Service Area Strategic Plan
11/23/2009   5:44 am
Department of Health (601)
Biennium: 2008-10
Service Area 1 of 1
Medical Examiner Services (601 403 02)
Description

This service area provides medicolegal death investigation. In Virginia, the first line of death investigation is the local city/county Medical Examiners (ME) who conduct the initial medicolegal death investigation and serve as the principal case investigator in the locality for deaths falling within their jurisdiction and statutory authority. The VDH Office of the Chief Medical Examiner (OCME) currently supports more than 225 local medical examiners. They receive the initial notification of death, collect the history of events surrounding the death and determine if the death should come under the jurisdiction of the medical examiner. Local medical examiners attend death scenes, examine the body, and sign the certificate of death on medical examiner cases or, in accordance with OCME professionally established guidelines, refer certain classes of cases for more intensive death investigation and medicolegal autopsy at a district office.
Background Information
Mission Alignment and Authority
  • Describe how this service supports the agency mission
    This service area is aligned with Virginia Department of Health’s mission to promote and protect the health of Virginian’s by maintaining an effective and efficient system for the investigations of deaths that are unexplained or suspicious deaths of public interest. This service area is aligned with the mission of promoting and protecting public health by diagnosing the cause of sudden and unexpected deaths, conducting surveillance for deaths that present a hazard to Virginia’s citizens, identifying emerging infectious deaths, bioterrorism deaths, and documenting injuries associated with violent deaths.
  • Describe the Statutory Authority of this Service
    Pursuant to § 32.1-283 of the Code of Virginia, all of the following types of deaths are investigated by the OCME:

    • any death from trauma, injury, violence, or poisoning attributable to accident, suicide or homicide;
    • sudden deaths of persons in apparent good health or deaths unattended by a physician;
    • deaths of persons in jail, prison, or another correctional institution, or in police custody (this includes deaths from legal intervention);
    • deaths of patients/residents of state mental health or mental retardation facilities;
    • the sudden death of any infant less than eighteen months of age whose death might be attributable to Sudden Infant Death Syndrome; and
    • any other suspicious, unusual, or unnatural death.
Customers
Agency Customer Group Customer Customers served annually Potential annual customers
Attorney General and Inspector General 2 2
Cadaver dog search and rescue/recovery programs 20 25
Centers for Disease Control and Injury Prevention (CDC) 1 1
Commonwealth's Attorneys and public defenders 200 200
Department of Corrections (deaths in custody and executions) 15 15
Department of Criminal Justice Services 1 1
Department of Forensic Science (district offices) 4 4
Department of Game and Inland Fisheries (water and boating deaths) 5 5
Department of Labor (occupational deaths) 30 30
Department of Mental Health and Mental Retardation Services (deaths of patients) 50 50
Department of Social Services (paternity establishment and child abuse cases) 100 150
Division of Consolidated Labs Services 1 1
Division of Vital Records (death certificates on all decedents) 20 20
EMS, hospitals, nursing homes, adult centers, and related physicians 4,000 5,000
Families of decedents 6,000 7,500
Fort Lee Army Mortuary Affairs (training of soldiers in mortuary affairs before going to war) 200 250
Funeral homes and body transport services 750 900
General Assembly 1 1
Insurance companies (death benefits and lawsuits) 2,000 2,500
Law enforcement, all levels 5,000 8,000
Media 80 100
Schools and universities (deaths on property or campus) 28 28

Anticipated Changes To Agency Customer Base
As the population of Virginia rises, the number of cases that the OCME investigates has increased approximately by 200 cases a year since 1999. This trend is expected to continue.

The customers of the OCME are more aware of services through the website and can now e-mail inquiries directly to the OCME. Forensic television shows like CSI and educational shows through the Discovery Channel have increased customer awareness and expectations. The numbers of requests for reports from family have doubled this past year. The “CSI Effect” has resulted in increased requests for special testing, data, tours of our facilities, and for our staff to provide instructional classes and make presentation to groups.

The Virginia Commonwealth University undergraduate and graduate programs in Forensic Science sought OCME expertise to teach a course in Forensic Pathology this year and it is anticipated that this will be a continuing responsibility. The newly established School of Public Health will draw on the forensic expertise of the OCME for research as well as teaching. OCME staff teach at the medical schools, law schools, and institutions of higher learning as mandated by the Code.

The five non fatal cases of anthrax in Northern Virginia due to bioterrorism have placed a heavy burden of surveillance for bioterrorism death on the OCME. Deaths due to infection, that previously were assumed to be natural deaths due to natural disease, must now be screened in real time to capture, investigate and autopsy for a possible bioterrorism agent. Deaths due to “biological bullets” are homicides and of interest to the criminal justice system as well as public health.

