216-RICR-60-10-1. Medical Examiner System (version Amendment, 12/10/2012 to 04/17/2018)

RULES AND REGULATIONS PERTAINING TO MEDICAL EXAMINER SYSTEM [R23-4-ME] STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DEPARTMENT OF HEALTH March 1978 AS AMENDED: June 1983 October 1990 August 1992 (E) January 2007 (re-filing in accordance with the provisions of section 42-35-4.1 of the Rhode Island General Laws, as amended) October 1992 September 2007 February 1993 (E) July 1993 (E) July 1993 (E) January 2012 (re-filing in accordance with the provisions of section 42-35-4.1 of the Rhode Island General Laws, as amended) August 1993 September 2012 December 1993 (E) February 1994 January 2002 (re-filing in accordance with the provisions of section 42-35-4.1 of the Rhode Island General Laws, as amended) i INTRODUCTION These amended Rules and Regulations Pertaining To Medical Examiner System [R23-4-ME] are promulgated pursuant to the authority conferred under section 23-4-6 of the General Laws of Rhode Island, as amended and are established in the public interest for the purpose of assuring proper certification of cause and manner of medico-legal deaths. These rules and regulations provide minimum uniform standards governing the reporting, investigation, and disposition of reportable deaths to assist the Office of State Medical Examiners and any person, law enforcement agency, hospital, or physician to maintain an effective medical examiner system. Pursuant to the provisions of section 42-35-3 of the General Laws of Rhode Island, as amended, the following issues were considered in arriving at the proposed regulations: (1) alternative approach; and (2) duplication or overlap with other state regulations. Based on the available information, no known alternative approach, duplication or overlap was identified. These amended regulations shall supercede all previous Rules and Regulations Pertaining to Medical Examiner System promulgated by the Department of Health and filed with the Secretary of State. ii TABLE OF CONTENTS Section Page 800.0 Definitions 1 801.0 Office of State Medical Examiners 1 802.0 Reportable Deaths and Occurrences 2 803.0 Procedure for Reporting Deaths 5 804.0 Procedure for Investigations 6 805.0 Removal of Body from Scene 7 806.0 Autopsies 7 807.0 Effects and Property of Deceased-Release of Body 8 808.0 Unclaimed Bodies 8 809.0 Pronouncement of Death and Issuance of Death Certificate 8 810.0 Special Requirements for Law Enforcement Agencies 8 811.0 Special Requirements for Hospitals-Emergency Room 9 812.0 Transplantation of Organs From Decedent Bodies or Cadavers 10 813.0 Cremation 10 814.0 Records and Reports 11 815.0 Fees For Reports and Services 11 816.0 Violations and Penalties 11 817.0 Exception and Severability 12 Appendix A 13 1 800.0 Definitions Whenever used in these rules and regulations, the following terms shall be construed as follows: 800.1 "Chief Medical Examiner" shall mean the person responsible for the immediate supervision of the Office of State Medical Examiners. 800.2 "Assistant Medical Examiners" shall mean a duly licensed doctor of medicine or osteopathy appointed to assist the Office of State Medical Examiners on a part-time basis. 800.3 "The Medical Examiner" shall mean the Chief Medical Examiner, or his duly authorized agent or representative. 800.4 "Law Enforcement Agencies" shall include but not be limited to state or municipal organized police forces, and federal, state or municipal officers concerned with law enforcement investigations. 801.0 Office of State Medical Examiners 801.1 Established in the Department of Health is the Office of State Medical Examiners in accordance with section 23-4-2 of the General Laws of Rhode Island, as amended. 801.2 The Chief Medical Examiner shall have general supervision over the administration of and shall enforce the provisions of Chapter 23-4 of the General Laws of Rhode Island, as amended. He shall recommend to the State Medical Examiners Commission such rules and regulations as he may deem necessary to effectuate the provisions of aforementioned statute. 801.3 The Chief Medical Examiner shall appoint with the approval of the Director of Health such assistant medical examiners and shall hire such other staff as necessary to carry out the provisions of Chapter 23-4 of the General Laws of Rhode Island, as amended. 801.4 The State Medical Examiners Commission: (a) Duties - The Medical Examiners Commission shall promulgate rules and regulations; hear and determine appeals from decisions of chief medical examiners regarding the undertaking of investigations, inquests and autopsies; and shall advise the chief medical examiner on matters of public concern (Section 23-4-6); (b) Appeals - Appeals from decisions of medical examiners regarding the undertaking and results of postmortem examinations, investigations, inquests and/or autopsies shall be heard by a Hearing Committee of the Medical Examiners Commission. Upon receipt of a notice of appeal, the Chairman of the Commission shall appoint three (3) members of the Commission, at least two (2) of whom shall be physicians, to hear the appeal. Hearings on said appeals shall be held in accordance with the provisions of the Administrative Procedures Act (Chapter 42-35) of the Rules and Regulations Governing Practices and Procedures Before the Department of Health (R42-35-PP). 