Attorneys have asked me what discovery should be available from the Office of the Chief Medical Examiner in cases where an autopsy was performed by that office.
The Autopsy Report is a public record. It can be requested through the OCME website, or it can be provided through discovery. Photos, videos, or audio recordings of an autopsy are available for inspection, but copies are not provided except through discovery. The Office of the Chief Medical Examiner’s file often includes:
- Autopsy report (when performed)
- Toxicology report (the final report, not the underlying data)
- Report of Investigation by Medical Examiner (RIME) – serves as medical examiner’s summary of the facts and circumstances surrounding a decedent’s death. Includes biographical data and may include references to other investigative agencies including law enforcement.
- Consultation reports, for example, with neuropathology or ophthalmology (if done)
- Body diagrams
- Autopsy photographs
Additional items are available in the Medical Examiner file. Typically, a subpoena or court order is needed to see the file and to receive copies of the items in there. The items in the Medical Examiner file can include:
- Case encounter form
- Release of the body paperwork
- Evidence inventory and disposition
- Copy of death certificate
- For older cases with a paper file, the front of the file will list who has received a copy of the autopsy report and date. OCME is transitioning to an electronic system, so this may not be available.
- Handwritten bench notes (notes about organs, weights, findings at autopsy)
- Possibly emails about the case, notes from phone calls, or notes from talking to law enforcement during or after the autopsy
- Toxicology report (toxicology testing data is provided only with a specific request for a litigation package)
- Results of other test such as cultures, vitreous chemistry and other lab tests
- Possibly results of DNA testing for identification
- Histology key (list of tissues submitted for microscopic slides)
These items typically are not in the Medical Examiner file, but can be requested, where applicable:
- Documentation of items kept at autopsy
- Brain tissue
- Sections of bone with fractures
- Sections of bone with tool mark
- Documentation of the transport of the body from the scene to hospital or morgue coolers or funeral home cooler to the final destination for autopsy
- List of medication that came in with the body
Medical records that are reviewed by the OCME are kept in a separate folder. They are not released because they are considered third party medical records that are HIPPA-protected. The medical records file may not be the entirety of the records they reviewed, as they might only keep what they feel is relevant. This may include:
- Hospital records
- EMS run sheets
- Primary care physician records
- NC prescription drug search
- Antemortem dental records or x-rays used for identification
Questions about obtaining these records can be directed to Bradley Brecher, Agency Legal Consultant to the OCME at 919-743-9075.
Thank you to Dr. Christena (Cat) Roberts for her assistance with this post.