There is also a focus on elder abuse and neglect deaths which will increase the surveillance for this special class of death. During the 2003 session of the General Assembly, Senate Bill (SB) 318 and House Bill (HB) 952 amended the Adult Protective Services statute, § 63.2-1603 through 1610 of the Code of Virginia, by requiring the Virginia Department of Social Services (VDSS) to develop an adult fatality review team. Specifically, the enactment clause for the Adult Protective Services Act required the Virginia Department of Social Services to develop by November 1, 2004 a model protocol and procedures for, as well as cost estimates for, the operation of an adult fatality review team.

The Virginia Adult Fatality Review Team Advisory Committee, comprised of a broad variety of representatives from local and state agencies, private organizations, advocates, and other interested parties, convened in order to meet the requirements of the mandate. The Advisory Committee established the model protocol and procedures, and the cost estimates were based on costs incurred from the maternal and child fatality review teams staffed through the Office of the Chief Medical Examiner. Legislation has been offered the last two years to establish staff and fund a team. The bills died in committee. It is anticipated that this focus will continue in the next years and that the OCME will be tasked with an Adult Fatality Review Team.

The OCME will soon take responsibility for the tracking, entry and retrieval of information on Virginia’s unidentified decedents. This project in cooperation with the Virginia State Police will entail the installation of a National Crime Information Center (NCIC) terminal in the Richmond office, training of OCME investigators in its operation and the entry into the FBI Unidentified Persons File data base of current and archival unidentified person cases. Query of the NCIC missing persons database will allow retrieval and screening of possible matches. This activity is expected to be labor intensive with lists of “best bets” being referred for follow-up to the jurisdiction of discovery of the unidentified remains. This endeavor will assist with the resolution of “cold cases”.

An increased number of requests for data from members of the General Assembly reflect their effort to develop data driven legislation.

As the second largest statewide medical examiner system in the nation, OCME data and case records information is highly valued by state and federal agencies, including the CDC and FBI. The OCME will continue to partner with the CDC to conduct population based studies of disease and death.
Partners
Partner Description
[None entered]
Products and Services
  • Factors Impacting the Products and/or Services:
    The OCME is required to achieve direct real time reporting of all death cases of concern to the Commonwealth to achieve full accreditation status by the National Association of Medical Examiners. The OCME was only granted provisional accreditation unless this deficiency is corrected within the year. The current staffing level, of 14 death investigators to staff four OCME district offices in Virginia, is not enough to cover all shifts to handle real time death reporting from law enforcement and local medical examiners for two of the four regions of Virginia. During the 2006 inspection for the OCME to retain its National Association of Medical Examiner accreditation (which sets the national standard for medical examiners systems) which is important for the credibility of the medical examiner system in court, and is a factor considered when obtaining federal grant funding that supports several OCME programs), the inspector identified that the OCME is operating with a deficiency in death investigators and local medical examiners to cover 24 hours a day, seven days a week. The standard for medical examiner systems nationwide is to have coverage of death investigators 24 hours a day, seven days a week to receive and make dispositions on death calls, consult with and assist local medical examiners from each county/city, and assist forensic pathologists who are working autopsies and investigations on holidays and weekends. A letter received in 2007 by the National Association of Medical Examiners regarding the upcoming inspection of two of the four OCME district offices states that these two offices are currently not in compliance with current accreditation criteria in this area of staffing.
    Currently cases are reported to local medical examiners that may not send in documentation on the case for weeks. There is no real time screening for bioterrorism deaths or immediate knowledge or documentation of cases that have been turned down. Local medical examiners do not have an immediate resource to ask questions on cases. Law enforcement complains regularly that they are not able to reach the local medical examiners and get disposition on a timely basis. Bodies lay in place for hours. People die 24 hours a day, seven days a week, so the cases do not stop on weekends and holidays. An additional 10 death investigator positions are needed to provide this real time coverage for law enforcement, local medical examiners, and families. Most nationwide medical examiner systems with a population equivalent to Virginia have thirty death investigators, and accept double the cases that Virginia does. In Virginia the OCME, to control costs, utilizes stringent criteria for accepting cases and investigates one out of 10 deaths; other systems investigate one out of five deaths.

    The number of local medical examiners has also drastically declined. The number of local medical examiners has decreased from 430 in 1994 to the present 2007 level of 250. The local medical examiner fee was increased from $50 to $150 (as recommended and approved by the Board of Health) so that recruitment of more local medical examiners can be achieved to cover the many counties currently underserved. The fee had not been increased since 1980 and did not adequately comensate medical examiners for the several hours they spend on each medical examiner's case. The increase was implemented in FY07.