801.5 The Director of the Department of Health and the Attorney General shall be the chairman and vice chairman respectively of the commission. The Chief Medical Examiner of the Office of 2 State Medical Examiners shall serve as the executive secretary of the commission. 801.6 In accordance with Chapter 23-4 of the General Laws of Rhode Island, a amended the responsibilities of the Chief Medical Examiner in addition to those of sections 801.2, 801.3 and 801.4 above shall include the following functions of the Office of State Medical Examiners: i. the investigation of those deaths within the state which are considered reportable in accordance with section 802.1 herein. ii. the conduct of inquests when requested by the attorney general; iii. the performance of autopsies when appropriate; iv. the written determination of the causes of death investigated; v. the presentation to the courts of Rhode Island of expert testimony relating to the cause of death; vi. the keeping of complete records, copies of which shall be delivered to the attorney general and of which written determination of causes of death shall be made available for public inspection; vii. the disposition of bodies for burial in accordance with existing legal responsibility (see section 808.1 herein); viii. the development and enforcement of procedures for the pronouncement of death and the transplantation of organs from bodies of persons who have died in Rhode Island (see section 812.0 herein); ix. the maintenance and operation of the state morgue; x. allowance of such compensation for the recovery of body or bodies from water as he deems necessary in accordance with section 23-4-12 of the General Laws of Rhode Island, as amended. xi. the determination as to the appropriateness of carrying out specific procedures such as investigations, postmortem examinations and autopsies to ascertain the cause and manner of death consistent with the rules and regulations herein and Chapter 23-4 of the General Laws of Rhode Island, as amended; and xii. the determination of the efficacy of cooperating with other agencies, institutions, whether federal, state or local in order to carry out the provisions of the heretofore mentioned statues and the rules and regulations herein 802.0 Reportable Deaths and Occurrences 802.1 The Office of State Medical Examiners shall be notified by any person of all deaths which occur in any manner suggesting the possibility of any of the following types or occurrences of 3 deaths: 802.1.1 Abortion or Suspected Abortion: All maternal deaths in which there is reasonable evidence to suspect a criminal abortion, and those deaths during or following therapeutic abortion or delivery, and all maternal deaths up to six (6) weeks following normal or abnormal delivery, and those maternal deaths after six (6) weeks if thought to be due to or resulting from any procedure involving pregnancy, delivery and postpartum treatment. 802.1.2 Disease Following Injury: All cases where the immediate cause of death may be natural disease, but where a history of an injury exists which may have been responsible for initiating the sequence of events leading to death. 802.1.3 During or Immediately Following Anesthesia, Diagnostic or Therapeutic Procedures: All deaths during or following anesthesia, diagnostic or therapeutic procedures regardless of the location, procedure, and circumstances, or regardless of survival time if death is thought to be directly related to the procedure or complications resulting from said procedure. 802.1.4 Fetal Death: All fetal deaths occurring without medical attendance or after delivery of a live born fetus following therapeutic abortion, or when inquiry is required in accordance with section 23-3-17 (e) of the General Laws of Rhode Island, as amended. 802.1.5 Job Related Injury: All instances in which the environment of present or past employment may have caused or contributed to death by trauma or disease, including any consequence of any physical or toxic injury incurred while employed, and including all deaths during or related to employment. 802.1.6 Incarceration or Detention: All deaths occurring in any correctional institution, reformatory, or other incarceration and detention area such as prison, or death of any individual in custody. 