1

Coconino County Health and Human Services

Medical Examiner’s Office Annual Report

2019

2

TABLE OF CONTENTS

INTRODUCTION…………………………………………………………………………………………………………3

NEW FACILITY ………………………………………………………………..…………………………………………4

OVERVIEW……………………………………………………………………………………………..…………………5

DEFINITIONS……………………………………………………………………………………………………………..6

MEDICAL EXAMINER (ME) CASES……………………………………………………………………………….7

TOTAL CASES……………………………………………………………………………………………………………..9

MANNER OF DEATH………………………………………………………………………………………………….10

HOMICIDE DEATHS…………………………………………………………………………………………………..12

ACCIDENTAL DEATHS……………………………………………………………………………………………….14

SUICIDE DEATHS………………………………………………………………………………………………………16

NATURAL DEATHS……………………………………………………………………………………………………19

UNDETERMINED MANNER OF DEATH………………………………………………………………………21

OVERDOSE DEATHS………………………………………………………………………………………………….23

NATIONAL PARKS DEATHS……………………………………………………………………………………....26

SUMMARY………………………………………………………………………………………………………..……..27

3

INTRODUCTION

The Coconino County Health and Human Services Medical Examiner’s Office (CCHHS MEO) investigates any death in Coconino County that falls under the jurisdiction of the CCHHS MEO. Death investigations include sudden, violent, and unexpected deaths or deaths in which the cause of death is unknown. This report is a statistical review of the types of cases processed by the office over calendar year 2019 that fell under the jurisdiction of the CCHHS MEO. In 2019, there were 963 deaths in Coconino County (excluding deaths of Native Americans that occur on Tribal Lands); of these, 636 (66%) were reported to the CCHHS MEO for investigation and 328 (34%) received death certification. In addition to this, 76 deaths were referred to CCPHSD ME for examination from non-jurisdictional regions of the state.

901 914 899963

616 642 638 636

0

200

400

600

800

1000

1200

2016 2017 2018 2019 2016 2017 2018 2019

Deaths Total Deaths Investigated

Overview of Jurisdictional Coconino County Deaths

285

350 354328

55 46 5676

0

50

100

150

200

250

300

350

400

2016 2017 2018 2019 2016 2017 2018 2019

Deaths Certified Non-Jurisdictional

Overview of Jurisdictional Coconino County Deaths

4

NEW FACILITY 2019 In June of 2019, the Coconino County Health and Human Services Medical Examiner’s Office moved into a new state-of-the-art facility designed to meet the growing needs of the residents of Coconino County and neighboring jurisdictions which rely on the services. The previous ME facility, built in 1979, had exceeded its capacity. The new facility has an energy saving design, increases cooler capacity from 8 to 25 decedent’s, includes a large autopsy suite to accommodate 2 simultaneous complex examinations, improved exterior access and a large administrative area.

5

OVERVIEW Reportable Deaths Arizona Revised Statute §11 – 593 delineates 9 circumstances in which a death is reportable to a Medical Examiner’s Office:

1. Death when not under the current care of a health care provider (physician, nurse practitioner, physician assistant) for a potentially fatal illness or when an attending healthcare provider is unavailable. 2. Death resulting from violence. 3. Unexpected or unexplained death. 4. Death of a person in a custodial agency as defined in section 13-4401. 5. Unexpected or unexplained death of an infant or child. 6. Death occurring in a suspicious, unusual or non-natural manner, including death from an accident believed to be related to the deceased person's occupation or employment. 7. Death occurring as a result of anesthetic or surgical procedures. 8. Death suspected to be caused by a previously unreported or undiagnosed disease that constitutes a threat to public safety. 9. Death involving unidentifiable bodies.

6

Definitions Autopsy: A decedent is examined both externally and internally for evidence of injury or natural disease which may have caused or contributed to the individual’s death. External Examination: A decedent is examined externally, without an internal examination. Chart Review: A review of the medial records, law enforcement reports and any other information that may be necessary to determine the cause and manner of death without physical examination of the decedent. Cause of Death: A medical opinion, stating the disease or injury (or combination) that initiated the lethal chain of events that brought about a person’s death. Manner of Death: A description of the circumstances under which a person died. On Arizona’s death certificate, there are 5 manner of death categories: natural, suicide, accident, homicide and undetermined.

