Death Investigation:: A Guide For The Scene Investigator

U.S.
Department of Justice
Office of Justice Programs
National Institute of Justice
Death Investigation:
A Guide for the Scene Investigator
Research Report
U.S. Department of Justice
810 Seventh Street N.W.
Washington, DC 20531
Janet Reno
Attorney General
Daniel Marcus
Acting Associate Attorney General
Laurie Robinson
Assistant Attorney General
Noël Brennan
Deputy Assistant Attorney General
Jeremy Travis
Director, National Institute of Justice
Department of Justice Response Center:

800–421–6770
Office of Justice Programs National Institute of Justice

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National Guidelines
A Guide
forforDeath
the Scene Investigator
Investigation
Developed and Approved by the

National Medicolegal Review Panel
Executive Director
Steven C. Clark, Ph.D.
Occupational Research and Assessment, Inc.
Big Rapids, Michigan
Associate Professor
Ferris State University
November 1999
The title of this report, formerly “National Guidelines for Death

Investigation,” has been changed in this reprint for consistency with
the titles of other Guides in the NIJ series.
U.S. Department of Justice
National Institute of Justice

Jeremy Travis, J.D.
Director
Richard M. Rau, Ph.D.

Project Monitor
This project was cosponsored by the Centers for Disease Control and
Prevention and the Bureau of Justice Assistance.
“Every Scene, Every Time” logo designed and created by Steven Clark,
Ph.D., and Kevin Spicer of Occupational Research and Assessment, Inc.
This project was supported under grant number 96–MU–CS–0005 by the

National Institute of Justice, Office of Justice Programs, U.S. Department
of Justice, and by the Bureau of Justice Assistance and the Centers for
Disease Control and Prevention.
This document is not intended to create, does not create, and may not be
relied upon to create any rights, substantive or procedural, enforceable at
law by any party in any matter civil or criminal.
Opinions or points of view expressed in this document are those of the

authors and do not necessarily reflect the official position of the U.S.
Department of Justice.
NCJ 167568
The National Institute of Justice is a component of the Office of Jus-

tice Programs, which also includes the Bureau of Justice Assistance,
the Bureau of Justice Statistics, the Office of Juvenile Justice and
Delinquency Prevention, and the Office for Victims of Crime.
Message From the Attorney General
T he sudden or unexplained death of an individual has a profound
impact on families and friends of the deceased and places signifi-
cant responsibility on the agencies tasked with determining the cause of
death. Increasingly, science and technology play a key role in death
investigations. One of the hallmarks of science is adherence to clear and
well-grounded protocols.
In many jurisdictions, responsibility for conducting death investiga-

tions may rest with pathologists, medical examiners, or coroners, in
addition to their other duties. There is little training available in the best
procedures for handling these crucial and sensitive tasks. To help fill the
gap, the National Institute of Justice, joined by the Centers for Disease
Control and Prevention and the Bureau of Justice Assistance, supported
the development of the guidelines presented in this report.
These guidelines were produced with the vigorous participation of

highly experienced officials and professionals who served on the National
Medicolegal Review Panel. A technical working group of 144 profession-
als from across the country provided the grassroots input to the panel’s
work. I applaud their willingness to take the time to serve in this effort
and to hammer out this consensus on the best approach to conducting
thorough and competent death investigations.
Jurisdictions will want to carefully consider these guidelines and

their applicability to local agencies and circumstances. By adhering to
agreed-upon national standards, death investigators can arrive at the truth
about a suspicious death. Families and friends can be consoled by knowing
what happened to their loved one, and justice can be administered on the
foundation of truth that must always guide our work.
Janet Reno
Attorney General
iii
The National Medicolegal Review Panel (NMRP) represents a
multidisciplinary group of content area experts, each representing
members of his or her respective organization. Each organization has a
role—be it active involvement or oversight—in conducting death investi-
gations and in implementing these guidelines.
United States Conference of Mayors

The Honorable Scott L. King (Chairman, NMRP)
Mayor
Gary, Indiana
American Academy of Forensic Sciences

Joseph H. Davis, M.D.
Retired Director, Dade County Medical Examiner Department
Miami, Florida
American Bar Association

Bruce H. Hanley, Esq.
Partner, Hanley & Dejoras, P.A.
Minneapolis, Minnesota
American Medical Association

Mary E. S. Case, M.D.
Chief Medical Examiner
St. Louis, St. Charles, Jefferson, and Franklin Counties, Missouri
St. Louis University School of Medicine
College of American Pathologists

Jeffrey M. Jentzen, M.D.
Medical Examiner
Milwaukee, Wisconsin
International Association of Chiefs of Police

Chief Thomas J. O’Loughlin
Wellesley, Massachusetts
v
International Association of Coroners and Medical Examiners
Halbert E. Fillinger, Jr., M.D.
Coroner
Montgomery County, Pennsylvania
National Association of Counties

Douglas A. Mack, M.D., M.P.H.
Chief Medical Examiner and Public Health Director
Kent County, Michigan
National Association of Medical Examiners

Richard C. Harruff, M.D., Ph.D.
Associate Medical Examiner
Seattle/King County Department of Public Health
Seattle, Washington
National Conference of State Legislatures

Representative Jeanne M. Adkins
Colorado State Legislature
House Judiciary Committee
Denver, Colorado
National Governors’ Association

Richard T. Callery, M.D., F.C.A.P.
Wilmington, Delaware
National Sheriffs’ Association

Donald L. Mauro
Commanding Officer, Homicide Bureau
Los Angeles County Sheriff’s Department
Los Angeles, California
Colorado Coroners’ Association

Elaine R. Meisner
Logan County Coroner
Sterling, Colorado
South Dakota Funeral Directors’ Association

George H. Kuhler
Elected Coroner
Beadle County, South Dakota
vi
Acknowledgments
T he author wishes to thank the Technical Working Group for Death
Investigation (TWGDI). This 144-member reviewer network
gave of their time to review guideline content, providing the researcher
feedback from a national perspective. Additional thanks to the TWGDI
executive board: Mr. Paul Davison, Kent County M.E. Office, Grand
Rapids, Michigan; Mr. Bill Donovan, Jefferson Parish Coroner’s Office,
Harvey, Louisiana; Mr. Cullen Ellingburgh, Forensic Science Center,
Orange County, California; Ms. Roberta Geiselhart, R.N., Hennepin
County M.E. Office, Minneapolis, Minnesota; Dr. Elizabeth Kinnison,
Office of the Chief M.E., Norfolk, Virginia; Mr. Vernon McCarty,
Washoe County Coroner, Reno, Nevada; Mr. Joseph Morgan, Fulton
County M.E. Office, Atlanta, Georgia; Mr. Randy Moshos, M.E. Office,
New York, New York; Mr. Steve Nunez, Office of the Medical Investiga-
tor, Albuquerque, New Mexico; Ms. Rose Marie Psara, R.N., St. Louis
County M.E. Office, St. Louis, Missouri; and Mr. Michael Stewart,
Denver City and County Coroner’s Office, Denver, Colorado, whose
combined commitment to the field of death investigation is a tribute to
the quality of this document. In addition, the offices that employ each
member of the group share in this endeavor. Through their support, each
member was given the flexibility they needed to support the project.
The author also wishes to thank the National Institute of Justice’s

(NIJ’s) technical advisors: John E. Smialek, M.D., Chief Medical Exam-
iner, State of Maryland; Randy L. Hanzlick, M.D., Centers for Disease
Control and Prevention (CDC) and Emory University School of Medi-
cine; Ms. Mary Fran Ernst, Director of Medicolegal Education, St. Louis
University Medical School; and Ms. Mary Lou Kearns, Coroner, Kane
County, Illinois. Each made significant contributions to the project’s
inception, eventual funding, and timely completion. Their dedication to
the science of death investigation and to the members of the investigative
community is apparent throughout this document.
vii
The Director of NIJ, the Honorable Jeremy Travis; the Director of
NIJ’s Office of Science and Technology, Mr. David G. Boyd; and NIJ’s
Forensic Science Program Manager, Richard M. Rau, Ph.D., each share
responsibility for the success of this project. Credit also goes to R. Gib
Parrish, M.D., of CDC, for his support and commitment to the research.
In addition, the true strength of these guidelines is derived from the

stamina of the National Medicolegal Review Panel, whose members
represented 12 national organizations intimately involved in the investi-
gation of death and its outcomes. The panel also included two representa-
tives of elected coroners. NMRP’s contribution was invaluable.
And finally, the leadership of Joseph H. Davis, M.D., Medical

Examiner Emeritus, Dade County, Florida, and Mr. Donald Murray,
National Association of Counties, for their unrelenting efforts to get this
job done and improve their profession, every scene, every time.
Steven C. Clark, Ph.D.

Executive Director
viii
Contents
Message From the Attorney General .............................................................. iii
National Medicolegal Review Panel .................................................................. v
Acknowledgments ............................................................................................ vii
Foreword: Commentaries on the Need for

Guidelines for Death Investigation ........................................................ xiii
Jeanne M. Adkins, Representative, State Legislature ........................... xiii
Richard T. Callery, M.D., F.C.A.P., Chief Medical Examiner ............... xiv
Mary E.S. Case, M.D., Chief Medical Examiner .................................. xiv
Joseph H. Davis, M.D., Professor of Pathology Emeritus

and Retired Director, Medical Examiner Department .................... xv
Halbert E. Fillinger, Jr., M.D., Forensic Pathologist and Coroner ........ xvi
Bruce H. Hanley, Esq. ......................................................................... xvii
Randy Hanzlick, M.D., Centers for Disease Control and Prevention ...... xviii
Richard C. Harruff, M.D., Ph.D., Associate Medical Examiner ........... xix
Jeffrey M. Jentzen, M.D., Medical Examiner ......................................... xx
Mary Lou Kearns, R.N., M.P.H., Coroner ............................................. xxi
Scott L. King, Chairman, NMRP, and Mayor ..................................... xxii
George H. Kuhler, Elected Coroner..................................................... xxii
Douglas A. Mack, M.D., M.P.H., Chief Medical

