Medicolegal Death Investigation Report

Case Number: [Case identifiers (ME/C case #, associated law enforcement #, hospital MRN if applicable)]

Report Status: [Draft / Final / Addendum]

Date/Time Authored: [Date and time with time zone] (Use 24-hour format; update on addendum)

Author: [Name, title, credentials, contact information, office]

Decedent Name: [Full legal name or "Unidentified"]

Date of Birth: [YYYY-MM-DD or "Unknown"]

Sex: [Sex as documented or "Unknown"]

Race/Ethnicity: [As documented or "Unknown"]

Jurisdiction and Authority

[Jurisdiction rationale under statute/policy] (Brief statement of why the death is reportable; cite applicable authority if known.)

Jurisdiction Decision: [Accepted / Declined / Pending determination]

(If declined, state rationale and who assumed certification responsibility.)

• [Medical Examiner/Coroner personnel: names, roles, contact]
• [Law enforcement agency and lead officer/detective: names, badge/ID, contact]
• [EMS units and agency; crew names if available]
• [Fire department personnel/units if involved]
• [Hospital/medical staff with roles and contact]
• [Other agencies/participants as applicable]

Sources of Information

• [Scene walkthrough] (Date/time; by whom; scope)
• [Photographs/video] (By whom; device; file ranges; date obtained)
• [Witness/family interviews] (Names, relationships, method, date/time)
• [First responder briefing] (Agency; briefing officer; date/time)
• [EMS run sheet] (Run #; date/time; date accessed)
• [Hospital records] (Facility; encounter dates; sections reviewed; date accessed)
• [Prior medical records] (Provider/facility; timeframe; date accessed)
• [Prescription history/medication containers] (Source; reconciliation status)
• [Digital sources] (Type; legal authority reference; date accessed)
• [Prior ME/C case history] (Case #; relevant findings)

Limitations: [Persons not reached / Unavailable records / Language barriers / Informant impairment / Scene altered prior to arrival] (State what changed, when, by whom. Document attempts with dates/times and outcomes.)

Executive Synopsis

[6–12 sentence narrative capsule: identification status; location found; key timeline anchors (last known alive, found, pronounced); scene type; body findings at scene (position, postmortem changes, apparent injuries, resuscitation evidence); salient circumstances (witnessed events, threats, paraphernalia, weapons, environmental hazards); evidence handling summary; preliminary working impression and pending items.] (Label impression as preliminary.)

Decedent Identification

Identification Status: [Identified / Presumptive ID / Unidentified]

• Methods used/planned: [Visual ID (identifier and relationship) / Documents at scene / Fingerprints / Dental comparison / DNA / Device serial numbers / Other] (Specify steps initiated and current status.)
• Next of Kin or Legal Authorized Person: [Name, relationship, contact information]
• Distinguishing features: [Tattoos, scars, medical devices, prostheses, other identifiers]

Notification and Response Timeline

• [YYYY-MM-DD HH:MM] — ME/C office notified by [name/role]; [summary of report]
• [YYYY-MM-DD HH:MM] — Investigator dispatched
• [YYYY-MM-DD HH:MM] — Arrival at [scene location]
• [YYYY-MM-DD HH:MM] — Departure from [location]
• (Add entries for secondary scenes: hospital, separate incident location.)
• Scene hazards: [Hazards observed] — Access controlled by [agency/role]

Circumstances of Death

[Narrative with embedded time anchors and explicit attributions. Include: last known alive date/time and by whom; baseline condition with attribution; discovery narrative (who found decedent, relationship, original position before intervention); pre-EMS interventions (moved, naloxone, CPR); environmental context (locked doors, notes, medications, weapons, paraphernalia, disturbed furniture); pronouncement (by whom, time, location); transport and resuscitation course if applicable.] (Use attribution: "Per [name/role]," "Per EMS record," "Per hospital documentation.")

Key Timeline

• [YYYY-MM-DD HH:MM] — Last known alive (Per [source])
• [YYYY-MM-DD HH:MM] — Found (Per [source])
• [YYYY-MM-DD HH:MM] — EMS arrival (Per EMS record)
• [YYYY-MM-DD HH:MM] — Pronounced by [name/role] at [location]
• [YYYY-MM-DD HH:MM] — Transported to [facility] (if applicable)

Scene Findings

Location: [Full address and/or precise location; GPS coordinates if relevant]

Scene Type: [Residence / Outdoors / Vehicle / Workplace / Custodial facility / Medical facility / Other]

Access: [Access method; locked/unlocked status; points of entry/egress]

Environmental Conditions: [Lighting, odors, temperature, weather exposure, ventilation, fire/CO indicators] (Include only relevant conditions.)

Documentation: Photographs: [Yes/No, by whom, scope] — Diagram: [Yes/No] — Measurements: [Yes/No] (If evidence moved prior to documentation, state what, when, by whom.)

Notable Items: [Weapons, ligatures, containers, syringes, medication bottles (label vs contents if checked), notes, blood/body fluid patterns (location and pattern), signs of struggle or forced entry] (Use spatial references relative to body; describe without interpretation.)