    The Northern Virginia District facility in Fairfax, that houses the Office of the Chief Medical Examiner and the Division of Forensic Science in that region, has become outdated. A new facility is being planned through a public private partnership. This new facility is projected to be in Prince William County. This change of location will impact services by changed accessibility for some funeral home and transport services that deliver bodies to the OCME for autopsy. This location will have larger meeting areas for education and the ability for the OCME to offer its local medical examiner training at this facility.

    A growing concern for the OCME is mass fatality planning and its ability to manage a mass fatality event. Current staffing and supply is barely able to handle the daily services to the population today. There is no depth within the OCME to handle additional events or the growing change to population nor is there any surge capacity to manage larger mass fatality events. When there is a vacancy within the OCME, services are compromised and complaints increase. The most significant area of critical shortage is board certified forensic pathologists that serve as Assistant Chief Medical Examiners with five vacancies out of a total of 13 forensic pathologist positions in Virginia. There is a nationwide shortage of these trained individuals and vacancies within the OCME take over a year to fill.
  • Anticipated Changes to the Products and/or Services
    Population and public awareness of what the medical examiner does has increased, and the expectation for timely services has increased. There are several initiatives that are being sought to improve OCME service:

    The OCME is striving to serve its customers in a timely manner by obtaining more death investigators to provide direct reporting and quicker disposition of cases and identification of bodies.

    This direct reporting effort will be assisted through the current implementation of a new database at the OCME that is web based. Information has the potential to be entered immediately from the field or at time of call. Digital scene photos, autopsy photos, and digital x-ray images can be stored with the case in the database. The database has a bar coding module so the status of bodies, evidence, and lab specimens can be tracked. Reports and data can be more quickly disseminated electronically by reducing the interval between receipt/accessioning of a report and sending it to those in need.

    The OCME will be co-locating with the Division of Forensic Science in a new facility in Prince William County. The building is expected to be finished in FY08. This facility will be able to accommodate the growing case load in Northern Virginia and staff needed to handle the cases and real time death reporting. The facility is projected to have educational meeting areas so that the OCME can conduct medicolegal death investigation training for local medical examiners, law enforcement, and others.

    The OCME is striving to enhance its Forensic Pathology Fellow training program which prepares medical doctors specializing in Patholgoy to complete a year of required training in a medical examiners system to become a Forensic Pathologist and get Board Certified in the specialty. This program serves as a feeder of qualified candidates when there Forensic Pathologist vacancies.
  • Listing of Products and/or Services
    • Perform medicolegal death investigation, scientific identification of decedents, external examinations, medicolegal autopsy and anthropological review.
    • Certify the cause and manner of death for courts, vital records, families and others.
    • Collect toxicology and other specimens, process digital photography at scene and autopsy, document all findings.
    • Perform collections of DNA, fingerprints, x-ray, and records for identification of deceased.
    • Enter all information into a database and stores case files and records.
    • Establish and maintain unidentified persons files through NCIC
    • Provide reports and consultation on cases to law enforcement, attorneys, insurance companies, families, and other state and federal agencies.
    • Provide court testimony and depositions.
    • Provide training to forensic pathology fellows, medical students, residents, law enforcement, local medical examiners, EMS, attorneys and many others.
    • Teach courses at universities and with the Virginia Institute of Forensic Science and Medicine.
    • Provide data to various agencies (Dept. of Labor, Dept. of Criminal Justice Services), Centers for Disease Control, pharmaceutical research oversight companies, Fatality Teams, and more.
    • Administer the State Child Fatality Review Team, Maternal Mortality Review Team, Family and Intimate Partner Violence Review, and the National Violent Death Reporting System.
    • Partner with Virginia Commonwealth University to administer the Department of Legal Medicine (teach courses, train forensic pathology fellows, and house a forensic epidemiologist position for the university)
    • Partner with the CDC to continue to conduct population based studies.
Finance
  • Financial Overview
    General Funds comprise the majority (91%) of the service area's budget and support most of the code mandated, core mission activities of the OCME, which includes: personnel costs, body transport, local medical examiner fees, supplies, utilities, x-ray, digital cameras for scene and morgue photography, computers, database, fingerprinting, archiving, transcription, biohazard waste, training, court travel, vehicles, maintenance, office supply, communications equipment and other needs. Nongeneral funds comprise the remaining nine percent of the service area's budget. The fatality review teams, surveillance teams, forensic pathology fellows, and one staff forensic pathologist are supported by federal grants. These positions support core functions.