Examiner and Public Health Director ......................................... xxiii
Donald L. Mauro, Commanding Officer, Homicide Bureau .............. xxiii
Elaine R. Meisner, Coroner ................................................................. xxiv
Thomas J. O’Loughlin, Chief of Police ................................................ xxv
John E. Smialek, M.D., Chief Medical Examiner ............................... xxvi
ix
Introduction ........................................................................................................ 1
Medicolegal Death Investigation Guidelines .................................................. 11
Section A: Investigative Tools and Equipment ....................................... 13
Section B: Arriving at the Scene ............................................................. 15
1. Introduce and Identify Self and Role ........................................ 15
2. Exercise Scene Safety ............................................................... 16
3. Confirm or Pronounce Death .................................................... 17
4. Participate in Scene Briefing

(With Attending Agency Representatives) ............................. 18
5. Conduct Scene “Walk Through” ............................................... 19
6. Establish Chain of Custody ....................................................... 20
7. Follow Laws (Related to the Collection of Evidence) .............. 21
Section C: Documenting and Evaluating the Scene ............................... 23
1. Photograph Scene ..................................................................... 23
2. Develop Descriptive Documentation of the Scene ................... 24
3. Establish Probable Location of Injury or Illness ....................... 25
4. Collect, Inventory, and Safeguard Property and Evidence ........ 26
5. Interview Witness(es) at the Scene ........................................... 27
Section D: Documenting and Evaluating the Body ................................ 29
1. Photograph the Body ................................................................ 29
2. Conduct External Body Examination (Superficial) .................. 30
3. Preserve Evidence (on Body) .................................................... 31
4. Establish Decedent Identification ............................................. 33
5. Document Post Mortem Changes ............................................. 33
6. Participate in Scene Debriefing ................................................. 35
7. Determine Notification Procedures (Next of Kin) .................... 36
8. Ensure Security of Remains ...................................................... 37
x
Section E: Establishing and Recording
Decedent Profile Information .......................................................... 39
1. Document the Discovery History .............................................. 39
2. Determine Terminal Episode History ....................................... 40
3. Document Decedent Medical History ....................................... 41
4. Document Decedent Mental Health History ............................. 42
5. Document Social History .......................................................... 43
Section F: Completing the Scene Investigation ...................................... 45
1. Maintain Jurisdiction Over the Body ........................................ 45
2. Release Jurisdiction of the Body ............................................... 46
3. Perform Exit Procedures ........................................................... 47
4. Assist the Family ....................................................................... 48
xi
Commentaries on the Need for
Foreword: Guidelines for Death Investigation
Commentary
Jeanne M. Adkins
Representative
State Legislature, Colorado
Few things in our democracy are as important as ensuring that
citizens have confidence in their institutions in a crisis. For many
individuals the death of a loved one is just such a crisis. Ensuring that
the proper steps and procedures are taken at the scene of that death to
reassure family members that the death was a natural one, a suicide, or
a homicide is a key element in maintaining citizen confidence in local
officials.
How local death investigators do their job is crucial to family

members who are mourning a loss today and who may be seeking justice
tomorrow. Most of us cringe at the idea of death investigations where
important steps were omitted that might have led to arrests and ultimately
convictions in those deaths. Justice denied breeds contempt for the
institutions created to ensure that justice is done.
It is with such thoughts in mind that I encourage State legislators to

focus some attention on this issue and look at adopting model legislation
that establishes death investigation procedures and encourages all local
jurisdictions to spend some resources training those on the front lines to
follow those procedures. Success in this national effort depends on the
initiative of State legislators to take the first steps by making this a
priority.
xiii
Commentary
Richard T. Callery, M.D., F.C.A.P.
Director, Forensic Sciences Laboratory
Wilmington, Delaware
As the representative of the National Governors’ Association, I am
honored to have been chosen to participate in the National Medicolegal
Review Panel. The hard work and commitment by the panel resulted in
guidelines that are long overdue for setting the standard of practice for
death investigation of “other than natural” cases. We are all acutely aware
of the ramifications of our proposed national guidelines. Each death,
especially those other than natural, has a profound impact on society,
particularly the criminal justice system. Standardization nationwide is
long overdue. This panel can take pride in producing a work product of
such high quality that will assist in establishing a standard of practice for
death investigation in the United States.
Commentary
Mary E. S. Case, M.D.
St. Louis, St. Charles, Jefferson, and
Franklin Counties, Missouri
As the representative member from the American Medical Associa-
tion serving on the National Medicolegal Review Panel, I have had the
opportunity to observe and become familiar with the development of the
Death Investigation: A Guide for the Scene Investigator. I am delighted
with this effort and enthusiastically support and endorse the guidelines
that have been developed.
As a faculty member at St. Louis University Health Sciences Center

in the Division of Forensic Pathology, I have been part of our Medicole-
gal Death Investigators Course since its inception in 1978. I am aware of
xiv
the tremendous importance of medicolegal death investigation in the
proper administration of justice and criminal proceedings, adjudicating
estates, and handling of death certification; and, unfortunately, I am
aware of the all too common poor level at which some jurisdictions
function in death investigation.
One of the most certain methods of ensuring uniform and proper

procedural compliance in death investigation is to establish guidelines
that can be followed in every instance. A good example of the use of
guidelines in death investigation is the death investigation of an infant,
for which many jurisdictions have established a protocol for conducting
the scene investigation. By definition, a diagnosis of Sudden Infant Death
Syndrome (SIDS) can be made only after the scene investigation, autopsy,
microscopic, toxicology, and medical history have been conducted, and all
have been unrevealing as to a cause of death.
The first step toward uniform excellence in death investigation is to

establish guidelines that can be followed by even those jurisdictions
having minimal resources. The efforts of the National Medicolegal Death
Investigation Guidelines Project to create a structured protocol for the
necessary tasks to be accomplished at death scenes have been highly
successful in fulfilling that goal.
Commentary
Joseph H. Davis, M.D.
Retired Director, Dade County
Medical Examiner Department
Professor of Pathology Emeritus,
University of Miami
The objectives of the American Academy of Forensic Sciences are
enunciated in the Preamble of its Bylaws and include: “to improve the
practice, elevate the standards and advance the cause of the forensic
sciences . . . .” Death Investigation: A Guide for the Scene Investigator
most certainly supports the objectives of the academy when sudden,
xv
unexpected, and violent deaths are investigated by forensic pathologists
and other scientists. Sudden death investigation is multidisciplinary, with
involvement of scientists representing all sections of the academy—
pathology, odontology, criminalistics, toxicology, psychiatry, questioned
documents, jurisprudence, and even engineering. None of these scientists
can be truly effective if the death investigation is faulted by errors of
omission or commission during the initial scene investigation.
Eventually, the States of the Union will see the wisdom of uniform
quality of standards and training for medicolegal death investigators.
However, such standards are impossible unless consensus is reached as
to what subjects should be taught and how investigators should be judged
as to entry and performance in the field of death investigation. These
guidelines are the first step for the eventual implementation of proper
standards and training throughout the United States.
Commentary
Halbert E. Fillinger, Jr., M.D.
Forensic Pathologist
Coroner
Montgomery County, Pennsylvania
I have been honored to represent the International Association of
Coroners and Medical Examiners on the National Medicolegal Review
Panel. The end product of the efforts of this panel in developing universal
guidelines for death-scene investigation fills a long-vacant gap in the
training and investigation of sudden, suspicious death.
It has been apparent to me in my 40 years of experience as a

forensic pathologist, assistant medical examiner and coroner, as well as
death-scene investigation trainer, that systematic, specific guidelines are
essential to good death-scene investigation. The guidelines promulgated
by the National Medicolegal Review Panel fill a need that has long been
recognized by most of our colleagues in the field, and this can only
greatly enhance and improve the quality of our work.
xvi
With many of the deaths today having more and more civil as well
as criminal implications, top-quality death-scene investigation becomes a
must in any jurisdiction, and I feel that the product of the National
Medicolegal Review Panel will fill this need.
I am incorporating the guidelines developed thus far in the manda-

tory training program for the Commonwealth of Pennsylvania as directed
by the Attorney General’s Office, and find that the guidelines are well
structured and comprehensive, yet simple to follow. One can systemati-
cally start with an experienced investigator or a very inexperienced one
and, by following these guidelines, a competent quality death-scene
investigation can be carried out.
Without the efforts of the National Medicolegal Review Panel, no

systematic, universal, top-quality investigation can be expected with the
diverse backgrounds of the coroners and medical examiners in the United
States.
Commentary
Bruce H. Hanley, Esq.
Partner, Hanley & Dejoras, P.A.
Minneapolis, Minnesota
The development of Death Investigation: A Guide for the Scene
Investigator will be of great benefit to all citizens. The guidelines will
help to promote consistency, accuracy, predictability, and reliability in
death-scene investigations. As a criminal defense lawyer, it is a chief
concern that a person is not wrongfully accused of having participated in
a homicide. Complete, thorough, and careful death-scene investigations
can lead to greater faith in the system by family and friends of those
whose deaths may have been caused by homicide, suicide, accident, or
natural causes. Elimination of unanswered questions, confusion, sloppi-
ness, and the lack of attention to detail all can contribute to the genuine
acceptance that the cause of death has been properly determined. More-
over, in the case of homicide, all can have a strong belief in the accuracy
xvii
of the identification of the perpetrator. The guidelines will assist the
actual investigators in following the proper protocol and consistently
obtaining all available evidence to show that the death was the result of
either unlawful or lawful activity. Proper adherence to the guidelines,
coupled with proper training to implement the guidelines, will serve to
satisfy finders of fact in criminal cases that the State has presented
accurate, reliable, and trustworthy evidence. Additionally, it will serve to
defuse attacks by defense counsel on the investigative methods and
techniques, chain of custody, and the reliability of any testing that may
have been conducted during the course of the investigation. It may also
serve to prevent innocent people from being accused of criminal activity
when, in fact, a crime was not committed, or the person suspected was
not involved. The truth is the outcome sought, and the guidelines will
assist the system in obtaining the truth. In a criminal investigation, when
the government follows the rules and properly conducts its investigation,
it will win most of the time. When it does not follow the rules or properly
conduct its investigation, it should lose.
Commentary
Randy Hanzlick, M.D.
Centers for Disease Control and Prevention
Atlanta, Georgia
Variations in statutes, levels of funding, geography and population
density, and death investigator education, training, and experience result
in variations in the quality and extent of medicolegal death investigations.
Front-line, on-scene death investigations are performed by people whose
jobs range from part-time to full-time, and whose education, training,
and experience vary substantially and range from minimal to extensive.
The outcome of death investigations may impact personal liberty and
well-being, adjudication of cases, public health and safety, mortality
statistics, research capabilities, and governmental approaches to legisla-
tion and programs. Therefore, high-quality death investigation through-
out the United States is a desirable goal for many reasons.
xviii
The creation of guidelines for medicolegal death investigations is
one method of promoting uniformity in the approach to death investigations
and improving or assuring their quality at the same time. Guidelines may
also be used as a basis for developing educational programs, to evaluate
work performance, and as a basis for credentialing or certification of
death investigators. To those ends, the National Medicolegal Review
Panel has taken an important step by developing this initial set of death
investigation guidelines as a model for nationwide use, pursuant to a
grant funded by the National Institute of Justice and the Centers for
Disease Control and Prevention.
The development of such guidelines will not be enough in and of

