Fishbain reviewed seven case studies with cocaine involved with all and the decedents being hyperactive, violent, yelling, and thrashing around. Six of the seven case studies had increased strength, and all required restraints to reduce the violence. A 1998 review of 21 excited delirium deaths in Ontario, Canada, showed that all cases involved restraint for violence and hyperactivity with 18 people being in the prone position and three having pressure placed on their necks at the time of death, suggesting that the position of restraint may be directly related to the death and not the excited delirium itself. At least 166 deaths in police custody from 2010-2020 were attributed to excited delirium across the nation, though required reporting through the 2013 Death in Custody Reporting Act is complicated with data collection and antiquated reporting mechanisms.

The AMA noted that excited delirium was not a supported medical diagnosis and condemned the potential recognition of excited delirium as the sole reason for law enforcement officers to use excessive force. The AMA recognized that excited delirium has been disproportionately used in diagnoses for in-custody deaths of underrepresented minorities and misused to justify police actions. The 2021 policy also recommended utilizing non-law enforcement practitioners for de-escalation efforts and appropriate medication intervention, further recognizing racism as a threat to public health. One of the physicians who coined the term excited delirium completed a review of sex workers with a recreational drug use history and suggested that the deaths were due to a variant of excited delirium. All of the sex workers were Black women, and exhumations of some decedents after the forensic pathologist’s cause of death attribution to excited delirium was incorrect as the decedents were strangled to death, later leading to the arrest of a serial killer.

Citing Proper Cause of Death Classification

California banned the use of an excited delirium diagnosis as a cause of death, in medical treatments, police reports, and court proceedings. Assembly Bill 360 updated the California Evidence Code to state that excited delirium is not a valid cause of death or medical diagnosis but that descriptions of behavioral signs and symptoms can be stated in police reports and civil actions. The bill was signed into law in October 2023, marking the first state in the union to restrict the use of excited delirium. Some law enforcement agencies in California, in advance of the ban, removed the controversial term from policies and training material to focus on racial equity. Colorado’s Peace Officer Standards and Training, a law enforcement certifying board, will be removing excited delirium from law enforcement training starting on January 1, 2024. The updated training curriculum will focus on providing care to subjects in custody and requesting appropriate levels of care.

While the banning of the term excited delirium is logical based on its history and unsupported medical research, there are concerns about the government restricting medical professionals from being able to properly diagnose and classify their work. The Texas Governor signed HB 6 into law in June 2023, classifying all opioid toxicity-related deaths as poisonings to allow for homicide charges against those who manufacture and sell illegal drugs. California had its first successful prosecution of a drug dealer who sold a fentanyl-laced pill to a decedent in August 2023. However, there is no evidence that prosecutions for drug toxicity-related deaths are a deterrent to drug use or save lives. Texas did not pass the legalization of fentanyl test strips, allowing people to test their drugs for the presence of fentanyl prior to ingestion. Dictating exact wording for death certificates, such as “fentanyl poisoning” for opioid-related deaths may be the start of a slippery slope for laws restricting medical expertise and diagnoses.

History has been made to bar the use of excited delirium in medical and law enforcement settings, though recognizing medical and psychiatric emergencies is vitally important for the person in crisis to receive appropriate treatment. When someone shows signs of extreme agitation, incoherent speech, confusion, and paranoia, activating the emergency 9-1-1 system is essential to reducing mortality. Law enforcement officers should follow appropriate policies and procedures for deescalating and obtaining immediate care and referrals to mental health professionals to increase survival and recovery through crisis events.