Natural: The death occurs as a result of natural disease processes, without the significant influence of any type of injury, drug toxicity, or environmental or other non-natural factor.

Accident: The death occurs due to an unintentional injury or poisoning.

Suicide: The death results from an injury or poisoning of an intentional, self-inflicted act committed to do self harm or cause the death of one’s self

Homicide: The death occurs from the volitional act committed by another person to cause fear, harm, or death.

Undetermined: A classification that is used after all information is considered and insufficient information is available to classify the death in one of the preceding categories.

MEDICAL EXAMINER (ME) CASES Medical Examiner (ME) cases are defined as all reportable cases as defined by ARS 11-593 in which jurisdiction is assumed and cause and manner of death are assigned by the medical examiner. Those cases include autopsies, external examinations and chart reviews. In 2019, for jurisdictional Coconino County and non-jurisdictional regions of Arizona, 280 autopsies, 2 external examinations and 117 chart reviews were performed. Jurisdictional Coconino County alone accounted for 204 autopsies, 2 external examinations and 117 chart reviews. In 2019, jurisdictional autopsies decreased by 16% from 2018, and non-jurisdictional autopsies increased by 36% from 2018. In 2019, 610 death certificates were reviewed for cremation authorization.

7

169217 243

204

55

4656

76

0

50

100

150

200

250

300

350

2016 2017 2018 2019

Total Autopsies 2016-2019

Autopsy Jurisdictional Autopsy Non-jurisdictional

224263

299 280

36% from 2018

16% from 2018

External Examination, 2

Chart Review, 117

Autopsy, 204

8

169

217243

204

39 26 10 273

96 101117

0

50

100

150

200

250

300

2016 2017 2018 2019 2016 2017 2018 2019 2016 2017 2018 2019AUTOPSY EXTERNAL CHART REVIEW

Cerified Cases 2016-2019 Jurisdictional Coconino County

9

TOTAL CASES The CCHHS Medical Examiner’s Office forensic investigators processed 712 reports of death, 636 from Jurisdictional Coconino County and 76 reports from other entities (Federal Bureau of investigation, Bureau of Indian Affairs, Navajo County, etc.). Deaths of Native Americans that occur on Tribal Lands (Navajo Nation, Hopi Nation, Hualapai Tribe, Havasupai Tribe, San Juan Paiute Tribe and Kaibab Paiute Tribe) within Coconino County do not fall under the jurisdiction of the CCHHS Medical Examiner’s Office.

636

712

580

600

620

640

660

680

700

720

Jurisdictional Coconino County All Cases

Total Cases 2019

10

MANNER OF DEATH (Jurisdictional Coconino County)

The manner of death represents the means or circumstances by which the cause of death occurred. There are 5 categories on the Arizona death certificate: Natural, Accident, Suicide, Homicide and Undetermined.

Natural 447

Accident 121

Suicide 42

Undetermined 13 Homicide 13

Jurisdictional Coconino county (ME) Cases by Manner of Death 2019

Natural 70%

Accident 19%

Suicide 7%

Undetermined 2%

Homicide 2%

11

Natural 17

Accident 30

Suicide 3

Undetermined 8

Homicide 14

Non-jurisdictional Cases by Manner of Death 2019

428

120

41 22 5

449

127

4511 10

430

141

4612 9

447

121

4213 13

050

100150200250300350400450500

Natural Accident Suicide Undetermined Homicide

Jurisdictional Coconino County (ME) Cases by Manner of Death 2016-2019

2016 2017 2018 2019

12

HOMICIDE DEATHS (Jurisdictional Coconino County) Deaths due to homicides, accounted for 2% of the Jurisdictional Coconino County ME deaths investigated by the CCPHHS Medical Examiner’s Office in 2019. For Jurisdictional Coconino County, homicide victims were most frequently male (70%), Caucasian (92%) and between the ages of 30 to 39 (30%) and died as a result of firearms (54%).