themselves, however. The best intended and designed guidelines will
have little effect if death investigators are not provided with funds
adequate to meet the provisions of the guidelines. Funding for the
education and training of death investigation practices and for the
implementation of the guidelines will be necessary, and funding needs
pose a significant obstacle to the long-term goal of nationwide improve-
ment in death investigation practices. Governments at every level of
organization will need to explore methods for acquiring or providing
funds and providing the education, training, and manpower to effectively
implement these and any subsequent guidelines. In the meantime, these
guidelines provide a starting point from which we can proceed.
Commentary
Richard C. Harruff, M.D., Ph.D.
Associate Medical Examiner
Seattle/King County
Department of Public Health
Seattle, Washington
A competent and thorough death-scene investigation provides the
basis for a comprehensive medicolegal autopsy, and together the scene
investigation and autopsy provide the basis for an accurate determination
of cause and manner of death. Furthermore, following specific guidelines
xix
helps assure that all relevant aspects of all deaths are fully investigated.
Representing the National Association of Medical Examiners on the
National Medicolegal Review Panel, I believe that the national guidelines
for death-scene investigation offer medical examiners and coroners a
valuable means for substantially enhancing performance in fulfilling their
far-ranging responsibilities. As the guidelines have been formulated with
the consensus of several prominent forensic and legal experts, they
represent a major advancement in scientific death investigation and
deserve the attention of all who claim competency in this field.
Commentary
Jeffrey M. Jentzen, M.D.
Medical Examiner
Milwaukee County, Wisconsin
As a member of the Forensic Pathology Committee of the College
of American Pathologists, I would like to encourage my colleagues to
consider the impact that national guidelines would have on the investiga-
tion of sudden and unexpected deaths. Most pathologists assist law
enforcement officials in medicolegal death investigations during their
careers in some form or another. We are aware that an investigation
requires the proper coordination of a number of agencies and that the
breakdown of the investigative procedures may jeopardize the successful
outcome of the case. Death Investigation: A Guide for the Scene Investi-
gator provides procedures for uniform death-scene processing, which
ensures competent and complete examination of the death scene in a
judicious manner that also respects the concerns of the family and loved
ones. The guidelines set forth in this document have been developed by
a diverse panel of professional death investigators who understand the
common pitfalls of everyday medicolegal death investigation. Medicole-
gal death investigation has become a sophisticated process subject to
critical review and high expectations of the community, the legal system,
and family members. These guidelines provide the essential tasks for
death-scene investigation and go a long way toward ensuring quality
death-scene investigations.
xx
Commentary
Mary Lou Kearns, R.N., M.P.H.
Coroner
Kane County, Illinois
Historically, the Office of Coroner has been charged with the
responsibilities and duties of answering pertinent questions related to
death investigation: Who, What, When, Where, How, and Why. Only
when these questions have been answered correctly can all the proper
legal issues that arise at death be handled expertly and completely for
the administration of justice. As the representative of the coroners of
America on the NIJ Peer Review Panel, I applaud the efforts that have
produced Death Investigation: A Guide for the Scene Investigator. These
guidelines provide the necessary policies and procedures for universal
and professional death-scene investigations, as well as the criteria for
when to be suspicious. And by having properly coordinated death-scene
investigative procedures, the community, the legal system, and family
members will be well served.
I have long been committed to this quest for universal guidelines

and the eventual training of death investigators nationwide. Coroners
who are well trained in their jobs make fewer mistakes. The more
training and confidence coroners have, the better our offices will run.
An ideal coroner’s office is well prepared to investigate and evaluate a
scene, to examine a body, to write quality reports, and to interact with
the family, all in a professional manner. These national guidelines for
death-scene investigations will go a long way toward enhancing our
professionalism.
xxi
Commentary
Mayor Scott L. King, Chairman, NMRP
Mayor
Gary, Indiana
As the representative of the United States Conference of Mayors,
I was pleased to serve as Chairman of the National Medicolegal Review
Panel, particularly given the expertise and wide range of diverse experi-
ence of the balance of the panel. Because the duties of a mayor include
responsibility for public safety functions, and because I served for 20
years as both a prosecution and defense attorney before assuming my
present office, I am acutely aware of the importance of establishing and
utilizing appropriate protocol for death-scene investigations. These
guidelines will, I hope, accomplish the goal of uniformity in the conduct
of such investigations nationwide without requiring significant additional
expenditure of budget funds.
Commentary
George H. Kuhler
Elected Coroner
Beadle County, South Dakota
I would like to encourage all elected coroners to consider support-
ing national guidelines for coroner investigations. As a funeral director
and elected coroner, I know firsthand how important proper investigation
is to the law enforcement community, as well as to the forensic medical/
legal investigation of the death. With no “official training” required for
elected coroners, it is difficult for the elected coroner to know what
should be done in investigations. Most elected coroners have begun their
jobs with little or no knowledge as to how and what they need to do.
Having a set of national guidelines for medicolegal death investigation
would ensure that at least the elected coroner would have a “cookbook”
to follow and would have some idea of what is expected of him/her in
every case.
xxii
I would encourage the adoption and use of the following guidelines
for all coroners, medical examiners, and death investigators. These
guidelines have been developed by a panel of members from all of these
fields from across the United States. The use of these guidelines on every
scene will ensure quality and uniform death investigation every time.
Commentary
Douglas A. Mack, M.D., M.P.H.
Chief Medical Examiner and
Public Health Director
Kent County, Michigan
As a representative of the National Association of Counties and as
Chief Medical Examiner for Kent County, Michigan, I enthusiastically
endorse the medicolegal guidelines developed by the National Medicole-
gal Review Panel for death-scene investigation and medical examiner
system processes. An efficient, well-managed, and high-quality medical
examiner system is a critical element in death investigation and benefits
the law enforcement, criminal justice, and public health systems. This
protocol provides direction for the interaction of these systems, and helps
assure that the work of those involved results in high-quality investiga-
tions and outcomes.
Commentary
Donald L. Mauro
Commanding Officer, Homicide Bureau
Los Angeles County Sheriff’s Department
Los Angeles, California
As a representative of the National Sheriffs’ Association, I have
been honored to participate with the very capable and diverse group that
comprises the National Medicolegal Review Panel. The results of our
efforts are the national guidelines, which will direct the efforts of fellow
death investigators in “other than natural” death investigations. The
xxiii
procedures developed by the panel constitute a baseline protocol that
should serve to support and direct the efforts of all of us who work in this
field. Because each death has profound implications for family and
friends, and because each investigation ultimately has financial, legal,
and societal implications, we can take satisfaction in knowing that
standards now exist for death investigators across the country, which,
when followed, will yield comprehensive, high-quality death-scene
investigations.
Commentary
Elaine R. Meisner
Logan County Coroner
Sterling, Colorado
As a member of the Colorado Coroners’ Association, it is with a
great deal of pride and sense of accomplishment that I have been their
representative on the National Medicolegal Review Panel for death
investigation guidelines. In the rural areas, the importance and necessity
of thorough and proper death investigations have not always been
thought of as an area of much importance, not so much by the agencies
doing the investigations, but by the agencies who financially support
them. As a lifelong resident of a rural community, I value and appreciate
the importance and need of a thorough and proper death investigation.
These guidelines have been long awaited by many death investigators
across the country. The National Medicolegal Review Panel has worked
hard to develop a sound, well-described set of death investigation guide-
lines. Today, the modern range of knowledge is much greater, techniques
are precise and specialized. These methodically well-planned guidelines
were much needed to ensure and maintain uniformity and to help de-
crease chance for error. This has been a unique experience with the
display of utmost professionalism and collaboration by committee
members. Without the unstinting cooperation and help of all concerned,
it would have been impossible to finish this project. It is in the best
interests of death investigators nationwide to utilize these appropriately
developed guidelines for the purpose of improving death investigations
and for other agencies to properly support them.
xxiv
Commentary
Thomas J. O’Loughlin
Chief of Police
Wellesley, Massachusetts
The proposed Death Investigation: A Guide for the Scene Investiga-
tor has been developed with the input of members of the various and
many disciplines that are involved in the investigation of sudden and
unexpected deaths.
The investigation of the death of another human being is a weighty

responsibility. It has been a pleasure to represent and serve the interests
of the International Association of Chiefs of Police in participating
in the development of Death Investigation: A Guide for the Scene
Investigator.
As a police officer and chief of police, I am well aware of the

multifaceted and multidisciplinary approach that is necessary in many of
these investigations. As professionals, we are all aware of investigations
that have been met with professional success and those that have been,
unfortunately, less than professional.
As important as the actual performance of the investigative proce-

dures is an understanding of the diverse and mutual responsibilities held
by involved and participating professionals. Death Investigation: A Guide
for the Scene Investigator will provide standardized procedures so that
each and every participant in the death-scene investigation will have a
clear and concise understanding of the professionally accepted standards
and procedures necessary in conducting a death-scene investigation.
In the long term, it is the expected goal that each of the participants
within the death investigation process will meet these established profes-
sional standards and their obligation to fulfill their responsibilities in a
competent and professional manner.
xxv
Commentary
John E. Smialek, M.D.
State of Maryland
A major step in the advancement of the American system of justice
was taken recently with the recognition of standard guidelines for scene
investigation in medical examiner and coroner cases.
Awareness of inadequate death investigation operations in jurisdic-

tions around the country resulted in a project supported by the National
Institute of Justice that has produced the new guidelines.
The panel of experts assembled by NIJ considered the need for

standards that were comprehensive but flexible and capable of being
adapted to operations that utilize a variety of investigative officials
including police officers, sheriffs, justices of the peace, physicians, and
pathologists.
Further progress in achieving a system of death investigation that

meets the needs of law enforcement agencies and families will depend
on the willingness of State and local government officials to support the
introduction of these guidelines and provide the necessary resources to
implement them.
As a representative of the National Association of Medical Examin-

