CAUSE AND MANNER OF DEATH
The cause of death is divided into the primary and secondary causes of death. The primary cause of death or immediate cause of death is a three-link causal chain that explains the cessation of life starting with the most recent condition and going backward in time. For example,
1. Most recent condition (coronary bypass surgery, for example), due to or as a consequence of;
2. Next oldest condition (a rupture of the heart’s lining due to tissue death from lack of oxygen, for example), due to or as a consequence of;
3. Oldest (original, initiating) condition (coronary artery disease, for example).
Each condition is a result of the one before it. At least one cause must be listed, but always using all the three is not necessary. The secondary cause of death, which includes conditions that are not related to the primary cause of death but contribute substantially to the individual’s demise, such as extreme heat or frigid temperatures, is typically listed. A distinct difference exists between the standard hospital autopsy and a med ico-legal autopsy. The hospital autopsy is conducted based on a doctor’s request and the family’s permission. If the family denies the request for personal or religious reasons, the autopsy is not performed. A medico-legal autopsy, however, is performed pursuant to a medical investigation of death for legal purposes. For more information on the history of the autopsy, see “History: The Autopsy” later in this chapter. If a person dies unexpectedly, unnaturally, or under suspicious circumstances, the coroner or medical examiner (ME) has the authority to order an examination of the body to determine the cause of death. The manner of death is the way in which the causes of death came to be. Generally, only four manners of death are acknowledged: homicide, suicide, accidental, and natural. The deceased may have met his or her end in a way that appears suspicious to the authorities, and therefore, the cause and manner of death must be established. Other purposes for a medico-legal autopsy may be to identify the deceased, establish a time of death, or collect evidence surrounding the death. The cause of death is often known, but the manner and mechanism of death may not be immediately obvious and are crucial to the goals of a medico-legal autopsy. Imagine a body found at the base of a cliff: The cause of death may be the obvious cause of death (a fractured skull), but was the individual pushed, did the person jump, or did he or she slip? The pathologist may never know from the results of the autopsy alone. An important consideration to keep in mind is that if an unnatural event starts a chain of direct consequences, then the manner of that initial event determines the ultimate manner of death. A simple example would be an elderly individual who falls, suffers a hip fracture, and subsequently dies in the hospital of a blood clot in the lung (pulmonary embolus); that is an accidental death. Somewhat more difficult to determine might be the case of a young person who suffers a severe, closed head injury as a result of an assault and dies in a chronic care facility three years later, having never recovered consciousness. The manner of death in this instance is homicide. While a pathologist can perform a hospital autopsy, more than normal medical training is required to interpret morbid anatomy and fatal trauma. In one study by Collins and Lantz (1994), trauma surgeons misinterpreted both the number and the sites of the entrance and exit wounds in up to half of fatal gunshot wounds (GSWs).
