We are all patients at some point in our lives. Many of us are familiar with signing the reams of paperwork required at a doctor’s visit, regardless of what complaint we’re there to address. How well we understand the jargon in between insurance preauthorization, copayments and our own illness is up for interpretation. Doctors are people (and patients) too, and sometimes make mistakes. Most mistakes are relatively minor, but rarely, the worst does occur, and a death results. When these fatal mistakes occur, what is the manner of death? Is it a mistake or a complication? Could it have been prevented, or was it a foregone conclusion? How does a forensic pathologist approach this conundrum?
The manner of death is distinct from the cause of the death in that it describes the circumstances of how a person died. The five most common “manner of death” classifications in the United States are natural, accident, homicide, suicide, and undetermined. It is worth noting that some states have “therapeutic complication” as a manner of death in its own right. Certain jurisdictions, such as Connecticut and New York, allow for this manner of death. However, they are in the decided minority. The term is used for “fatalities due to predictable complications of appropriate medical therapy.1”
“Therapeutic complication” as a manner of death has faced pushback within the medical community due to the erroneous fear it may lead to litigation. However, from a public health standpoint, a therapeutic complication is a worthwhile measure to record, given that many can possibly be avoided. What do forensic pathologists do when “therapeutic complication” isn’t an option for the death certificate? Well, it is all a matter of opinion.
Rarely do these cases come to light in the media, but when they do, they are usually the most egregious forms of malpractice. The world was shocked when a Georgia OB/GYN decapitated an infant during a difficult delivery then lied about it2 and when a Florida surgeon fatally removed the liver instead of the spleen3. The manner of these deaths was ruled as “homicide.” These are certainly not predictable outcomes. Think of it as a matter of degree—just how bad was the complication? Did it actually occur in a therapeutic environment?
This takes us to a recent tragic example where a five-year-old boy died in an explosion of a hyperbaric oxygen chamber. He was ostensibly being treated for ADHD and sleep apnea, even though the use of a hyperbaric oxygen chamber is not approved for these diagnoses. Four people have since been criminally charged with homicide, because this was not appropriate medical therapy. What about the more banal types of complications that never make the news? Was it a misdiagnosis, due to an intervention, or a lack of intervention? The critical question arises of how sick was the patient in the first place? Did the death occur under emergent circumstances? Was it a predictable outcome? If it were, the death could be certified as “natural.” Was it an elective procedure, with an incredibly rare complication that may have been avoided? Then it’s probably an accident. Therapeutic complications are particularly frightening, especially because of how vulnerable we are in the hands of doctors—we literally put our lives in their hands. These deaths need to be examined, not just for the survivors, but for the good of us all.
- Gill JR, Goldfeder LB, Hirsch CS. Use of “Therapeutic Complication” as a Manner of Death. Journal of Forensic Sciences. 2006;51(5):1127-1133. doi:10.1111/j.1556-4029.2006.00222.x
- Georgia baby’s decapitation during labor is ruled a homicide by medical examiner. Accessed March 17, 2025 NBC News.
- Marnin J. Surgeon removed wrong organ, killing man — and a cover-up followed, Florida suit says. Miami Herald. January 31, 2025.
About the Author
Dr. Alexander is a graduate of Northeastern University and the University of Miami School of Medicine. She completed her anatomic and clinical pathology training at Brown University and was a fellow in forensic pathology at the Broward County Office of Medical Examiner and Trauma Services in Fort Lauderdale. Dr. Alexander currently serves as Associate Medical Examiner in the Office of the Chief Medical Examiner for the State of New Hampshire. With already 14 peer-reviewed papers to her credit, it is clear that the future of forensic pathology – at least in New Hampshire – is in good hands.