ers, I strongly urge the careful study and acceptance of these standards.
xxvi
Introduction
“Is it [death investigation] an enlightened system? No, it’s not. It’s
really no better than what they have in many Third World countries.”
Dr. Werner Spitz, Former Chief Medical Examiner,
Wayne County (Detroit), Michigan
T he first thing one must realize is that the word “system” is a

misnomer, when used in the context of death investigation in the
United States. There is no “system” of death investigation that covers the
more than 3,000 jurisdictions in this country.1 No nationally accepted
guidelines or standards of practice exist for individuals responsible for
performing death-scene investigations. No professional degree, license,
certification, or minimum educational requirements exist, nor is there a
commonly accepted training curriculum. Not even a common job title
exists for the thousands of people who routinely perform death investiga-
tions in this country.2, 3
This report describes a study that focused on the establishment of

guidelines for conducting death investigations.
Purpose and Scope of the Study

The principal purpose of the study, initiated in June 1996, was to
identify, delineate, and assemble a set of investigative tasks that should
and could be performed at every death scene. These tasks would serve as
the foundation of the guide for death scene investigators. The Director of
the National Institute of Justice (NIJ) selected an independent review
panel whose members represented international and national organiza-
tions whose constituents are responsible for the investigation of death
and its outcomes. The researcher organized two multidisciplinary techni-
cal working groups (TWGs). The first consisted of members representing
the investigative community at large, and the second consisted of an
executive board representing the investigative community at large.
1
The study involved the use of two standardized consensus-seeking
research techniques: (a) the Developing A CurriculUM (DACUM)4
process, and (b) a Delphi5 survey.
In this report, the author does not attempt to assign responsibility

for task (guideline) performance to any one occupational job title (e.g.,
Guideline D4 is performed by law enforcement personnel). Research
design and selected methodology focused on the establishment of
performance guidelines for death-scene investigations. The research
design did not allow TWGs to assume investigative outcomes during the
development phase of the project; therefore, no attempt was made to
assign a “manner” of death to individual guidelines (e.g., Guideline C2
applies to homicide scenes), to maintain objectivity and national practicality.
The author does not claim to be an expert in the science and/or

methodology of medicolegal death investigation. This research was based
on the collective knowledge of three multidisciplinary content area expert
groups. The focus was on the death scene, the body, and the interactive
skills and knowledge that must be applied to ensure a successful case
outcome.
The balance of this introduction outlines the study design and

provides basic background information on the selection of the National
Medicolegal Review Panel (NMRP) and TWG memberships and the
research methodology, its selection, and application. The study findings
(investigative guidelines) follow this introduction.
Study Design
Identification of NMRP and TWGs
The methodology selected for this occupational research required
collection of data from a sample of current subject matter experts,
practitioners from the field who perform daily within the occupation
being investigated. This “criterion” was used to identify members of the
various multidisciplinary groups that provided the data for this research.
2
The following groups were formed for the purpose of developing national
guidelines for conducting death investigations.

NMRP members represent an independent multidisciplinary group
of both international and national organizations whose constituents are
responsible for investigating death and its outcomes. Each member of
NMRP was selected by the Director based on nominations made by the
various associations. The rationale for their involvement was twofold:
(a) they represent the diversity of the profession nationally, and (b) their
members are the key stakeholders in the outcomes of this research. Each
organization has a role in conducting death investigations and in imple-
menting these guidelines.
Technical Working Group for

Death Investigation (TWGDI)
1. National Reviewer Network
Technical Working Group for Death Investigation (TWGDI) mem-
bers represent a sample of death investigators from across the country.
They are the content area experts who perform within the occupation
daily. The following criteria were used to select the members of the
TWGDI reviewer network:
◆ Each member was nominated/selected for the position by a person

whose name appeared on the most recent (1995) Centers for Disease
Control and Prevention (CDC) national database of death investigation.6
◆ Each member had specific knowledge regarding the investigation of

death.
◆ Each member had specific experience with the process of death

investigation and the outcomes of positive and negative scene
investigations.
◆ Each member could commit to four rounds of national surveying

over a 6-month period.
3
A 50-percent random sample (1,512) of death investigators was
drawn from the Centers for Disease Control and Prevention database.7
A letter was sent to each member of the sample, inviting him or her to
participate in the national research to develop death investigative guide-
lines or to nominate a person who participates in death investigations.
Two hundred and sixty-three individuals were nominated (17 percent).
Nominees were contacted by mail and asked to provide personal demo-
graphic data including job title, years of experience, and educational
background, in addition to general information (name/address, etc.)
necessary for participation in the research.
Region 1
Northeast
Region 2
Southeast
Region 3
Midwest
Region 4
Southwest
Region 5
West
The TWGDI national reviewer network consisted of 263 members

from 46 States, representing 5 regions as follows:
Region Location Number of Participants Percentage

1 Northeast 32 12.2%
2 Southeast 56 21.3%
3 Midwest 94 35.7%
4 Southwest 47 17.9%
5 West 34 12.9%
4
The educational backgrounds of the national reviewer network
members were as follows:
Education Number Percentage

Law Enforcement 82 31.2%
Medical 157 59.8%
Unknown 24 9.0%
The types of investigative systems represented on the reviewer

network were as follows:
System Number Percentage
Medical Examiner 44 16.6%

Coroner 161 61.3%
Mixed ME/Coroner 58 22.1%
The average age of TWGDI members was 47.6 years. They had an
average of 10.5 years of experience. There were 80.6 percent (212) males
and 19.4 percent (51) females in the group.
2. Executive Board
Representatives from each region were selected to maintain consis-
tency within regions across the United States. These representatives made
up the TWGDI executive board.
Criteria for selection to the TWGDI executive board were as follows:
◆ Each member had specific knowledge regarding the investigation

of death.
◆ Each member had specific experience with the process of death

investigation and the outcomes of positive and negative scene
investigations.
◆ Each member could commit to attend four workshops held within the
grant period.
5
TWGDI Executive Board DACUM Workshop. In November
1996, the TWGDI executive board met in St. Louis to begin developing
the national Delphi survey. The survey content was to reflect “best
practice” for death-scene investigation. DACUM is a process for analyz-
ing an occupation systematically. The 2-day workshop used the investiga-
tive experts on the executive board to analyze job tasks while employing
modified brainstorming techniques. The board’s efforts resulted in a
DACUM chart that describes the investigative occupation in terms of
specific tasks that competent investigators must be able to perform
“every scene, every time.”8 A task was defined as a unit of observable
work with a specific beginning and ending point that leads to an investi-
gative product, service, or decision. The DACUM chart served as the
outline for the Delphi survey.
This initial process resulted in six major areas of work. In attempts

to simplify the survey for the members of the national reviewer network,
the areas of work were placed into a logical sequence of events (as they
might be performed while investigating a case). Within the five major
areas of work (Investigative Tools and Equipment was excluded at this
point because tools and equipment are “things,” not procedural steps),
29 tasks were identified. Within the 29 identified investigative tasks
were 149 discrete steps and/or elements. Theoretically, each step and/or
element must be performed for the task to be completed “successfully.”
The results were placed in survey format for NMRP review and pilot
testing.
National Medicolegal Review Panel Meeting. In December 1996,

NMRP met in Washington, D.C., to review the DACUM chart and
comment on the research methodology proposed by the researcher. The
members of the panel recommended modifications to the survey design
and approved response selections. Respondents would attempt to rate, by
perceived importance, each of the investigative tasks/steps and/or ele-
ments on a five-point scale.
The Delphi Survey. The Delphi technique, although it employs

questionnaires, is much different from the typical questionnaire survey.
Developed by the RAND Corporation as a method of predicting future
6
defense needs, the technique is used whenever a consensus is needed
from persons who are knowledgeable about a particular subject.9 The
goal of a Delphi survey is to engage the respondents in an anonymous
debate in order to arrive at consensus on particular issues or on predic-
tions of future events.
The Delphi requires at least four rounds in an effort to obtain a

well-thought-out consensus. After the first-round results were received,
coded, and recorded, a revised questionnaire was developed for round
two. The second-round survey provided each member of TWGDI with
the national median and mean scores for each of the task statements
presented, as well as their first-round responses. Respondents were asked
to compare their original ratings with the median and mean scores and to
revise their original evaluations as they saw fit. This procedure was
repeated for each of the four rounds of the survey.
The Delphi survey was conducted during the first 6 months of 1997.
The table below provides general TWGDI response data:
Round Surveys Surveys Cumulative Respondent

Sent Received Loss (%)
1 263 199 24.3%
2 199 163 13.72%
3 163 149 5.33%
4 149 146 1.14%
As shown in the preceding table, final membership in the TWGDI

national reviewer network was 146. This number represents approxi-
mately 56 percent of the originally nominated members.
Guideline Development. During the 6 months of the Delphi

process, both the TWGDI executive board and NMRP met to review
survey data (to date) and to begin the process of moving task-based data
into guideline format.
7
In May 1997, the executive board met for a 2 1/2 -day working
session in New Orleans to begin the guideline development process.
The consensus of the board was to establish 29 guidelines based on the
national reviewer network data and present them to NMRP for review.
Each guideline would have the following content:
◆ A statement of principle, citing the rationale for performing the guideline.
◆ A statement of authorization, citing specific policy empowering the

investigator.
◆ A statement of policy to the investigator regarding guideline performance.
◆ The procedure for performing the guideline.
◆ A statement of summary, citing justification for performing the

procedures.
In June and July 1997, NMRP met for two 1 1/2 -day working
sessions in St. Louis and Chicago to review the draft guidelines devel-
oped by the executive board and offer recommendations and changes
based on jurisdictional variances and organizational responsibilities.
Those sessions resulted in the final draft of the 29 guidelines for
conducting death investigations. The 29 guidelines are presented in
the next main section.
Guideline Status
Currently, NMRP members are presenting the guidelines to their
respective organizations’ leadership (or appropriate internal committees)
for review. This researcher is collecting anecdotal comments for future
modification of the existing guidelines during the validation procedures.
8
Training Guidelines
The purpose of the second part of the national death investigator
guidelines research was to identify training criteria for each of the
29 guidelines. This research is now completed. For each of the
guidelines presented in this report, “minimum levels of performance”
will be developed and verified by the members of the various TWGs.
These “training guidelines” will provide both individuals and educational
organizations the material needed to establish and maintain valid exit
outcomes for each investigative trainee.
Guideline Validation
In this initial research, 29 investigative tasks were identified. Each
task was developed into a guideline for investigators to follow while
conducting a death investigation. Although each TWG believed in the
validity of each guideline, no attempt was made to validate actual
significance (e.g., if guideline C1 is trained and implemented, a [%]
decrease in poor scene photographs should occur). The researcher is
currently developing a national validation strategy for the implementa-
tion and validation of each guideline.
Notes
1. “It is important to note that even the use of the word ‘system’ to
describe a process that encompasses more than 3,000 individual
jurisdictions is a misnomer.” Hansen, M., “Body of Evidence,”
American Bar Association Journal (June 1995).
2. Jentzen, J.M., S.C. Clark, and M.F. Ernst, “Medicolegal Death