802.1.7 Long Term Confinement: All sudden, unexpected, traumatic or any unnatural death after long term confinement of patients suffering from mental and physical disorders in hospitals, or nursing or personal care homes in accordance with the Rules and Regulations for Nursing or Personal Care Homes. 802.1.8 Suspicious, Unusual or Unnatural: All deaths in which there is reasonable evidence to suspect accident, suicide, homicide or other unnatural process or unusual manner. 4 802.1.9 Sudden, In Apparent Good Health: All deaths occurring unexpectedly where the decedent was not under continuous medical treatment for the disease or condition believed to be the cause of death including: i. instantaneous death without obvious cause; ii. death during or after an acute, unexplained rapidly fatal illness, including "crib death" (SIDS) of young infants; iii. deaths occurring in public places, such as buildings, streets, parks or like areas; iv. sudden deaths occurring on flights of aircraft landing in the state; and v. sudden deaths occurring on board ship docked at piers in the state or in state territorial waters. 802.1.10 Suspicion of a Contagious Disease or Agent: All deaths where suspicion exists of a highly infectious process capable of spreading an epidemic within the State. 802.1.11 Unattended by a Physician: All deaths in which the decedent was: i. unattended by a physician in accordance with section 23-3-16 (d) of the General Laws of Rhode Island, as amended; ii. found dead without obvious cause; iii. not under treatment for the apparent cause of death; iv. not seen by the attending physician within two weeks prior to death. 802.1.12 Medicinal, Pharmaceutical or Other Chemical Agents, including Addictive Substances: All deaths occurring, whether directly or indirectly related, from a narcotic drug, medicinal substance, drug treatment modality and including ethyl alcohol containing beverages, whether sudden, or whether short or long term survival has occurred. 802.1.13 Violence: All deaths (whether homicide, suicide or accident) in which an external cause or agent contributes to the death irrespective of the period of time between injury and death. External agents may include mechanical, chemical, electrical, thermal or other trauma. 5 802.1.14 Anatomical material suspected of being or determined to be part of a human body. 802.1.15 Newborn Infants: Deaths of newborns and stillbirths delivered or occurring outside of a hospital or when the mother was involved in a recent or past traumatic event (motor vehicle crash, suicide attempt, etc.) that may have precipitate the delivery and may have a causal relationship to the newborn death, and all infant deaths occurring within 24 hours of delivery without known reasonable cause of death, or if the cause is suspected to be traumatic before, during or after said delivery. 802.1.16 In-Hospital Deaths: a) All deaths suspected to be due to or contributed to by trauma or whatever type (physical, firearms, chemical abortion, etc.) including accidentally, suicidally, and homicidally inflicted trauma. b) Deaths occurring while under the influence of anesthesia, during the postanesthetic period without the patient regaining consciousness, or following long term survival if the original incident is thought to be related to the surgical procedure or the anesthetic agent. c) All deaths occurring during or following therapeutic or diagnostic procedures, including blood transfusions, whether thought to be related to death or independent therefrom. d) All deaths where the industrial environment is suspected as cause of the terminal disease or where illness began on the job or at place of employment. e) All deaths occurring within 24 hours of admission. 802.1.17 Hospital Emergency Room Deaths: a) All cases "dead on arrival." b) Deaths due to or suspected from trauma in accordance with Section 802.1.13 herein. c) Deaths occurring within 24 hours of entry into the emergency room. 802.1.18 In-hospital or emergency room deaths specified in sections 802.1.16 and 802.1.17 where the attending physician has no adequate or reasonable explanation of the cause of death. 803.0 Procedure for Reporting Deaths 803.1 It shall be the duty and responsibility of any person, be he or she physician, law enforcement officer, funeral director, hospital official, relative of the deceased person responsible for burial or cremation, or other individual having knowledge of any person, the circumstances of whose death may be categorized in accordance with section 802.0 herein, to immediately notify the Office of State Medical Examiners. 