Body as Found

• Position: [Supine / Prone / Lateral / Seated / Suspended]; [Surface]; [Head/limb orientation]; [Proximity to objects]
• Clothing: [Status and disturbances; footwear; accessories]
• Visible Fluids: [Froth / Purge / Emesis / Blood] with precise locations
• Postmortem Changes: Livor: [Color, distribution, blanchability, consistency with position]; Rigor: [By region, inconsistencies]; Algor: [Warm/cool/cold/frozen, temperature if measured with method and time]; Decomposition: [Degree and features]; Insect/animal activity: [Present/absent, description]
• Resuscitation Evidence: [CPR marks, defibrillator pads, airway adjuncts, IV/IO sites, tubes/lines]

External Body Examination

Scope: [Full unclothed exam / Limited exam (with reason)] at [location]

• [Injury: type (abrasion/contusion/laceration/incised/puncture/petechiae); exact anatomic location with laterality; size/shape; color; photographed: Yes/No]
• (Add additional injury entries as needed.)
• Pertinent negatives: [Decision-relevant negatives only] (e.g., no visible trauma in reported fall; no ligature furrow in reported hanging; no injection sites or paraphernalia in suspected overdose.)

Evidence and Property Handling

Chain of Custody: Initial custodian: [Role/agency, name]; Custody began: [Date/time]; Transfers: [Date/time, to whom, agency]; Packaging/labeling: [Method]; Storage: [Location]; Final disposition: [If known]

Evidence Inventory

• [Item ID] — [Description] — [Location found] — [Time collected] — [Collector] — [Packaging] — [Transfer: destination, date/time, recipient]
• (Repeat for each item.)

Personal Effects/Valuables: [Safeguarding method; inventory; release procedures or agency retaining responsibility]

Interviews and Statements

• Interviewee: [Name; contact; relationship to decedent] — Basis of knowledge: [Personally observed / Heard from others] — Method: [In-person / Phone / Video] — [Date/time] — Interpreter: [Yes/No]

  [Neutral summary with attribution. Use direct quotes only for: statements of threat or intent, critical observations, disputed or legally significant language.]

• (Add additional interviews as needed.)

Discrepancies: [Conflicts across witnesses or between statements and scene findings] (State discrepancies without speculation; document planned steps to resolve.)

Decedent Profile

• Medical History: [Diagnoses; recent symptoms; recent encounters; medications (prescribed/OTC) with adherence; substance use treatment history] (Attribute to sources with dates.)
• Mental Health History: [Diagnoses; hospitalizations; providers; prior suicidal ideation/attempts; recent stressors; recent medication changes] (Include only if relevant; attribute with sources and dates.)
• Social History: [Living situation; relationships; recent conflict/IPV concerns; employment/financial stressors; legal issues; cultural/religious considerations] (Include only if relevant; attribute to sources.)

Special Population Details

(Include applicable subsection only; omit others entirely.)

• Infant/Child Death: [Sleep environment; reenactment performed: Yes/No; caregivers present; daycare/school timeline]
• Custody-Related Death: [Housing status; watch status; restraints used; force details; monitoring; medical care provided]
• Suspected Overdose: [Paraphernalia inventory; prescription reconciliation; pill counts; bystander naloxone administered]
• Occupational Death: [Machinery involved; PPE status; lockout/tagout context]
• Fire/CO/Environmental Exposure: [Source assessment; measured readings with device and time]

Investigative Impression and Plan

Preliminary Working Impression: [Working cause-of-death possibilities with brief rationale tied to circumstances, findings, and history] (This impression is preliminary pending ancillary studies and forensic pathologist review.)

Manner of Death: [Working possibilities or "Manner pending"] (Per office policy on investigator input.)

Pending Items

• Autopsy: [Planned / Completed / Not planned]; Assigned pathologist: [Name]
• Toxicology: [Ordered / Not ordered]; Specimens: [Types obtained]
• Additional testing: [Histology / Radiology / Microbiology / Vitreous chemistry / Other]
• Records requested: [EMS / Hospital / Mental health / Primary care / Other] — Date requested: [Date] — Expected timeline: [If known]
• Digital evidence: [Type; legal authority reference]

Notifications and Disposition

• Next-of-Kin Notification: [Notified / Not notified / Attempted] by [Name] on [Date/time] via [Method]
• Other Notifications: [Law enforcement detective; organ procurement organization; public health; other agencies]
• Family Communication: [Information provided regarding process, autopsy, timeline, how to request reports]

Body Custody and Transport

Transport: [Agency]; Body bag seal: [Status if tracked]; Property with remains: [Items]; Receiving facility: [Name]; Transfer: [Date/time]

Death Certification: [Who will certify]

Attachments

• [Photo/video log: device, file ranges, description]
• [Scene diagram and measurement log]
• [Evidence inventory forms; storage location]

(For critical fields—last known alive, found/pronounced, scene attendance, postmortem changes, evidence handling—use explicit placeholders if unknown: "Unknown," "Not available," "Not assessed," or "Not applicable." Document attempts to obtain missing information with dates/times and outcomes. Omit inapplicable conditional subsections entirely rather than leaving empty.)