Investigator Pre-Employment Test Development,” American Journal
of Forensic Medicine and Pathology 17 (1996):112–16.
3. Hanzlick, R., “Coroner Training Needs: A Numeric and Geographic

Analysis,” Journal of the American Medical Association 276
(1996):1775–1778.
9
4. The Ohio State University, Center on Education and Training for
Employment, DACUM, 1996.
5. Borg, W.R., and M.D. Gall, Educational Research: An Introduction,

New York: Longman Inc., 1983:413–415.
6. Combs, D., R.G. Parrish, and R.T. Ing, Death Investigation in the
United States and Canada, Atlanta: U.S. Department of Health and
Human Services, Public Health Service, Centers for Disease Control
and Prevention, 1995.
7. Ibid.
8. Clark, S.C., Occupational Research and Assessment, Inc., Big

Rapids, Michigan, 1996.
9. Borg and Gall, 413–415.
10
Medicolegal Death Investigation Guidelines
Investigative Tools
Section A and Equipment
Section B Arriving at the Scene
Documenting and
Section C Evaluating the Scene
Documenting and
Section D Evaluating the Body
Establishing and Recording

Section E Decedent Profile Information
Completing the
Section F Scene Investigation
11
Investigative Tools and Equipment
1. Gloves (Universal Precautions).
2. Writing implements (pens, pencils, markers).
3. Body bags.
4. Communication equipment (cell phone, pager, radio).
5.
6.
Flashlight.
Body ID tags.
A
7. Camera—35mm (with extra batteries, film, etc.).
8. Investigative notebook (for scene notes, etc.).
9. Measurement instruments (tape measure, ruler,
rolling measuring tape, etc.).
10. Official identification (for yourself).
11. Watch.
12. Paper bags (for hands, feet, etc.).
13. Specimen containers (for evidence items and toxicology specimens).
14. Disinfectant (Universal Precautions).
15. Departmental scene forms.
16. Camera—Polaroid (with extra film).
17. Blood collection tubes (syringes and needles).
18. Inventory lists (clothes, drugs, etc.).
19. Paper envelopes.
20. Clean white linen sheet (stored in plastic bag).
21. Evidence tape.
22. Business cards/office cards w/phone numbers.
23. Foul-weather gear (raincoat, umbrella, etc.).
24. Medical equipment kit (scissors, forceps, tweezers, exposure suit,
scalpel handle, blades, disposable syringe, large gauge needles,
cotton-tipped swabs, etc.).
25. Phone listing (important phone numbers).
26. Tape or rubber bands.
27. Disposable (paper) jumpsuits, hair covers, face shield, etc.
28. Evidence seal (use with body bags/locks).
13
29. Pocketknife.
30. Shoe-covers.
31. Trace evidence kit (tape, etc.).
32. Waterless hand wash.
33. Thermometer.
34. Crime scene tape.
35. First aid kit.
36. Latent print kit.
37. Local maps.
38. Plastic trash bags.
39. Gunshot residue analysis kits (SEM/EDS).
40. Photo placards (signage to ID case in photo).
41. Boots (for wet conditions, construction sites, etc.).
42. Hand lens (magnifying glass).
43. Portable electric area lighting.
44. Barrier sheeting (to shield body/area from public view).
45. Purification mask (disposable).
46. Reflective vest.
47. Tape recorder.
48. Basic handtools (boltcutter, screwdrivers, hammer,
shovel, trowel, paintbrushes, etc.).
49. Body bag locks (to secure body inside bag).
50. Camera—Video (with extra battery).
51. Personal comfort supplies (insect spray, sun screen, hat, etc.).
52. Presumptive blood test kit.
This handbook is intended as a guide to recommended

practices for the investigation of death scenes. Juris-
dictional, logistical, or legal conditions may preclude
the use of particular procedures contained herein.
14
Arriving at the Scene
1. Introduce and Identify Self and Role
Principle: Introductions at the scene allow the investigator to
establish formal contact with other official agency
representatives. The investigator must identify the first
responder to ascertain if any artifacts or contamination
may have been introduced to the death scene. The
investigator must work with all key people to ensure
scene safety prior to his/her entrance into the scene.
B
Authorization: Medical Examiner/Coroner Official Office Policy
Manual; State or Federal Statutory Authority.
Policy: The investigator shall take the initiative to introduce

himself or herself, identify essential personnel, establish
rapport, and determine scene safety.
Procedure: Upon arrival at the scene, and prior to entering the scene,
the investigator should:
A. Identify the lead investigator at the scene and present identification.

B. Identify other essential officials at the scene (e.g., law enforce-
ment, fire, EMS, social/child protective services, etc.) and explain
the investigator’s role in the investigation.
C. Identify and document the identity of the first essential official(s)
to the scene (first “professional” arrival at the scene for investiga-
tive followup) to ascertain if any artifacts or contamination may
have been introduced to the death scene.
D. Determine the scene safety (prior to entry).
15
1. Introduce and Identify Self and Role
Summary:
Introductions at the scene help to establish a collaborative investiga-
tive effort. It is essential to carry identification in the event of questioned
authority. It is essential to establish scene safety prior to entry.
2. Exercise Scene Safety

Principle: Determining scene safety for all investigative personnel
is essential to the investigative process. The risk of
environmental and physical injury must be removed
prior to initiating a scene investigation. Risks can include
hostile crowds, collapsing structures, traffic, and envi-
ronmental and chemical threats.

Policy: The investigator shall attempt to establish scene safety

prior to entering the scene to prevent injury or loss of
life, including contacting appropriate agencies for
assistance with other scene safety issues.
Procedure: Upon arrival at the scene, the investigator should:
A. Assess and/or establish physical boundaries.

B. Identify incident command.
C. Secure vehicle and park as safely as possible.
D. Use personal protective safety devices (physical, biochemical
safety).
E. Arrange for removal of animals or secure (if present and possible).
F. Obtain clearance/authorization to enter scene from the individual
responsible for scene safety (e.g., fire marshal, disaster coordinator).
16
G. While exercising scene safety, protect the integrity of the scene
and evidence to the extent possible from contamination or loss by
people, animals, and elements.
Note: Due to potential scene hazards (e.g., crowd control,
collapsing structures, poisonous gases, traffic), the body
may have to be removed before scene investigation can
be continued.
Summary:
Environmental and physical threats to the investigator must be
removed in order to conduct a scene investigation safely. Protective
devices must be used by investigative staff to prevent injury. The investiga-
tor must endeavor to protect the evidence against contamination or loss.
3. Confirm or Pronounce Death

Principle: Appropriate personnel must make a determination of
death prior to the initiation of the death investigation.
The confirmation or pronouncement of death determines
jurisdictional responsibilities.

Policy: The investigator shall ensure that appropriate personnel

have viewed the body and that death has been confirmed.
A. Locate and view the body.

B. Check for pulse, respiration, and reflexes, as appropriate.
C. Identify and document the individual who made the official deter-
mination of death, including the date and time of determination.
D. Ensure death is pronounced, as required.
17
3. Confirm or Pronounce Death
Summary:
Once death has been determined, rescue/resuscitative efforts cease
and medicolegal jurisdiction can be established. It is vital that this occur
prior to the medical examiner/coroner’s assuming any responsibilities.
4. Participate in Scene Briefing (With

Attending Agency Representatives)
Principle: Scene investigators must recognize the varying jurisdic-
tional and statutory responsibilities that apply to indi-
vidual agency representatives (e.g., law enforcement,
fire, EMT, judicial/legal). Determining each agency’s
investigative responsibility at the scene is essential in
planning the scope and depth of each scene investigation
and the release of information to the public.

Policy: The investigator shall identify specific responsibilities,

share appropriate preliminary information, and establish
investigative goals of each agency present at the scene.
Procedure: When participating in scene briefing, the investigator

should:
A. Locate the staging area (entry point to scene, command post, etc.).
B. Document the scene location (address, mile marker, building
name) consistent with other agencies.
C. Determine nature and scope of investigation by obtaining preliminary
investigative details (e.g., suspicious versus nonsuspicious death).
D. Ensure that initial accounts of incident are obtained from the first
witness(es).
18
Summary:
Scene briefing allows for initial and factual information exchange.
This includes scene location, time factors, initial witness information,
agency responsibilities, and investigative strategy.
5. Conduct Scene “Walk Through”

Principle: Conducting a scene “walk through” provides the investi-
gator with an overview of the entire scene. The “walk
through” provides the investigator with the first opportu-
nity to locate and view the body, identify valuable and/or
fragile evidence, and determine initial investigative
procedures providing for a systematic examination and
documentation of the scene and body.

Policy: The investigator shall conduct a scene “walk through” to

establish pertinent scene parameters.
A. Reassess scene boundaries and adjust as appropriate.

B. Establish a path of entry and exit.
C. Identify visible physical and fragile evidence.
D. Document and photograph fragile evidence immediately and
collect if appropriate.
E. Locate and view the decedent.
Summary:
The initial scene “walk through” is essential to minimize scene
disturbance and to prevent the loss and/or contamination of physical and
fragile evidence.
19
6. Establish Chain of Custody
Principle: Ensuring the integrity of the evidence by establishing and
maintaining a chain of custody is vital to an investigation.
This will safeguard against subsequent allegations of
tampering, theft, planting, and contamination of evidence.

