Facts, explanations, and opinions come from evidence and witnesses and are considered routinely in arriving at the cause and manner of death. Most such determinations are expeditiously made outside of any court of law, though always within some legal jurisdiction.

A "fact...or ordinary...witness" is generally not allowed to state opinions or conclusions about facts of a case in a court of law. An "expert witness," however, upon being recognized by the court (the judge) as an expert, is expected to give facts and draw conclusions or state opinions. An "expert witness" is anyone the judge will allow as an expert.

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Cause of Death

The CAUSE of a person's death is...in the final analysis...a medical determination or finding based on evidence and opinion. The cause may be considered over several time frames: the original or underlying (proximate) cause; intermediate or intervening causes; and immediate (or dependent) causes...the latter sometimes referred to as the "mode" of death.

For example, a 48 year old woman has a breast lump removed; following a number of years, the cancer re-appears in her bones...chemotherapy follows...she later dies with pneumonia. Breast cancer is the underlying or proximate cause of death and pneumonia is the immediate or dependent cause (or mode) of death.

And scientists might also be interested in the biological mechanism (probably either hypoxia or a fatal arrhythmia) of the death.

BUT, "proximate cause" becomes a different thing when applied to civil lawsuits for medical malpractice. The South Carolina Medical Association handbook, "Physicians Guide to Malpractice Law in South Carolina" [updated March 2000, pages 59-70) indicates that the legal definition of "proximate cause" in medical malpractice is one of the trickiest legal definitions in law. In that area, proximate cause of death or injury to plaintiff is more like the "dependant cause".

It is the event (or lack of, or failure of an event or action) that "but for" the fact that it happened or failed to happen, the injury or death would never have happened [the "responsible cause"]. Also, in the malpractice arena, expert testimony is usually required to pinpoint or fix the "proximate cause"; and the winning of a case by plaintiff usually requires 3 interconnected things:

(1) plaintiff must have actually suffered damages or injury (or death) (2) defendant physician (health-care worker) performance or nonperformance is negligent (3) the interconnection between the first two is explained to the jury's satisfaction by the "proximate cause".

and, the "most probable standard" indicates that plaintiff must introduce evidence that the injuries complained of "most probably" [greater than 50% probability] resulted from the alleged negligence.

and, negligence need not be the sole cause of an injury...it can be sufficient for the alleged negligence to be a "proximate concurring cause" or a "contributing cause".

and, though it might be established that a physician's conduct has in fact been one of the causes of the patient's injuries, the defendant is not necessarily liable in the absence of "foreseeability". A defendant cannot be condemned for that which cannot be foreseen, is unpredictable, and could not be expected to happen.

and, some states have adopted a "loss of chance doctrine" ["increased risk of harm doctrine"] whereby the defendant can be held liable if his conduct increased the risk of harm to the patient (plaintiff).

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Amazingly, even after a thorough autopsy, the cause of death may be uncertain or "unascertained". Most are comfortable with the designation of SIDS (sudden infant death syndrome) in infants. Society finds it difficult to accept inability to determine an exact cause of death at an age beyond infancy. But, I can personally attest that these are not rare situations (the "obscure autopsy" rate is published as no less than 5% of autopsies). Manner of Death The MANNER of a person's death is...in the final analysis...a legal determination or finding based on evidence and opinion. It is usually routinely assigned, but it is always subject to dispute/challenge and might not come to a truly finalized assignment until decided in a court of law after all appeals are exhausted.

That is, if someone wants to contest a manner of death, it is ultimately decided in a court of law...court actions tending to drag along slowly. Outside of court proceedings, such findings are legally made by government-employed or elected medical examiners or coroners.

Medical opinions or conclusions obtained during the case investigation are usually given great weight, whether from general doctors or pathologists trained in (and practicing) forensic pathology (remember the TV program, Quincy)? Manner of death can have immense importance in whether people undergo intense personal investigation, go to jail, receive large lawsuit awards, or receive multiple (double or triple indemnity) payments on life insurance.

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There are six categories of manner of death:

1. Natural: the death is a consequence of natural disease

2. Accidental: unintended and essentially unavoidable death, not by a natural, suicidal or homicidal manner [see below]

3. Suicidal: Death caused by self, with some degree of conscious intent.

While Munchhausen syndrome deaths are caused by the deceased, society does not...by convention...count these as suicidal. Society also does not count deaths due to poor lifestyle habits or known self-destructive habits...when the deceased unequivocally knew that he/she was putting his/her life in danger...as suicide.

4. Homicidal: death caused by another human [check out types & degrees]

5. Undetermined: not enough evidence, yet or ever, to choose the manner of death

6. Unclassified: too complex to classify; it either stays in that category or has to be clarified and declared in a court of law (rare).

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Some Manner-of-Death Conventions

(1) By common convention, an unavoidable killing of another person by a sober person responsibly going about his/her business is considered to be an accidental manner of death...not homicide. Sadly, too often the declaration of "unavoidable" is made too quickly because of the human-nature discomfort over the distress of the killer and his/her family (who are still alive).

My partner, Dr. John Carter, and I (he has discovered, defined, and best articulated the problem with this common convention; and I agree) think that any and all deaths should undergo a thorough, essentially check-listed investigation, hammering at the issue of avoidability.

Example: auto-pedestrian deaths...(1) what is the evidence for or against "visibility" (was location such that intense sunlight was in the driver's eyes...and was the windshield visor up or down?) (2) was there any posted sign declaring a pedestrian crossing? (3) was a car phone in the vehicle? If so, what was the exact time of calls about the time of the killing? (4) what was the emotional state of the killer and of the deceased just prior to the killing event...the sobriety of each? (5) what human distractions were available to killer and deceased (driver distracted by crying infant?)...deceased distracted by an ongoing argument?

We have seen at least one instance where the driver was alcohol-intoxicated and the sober lover switched & claimed to be the driver prior to arrival of anyone else on the scene. When Dr. Carter assigned "homicide" as the manner of death, the stories quickly changed and the case clarified. As you can imagine, it could take some real questioning investigation...even lie detector testing...to truly settle the question of "unavoidable".

(2) By common convention, an accidental killing of oneself is an accidental manner of death...not suicide.

(3) By nearly common convention, those found dead of a disease known to be associated with unexpected sudden death [see listing] are declared dead by natural manner unless complicated by an obvious accidental component (then reasonably declared an accidental manner of death).

For example, epileptics may be found dead...an accepted, though sad and disappointing outcome. If found face down in the pillow, one might propose asphyxia as the proximate cause, accidental manner of death. But such asphyxia in an adult (as opposed to an infant) is more of a speculation; most would certify the manner as natural (possibly...not surely...proximately axphyxiating). But, an epileptic found dead in the bath-tub, head submerged, would be certified as accidental manner (probably...essentially surely...proximately drowning). The above examples assume autopsy absence of medication overdose & failure to detect other over-riding causes.

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Autopsies often provide critical information in determination of THE TRUTH of the cause and manner of death!

The "system"...law enforcement agencies, coroner's staff, or those in the medical examiner's office...only "knows" what it finds out (or what comes to light) by the point in time when preliminary, updated, or "final" determinations of cause and manner of death need to be made. Depending on a large number of factors, the urgency and pressure to "finalize" a case can vary from intense to mild.

Though it may require legal action to do so, it is always possible to attempt a change in cause or manner of death based on new information. Barring any apparent controversy or high-profile factors in a case, deaths which appear to have straightforward cause and manner are fairly quickly classified as what they appear to be. With or without postmortem or autopsy exam or other special tests or procedures, the classification is...simply...whatever the medical examiner or coroner says it is.

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