10 Most Common Errors in Death Investigations: Part 1
©2007 Vernon J Geberth, P.H.I. Investigative Consultants Inc.
Reprint: Law and Order, Vol. 55, No. 11, November, 2007
Article Expanded for Research
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Death investigation is a complicated process, which involves a number of different members of the police department as well as various other forensic disciplines working together towards the goal of solving the case. There are any numbers of things that can and will go wrong due to the nature of sudden and violent death. Furthermore, due to the various responsibilities of these individuals, who range from uniform officers to detectives to medical examiners to forensic experts to prosecutors and others in the process there may very well be miscommunications, which result in serious errors that effect the outcome of the case.
It all begins at the crime scene and this is where most of the errors occur.
1. Improper Response to the Scene
First Officers may not properly respond to and secure the scene and immediate area. The uniform officers may be afraid to stop or challenge superior officers and other unauthorized persons who insist on entering the scene. Many times police officers congregate in the scene inadvertently contaminating evidence as they haphazardly "go-through-the-motions" as they wait for additional responders and investigators to arrive. Examples of this are numerous. The First Officers might fail to notify investigators when at the death scene; they might wait too long before contacting investigators; they may assume that the death is a suicide or natural and there is no need to establish a crime scene; they might fail to detain all persons present in the scene, which might include the suspect; or they might fail to separate possible witnesses and obtain preliminary statements. Failing to make a determination of the boundaries of the crime scene and therefore not securing a sufficient area of protection. Instead of securing just the front door they should have surrounded the entire house and front walkway.
The examples of improper response continue, including failure to monitor and properly supervise EMT's and paramedics. EMS personnel are frequently at the scene before the police. First Officers must identify them and obtain their observations of the family members/friends of the victim who were at the scene. Keeping a chronological list of anyone entering the crime scene. A Sign-in Sheet should be initiated at the scene by the first responders. Errors include Failing to take notes of observations at the scene prior to arrival of detectives and failure to accompany any victims to hospital to obtain statements.
Uniform officers respond to a call, "Man out the window." When they arrive they observe a crowd gathered around a body in the alleyway of a tenement building. The officers determine that the man appears dead and call for an ambulance and detectives. They fail to establish any crime scene except where the body lies and they make no attempt to detain anyone or identify any witnesses. Instead they chase the crowd away and cordon-off the body pending the arrival of the ambulance crew, which pronounces the victim dead. During this time, a drunken man carrying a bottle persists on viewing the victim's body and states that the victim and him are roommates. The uniform officers threaten to arrest him if he doesn't go away. When the detectives arrive they ascertain from witnesses that the drunken man and the victim has been in an altercation earlier in the evening in a fifth floor apartment in the tenement. That an assault had occurred and the drunken man threw his friend out the window and his body ended up in the alleyway. None of these locations had been secured and the assailant had been chased away by the uniform officers.
Homicide investigation is not the exclusive purview of the investigator. In fact, successful homicide investigation often depends on the initial actions taken by patrol officers responding to any given scene. Technically speaking, all police officers have a responsibility to actively and skillfully contribute to the crime solving process.
2. Failure to Protect the Crime
Probably no other aspect of homicide investigation is more open to error than the preservation and protection of the crime scene. Crime Scene Contamination is a major problem. The first official actions taken at the scene by the first responders to isolate and protect the scene as well as the follow-up investigative response to prevent scene contamination and assure the proper crime scene process is paramount to the investigation.
When the crime scene is contaminated by the presence of unnecessary personnel, we risk the loss of crucial microscopic evidence. More importantly, once the crime scene damage is done, it is oftentimes irreparable.
Examples of Failure to protect the Crime Scene:
Any item can and may constitute physical evidence;
therefore, it is imperative that nothing be touched or moved at the scene
before the arrival of the investigators. If the need arises that something at
the scene be immediately secured or removed before it is destroyed or lost, the
officer handling the evidence must document its location, appearance,
condition, and any other feature that might affect the investigation. The
officer must be sure to inform the homicide detective of the item's original
position so that it does not lose its evidentiary
The homicide crime scene is not an everyday occurrence for most officers. Usual police activities are either emergencies, requiring automatic reaction, or routine handling of called-for-services. The officer who confronts the homicide crime scene, however, finds himself somewhere between these two extremes. He must therefore force himself to adapt to the situation. I offer the acronym ADAPT as a basic, five-step approach.
A Arrest the perpetrator, if possible.
D Detain and identify witnesses and/or suspects for follow-up investigators.
A Assess the crime scene.
P Protect the crime scene.
T Take notes.
3. Not Handling Suspicious Deaths as Homicides
All death inquiries should be conducted as homicide investigations and the scene handled as a crime scene until the facts prove differently. I recommend that an investigator be assigned to every unattended death case. Some agencies have mistakenly allowed patrol officers to conduct basic death investigations with the assumption that such deaths are generally not criminal incidents and don't require detective investigation.
On the contrary, these cases may very well be homicides, which have been staged to appear to be suicide, accidents or natural causes. In equivocal death investigations we see the potential for major errors. If in fact, the death is later attributed to be homicide valuable evidence will have been lost or contaminated because the scene was not handled as a homicide case. The critical interviews and interrogations as well as crime scene documentation and photographs are irretrievable.
Furthermore, how is the investigator supposed to gain experience in the analysis of estimating time of death, evaluating the morphologic post mortem changes, which occur in the postmortem interval? Practical Homicide Investigation® dictates that death investigation requires continuous and consistent training as well as refresher courses for veteran officers.
When all death investigations are conducted as homicide cases we minimize the possibility of missing some crucial clue or evidence because the scene has been altered or staged to misdirect the investigation. I use the term "CSI Criminals" to refer to offenders who have been known to implement some of the "insider tips" from one of the country's most popular crime series.