Policy: Prior to the removal of any evidence, the custodian(s) of

evidence shall be designated and shall generate and
maintain a chain of custody for all evidence collected.
Procedure: Throughout the investigation, those responsible for

preserving the chain of custody should:
A. Document location of the scene and time of arrival of the death

investigator at the scene.
B. Determine custodian(s) of evidence, determine which agency(ies)
is/are responsible for collection of specific types of evidence, and
determine evidence collection priority for fragile/fleeting evidence.
C. Identify, secure, and preserve evidence with proper containers,
labels, and preservatives.
D. Document the collection of evidence by recording its location at
the scene, time of collection, and time and location of disposition.
E. Develop personnel lists, witness lists, and documentation of times
of arrival and departure of personnel.
Summary:
It is essential to maintain a proper chain of custody for evidence.
Through proper documentation, collection, and preservation, the integrity
of the evidence can be assured. A properly maintained chain of custody
and prompt transfer will reduce the likelihood of a challenge to the
integrity of the evidence.
20
7. Follow Laws (Related to the
Collection of Evidence)
Principle: The investigator must follow local, State, and Federal
laws for the collection of evidence to ensure its admissi-
bility. The investigator must work with law enforcement
and the legal authorities to determine laws regarding
collection of evidence.

Policy: The investigator working with other agencies must

identify and work under appropriate legal authority.
Modification of informal procedures may be necessary
but laws must always be followed.
Procedure: The investigator, prior to or upon arrival at the death

scene, should work with other agencies to:
A. Determine the need for a search warrant (discuss with appropriate

agencies).
B. Identify local, State, Federal, and international laws (discuss with
appropriate agencies).
C. Identify medical examiner/coroner statutes and/or office standard
operating procedures (discuss with appropriate agencies).
Summary:
Following laws related to the collection of evidence will ensure a
complete and proper investigation in compliance with State and local
laws, admissibility in court, and adherence to office policies and protocols.
21
Documenting and Evaluating the Scene
1. Photograph Scene
Principle: The photographic documentation of the scene creates a
permanent historical record of the scene. Photographs
provide detailed corroborating evidence that constructs a
system of redundancy should questions arise concerning
the report, witness statements, or position of evidence at
the scene.

Policy: The investigator shall obtain detailed photographic

documentation of the scene that provides both instant C
and permanent high-quality (e.g., 35 mm) images.
Procedure: Upon arrival at the scene, and prior to moving the body
or evidence, the investigator should:
A. Remove all nonessential personnel from the scene.

B. Obtain an overall (wide-angle) view of the scene to spatially
locate the specific scene to the surrounding area.
C. Photograph specific areas of the scene to provide more detailed
views of specific areas within the larger scene.
D. Photograph the scene from different angles to provide various
perspectives that may uncover additional evidence.
E. Obtain some photographs with scales to document specific
evidence.
F. Obtain photographs even if the body or other evidence has been
moved.
23
1. Photograph Scene
Note: If evidence has been moved prior to photography, it
should be noted in the report, but the body or other
evidence should not be reintroduced into the scene in
order to take photographs.
Summary:
Photography allows for the best permanent documentation of the
death scene. It is essential that accurate scene photographs are available
for other investigators, agencies, and authorities to recreate the scene.
Photographs are a permanent record of the terminal event and retain
evidentiary value and authenticity. It is essential that the investigator
obtain accurate photographs before releasing the scene.
2. Develop Descriptive
Documentation of the Scene
Principle: Written documentation of the scene(s) provides a
permanent record that may be used to correlate with and
enhance photographic documentation, refresh recollec-
tions, and record observations.

Policy: Investigators shall provide written scene documentation.
Procedure: After photographic documentation of the scene and prior

to removal of the body or other evidence, the investigator
should:
A. Diagram/describe in writing items of evidence and their relation-

ship to the body with necessary measurements.
B. Describe and document, with necessary measurements, blood and
body fluid evidence including volume, patterns, spatters, and other
24 characteristics.
C. Describe scene environments including odors, lights, tempera-
tures, and other fragile evidence.
Note: If evidence has been moved prior to written documenta-
tion, it should be noted in the report.
Summary:
Written scene documentation is essential to correlate with photo-
graphic evidence and to recreate the scene for police, forensic(s), and
judicial and civil agencies with a legitimate interest.
3. Establish Probable Location

of Injury or Illness
Principle: The location where the decedent is found may not be the
actual location where the injury/illness that contributed
to the death occurred. It is imperative that the investiga-
tor attempt to determine the locations of any and all
injury(ies)/illness(es) that may have contributed to the
death. Physical evidence at any and all locations may be
pertinent in establishing the cause, manner, and circum-
stances of death.

Policy: The investigator shall obtain detailed information

regarding any and all probable locations associated with
the individual’s death.
Procedure: The investigator should:
A. Document location where death was confirmed.

B. Determine location from which decedent was transported and how
body was transported to scene.
25
3. Establish Probable Location of Injury or Illness
C. Identify and record discrepancies in rigor mortis, livor mortis, and
body temperature.
D. Check body, clothing, and scene for consistency/inconsistency of
trace evidence and indicate location where artifacts are found.
E. Check for drag marks (on body and ground).
F. Establish post-injury activity.
G. Obtain dispatch (e.g., police, ambulance) record(s).
H. Interview family members and associates as needed.
Summary:
Due to post-injury survival, advances in emergency medical ser-
vices, multiple modes of transportation, the availability of specialized
care, or criminal activity, a body may be moved from the actual location
of illness/injury to a remote site. It is imperative that the investigator
attempt to determine any and all locations where the decedent has
previously been and the mode of transport from these sites.
4. Collect, Inventory, and Safeguard

Property and Evidence
Principle: The decedent’s valuables/property must be safeguarded
to ensure proper processing and eventual return to next
of kin. Evidence on or near the body must be safe-
guarded to ensure its availability for further evaluation.

Policy: The investigator shall ensure that all property and

evidence is collected, inventoried, safeguarded, and
released as required by law.
26
Procedure: After personal property and evidence have been identi-
fied at the scene, the investigator (with a witness) should:
A. Inventory, collect, and safeguard illicit drugs and paraphernalia at

scene and/or office.
B. Inventory, collect, and safeguard prescription medication at scene
and/or office.
C. Inventory, collect, and safeguard over-the-counter medications at
scene and/or office.
D. Inventory, collect, and safeguard money at scene and at office.
E. Inventory, collect, and safeguard personal valuables/property at
scene and at office.
Summary:
Personal property and evidence are important items at a death
investigation. Evidence must be safeguarded to ensure its availability if
needed for future evaluation and litigation. Personal property must be
safeguarded to ensure its eventual distribution to appropriate agencies or
individuals and to reduce the likelihood that the investigator will be
accused of stealing property.
5. Interview Witness(es) at the Scene

Principle: The documented comments of witnesses at the scene
allow the investigator to obtain primary source data
regarding discovery of body, witness corroboration, and
terminal history. The documented interview provides
essential information for the investigative process.

Policy: The investigator’s report shall include the source of

information, including specific statements and informa-
tion provided by the witness.
27
5. Interview Witness(es) at the Scene
Procedure: Upon arriving at the scene, the investigator should:
A. Collect all available identifying data on witnesses (e.g., full name,

address, DOB, work and home telephone numbers, etc.).
B. Establish witness’ relationship/association to the deceased.
C. Establish the basis of witness’ knowledge (how does witness have
knowledge of the death?).
D. Obtain information from each witness.
E. Note discrepancies from the scene briefing (challenge, explain,
verify statements).
F. Tape statements where such equipment is available and retain them.
Summary:
The final report must document witness’ identity and must include a
summary of witness’ statements, corroboration with other witnesses, and
the circumstances of discovery of the death. This documentation must
exist as a permanent record to establish a chain of events.
28
Documenting and Evaluating the Body
1. Photograph the Body
Principle: The photographic documentation of the body at the
scene creates a permanent record that preserves essential
details of the body position, appearance, identity, and
final movements. Photographs allow sharing of informa-
tion with other agencies investigating the death.

Policy: The investigator shall obtain detailed photographic

documentation of the body that provides both instant and
permanent high-quality (e.g., 35 mm) images.
Procedure: Upon arrival at the scene, and prior to moving the body
or evidence, the investigator should:
A. Photograph the body and immediate scene (including the decedent

D
as initially found).
B. Photograph the decedent’s face.
C. Take additional photographs after removal of objects/items that
interfere with photographic documentation of the decedent
(e.g., body removed from car).
D. Photograph the decedent with and without measurements (as
appropriate).
E. Photograph the surface beneath the body (after the body has been
removed, as appropriate).
Note: Never clean face, do not change condition. Take multiple
shots if possible.
29
1. Photograph the Body
Summary:
The photographic documentation of the body at the scene provides
for documentation of the body position, identity, and appearance. The
details of the body at the scene provide investigators with pertinent
information of the terminal events.
2. Conduct External Body

Examination (Superficial)
Principle: Conducting the external body examination provides the
investigator with objective data regarding the single most
important piece of evidence at the scene, the body. This
documentation provides detailed information regarding
the decedent’s physical attributes, his/her relationship to
the scene, and possible cause, manner, and circum-
stances of death.

Policy: The investigator shall obtain detailed photographs and

written documentation of the decedent at the scene.
Procedure: After arrival at the scene and prior to moving the

decedent, the investigator should, without removing
decedent’s clothing:
A. Photograph the scene, including the decedent as initially found

and the surface beneath the body after the body has been removed.
Note: If necessary, take additional photographs after removal of
objects/items that interfere with photographic documentation of
the decedent.
B. Photograph the decedent with and without measurements (as
appropriate), including a photograph of the decedent’s face.
30
C. Document the decedent’s position with and without measurements
(as appropriate).
D. Document the decedent’s physical characteristics.
E. Document the presence or absence of clothing and personal
effects.
F. Document the presence or absence of any items/objects that may
be relevant.
G. Document the presence or absence of marks, scars, and tattoos.
H. Document the presence or absence of injury/trauma, petechiae, etc.
I. Document the presence of treatment or resuscitative efforts.
J. Based on the findings, determine the need for further evaluation/
assistance of forensic specialists (e.g., pathologists, odontologists).
Summary:
Thorough evaluation and documentation (photographic and written)
of the deceased at the scene is essential to determine the depth and
direction the investigation will take.
3. Preserve Evidence (on Body)

Principle: The photographic and written documentation of evidence
on the body allows the investigator to obtain a permanent
historical record of that evidence. To maintain chain of
custody, evidence must be collected, preserved, and
transported properly. In addition to all of the physical
evidence visible on the body, blood and other body fluids
present must be photographed and documented prior to
collection and transport. Fragile evidence (that which
can be easily contaminated, lost, or altered) must also be
collected and/or preserved to maintain chain of custody
and to assist in determination of cause, manner, and
circumstances of death.
31
3. Preserve Evidence (on Body)
Policy: With photographic and written documentation, the

investigator will provide a permanent record of evidence
that is on the body.
Procedure: Once evidence on the body is recognized, the

investigator should:
A. Photograph the evidence.

