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The Medicolegal Death Investigator
An Evolution in Crime Scene Investigations Relating to Unexpected Deaths

(Released October 2008)

  by Emil Moldovan  


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Case Histories


Case Histories The following cases histories are taken from my files of death investigations, handled during my tenure as a Deputy Coroner Investigator at the Los Angeles County Department of Medical Examiner/Coroner. The County of Los Angeles has one of the highest case loads of any Medical Examiner/Coroner in the country.

photo of Emil Moldovan
The author as Deputy Coroner Investigator
Photo by Radford University Publicity Department

Case Histories: Case #1, Death by Train

It was early morning in Los Angeles and the phone at the Medical Examiner/Coroner for the County of Los Angeles began ringing in earnest. Under California law, all sudden and unexpected deaths and those deaths defined by statute3 must be immediately reported to the Medical Examiner/Coroner's office as soon as they are discovered (Calif. Government Code Sec. 27491). On the telephone was a Los Angeles County sheriff's dispatcher reporting what appeared to be a suicide by train. Information was sketchy and although the coroner's protocols required obtaining as much information as possible when the death was reported, little additional information was available from the field units at the scene. Even the sex of the decedent was in question due to traumatic injuries sustained after being struck by a slow-moving freight train. California law states that, unless prior permission is given, no one but the coroner/medical examiner representative may touch the body of a decedent, once it is established that it may be a reportable case to the coroner's office. The obvious exclusion is the examination of the body upon arrival at a scene of the first responder to determine signs of life. Once death is pronounced by a competent authority, the Medical Examiner/Coroner has jurisdiction over the body, along with all property and evidence within close proximity. Consequently, the deputies on the scene could do little more than document their arrival, cordon off the scene by yellow police "crime scene - do not cross" tape, and wait for homicide detectives, train administrative personnel and the coroner's investigator to arrive and process the scene.

Union Pacific engine

In Los Angeles County, the investigator assigned to field calls representing the Medical Examiner/Coroner is referred to as "Coroner's Investigator." California State Law identifies coroner's investigators as "Peace Officers" (California Penal Code Sec. 830.35.c). I was assigned the case and quickly responded to the scene. Upon arrival I made contact with the lead homicide detective and obtained the following information relating to the death.

The train engineer reported that he was heading slowly westward towards Los Angeles when he observed an individual standing on the railroad tracks. It was just after dawn and the weather was dry and cool. He said he could clearly see the individual and, although he sounded the train horn several times, the person did not attempt to move out of harm's way. He activated the emergency brakes, dropping sand onto the track to help facilitate stopping in an attempt to avoid hitting the individual. He could only watch as the individual disappeared beneath his engine. When the train was able to come to a complete stop, the victim was discovered beneath one of the freight cars several hundred feet down track from the front engine.

That same morning, a woman appeared at the sheriff's local substation to report her teenaged son missing. She filed a "missing person's" report with the desk officer stating that her son had been home when she went to bed, but was gone when she awoke to prepare to go to work. The behavior was unusual for him and she was concerned. Her concerns were heightened, she said, because her son told her he had an argument with his high school girlfriend that evening and she had ended their relationship. She was worried that he may have run away from home to deal with his emotional state. Missing person's reports, under any circumstance, are taken seriously. Unlike in years past when many police departments required a waiting period of 24 hours, current laws mandate the immediate filing of missing person's reports.

The detective assigned to the juvenile desk read the missing juvenile report and remembered the train incident from his morning briefing. He phoned the Medical Examiner's office and we discussed the possibility of the suicide victim being his missing juvenile. The description provided by the missing juvenile's mother closely matched the physical characteristics and clothing worn by the victim of the train incident. We agreed to meet at his office and confer on how to confirm the identity and notify the mother of the death.

California law (California Government Code 27472a) states that it is the responsibility of the coroner/medical examiner to make a death notification when the death falls under the jurisdiction of that office. A death notification can be made by an assortment of different professions or agencies, depending on the local statute. Some jurisdictions may handle a death notification by sending a police officer, a medical person or clergy. (Leash, 1994)

We decided the best course of action was to try and have the juvenile's mother return home from work and show her a facial photograph taken of the victim at the site earlier that morning. Most identification of unknown persons is made by fingerprint comparison submitted through the Automated Fingerprint Identification System (AFIS) or through the FBI fingerprint database. In some instances, identification is confirmed by showing a facial photograph taken of the decedent at the scene.