    Personnel costs account for 75 percent of the service area's budget.
  • Financial Breakdown
    FY 2009    FY 2010
      General Fund     Nongeneral Fund        General Fund     Nongeneral Fund  
    Base Budget $7,321,047 $676,844    $7,573,775 $676,844
    Change To Base $20,497 $0    $426,832 $0
               
    Service Area Total   $7,341,544  $676,844     $8,000,607  $676,844 
Human Resources
  • Human Resources Overview
    [Nothing entered]
  • Human Resource Levels
    Effective Date      
    Total Authorized Position level Ø    
    Vacant Positions Ø    
    Current Employment Level 0.0    
    Non-Classified (Filled)    
    Full-Time Classified (Filled)    breakout of Current Employment Level
    Part-Time Classified (Filled)    
    Faculty (Filled)    
    Wage    
    Contract Employees    
    Total Human Resource Level 0.0   = Current Employment Level + Wage and Contract Employees
  • Factors Impacting HR
    [Nothing entered]
  • Anticipated HR Changes
    [Nothing entered]
Service Area Objectives
 
  • Enhance Virginia’s medicolegal death investigation system through increased local medical examiner recruitment.
    Objective Description
    This service area is highly dependent upon work performed by local medical examiners, who are appointed by the Chief Medical Examiner. Local medical examiners are responsible for the medical investigation of the circumstances of death, physical examination of the body, collection and shipping of toxicologic specimens, recognition, collection and referral to law enforcement of physical evidence on the body, diagnosing cause and manner of death, signing the certificate of death and the making and sending of the required reports to the district office for processing and distribution.
    Objective Strategies
    • Increase the training and tools for death investigation provided to local medical examiners.
    • Educate eligible phsyicians regarding the increased case fee and benefits of being a medical examiner through presentations at medical society meetings.
    Objective Measures
    • Number of local medical examiners.
      Measure Class:
      Other
      Measure Type:
      Input
      Measure Frequency:
      Annual
      Preferred Trend:
      Up
      Measure Baseline Value:
      225
      Date:
      6/30/2005

      Measure Baseline Description: Number of local medical examiners

      Measure Target Value:
      275
      Date:
      6/30/2010

      Measure Target Description: Number of local medical examiners

      Data Source and Calculation: The data source for this calculation is the Office of the Chief Medical Examiner database that stores information on active local medical examiners appointed to perform death investigation. This can also be measured by counting the files kept on each local medical examiner that is appointed.

  • Improve the quality and quantity of medicolegal death investigation in Virginia by implementing real time 24/7 direct reporting of deaths to district offices.
    Objective Description
    Real time reporting of deaths will improve medical examiner case acquisition and disposition, and provide surveillance for bioterrorism, emerging infections, and elder abuse. Presently, only homicides and most suicides are reported contemporaneously with the death because they are sent to a district OCME office to be autopsied. Reports of all other deaths which are not autopsied come in over days to months later. The OCME is not aware of the death until the report is mailed in. For statewide ME systems the standard rate of acceptance of cases is one for each four or five deaths. Virginia accepts one in ten. Missed cases are partially investigated retrospectively. Additional statewide positions statewide are needed to receive calls and provide 24 hour 7 day a week real time death reporting coverage for law enforcement, local medical examiners and hospitals, nursing homes and others that are reporting deaths.
    Objective Strategies
    • Seek appropriation funding and position allotment for the addition of 10 medical death investigator positions.
    • Educate members of the Executive Branch, General Assembly and partner agencies on the critical need for real time 24/7 coverage for death reporting.
    Objective Measures
    • Number of medicolegal death investigators.
      Measure Class:
      Other
      Measure Type:
      Input
      Measure Frequency:
      Annual
      Preferred Trend:
      Up
      Measure Baseline Value:
      8
      Date:
      6/30/2005

      Measure Baseline Description: Number of medicolegal death investigators

      Measure Target Value:
      24
      Date:
      6/30/2010

      Measure Target Description: Number of medicolegal death investigators

      Data Source and Calculation: Classified position count for this role.