6 803.2 Information Required Any person, law enforcement agency or hospital, in reporting deaths to the Office of State Medical Examiners, shall submit the following data: the name, address, and age of the decedent, if known; the location of the body, a summary of the circumstances of death, and any pertinent medical information, such as names of doctor, hospital, prescription, etc. 804.0 Procedure for Investigations 804.1 In those instances where a person has met death in any manner or circumstance as stated in section 802.0 herein, the Medical Examiner shall determine the medico-legal jurisdiction of the case, and if accepted, shall take charge at the scene, if appropriate, in accordance with section 23-4-8 of the General Laws of Rhode Island, as amended, and shall be the first to examine the dead body (except in the situation stated in section 804.3 herein). The Medical Examiner shall initiate the necessary investigatory procedures, which may include but shall not be limited to: a) investigation of circumstances surrounding the death; b) viewing the scene of death; c) reviewing past medical and other history; d) conducting toxicology and other laboratory tests; e) examining physical evidence; and f) performing postmortem examinations or autopsies. 804.2 Any information required by the Medical Examiner to conduct investigations shall be made available to the Office of State Medical Examiners. Such information may include but shall not be limited to: a) medical histories; b) witnesses' statements; and c) hospital records including X-rays, pertinent body fluid and other specimens, clothing, personal effects, medications and prescriptions, and any other items having a possible bearing on the cause and manner of death. 804.3 In cases accepted for jurisdiction, the Medical Examiner shall be the first to examine the dead body on the scene. In such situations, the body shall not be disturbed without authorization of the Medical Examiner; except that in those cases in which a possibility of life remains whereupon, the law enforcement officer or appropriate rescue team personnel on the scene shall 7 initiate and facilitate such life saving procedures as may be appropriate. 805.0 Removal Of Body From Scene 805.1 The Medical Examiner shall authorize the removal of the body of the decedent including pertinent evidence on or about the body, and including instrumentalities which may be pertinent to the cause and manner of death, to the state morgue, or to whatever place is deemed appropriate by the medical examiner. 805.2 In the event a person dies suddenly in a public place from apparent natural causes or from a highway accident, the law enforcement agency or the medical examiner may order the removal of the body from the place of death, upon completion of an investigation as to the cause and manner of death, to the state morgue, a local hospital or funeral home designated by a family representative of the deceased in accordance with section 23-4-9 of the General Laws of Rhode Island, as amended. 806.0 Autopsies 806.1 Autopsies shall be performed by the Medical Examiner in those cases where, in the judgement of the Medical Examiner, the cause of death cannot be established with a reasonable degree of certainty and in those cases where the actual pathological findings must be documented, and in those instances where indicated in support of the provisions of this chapter. In such cases autopsies may be performed by the Medical Examiner on all reportable deaths without requiring permission of next of kin or legal representative. 806.2 Hospitals may request permission to perform autopsies on reportable death cases (see section 802.0) only upon completion of the investigation by the Medical Examiner or upon release of jurisdiction of the case by the Medical Examiner. 806.2.1 However, in some circumstances, the Medical Examiner may permit the hospital to perform the autopsy prior to issuance of the death certificate, provided that hospitals obtain the proper permission from the next of kin or legal representative. 806.2.2 Hospitals performing autopsies must meet the requirements of the Rules and Regulations for the Licensing of Hospitals. 806.2.3 Copies of any autopsy reports performed by hospitals on cases referred to or released by the Medical Examiner shall, upon request, be submitted to the Office of State Medical Examiners. 807.0 Effects And Property Of Deceased - Release Of Body 807.1 All articles and property of a deceased on or about the body may be taken by the Medical Examiner only if an autopsy or postmortem examination is to be done and shall then be disposed of in accordance with section 23-4-11 of the General Laws of Rhode Island, as 8 amended. 807.2 The Office of State Medical Examiners shall, after any postmortem examination or any autopsy, promptly release the deceased body to the relatives or representatives of the deceased, provided proper identification has been established and any procedures relevant to evidentiary examination have been performed. 807.3 Any funeral director receiving permission to remove a decedent shall provide a written communication from the next of kin to the Office of State Medical Examiners prior to removal of said decedent. 