Department of Health Office of the Chief Medical Examiner 400 E. Jackson Street Richmond, VA

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1 CENTRAL DISTRICT: 400 E. Jackson St. Richmond, Virginia (804) FAX (804) WESTERN DISTRICT: 6600 Northside High School Road Roanoke, Virginia (540) FAX (540) COMMONWEALTH off VIIRGIINIIA Department of Health Office of the Chief Medical Examiner 400 E. Jackson Street Richmond, VA TIDEWATER DISTRICT: 830 Southampton Ave., Suite 100 Norfolk, Virginia (757) FAX (757) NORTHERN VA. DISTRICT: Pyramid Place, Suite 121 Manassas, Virginia (703) FAX (703) Virginia Office of the Chief Medical Examiner (OCME) Body Storage Guidelines Guidelines for Fatality Management These guidelines reflect Virginia statutes in effect as of July 2012, and best practices that are used by Local Medical Examiners and hospitals to address issues related to fatality management. I. Office of Chief Medical Examiner A Chief Medical Examiner (CME) is appointed by the Commissioner of Health ( ) The Commissioner of Health establishes a central office and district offices for medicolegal investigation of deaths and postmortem examinations that: 1) have adequate professional, technical and medical investigative personnel and physical facilities to conduct the examinations and investigations as authorized or required by law ( ); and 2) are under the supervision of the CME ( ) II. Responsibilities of Local Medical Examiners A. General: The CME appoints one or more local medical examiners (LME) for each county and city ( ). By code, local medical examiners shall be licensed to practice medicine in the Commonwealth and shall be appointed from a list of two or more nominations submitted by the medical society for the county or city for which the appointment is to be made. The LME of the county or city in which certain types of death occur shall be notified by the physician in attendance, hospital, law-enforcement officer, funeral director or any other person having knowledge of such deaths. These include: Accredited by the National Association of Medical Examiners

2 Trauma Injury Violence Poisoning Accident Suicide Homicide Sudden death, when in apparent good health When unattended by a physician (no physician of record) Sudden death as an apparent result of fire Sudden death in any suspicious or unusual manner Sudden death of infant less than 18 months where suspected cause of death is SIDS Death in jail, prison, other correctional institution or police custody Patient or resident of a state behavioral health or intellectual disabilities facility Upon notification of the death, the LME appointed for the city or county of death takes charge of the body within the locality and makes an investigation into the cause and manner of death ( ) This allows for the examination and death certification of decedents who fall under the jurisdiction of the medical examiner to occur within the locality when no medicolegal autopsy performed at the OCME district offices is required. The facilities and personnel under the CME shall be made available to LMEs in such investigations ( B.) This provides for district pathologists to perform medicolegal autopsies ordered by the LME and medicolegal death investigators to assist with LME investigations A states that the death shall be reported to the LME appointed for the county or city in which death occurs, not to the district OCME.,. Therefore, the intent of A is for ME cases to be investigated in the locality by the LME who is appointed for the locality and for bodies to stay within that locality unless moved to the district office for autopsy or further examination. Full directions as to the nature, character and extent of the investigation to be made in such cases shall be furnished each medical examiner by the Chief Medical Examiner ( ). If the body is not being sent in for autopsy, OCME policy dictates that the LME must examine the body and draw blood for toxicology testing within the locality of death at a local hospital, a nearby funeral home or rarely the death scene as described in Chapter 12 of the Medical Examiner s Handbook, A Guide to Medicolegal Death Investigation in Virginia (see below) to make a determination of the cause and manner of death., Instructions for Local Medical Examiners Without exception, local medical examiners should make every effort to draw toxicology specimens on every non-autopsy death where the medical examiner will conduct an external examination regardless of the decedent s age or physical condition. Conversely, the LME should not draw toxicology specimens on those individuals sent for autopsy. Toxicology specimens are such a crucial part of the death investigation process, therefore if the local medical examiner cannot obtain uncontaminated blood, urine, or vitreous from the body or admission hospital blood or urine samples, he or she should contact the appropriate OCME district office about the advisability of autopsy or further examination and toxicology sampling of the body.

3 B. Non-Autopsy Cases In about half of the cases investigated by the OCME, no autopsy is necessary to determine the cause and manner of death as the cause and manner of death are easily determined from the external examination of the body, the history and circumstances of death, toxicology testing and medical record review. When no autopsy is required, the LME shall investigate the death, review records, examine the decedent s body, draw necessary blood and other body fluids and certify the cause and manner of death within the locality at a local hospital or funeral home. The Virginia Code states that full directions as to the nature, character and extent of the investigation to be made in such cases shall be furnished each medical examiner by the Chief Medical Examiner ( ). If the body is not being sent in for autopsy, OCME policy dictates that the LME must examine the body and draw blood for toxicology testing within the locality of death at a local hospital, a nearby funeral home or rarely the death scene as described in Chapter 12 of the Medical Examiner s Handbook, A Guide to Medicolegal Death Investigation in Virginia to make a determination of the cause and manner of death. C. Autopsy Cases If an autopsy is required in accordance with , the body is transported to the District OCME for the autopsy to be performed by forensic pathologists and the OCME pays the transportation costs to the district offices for decedents requiring autopsy. III. Body Storage A. General In order to allow the LME access to the decedent s body locally, the body must be stored temporarily within the locality at a funeral home of the family s choice, a funeral home designated by the investigating law enforcement agency as a temporary holding site for LME cases or, when prior agreements have been made, a local hospital. Local storage is always temporary, usually for no more than a few hours, to allow the LME time to perform the examination of the body as mandated by state code. Traditionally, since the inception of the OCME through code mandate in 1946, the OCME has maintained a cooperative relationship with funeral homes and hospitals throughout Virginia allowing for local, temporary storage of an OCME decedent s remains until the LME can respond to examine the body or to arrange for transportation to the district office for autopsy. Although hospitals are not legally required to serve as a temporary storage area for deaths that occur outside the hospital, they are encouraged to do so within the limits of their own space capacity and staff availability when such needs arise. OCME is always willing to store its medical examiner cases at district offices, including unclaimed bodies that fall under the OCME jurisdiction, if requested. Any questions concerning the temporary storage of medical examiner cases should be directed to the District Office of the Chief Medical Examiner serving the locality. B. Non-Autopsy Cases It is common practice that bodies falling under the jurisdiction of the Virginia OCME remain within the locality of death under the control of the local medical examiner if they do not require an autopsy. ( A: Upon the death of any person from trauma, injury, violence, poisoning, accident, suicide or homicide, etc the medical examiner of the county or city in which death occurs shall be notified by the physician in attendance, hospital, law-enforcement officer, funeral director or any other person having knowledge of such death. and B: Upon being notified of a death as provided in subsection A, the medical examiner shall take charge of the dead body, make an investigation into the cause and manner of death, reduce his findings to writing, and promptly make a full report to the Chief Medical Examiner ).