B. Document blood/body fluid on the body (froth/purge, substances
from orifices), location, and pattern before transporting.
C. Place decedent’s hands and/or feet in unused paper bags (as
determined by the scene).
D. Collect trace evidence before transporting the body (e.g., blood,
hair, fibers, etc.).
E. Arrange for the collection and transport of evidence at the scene
(when necessary).
F. Ensure the proper collection of blood and body fluids for subse-
quent analysis (if body will be released from scene to an outside
agency without an autopsy).
Summary:
It is essential that evidence be collected, preserved, transported,
and documented in an orderly and proper fashion to ensure the chain of
custody and admissibility in a legal action. The preservation and docu-
mentation of the evidence on the body must be initiated by the investiga-
tor at the scene to prevent alterations or contamination.
32
4. Establish Decedent Identification
Principle: The establishment or confirmation of the decedent’s
identity is paramount to the death investigation. Proper
identification allows notification of next of kin, settle-
ment of estates, resolution of criminal and civil litiga-
tion, and the proper completion of the death certificate.

Policy: The investigator shall engage in a diligent effort to

establish/confirm the decedent’s identity.
Procedure: To establish identity, the investigator should document

use of the following methods:
A. Direct visual or photographic identification of the decedent if

visually recognizable.
B. Scientific methods such as fingerprints, dental, radiographic, and
DNA comparisons.
C. Circumstantial methods such as (but not restricted to) personal
effects, circumstances, physical characteristics, tattoos, and
anthropologic data.
Summary:
There are several methods available that can be used to properly
identify deceased persons. This is essential for investigative, judicial,
family, and vital records issues.
5. Document Post Mortem Changes

Principle: The documenting of post mortem changes to the body
assists the investigator in explaining body appearance in the
interval following death. Inconsistencies between post
33
5. Document Post Mortem Changes
mortem changes and body location may indicate move-
ment of body and validate or invalidate witness state-
ments. In addition, post mortem changes to the body,
when correlated with circumstantial information, can
assist the investigators in estimating the approximate time
of death.

Policy: The investigator shall document all post mortem changes

relative to the decedent and the environment.
Procedure: Upon arrival at the scene and prior to moving the body,
the investigator should note the presence of each of the
following in his/her report:
A. Livor (color, location, blanchability, Tardieu spots) consistent/

inconsistent with position of the body.
B. Rigor (stage/intensity, location on the body, broken, inconsistent
with the scene).
C. Degree of decomposition (putrefaction, adipocere, mummifica-
tion, skeletonization, as appropriate).
D. Insect and animal activity.
E. Scene temperature (document method used and time estimated).
F. Description of body temperature (e.g., warm, cold, frozen) or
measurement of body temperature (document method used and
time of measurement).
Summary:
Documentation of post mortem changes in every report is essential
to determine an accurate cause and manner of death, provide information
as to the time of death, corroborate witness statements, and indicate that
the body may have been moved after death.
34
6. Participate in Scene Debriefing
Principle: The scene debriefing helps investigators from all participat-
ing agencies to establish post-scene responsibilities by
sharing data regarding particular scene findings. The scene
debriefing provides each agency the opportunity for input
regarding special requests for assistance, additional infor-
mation, special examinations, and other requests requiring
interagency communication, cooperation, and education.

Policy: The investigator shall participate in or initiate inter-

agency scene debriefing to verify specific post-scene
responsibilities.
Procedure: When participating in scene debriefing, the investigator

should:
A. Determine post-scene responsibilities (identification, notification,

press relations, and evidence transportation).
B. Determine/identify the need for a specialist (e.g., crime laboratory
technicians, social services, entomologists, OSHA).
C. Communicate with the pathologist about responding to the scene
or to the autopsy schedule (as needed).
D. Share investigative data (as required in furtherance of the
investigation).
E. Communicate special requests to appropriate agencies, being
mindful of the necessity for confidentiality.
Summary:
The scene debriefing is the best opportunity for investigative partici-
pants to communicate special requests and confirm all current and additional
scene responsibilities. The debriefing allows participants the opportunity to
establish clear lines of responsibility for a successful investigation.
35
7. Determine Notification Procedures
(Next of Kin)
Principle: Every reasonable effort should be made to notify the
next of kin as soon as possible. Notification of next of
kin initiates closure for the family, disposition of re-
mains, and facilitates the collection of additional infor-
mation relative to the case.

Policy: The investigator shall ensure that next of kin is notified

of the death and that all failed and successful attempts at
notification are documented.
Procedure: When determining notification procedures, the investiga-

tor should:
A. Identify next of kin (determine who will perform task).

B. Locate next of kin (determine who will perform task).
C. Notify next of kin (assign person(s) to perform task) and record
time of notification, or, if delegated to another agency, gain
confirmation when notification is made.
D. Notify concerned agencies of status of the notification.
Summary:
The investigator is responsible for ensuring that the next of kin is
identified, located, and notified in a timely manner. The time and method
of notification should be documented. Failure to locate next of kin and
efforts to do so should be a matter of record. This ensures that every
reasonable effort has been made to contact the family.
36
8. Ensure Security of Remains
Principle: Ensuring security of the body requires the investigator to
supervise the labeling, packaging, and removal of the
remains. An appropriate identification tag is placed on
the body to preclude misidentification upon receipt at the
examining agency. This function also includes safe-
guarding all potential physical evidence and/or property
and clothing that remain on the body.

Policy: The investigator shall supervise and ensure the proper

identification, inventory, and security of evidence/
property and its packaging and removal from the scene.
Procedure: Prior to leaving the scene, the investigator should:
A. Ensure that the body is protected from further trauma or contami-

nation (if not, document) and unauthorized removal of therapeutic
and resuscitative equipment.
B. Inventory and secure property, clothing, and personal effects that
are on the body (remove in a controlled environment with witness
present).
C. Identify property and clothing to be retained as evidence (in a
controlled environment).
D. Recover blood and/or vitreous samples prior to release of remains.
E. Place identification on the body and body bag.
F. Ensure/supervise the placement of the body into the bag.
G. Ensure/supervise the removal of the body from the scene.
H. Secure transportation.
37
8. Ensure Security of Remains
Summary:
Ensuring the security of the remains facilitates proper identification
of the remains, maintains a proper chain of custody, and safeguards
property and evidence.
38
Establishing and Recording Decedent Profile Information
1. Document the Discovery History

Principle: Establishing a decedent profile includes documenting a
discovery history and circumstances surrounding the
discovery. The basic profile will dictate subsequent
levels of investigation, jurisdiction, and authority. The
focus (breadth/depth) of further investigation is depen-
dent on this information.

Policy: The investigator shall document the discovery history,

available witnesses, and apparent circumstances leading
to death.
Procedure: For an investigator to correctly document the discovery

history, he/she should:
A. Establish and record person(s) who discovered the body and when.
B. Document the circumstances surrounding the discovery (who,
what, where, when, how). E
Summary:
The investigator must produce clear, concise, documented informa-
tion concerning who discovered the body, what are the circumstances of
discovery, where the discovery occurred, when the discovery was made,
and how the discovery was made.
39
2. Determine Terminal Episode History
Principle: Pre-terminal circumstances play a significant role in
determining cause and manner of death. Documentation
of medical intervention and/or procurement of ante
mortem specimens help to establish the decedent’s
condition prior to death.

Policy: The investigator shall document known circumstances

and medical intervention preceding death.
Procedure: In order for the investigator to determine terminal

episode history, he/she should:
A. Document when, where, how, and by whom decedent was last

known to be alive.
B. Document the incidents prior to the death.
C. Document complaints/symptoms prior to the death.
D. Document and review complete EMS records (including the initial
electrocardiogram).
E. Obtain relevant medical records (copies).
F. Obtain relevant ante mortem specimens.
Summary:
Obtaining records of pre-terminal circumstances and medical
history distinguishes medical treatment from trauma. This history and
relevant ante mortem specimens assist the medical examiner/coroner in
determining cause and manner of death.
40
3. Document Decedent Medical History
Principle: The majority of deaths referred to the medical examiner/
coroner are natural deaths. Establishing the decedent’s
medical history helps to focus the investigation. Docu-
menting the decedent’s medical signs or symptoms prior
to death determines the need for subsequent examina-
tions. The relationship between disease and injury may
play a role in the cause, manner, and circumstances of
death.

Policy: The investigator shall obtain the decedent’s past medical

history.
Procedure: Through interviews and review of the written records,

A. Document medical history, including medications taken, alcohol

and drug use, and family medical history from family members
and witnesses.
B. Document information from treating physicians and/or hospitals
to confirm history and treatment.
C. Document physical characteristics and traits (e.g., left-/right-
handedness, missing appendages, tattoos, etc.).
Summary:
Obtaining a thorough medical history focuses the investigation, aids
in disposition of the case, and helps determine the need for a post mortem
examination or other laboratory tests or studies.
41
4. Document Decedent
Mental Health History
Principle: The decedent’s mental health history can provide insight
into the behavior/state of mind of the individual. That
insight may produce clues that will aid in establishing
the cause, manner, and circumstances of the death.

Policy: The investigator shall obtain information from sources

familiar with the decedent pertaining to the decedent’s
mental health history.
Procedure: The investigator should:
A. Document the decedent’s mental health history, including hospi-

talizations and medications.
B. Document the history of suicidal ideations, gestures, and/or
attempts.
C. Document mental health professionals (e.g., psychiatrists,
psychologists, counselors, etc.) who treated the decedent.
D. Document family mental health history.
Summary:
Knowledge of the mental health history allows the investigator to
evaluate properly the decedent’s state of mind and contributes to the
determination of cause, manner, and circumstances of death.
42
5. Document Social History
Principle: Social history includes marital, family, sexual, educa-
tional, employment, and financial information. Daily
routines, habits and activities, and friends and associates
of the decedent help in developing the decedent’s profile.
This information will aid in establishing the cause,
manner, and circumstances of death.

