Factors that impact the determination by medical examiners of elder mistreatment as a cause of death in older people

With medical examiners rarely considering elder mistreatment (EM) as a cause of death due to the possible lack of research and evidence to support this determination, this study was undertaken to begin to develop primary data and a literature base on the forensics of elder mistreatment. The four phases of this study shed light on multiple issues concerning the forensics of elder mistreatment (EM). Phase I results showed that medical examiners infrequently determined EM as a cause of death in older decedents. Phase II results show that while the medical examiners are expert at performing autopsies, interpreting toxicology and determining the cause and manner of death, they are not versed in the standard of care of older persons. Phase III shows that the scene investigation is not necessarily geared to the detection of forensic markers and risk factors for EM and that the training of investigators in the specifics of EM may be helpful. Phase IV showed that cases where dementia was documented or there were skin findings such as pressure ulcers were more likely to be autopsies and were more likely to have been an Adult Protective Service (APS) case prior to the death of the decedent. The four studies show that determination of death due to elder mistreatment is very difficult. There is not the data on forensic markers needed to support the medical examiners assessments, they have little training in geriatric medicine, and it is difficult to evaluate the differences in old age and disease versus EM. In this study a research team conducted four distinct projects to evaluate three aspects of death determination by medical examiners: autopsy or external examination, medical records and toxicology, and scene investigation. These included: (1) a survey exploring the views of medical examiners concerning all three areas of death determination; (2) evaluating scene investigation and medical records and toxicology by studying the medical examiners case conferences and case records; (3) studying the scene investigation; and (4) exploring autopsy and physical examination findings.