We contact the Sheriff's Chaplain who lived locally and he agreed to accompany us to the home of the victim when we spoke to his mother. One of the most difficult assignments in medicolegal death investigation is confirming identity and making the notification to surviving family members. It is always an emotionally charged environment and can be extremely difficult for many professionals. It is recommended at least two persons make the notification and, if possible, a clergy member or family support member be present at the time of notification. (Leash, 1994) The case concluded with a finding of suicide based on the actions observed by the train engineer, the recent breakup with his girlfriend and his mother's statements as to his emotional state the previous night.

Case Histories: Case #2, Murder or suicide?

The building was a two-story men's health spa, located in a commercial area of West Hollywood, California The spa was frequented primarily by gay men who paid membership or daily user fees and took advantage of the establishment's pool, health gym, health bar and other amenities. The second story was dedicated to small rooms, rented by the hour, day or half-day. Each room contained a single bed, built on a platform station, elevated off the floor approximately 30-inches.

The body on the bed was that of an African-American male in his early 20s. He was lying supine with his head resting on the single pillow and his feet extended off the end of the bed. He was wearing a black sweatshirt over a white T-shirt, blue jeans and white socks. A dark baseball cap was on his head. His white gym shoes were found on the floor near the bed. Over his head was a black plastic bag, held in place by a large rubber band fastened around his neck. Along the left side of the bed was a small counter top affixed to the wall. There was a mirror that measured approximately 3' x 6' in length along the wall next to the mattress. On the counter top near the bed were the room keys (one key for the door and another for a valuables locker kept on the first floor level). There was the bottom half of an aluminum soft drink can with the bottom turned up. A plastic Bic-type lighter and a syringe (the type used by diabetics to inject themselves with insulin) with the orange top securing the needle removed were observed near the bed.

two books on how to commit suicide

The half-can showed evidence of a brown substance that had dried (it had been heated with water prior to inserting the mixture into the syringe--a typical procedure used by heroin users.) Located on the mirror was a yellow "post-it note" that had a poem written out in block letters. The poem read "Life is a constant youth I take as my own. I've been pricked by a rose & counseled by the trees of things to you unknown. "Beneath the writing was drawn three symbols, a peace sign, a heart and the letter 'K' written backwards followed by three horizontal lines as in the letter 'E'.

This scene held a wealth of information for a trained MDI. It is important to try and decipher what the evidence indicates while processing the scene. Was this a murder committed by a jealous lover? Or, was it a case of autoerotic sexual gratification gone awry? Were the homicide detectives to search for one suspect, two or none?

Every death scene is a potential crime scene. It is the job of the responding investigators, whether they are police officers, paramedics, medicolegal death investigators, or from other forensic disciplines involved in death investigation, to carefully examine the scene for evidence or unusual circumstances that may indicate the death of the person is other than by natural causes.

Through training, experience and careful crime scene processing, the death investigator, after examining the death scene described above, could reach some preliminary conclusions. Interviews of management and staff by the investigator could determine the time of day the decedent arrived at the facilities. This information, combined with the condition of the body, could help establish a reasonable time of death interval. Did the body condition conform to the time elements provided by the staff? If not, how much time difference may have occurred between the time of death interval (the actual time of death and the discovery of the body?)

The investigator might be able to determine the mental state at the time of arrival. Was he nervous? Was he alone? Did he seem quiet and non-communicative or was he jabbering? Did the decedent seem under the influence of drugs or alcohol? Was he a frequent guest of the facilities or was this his only visit? This type of questioning could help establish the manner of death.

An experienced death investigator would recognize several ingredients described in this scene. A plastic bag, a large rubber band used to hold the bag in place, and drugs or alcohol are often present in suicide scenes. In his book Final Exit, Derek Humphry describes in detail how a person can take their own life using the equipment and procedure described here. (Humphry, 1991) I had observed this death scene frequently in the many suicide scenes I investigated. I often found the book Final Exit near the body, indicating that the decedent used it as a reference for the final act of self destruction.

The scene and all the ingredients, or evidence, provide clues as to the cause and manner of death. It should be noted that while the experience of the investigator will contribute to findings, the cause and manner of death should only be ascribed to the case after all the elements of the investigation are completed. These include a complete medical history of the decedent, interviews with family, friends and witnesses, and in most cases, a complete autopsy by a qualified forensic pathologist.

After conducting a thorough review of the decedent's medical history, looking into his daily habits and interviewing his family and friends who last saw him alive, the manner of death in this case was determined to be a suicide. Asphyxia was listed as the official cause of death on the death certificate. Interviews with his family indicated a pattern of suicidal ideations. He had not arrived at the location in the company of any other person and the staff discovered the body within a time period that made the possibility of foul play highly unlikely. The presence of the narcotic paraphernalia was consistent with the decedent's behavior pattern. The lack of any bruising on the body or other signs of struggle was consistent with the ruling of suicide.

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