Ambiguous Deaths: Critical Analysis in Determining Investigative Direction
Written by Michael S. Maloney   

A COLLEAGUE OF MINE, Lou Elliopulos, has often said, “Some investigations define an agency,” and he goes on to add the caveat, “We don’t get to choose those investigations.” It is death investigations—and often more accurately, the ambiguous death investigations—that end up leading the newsfeeds. The challenge for us as investigators is to be able to quickly establish an accurate investigative direction while remaining flexible enough to change course as the evidence and investigation dictate.

 

This article appeared in the July-August 2020 issue of Evidence Technology Magazine.
You can view that issue here.

So, what is an ambiguous death? Quite simply, it is a death that defies easy categorization for its manner of death. From a scene perspective, it is the suicide that could be a homicide, the accident that could be a suicide or homicide, and the cleverly staged, not-so-natural death.

Manners Of Death
The cause of death, such as gunshot wound, asphyxiation, or blunt force trauma, is seldom open to myriad discussions and armchair quarterbacking that takes place with the determination of manner of death. The manner of death is an opinion, based on at least a preponderance of the evidence that allows the death to be neatly (or not so neatly) filed into its appropriate legal box. Homicide, suicide, natural, or accidental are all manners of death that, based upon the opinion of the medical examiner or coroner, meet the requirements to be categorized. In ambiguous deaths, this should never be done without an autopsy (if possible) and a thorough scene examination. On review, the determinations on manner of death and an example of each are as follows:

  • Natural deaths result from the natural process of disease whose expected outcome is death. An example might be a skydiver who has a fatal heart attack while in the plane prior to jumping.
  • Accidental deaths are the result of an activity or action that is not intended or expected to lead to death. For example, a skydiver who fails to completely cut away their malfunctioning primary chute before deploying their reserve, resulting in a failure for either the main or reserve to properly deploy.
  • Suicidal death is the act of taking one’s own life through deliberate action with the intent to die. An example would be a skydiver that leaves a note stating they intend to take their own life on this jump and then fails to deploy either their main or reserve chute. On the parachute function checks, both chutes are found to be fully operational.
  • Homicidal death involves the taking of another’s life by an action, or inaction (if action is required). An example would be if a skydiver is having an affair with the parachute rigger's wife. The parachute rigger packs the skydiver’s chute in such a manner that the pilot chute will not deploy. There are no indications of suicide, and the parachute function check shows it was tampered with in order to force a malfunction.
  • With undetermined death, there is insufficient information to make a determination.

How many of our agencies will, with great enthusiasm, make the public statement “We treat every death as a murder…”? Though that sounds like a catchy and effective way to state our investigative thoroughness, I would challenge this concept and say instead, “We treat every death exactly as it appears to be.” Granted, on the apparent suicide we may look into other possible causal factors where nefarious actions may come into play. On the natural death we may do a surface scan for red flags or other indicators. And on the accidental death we may look for some motive that takes it out of the realm of accident.

In all, though, we are investigating natural, suicidal, or accidental deaths with an eye toward the item or factor that would drop it out of that pattern. Unfortunately, our ability and accuracy at catching those “red flags” that elevate from suicide or accidental to homicide is often a direct result of our experience at investigating deaths. This leaves the novice—and, unfortunately, every experienced death investigator was once a novice—with a dearth of experience, coupled with the knowledge necessary to root out these red flags and elevate the investigation to the next level.

No one will argue that rendering the opinion as to manner of death is the sole responsibility of the medical examiner or duly-appointed coroner. That said, it is also not a proprietary domain where only they can tread. In the medical profession, physician assistants and nurse examiners often make the early diagnosis that is based on their examination of the patient coupled with their experience and training. The death investigator is in the same situation. Their patient (the deceased) requires a preliminary diagnosis as to cause and manner of death prior to the formal cause and manner of death that may not be pronounced hours or even days later, after autopsy and laboratory analysis.

This initial or “preliminary” cause and manner of death determination is vital in determining initial investigative direction in the documentation and collection of evidence, as well as the initial interviews of suspects and witnesses. We would never suggest that this “preliminary” cause and manner of death is equivalent to the end product of a thorough medicolegal autopsy and investigation. However, the exigent needs of determining an investigative direction keeps us from holding the investigation in stasis until a legal cause and manner is determined.