  • Provide Virginia with enhanced medicolegal death investigation through increased training and resources provided to local medical examiners serving in Virginia.
    Objective Description
    Standard medical education of physicians does not include death investigation, forensic pathology or medical jurisprudence. Virginia licensed physicians, who serve as local medical examiners, need specialized training to apply the principles and practice of medicine to the subspecialties of forensic pathology and legal medicine as they apply to death investigation.
    Objective Strategies
    • Conduct training at four different sites around the State for local medical examiners.
    • Offer continuing medical education (CME) credits for this training.
    • Engage subject matter experts on death investigation in areas to include but not be limited to: jurisdiction, recognition of classes of injury, causes of death, scene investigation, forensic evidence recognition, and the ancillary procedures associated with death investigation.
    • Design educational space, in the new public/private partnership facility for the Office of the Chief Medical Examiner and the Department of Forensic Science, to conduct local medical examiner training.
    • Write the guidelines for the local medical examiners that they will need in conducting medicolegal death investigations.
    • Promulgate copies of the guidelines in book and a CD form to all appointed local medical examiners.
    Objective Measures
    • Number of training seminars conducted for local medical examiners that are taught by subject area experts on death investigation.
      Measure Class:
      Other
      Measure Type:
      Output
      Measure Frequency:
      Annual
      Preferred Trend:
      Up
      Measure Baseline Value:
      1
      Date:
      6/30/2005

      Measure Baseline Description: Number of training seminars

      Measure Target Value:
      4
      Date:
      6/30/2010

      Measure Target Description: Number of training seminars

      Data Source and Calculation: The data source for this calculation is the Office of the Chief Medical Examiner schedule and website that offers the training.

  • Produce and promulgate data and results from Medical Examiner case investigations and Fatality Review and Surveillance Teams for policymakers, decision makers, and prevention specialists.
    Objective Description
    Development and dissemination of information concerning the extent and causes of sudden, unexpected, and/or violent deaths in the Commonwealth is a key public health function. This type of information is vital to the development of public health policies and practices aimed at preventing sudden, unexpected deaths.
    Objective Strategies
    • Utilize the grant funded forensic epidemiology position to collate data and present in a format consistent with the first annual report produced by the Office of the Chief Medical Examiner. The format used is comparable to other systems.
    • Utilize the grant funded positions to collate data and present in a format consistent with prior reports produced by the Office of the Chief Medical Examiner.
    • Print report for distribution and place on the Office of the Chief Medical Examiner website.
    Objective Measures
    • Produce and distribute an Office of the Chief Medical Examiner annual report that lists, sorts and interprets data relating to Medical Examiner deaths that can be used by policy makers and prevention groups.
      Measure Class:
      Other
      Measure Type:
      Output
      Measure Frequency:
      Annual
      Preferred Trend:
      Maintain
      Measure Baseline Value:
      1
      Date:
      6/30/2005

      Measure Baseline Description: Number of reports

      Measure Target Value:
      1
      Date:
      6/30/2010

      Measure Target Description: Number of reports

      Data Source and Calculation: Office of the Chief Medical Examiner.

    • Number of Fatality and Mortality Review reports produced.
      Measure Class:
      Other
      Measure Type:
      Output
      Measure Frequency:
      Annual
      Preferred Trend:
      Up
      Measure Baseline Value:
      2
      Date:
      6/30/2005

      Measure Baseline Description: Two reports produced for the Child Fatality Review Team with grant funding, and one report produced for the National Violent Death Reporting System project.

      Measure Target Value:
      4
      Date:
      6/30/2010

      Measure Target Description: One report produced and distributed for each Fatality or Surveillance Review team which would be a total of four different reports.

      Data Source and Calculation: Office of the Chief Medical Examiner

  • Increase the number of identified decedents by implementing the tracking, entry and retrieval of information on Virginia’s unidentified decedents.
    Objective Description
    This project in cooperation with the Virginia State Police will entail the installation of a National Crime Information Center (NCIC) terminal in the Richmond office, training of OCME investigators in its operation and the entry into the FBI Unidentified Persons File data base of current and archival unidentified person cases. Retrieval and screening of possible matches is expected to be labor intensive with “best bets” being referred for follow-up to the jurisdiction of discovery of the unidentified remains. This endeavor will assist with the resolution of “cold cases”.
    Objective Strategies
    • Install an National Crime Information Center terminal in the Office of the Chief Medical Examiner and train the death investigators in its use in partnership with Virginia State Police and the FBI.
    • Seek grant funding for the installation and maintenance of the terminal.
    Objective Measures
    • Number of identified decedents in the Commonwealth of Virginia.
      Measure Class:
      Other
      Measure Type:
      Outcome
      Measure Frequency:
      Annual
      Preferred Trend:
      Down
      Measure Baseline Value:
      1
      Date:
      6/30/2005

      Measure Baseline Description: Percent of medical examiner cases remaining unidentified through modern forensic means of identification.

      Measure Target Value:
      .7
      Date:
      6/30/2010

      Measure Target Description: Percent of medical examiner cases remaining unidentified through modern forensic means of identification.

      Data Source and Calculation: Unidentified logbook and Office of the Chief Medical Examiner database.


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