Policy: The investigator shall obtain social history information

from sources familiar with the decedent.
Procedure: When collecting relevant social history information,

A. Document marital/domestic history.

B. Document family history (similar deaths, significant dates).
C. Document sexual history.
D. Document employment history.
E. Document financial history.
F. Document daily routines, habits, and activities.
G. Document relationships, friends, and associates.
H. Document religious, ethnic, or other pertinent information
(e.g., religious objection to autopsy).
I. Document educational background.
J. Document criminal history.
Summary:
Information from sources familiar with the decedent pertaining to
the decedent’s social history assists in determining cause, manner, and
circumstances of death.
43
Completing the Scene Investigation
1. Maintain Jurisdiction Over the Body
Principle: Maintaining jurisdiction over the body allows the
investigator to protect the chain of custody as the body is
transported from the scene for autopsy, specimen collec-
tion, or storage.

Policy: The investigator shall maintain jurisdiction of the body

by arranging for the body to be transported for autopsy,
specimen collection, or storage by secure conveyance.
Procedure: When maintaining jurisdiction over the body, the investi-

gator should:
A. Arrange for, and document, secure transportation of the body to

a medical or autopsy facility for further examination or storage.
B. Coordinate and document procedures to be performed when the
body is received at the facility.
Summary:
By providing documented secure transportation of the body from
the scene to an authorized receiving facility, the investigator maintains
jurisdiction and protects chain of custody of the body. F
45
2. Release Jurisdiction of the Body
Principle: Prior to releasing jurisdiction of the body to an autho-
rized receiving agent or funeral director, it is necessary
to determine the person responsible for certification of
the death. Information to complete the death certificate
includes demographic information and the date, time,
and location of death.

Policy: The investigator shall obtain sufficient data to enable

completion of the death certificate and release of juris-
diction over the body.
Procedure: When releasing jurisdiction over the body, the investiga-

tor should:
A. Determine who will sign the death certificate (name, agency, etc.).
B. Confirm the date, time, and location of death.
C. Collect, when appropriate, blood, vitreous fluid, and other
evidence prior to release of the body from the scene.
D. Document and arrange with the authorized receiving agent to
reconcile all death certificate information.
E. Release the body to a funeral director or other authorized
receiving agent.
Summary:
The investigator releases jurisdiction only after determining who
will sign the death certificate; documenting the date, time, and location
of death; collecting appropriate specimens; and releasing the body to the
funeral director or other authorized receiving agent.
46
3. Perform Exit Procedures
Principle: Bringing closure to the scene investigation ensures that
important evidence has been collected and the scene has
been processed. In addition, a systematic review of the
scene ensures that artifacts or equipment are not inad-
vertently left behind (e.g., used disposable gloves,
paramedical debris, film wrappers, etc.), and any
dangerous materials or conditions have been reported.

Policy: At the conclusion of the scene investigation, the investi-

gator shall conduct a post-investigative “walk through”
and ensure the scene investigation is complete.
Procedure: When performing exit procedures, the investigator

should:
A. Identify, inventory, and remove all evidence collected at the scene.

B. Remove all personal equipment and materials from the scene.
C. Report and document any dangerous materials or conditions.
Summary:
Conducting a scene “walk through” upon exit ensures that all
evidence has been collected, that materials are not inadvertently left
behind, and that any dangerous materials or conditions have been
reported to the proper entities.
47
4. Assist the Family
Principle: The investigator provides the family with a timetable
so they can arrange for final disposition and provides
information on available community and professional
resources that may assist the family.

Policy: The investigator shall offer the decedent’s family information

regarding available community and professional resources.
Procedure: When the investigator is assisting the family, it is

important to:
A. Inform the family if an autopsy is required.

B. Inform the family of available support services (e.g., victim
assistance, police, social services, etc.).
C. Inform the family of appropriate agencies to contact with
questions (medical examiner/coroner offices, law enforcement,
SIDS support group, etc.).
D. Ensure family is not left alone with body (if circumstances
warrant).
E. Inform the family of approximate body release timetable.
F. Inform the family of information release timetable (toxicology,
autopsy results, etc., as required).
G. Inform the family of available reports, including cost, if any.
Summary:
The interaction with the family allows the investigator to assist and
direct them to appropriate resources. It is essential that families be given
a timetable of events so that they can make necessary arrangements. In
addition, the investigator needs to make them aware of what and when
information will be available.
48
About the National Institute of Justice
The National Institute of Justice (NIJ), a component of the Office of Justice Programs, is the research
agency of the U.S. Department of Justice. Created by the Omnibus Crime Control and Safe Streets Act
of 1968, as amended, NIJ is authorized to support research, evaluation, and demonstration programs,
development of technology, and both national and international information dissemination. Specific
mandates of the Act direct NIJ to:
◆ Sponsor special projects, and research and development programs, that will improve and strengthen
the criminal justice system and reduce or prevent crime.
◆ Conduct national demonstration projects that employ innovative or promising approaches for
improving criminal justice.
◆ Develop new technologies to fight crime and improve criminal justice.
◆ Evaluate the effectiveness of criminal justice programs and identify programs that promise to be
successful if continued or repeated.
◆ Recommend actions that can be taken by Federal, State, and local governments as well as by private
organizations to improve criminal justice.
◆ Carry out research on criminal behavior.
◆ Develop new methods of crime prevention and reduction of crime and delinquency.
In recent years, NIJ has greatly expanded its initiatives, the result of the Violent Crime Control and Law
Enforcement Act of 1994 (the Crime Act), partnerships with other Federal agencies and private
foundations, advances in technology, and a new international focus. Some examples of these new
initiatives:
◆ New research and evaluation is exploring key issues in community policing, violence against
women, sentencing reforms, and specialized courts such as drug courts.
◆ Dual-use technologies are being developed to support national defense and local law enforcement
needs.
◆ Four regional National Law Enforcement and Corrections Technology Centers and a Border
Research and Technology Center have joined the National Center in Rockville, Maryland.
◆ The causes, treatment, and prevention of violence against women and violence within the family are
being investigated in cooperation with several agencies of the U.S. Department of Health and
Human Services.
◆ NIJ’s links with the international community are being strengthened through membership in the
United Nations network of criminological institutes; participation in developing the U.N. Criminal
Justice Information Network; initiation of UNOJUST (U.N. Online Justice Clearinghouse), which
electronically links the institutes to the U.N. network; and establishment of an NIJ International
Center.
◆ The NIJ-administered criminal justice information clearinghouse, the world’s largest, has improved
its online capability.
◆ The Institute’s Drug Use Forecasting (DUF) program has been expanded and enhanced. Renamed
ADAM (Arrestee Drug Abuse Monitoring), the program will increase the number of drug-testing
sites, and its role as a “platform” for studying drug-related crime will grow.
◆ NIJ’s new Crime Mapping Research Center will provide training in computer mapping technology,
collect and archive geocoded crime data, and develop analytic software.
◆ The Institute’s program of intramural research has been expanded and enhanced.
The Institute Director, who is appointed by the President and confirmed by the Senate, establishes the
Institute’s objectives, guided by the priorities of the Office of Justice Programs, the Department of
Justice, and the needs of the criminal justice field. The Institute actively solicits the views of criminal
justice professionals and researchers in the continuing search for answers that inform public
policymaking in crime and justice.
For information on the National Institute of Justice, please contact:
National Criminal Justice Reference Service
Box 6000
Rockville, MD 20849–6000
800–851–3420
e-mail: [email protected]
You can view or obtain an electronic version of this document from the
NCJRS Justice Information Center World Wide Web site.
To access this site, go to http://www.ncjrs.org
If you have questions, call or e-mail NCJRS.

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U.S.

Department of Justice Response Center:

Office of Justice Programs National Institute of Justice

Developed and Approved by the

The title of this report, formerly “National Guidelines for Death

National Institute of Justice

Richard M. Rau, Ph.D.

This project was supported under grant number 96–MU–CS–0005 by the

Opinions or points of view expressed in this document are those of the

The National Institute of Justice is a component of the Office of Jus-

In many jurisdictions, responsibility for conducting death investiga-

These guidelines were produced with the vigorous participation of

Jurisdictions will want to carefully consider these guidelines and

United States Conference of Mayors

American Academy of Forensic Sciences

American Bar Association

American Medical Association

College of American Pathologists

International Association of Chiefs of Police

National Association of Counties

National Association of Medical Examiners

National Conference of State Legislatures

National Governors’ Association

National Sheriffs’ Association

Colorado Coroners’ Association

South Dakota Funeral Directors’ Association

The author also wishes to thank the National Institute of Justice’s

In addition, the true strength of these guidelines is derived from the

And finally, the leadership of Joseph H. Davis, M.D., Medical

Steven C. Clark, Ph.D.

National Medicolegal Review Panel .................................................................. v

Acknowledgments ............................................................................................ vii

Foreword: Commentaries on the Need for

Jeanne M. Adkins, Representative, State Legislature ........................... xiii

Richard T. Callery, M.D., F.C.A.P., Chief Medical Examiner ............... xiv

Mary E.S. Case, M.D., Chief Medical Examiner .................................. xiv

Joseph H. Davis, M.D., Professor of Pathology Emeritus

Bruce H. Hanley, Esq. ......................................................................... xvii

Richard C. Harruff, M.D., Ph.D., Associate Medical Examiner ........... xix

Jeffrey M. Jentzen, M.D., Medical Examiner ......................................... xx

Mary Lou Kearns, R.N., M.P.H., Coroner ............................................. xxi

Scott L. King, Chairman, NMRP, and Mayor ..................................... xxii

George H. Kuhler, Elected Coroner..................................................... xxii

Douglas A. Mack, M.D., M.P.H., Chief Medical

Donald L. Mauro, Commanding Officer, Homicide Bureau .............. xxiii

Elaine R. Meisner, Coroner ................................................................. xxiv

Thomas J. O’Loughlin, Chief of Police ................................................ xxv

John E. Smialek, M.D., Chief Medical Examiner ............................... xxvi

Medicolegal Death Investigation Guidelines .................................................. 11

Section A: Investigative Tools and Equipment ....................................... 13

Section B: Arriving at the Scene ............................................................. 15

1. Introduce and Identify Self and Role ........................................ 15

2. Exercise Scene Safety ............................................................... 16

3. Confirm or Pronounce Death .................................................... 17

4. Participate in Scene Briefing

5. Conduct Scene “Walk Through” ............................................... 19

6. Establish Chain of Custody ....................................................... 20

7. Follow Laws (Related to the Collection of Evidence) .............. 21

Section C: Documenting and Evaluating the Scene ............................... 23