By determining a preliminary manner of death based upon the body of the deceased and the scene context, the investigative team is able to more effectively manage the documentation and collection of evidence that is germane to the investigation. As in the case of a skydiver that succumbs to a fatal fall from a height, the presence of the reserve chute tangled in the main chute is different from that of the chute never having been actuated—and very different from the chute’s cords being cut. Though the cause of death is the same in each of these cases, accidental, suicidal and homicidal are each suggested by the differing circumstances. Though the thorough inspection of the gear by a master rigger is required for all three, the malfunction is approached differently than the non-actuation and the deliberately caused malfunction.


Figure 1. Death Scene Investigation Decision Tree. Image: M. Maloney, Death Scene Investigation Procedural Guide, 2nd Ed., 2013, CRC Press

Find a printable version of the Death Scene Investigation Decision Tree in the ETM Printable PDF. More information here.

Using The Death Scene Investigation Decision Tree
The Death Scene Investigation Decision Tree (Figure 1) was created to allow investigators at all levels of experience to reap the benefits of directed critical analysis of scene indicators in determining investigative direction. At each decision point along the tree, an ambiguous or contradictory answer defaults the investigator toward the more critical investigative process.

As an example, often we know the death we respond to is different from the one to which we are dispatched. Our first decision point rests with the case being exactly what it appears to be or was reported as. It should be noted that all deaths in law enforcement custody, whether in the arrest or detention process, should be investigated as suspicious.

Case Study Using The Death Scene Investigation Decision Tree
An accidental fatal weapon discharge is reported on a military base at the ammunition supply point. Private Smith reported the accidental discharge while unloading his duty shotgun. This accidental discharge resulted in the death of Corporal Jones. (See Figure 2)


Figure 2.

The next critical decision point deals with a deceased victim versus a critically injured victim. In this instance, the victim had already been pronounced dead after being transported to the military hospital by ambulance. (See Figure 3)


Figure 3.

The third decision point deals with contradictory or ambiguous physical findings or evidence. In this case, the 9mm sidearm of the deceased had been removed from his holster. There was small blood spatter visible on the front of the slide on the Corporal's 9mm duty weapon. This is an area on the weapon that would have been protected had the weapon been in its issued holster. At this point, the prudent investigator could already justify moving toward a suspicious death, but for the sake of our example, let’s continue with de-conflicting, if possible, this finding by analyzing statements. (See Figure 4)


Figure 4.

The fourth decision point involves contradictory or “red flag” physical findings as compared to statements of the suspect or witnesses. The suspect, when asked about the weapon, stated that he removed it from the victim’s holster before he was transported to the hospital. This clearly contradicts the physical finding that the weapon was out of the holster at the time of the shooting. (See Figure 5)


Figure 5.

The fifth decision point allows for the context of the findings to be compared to the context of the manner of death. In this case, the discrepancy in the statement and physical evidence defaults the investigation to the “Suspicious Death” column. The next question is, “Could there have been someone present to inflict the fatal injury?” An affirmative moves the investigation into the preliminary indications of the homicide category. (See Figure 6)


Figure 6.

In each of these cases, ambiguous or contradictory findings defaulted the investigator to a more conservative approach for establishing investigative direction. This decision tree may be used by the first responder, first responding investigator, or the scene CSI (Crime Scene Investigator) or DSI (Death Scene Investigator). It allows them to examine the scene within the totality of its context to determine a meaningful investigative direction. It is critical for the investigator to remain sufficiently flexible so that, when mentally comparing the decision tree with new data, evidence, or statements, that they are willing to adjust or, in some cases, abandon their investigative direction to establish a new one.

Conclusion
Ambiguous deaths raise a unique challenge to the death scene investigator. The ability to spot discrepancies between the evidence, the scene, and the statements is critical in the early hours of the investigation in order to determine an investigative direction. This detailed, step-by-step critical-thinking process, where the scene is analyzed within its context, cannot just be the result of expertise gathered over years of experience. This Death Scene Investigation Decision Tree provides a template for critical analysis of many of the congruent factors that express themselves at the ambiguous death scene. It is hoped this may be used as a framework for both the new and experienced responder to death investigations.


About The Author
Michael Maloney is a former Special Agent/Forensic Investigator with the Naval Criminal Investigative Service (NCIS) and Senior Instructor for the Federal Law Enforcement Training Center (FLETC). He has authored Death Scene Investigation Procedural Guide, 1st and 2nd Editions. This Decision Tree is included in the second edition. He has also authored Crime Scene Investigation Procedural Guide, all published by CRC press. He holds Death Scene Investigation and Crime Scene Investigation Seminars that are popular with both law enforcement and medicolegal death investigators and are now being offered in a virtual format. His website is maloneyforensics.net.

 
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