The death investigation usually starts at the point where the body is originally found. This location is referred to as the primary crime scene. The term primary crime scene characterizes the significance of this location and the immediate concern of responding police officials to this forensically critical area in death investigations.
The reason why the homicide investigation starts at the Primary crime scene is twofold:
From an investigative point of view, the body and its surroundings
(including associative evidence and other factors unique to any specific crime)
provide the professional homicide detective with significant information on
which to base an investigation. For example, an intelligent examination of the
scene may reveal the identity of the victim, the approximate time of death, and
important evidence and/or clues to the circumstances of the death.
There is a principle in homicide investigation that refers to a theoretical exchange between two objects that have been in contact with one another. This theory of transfer or exchange is based on the following facts.
It is important to repeat that anything and everything may eventually
become evidence. The list of items that may constitute physical and/or
testimonial evidence is as extensive as the number, type, and causes of
homicide itself. Whether it be the res gestae utterances of the suspect
murderer at the scene or an important piece of trace evidence, the fact remains
that where the body was found, the Primary crime scene, is the logical
and proper point to start the death investigation.
4. Responding with a Preconceived Notion
In keeping with the paradigm that, "All death inquiries should be conducted as homicide investigations until the facts prove differently," it is absolutely imperative that investigators not allow themselves to respond to a death investigation with any preconceived notions about the case. Most agencies will dispatch a call based on the initial report.
If the case is reported as a "suicide," the police officer who respond as well as the investigators automatically tend to treat the call as a suicide. It is a critical error in thinking to handle the call based on the initial report. The immediate problem is that psychologically you are assuming the death to be a suicide case when in fact this is a basic death investigation, which could very well turn out to be a homicide.
There is no doubt in my mind that investigators take "short-cuts" when they hear the word suicide. In the many suicide cases that I have reviewed as a consultant, it was apparent to me that the investigation did not take each point to its ultimate conclusion. Instead, certain things that should have been done were not done, sufficient photographs were not taken and certain tests were not conducted. Even though in some instances the deaths were suicides the fact of the matter was that the incomplete and insufficient preliminary investigation raised legitimate concerns.
Any preconceived theories or notions are dangerous in professional death investigation. In addition to errors of assuming a "suicide" or natural death other preconceived notions may include deaths, which appear to be drug related and/or domestic violence. You must keep an open mind and not allow yourself to be influenced either by the initial reports or the presentation in the crime scene.
Death investigations of the elderly are oftentimes assumed to be naturals and there is a tendency on the part of uniforms and detectives to rush-through the crime scene process. Many investigators, who have "bought-into" the initial call and treated the case like a routine suicide or a natural death have been greatly embarrassed when the medical examiner's finding showed the death to be a homicide. They then find themselves in the unenviable position of having to explain how they missed crucial evidence or failed to take important crimes scene photos.
Another problem that occurs is focusing in on one suspect too soon, while eliminating other possibilities. This could be considered jumping to conclusions. Anther problem is tunnel vision. At times an investigators may closes their minds to other possibilities once they've developed a theory. Then they begin to try to make the evidence fit their theory instead of allowing the evidence to lead you to the suspect.
A professional homicide practitioner cannot be an individual with a "lock-and-load" mentality. The true professional must posses a flexible type of personality that is open to new suggestions, ideas and concepts that arise in these fluid types of investigations. The detective looks for consistencies as well as inconsistencies and must be prepared to change the focus of the investigation as new information is developed.
The remaining 10 most common errors in death investigation will be in the next issue of LAW and ORDER.
The following law enforcement professionals consulted with the author in
formulating the 10 Most Common Errors in Death Investigation. I have
named them in alphabetical order:
Detective (Ret.) Joe Burgoon St. Louis, MO Homicide
Detective Arthur Clark, East Providence, RI Police Department
Investigator Gloria Coppola, New York State Police
Commander (Ret.) Tom Cronin, Chicago Police Department
Detective Mark Czworniak, Chicago Police Department
CID Agent (Ret.) Bill Dortch, USACID
Detective/Sergeant David Eddy, Michigan State Police
Detective/Sergeant (Ret.) William Friedlander, NYPD
Supervisory Special Agent John Gerns, AFOSI
Larry Hobson, Former D.A Investigator San Luis Obispo, CA
Patrick Jones, Purdue University, IN
Detective William Lawler, Rochester, NY Police Department
Senior Investigator Dave Madden, New York Sate Police
Investigator Tom McAndrews Pennsylvania State Police
Tom Meloni, Deputy Chief Wheaton, IL Police Department
Detective/Sergeant Buddy NeSmith, Escambia, FL Sheriff's Office
Detective Mike O'Malley, Cleveland, OH Homicide (Ret.)
Lt. Richard Peffall, Montgomery County, PA Detectives
Detective Nick Petranovic, Waterford, MI Police Department
Detective 1st Grade (Ret.) Raymond Pierce NYPD
Detective Victor Regalado, Tulsa, OK Police Department
Detective/Sergeant Eric Schroeder, Michigan State Police
Peter Siekmann, Coroner DuPage County, IL
Investigator Marv Skeen, Washington State Attorney General's Office
Larry Thomas, Assistant Director, KBI
Detective Sam Todd, Kent, OH Police Department
Lieutenant Mike Wood, Rochester, NY Police Department
Vernon J. Geberth, M.S., M.P.S. is the author of "Practical Homicide Investigation: Tactics, Procedures, and Forensic Techniques" 4th Edition CRC Press, LLC. He retired from NYPD Homicide with the rank of Lieutenant Commander and has dual Master's Degrees.
These copyrighted materials have been excerpted with Geberth's permission. Article Has Been Expanded for Research.
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