9

4

Male Female

Homicide Victim by Gender 2019 Jurisdictional Coconino County

12

1

Caucasian American Indian

Homicide Victim by Race 2019 Jurisdictional Coconino County

13

0 0 0 0

3

4

3

0 1 1 1 0

Homicide Victim by Age 2019 Jurisdictional Coconino County

7

2

4

FIREARM SHARP FORCE BLUNT FORCE

Homicide Victim by Cause 2019 Jurisdictional Coconino County

14

ACCIDENTAL DEATHS (Jurisdictional Coconino County) Deaths due to accidents accounted for 19% of the ME deaths investigated by the CCHHS Medical Examiner’s Office in 2019. Accident victims were most frequently male (63%), between 60-69 years of age (19%), white (75%) and died as the result of a motor vehicle accident (37%).

4

6

3

7

0 2 0 2 1 2

54

0 0 1 0

2016 2017 2018 2019 2016 2017 2018 2019 2016 2017 2018 2019 2016 2017 2018 2019Firearms Sharp Force Blunt Force Other

Homicide Victim by Cause Jurisdictional Coconino County 2016-2019

76

45

MALE FEMALE

Accident by Gender 2019 Jurisdictional Coconino County

15

1 1 1 6

1613 12

15

23

11

18

4

Accident by Age 2019 Jurisdictional Coconino County

91

26

1 1 20

10

20

30

40

50

60

70

80

90

100

Caucasian American Indian Black Asian Eastern Indian

Accident by Race 2019 Jurisdictional Coconino County

16

SUICIDE DEATHS (Jurisdictional Coconino County) Suicide deaths accounted for 7% of the ME deaths investigated by the CCHHS Medical Examiner’s Office in 2019. Suicide victims were most frequently males (76%), between 20 – 29 years of age (29%), white (74%) and died as the result of firearms (45%).

45

35

23

66

4

2

Accident by Cause 2019 Jurisdictional Coconino County

Motor Vehicle Accident

Blunt Force Trauma

Overdose

Enviromental Exposure

Drowning

Asphyxia

Fire

32

10

MALE FEMALE

Suicide by Gender 2019 Jurisdictional Coconino County

17

0 0 0 3

12

7

4

10

5

1 0 0

Suicide by Age 2019 Juridictional Coconino County

31

81 1 1

Caucasian American Indian Black Asian Unknown

Suicide by Race 2019 Jurisdictional Coconino County

18

Firearm, 19

Train, 1

Hanging, 16

Overdose, 1

High Level Fall, 4Other (carbon monoxide), 1

Suicide by Cause 2019 Jurisdictional Coconino County

19

NATURAL DEATHS (Jurisdictional Coconino County) Natural deaths accounted for (70%) of the ME deaths investigated by the CCHHS Medical Examiner’s Office in 2019. In the majority of natural deaths, the death certificate is signed by the treating health care provider. Individuals who died from natural causes were most frequently male (60%), between the ages of 70-79 (25%), white (61%) and died from cardiovascular disease (40%).

267

178

2

MALE FEMALE UNKNOWN

Natural Deaths by Gender 2019, Jurisdictional Coconino County

22 0 0 0 6 2634

54

103112

61

29

Natural Deaths by Age 2019, Jurisdictional Coconino County

20

271

167

3 4 1 10

50

100

150

200

250

300

Caucasian AmericanIndian

Black Asian Eastern Indian Unknown

Natural Deaths by Race 2019, Jurisdictional Coconino County

Cardiovascular, 179

Chronic ETOH, 51Pulmonary, 35

Malignancy, 45

Infection, 48

Diabetes, 22

Obesity, 10

Fetal Demise, 20

Other, 37

Natural Deaths by Cause 2019, Jurisdictional Coconino County

21

UNDETERMINED MANNER OF DEATH (Jurisdictional Coconino County) Details in which the manner of death was undetermined accounted for 2% of the deaths investigated by the CCHHS Medical Examiner’s Office in 2019. The manner of death is classified as undetermined when there is an insufficient degree of certainty required to certify the manner as accident, suicide, homicide or natural. There are occasions where the cause and manner of death are classified as undetermined. Individuals who died with an undetermined manner were most frequently males (62%), between the ages of 20 to 29 (31%), white (46%) and died of blunt force injuries (54%). One of the thirteen undetermined cases from 2019 have yet to be identified, with an unknown gender, age and race.