4 Locally holding non-autopsy cases falling under the jurisdiction of the OCME allows the LME access to the body within that locality for examination, provides the funeral home quick access to the body for pick-up and funeral preparation, and gives the family an opportunity to claim the body without having to incur expenses for transportation back to the locality from the district office. In such cases the body may be released directly to the family or funeral home at the conclusion of the LME examination, and no further storage requirements exist. C. Autopsy Cases On rare occasions an autopsy case may require temporary storage prior to the arrangement of transportation to the district office. In such cases, if there is hospital involvement then the hospital is encouraged to provide such storage within the limits of its own space capacity and staff availability. If there is no hospital involvement then the LME shall, arrange for storage at a local funeral home. D. Routine Natural Deaths not under OCME/LME Jurisdiction Natural deaths where the LME s involvement is not required may fall into two categories: o Those that occur within a hospital In such cases the hospital is expected to provide temporary storage until the body is claimed by the relatives or friends of the deceased person for disposition. It is common practice for hospitals to notify the next of kin for the patients that expire in their facility and to work with the designated funeral home or Virginia State Anatomical Program, if the patient is an anatomical donor, for disposition. The disposition of unclaimed bodies falls under the jurisdiction of the sheriff as described in Section IV below, when not suitable for anatomical donation. o Those that occur outside of a hospital In these instances the hospital has no legal responsibility to provide temporary storage of the body. However, hospitals may, within the limits of their own capacity, provide temporary storage when there is no alternative morgue facility available in the community. Responsibilities for notification of next of kin and disposition of the body are not the responsibility of the hosting hospital, but are as described in the Disposition section below. E. Unnatural Deaths Resulting from Mass Casualty Events Unnatural deaths that occur within a hospital from mass casualty events are considered to be OCME cases, and are handled according to existing OCME protocols and guidelines. Deaths that occur within a hospital from a pandemic, at home following treatment of a pandemic illness or during other extended medical incidents are natural deaths and do not fall under the jurisdiction of the OCME. In an emerging, deadly, natural disease outbreak it is advisable and in the public interest that an autopsy be made in accordance with Virginia Code The OCME will perform such an autopsy in the public interest to identify the pathogen so it can be effectively treated. This initial identification of deadly emerging infections may require some natural infectious deaths to become OCME cases in the interest of public health for identification of the pathogen only. After the pathogen has been identified further involvement by the OCME in such natural disease incidents is not warranted as natural deaths attended by a physician are the responsibility of the attending or last treating physician as stated in Virginia Code In such cases, the disposition of remains should be handled by hospitals in a similar fashion to any non-ocme death, regardless of the number of deaths. Hospitals do not have a legal responsibility to accept remains of victims of mass casualty incidents who die outside the hospital, whether the OCME is involved or not. However, depending on the scope and extent of casualties involved, hospitals are encouraged, within the limits of available space and storage capacity, to provide temporary storage when there is no alternative morgue facility available in the community.

5 Hospitals that have augmented their morgue capacity through the expenditure of Hospital Preparedness Program funds may be requested to make such morgue facilities available for storage of remains where death occurred outside the hospital, provided that they are able to meet their internal needs for morgue facilities, and provided that requests are made through previously-established protocols developed within the state healthcare emergency preparedness system. IV. Disposition After any investigation by the LME or OCME, the law enforcement agency or other institution having initial custody of the dead body shall make a good faith effort to notify the next of kin so that the dead body may be claimed. If the claimant is financially unable to pay the cost of disposition, the cost shall be borne (i) by the county or city in which the deceased person resided at the time of death, if the person was a resident of Virginia, or (ii) by the county or city in which the death occurred if the deceased person was not a resident of Virginia or the location of the deceased person s residence cannot be reasonably determined ( A.) If a body is neither claimed by a person nor accepted by the State Health Commissioner through the Virginia State Anatomical Program for scientific study, then the body shall be accepted by the sheriff of the county or city where death occurred for proper disposition. ( B.) With certain exceptions, responsibility for the cost of such disposition is the same as described in the preceding paragraph. V. Hazardous Human Remains The State Health Commissioner has the authority to determine if human remains are hazardous to the public health. If such a determination is made, the Commonwealth, with direction from the Commissioner, shall be charged with the safe handling, identification and disposition of the remains ( ) The handling of any hazardous or contaminated human remains will be incident specific and managed through Virginia Emergency Operations Center (EOC) processes. This may require input from and coordination with the OCME, the Virginia Department of Emergency Management s (VDEM) Hazardous Materials (HAZMAT) team and others.

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