808.0 Unclaimed Bodies 808.1 In those instances where there are no known relatives or representatives to claim the body of the deceased, the Office of State Medical Examiners, after reasonable public notices of no less than fourteen (14) days, shall cause the body of the deceased to be buried in accordance with sections 23-4-10 and 23-42-1 of the General Laws of Rhode Island, as amended. 809.0 Pronouncement of Death And Issuance Of Death Certificate 809.1 Pronouncement of death shall be made, if appropriate, at the scene of death by the Medical Examiner only in those cases where the Office of State Medical Examiners has assumed jurisdiction for investigation in accordance with section 804.1 herein. 809.2 Following investigations, postmortem examinations, or autopsies, the death certificate shall be prepared by the Medical Examiner in medicolegal cases and including but not limited to cases referred to in section 809.1 above. 810.0 Special Requirements for Law Enforcement Agencies 810.1 Notification of the death of any individual to the next of kin shall be the responsibility of the law enforcement agency in whose jurisdiction the death occurred. 810.2 Traffic Death Situations: In all traffic death situations, the following evidence shall be made available to the Medical Examiner: a) The brake and accelerator pedals in all motor vehicle driver deaths; b) Helmets and other protective gear in all cyclist deaths; c) All clothing and personal effects of decedents from any vehicular death, especially those in which an offending vehicle has left the scene ("hit and run"); d) A copy of the incident report and subsequent investigation of any vehicular accident resulting in death; 9 e) Any vehicle, such as auto, cycles, or other when pertinent; and f) Any weapon, instrument or other modality possibly related to the cause and manner of death. 810.3 Crime Scene Situations: a) The Medical Examiner shall be notified immediately of any death occurring in a potential crime situation. In such cases, the body of the victim shall not be disturbed and any weapons, ligatures, drugs and any other evidence possibly related to the death shall be preserved at the scene for examination by the Medical Examiner. b) Normal police procedures such as inquiries, dusting for fingerprints, (excluding fingerprinting the deceased) and scene photography may be carried out prior to the arrival of the Medical Examiner. c) The Medical Examiner shall take charge, examine the body of the victim and cooperate with the law enforcement agency or agencies conducting the police investigation. 810.4 Narcotic or Drug Overdose Deaths: All related paraphernalia including needles, syringes, suspected drugs, tourniquet, etc., shall be removed by the Medical Examiner from the scene of occurrence. Such evidence as may be warranted shall subsequently be submitted by the Medical Examiner for toxicologic examination, analysis and report. In addition the requirements of sections 811.2 and 811.3 shall apply. 811.0 Special Requirements for Hospitals 811.1 Information from Pharmacists: In those cases under investigation, the Medical Examiner shall be furnished, upon request, all pharmaceutical prescriptions and other relevant information from any dispensing agency or drug rehabilitation program or like agency having contact with the decedent or his or her agent. 811.2 Hospital Emergency Rooms shall in all cases of reportable deaths, maintain the following practices: a) All clothing, including shoes, from any case of trauma including those possibly due to a criminal act, shall be retained and not washed, cleaned or disturbed; b) Any clothing, foreign materials or other debris lodged in wounds shall be preserved, when possible; c) Needle marks incurred before arrival at the hospital shall be marked so as to separate "marks" from those received in emergency room; d) All wounds of a serious nature shall be precisely documented by diagram and description in the hospital record; 10 e) X-rays, medical records, and other reports, or copies thereof, shall be made available to the Medical Examiner as requested; f) One blood specimen (full 10cc, red-top tube) shall be retained where feasible and labeled "Medical Examiner" from any victim of mechanical, (e.g. auto accident) chemical, ("overdose") or other trauma who is a potential fatality referable to the Medical Examiner. Such blood specimen shall be discarded by the hospital laboratory in those cases discharged alive. Other body fluid and tissue specimens, including gastric contents, shall likewise be retained at least in part, and made available to the Medical Examiner upon request in case of death and acceptance of jurisdiction. 812.0 Transplantation of Organs From Decedent Bodies Or Cadavers 812.1 The Office of State Medical Examiners shall be notified of all cases in which the transplantation of organs from bodies of persons who have died within the State of Rhode Island is to be carried out. A copy of any "document of gift", in accordance with section 23-47-5 of the General Laws of Rhode Island, as amended, shall be made available for examination by the Medical Examiner. 812.2 The Medical Examiner reserves the right to approve or disapprove the execution of a donor transplantation procedure in cases which would create conflict with the discharge of responsibilities of the Office of State Medical Examiners. When approval is given, a copy of approval, signed by the next of kin or legal representative shall be forwarded to the Medical Examiner. In homicide, suspected homicide cases, or those where a criminal act may have occurred, transplant of (donor) organs shall be prohibited unless specifically authorized by the Medical Examiner and the Attorney General. 813.0 Cremation 813.1 No body shall be cremated in, or removed from the state for purposes of cremation without a cremation certificate obtained from the Office of State Medical Examiners in accordance with section 23-3-18(e) of the General Laws of Rhode Island, as amended. 813.2 Whenever the death of a person whose body is to be cremated has occurred outside the state of Rhode Island, a cremation certificate shall be obtained from the Office of State Medical Examiners, following investigation of the case from the state or county in which the death occurred. The physician, hospital, and any other or involved party shall upon request of the Medical Examiner, supply appropriate information regarding the deceased. The funeral director shall provide, where feasible, a certified copy of the certificate of death to the Office of State Medical Examiners for their interpretation and records. 813.3 In those cases which appear suspicious or at variance from the available information, the Medical Examiner may request additional examinations including postmortem investigation and autopsy. 814.0 Records and Reports 11 814.1 Information and reports obtained from law enforcement agencies, local or state institutions, agencies such as hospitals, and employers in relation to deaths reported in accordance with section 802.0 herein which are deemed by federal or state law to be confidential, shall be kept confidential by the Office of the State Medical Examiners and be released only to person(s) who can demonstrate a legal right to said information and/or records and then only pursuant to a valid subpoena. 814.2 Autopsies and other reports and findings of the Office of State Medical Examiners (except homicides and other criminal cases remaining under investigation and awaiting adjudication) shall be available to: a) the next of kin or authorized legal representative responsible for the disposition of the body; b) insurance carriers subject to the written consent of the next of kin or authorized legal representatives; and c) physicians who were responsible for the care of the decedent. Copies of autopsy reports shall not be provided for inclusion in hospital medical records. 814.3 All requests for reports must be submitted in writing. 814.4 Certified copies of death certificates are to be procured from the Division of Vital Statistics, Rhode Island Department of Health. 814.5 Certified copies of "Proof of Death" are available from the Medical Examiner in lieu of a death certificate which has not been completed. 814.6 Cremation certificates shall be available from the Office of the State Medical Examiners, for Rhode Island Deaths. 815.0 Fees for Reports and Services 815.1 The office of the State Medical Examiner shall collect fees for reports and services performed by the Office in accordance with the fee schedule set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health. Agencies of state government, cities and towns shall be exempt from payment of fees. 8l6.0 Violations and Penalties 816.1 Any person who shall willfully neglect or refuse to abide by the statutory requirements of Chapter 23-4 and the rules and regulations herein shall be guilty of a misdemeanor in accordance with section 23-4-7, of the General Laws of Rhode Island, as amended. 12 817.0 Exception and Severability 817.1 Exception Modification of any individual standard herein, for experimental or demonstration purposes, or as deemed appropriate by the State Medical Examiners Commission, provided that such modification will not be contrary to the public interest and the public health, shall require advance written approval by the State Medical Examiners Commission. 817.2 Severability If any provision of these regulations or the application thereof to any facility or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of the regulations which can be given effect, and to this end the provisions of the regulations are declared to be severable. MedicalExaminer_Final_Sept2012.doc Monday, 17 September 2012