8

4

1

MALE FEMALE UNKNOWN

Undetermined by Gender 2019 Jurisdictional Coconino County

1 0 0 0

4

1 1

2

3

0 0 1

<1 1 TO 5 6 TO 12 13 TO 19 20 TO 29 30 TO 39 40 TO 49 50 TO 59 60 TO 69 70 TO 79 80 TO 89UNKNOWN

Undetermined by Age 2019 Jurisdictional Coconino County

22

6

5

0 1 0 1

CAUCASIAN AMERICAN INDIAN

BLACK ASIAN EASTERN INDIAN

UNKNOWN

Undetermined by Race 2019 Jurisdictional Coconino County

Blunt Force Injuries, 7

Overdose, 0

Undetermined, 4

SUID, 1

Other, 0

Undetermined by Cause 2019 Jurisdictional Coconino County

23

OVERDOSE DEATHS (Jurisdictional Coconino County) Overdose deaths accounted for 4% of the ME deaths investigated by the CCHHS Medical Examiner’s Office in 2019. Individuals who died from overdose were most frequently male (58%), between the ages of 40-49 (25%), white (71%) and died of a single opiate overdose or a mixed substance overdose which included an opiate (54%). 2019 showed a decrease from 2018 in accidental overdoses due to opiates. There were 10 non-opioid deaths, 5 of which were due to methamphetamine. There were 11 deaths involving opioids, 3 of which were due to heroin and 7 of which involved fentanyl.

14

10

MALE FEMALE

Overdose by Gender 2019 Jurisdictional Coconino County

0 0 1 0

54

65

3

0 0 0

Overdose by Age 2019 Jurisdictional Coconino County

24

17

6

1

CAUCASIAN AMERICAN INDIAN EASTERN INDIAN

Overdose by Race 2019 Jurisdictional Coconino County

Opioid, 8

Non-opioid, 10

Mixed including opioid, 3

Acute Ethanol, 3

Overdose Deaths by Drug 2019 Jurisdictional Coconino County

25

25

2932

23

2 5 4 1 3 4 3 0

2016 2017 2018 2019 2016 2017 2018 2019 2016 2017 2018 2019Accident Suicide Undetermined

Overdose Deaths by Manner Jurisdictional Coconino County 2016-2019

6 7 73

10

18

11 10

2 3

118

129 10

3 0 1 0 0

2016 2017 2018 2019 2016 2017 2018 2019 2016 2017 2018 2019 2016 2017 2018 2019 2016 2017 2018 2019Acute Ethanol Non-opioid Opioid Mixed Including Opioid Other

Overdose Deaths by Drug Jurisdictional Coconino County 2016-2019

26

NATIONAL PARK DEATHS (Jurisdictional Coconino County) National parks within Coconino County include the Grand Canyon and Horseshoe Bend. Below are graphs depicting the jurisdictional deaths that have occurred in these two parks. There were no Horseshoe Bend deaths in 2019, possibly due to changes at the park (i.e., park renovation, admission, hours, new safety features).

0

1

7 7

2016 2017 2018 2019

Deaths Involving Fentanyl 2016-2019

6

8 8

65

9

6

34

2 2 2 2

4

2 1 0 0 0 0

Natural Accident Suicide Undetermined Homicide

Grand Canyon National Park Deaths by Manner 2016-2019

27

SUMMARY The CCHHS Medical Examiner’s Office Annual Report reflects the activities associated with the investigation of the cause and manner of death of cases occurring in jurisdictional Coconino County and cases referred to the office for examination. This report presented an analysis of the different manners of death investigated and the demographics in which they occurred. In 2019, there were 963 deaths in Coconino County that were under the CCHHS Medical Examiner’s Office jurisdiction. Of these cases, 636 (66%) were reported for investigation and 328 (34%) received death certification by the Medical Examiner’s Office. In addition, 76 decedents were referred to the CCHHS Medical Examiner’s Office from non-jurisdictional regions of the state for examination. CCHHS Medical Examiner’s Office Forensic Pathologists performed 280 autopsies, 2 external examinations, and 117 chart reviews. For jurisdictional Coconino County, there were 13 homicides (54% involved firearms), 121 accidental deaths (37% involved a motor vehicle), 42 deaths by suicide (45% involved firearms), and 447 deaths due to natural causes (40% were due to cardiovascular disease). There were also 24 drug overdoses of which 54% were from an opioid or mixed substance including an opioid. The data contained within this report provides information to help guide the development of Public Health policies. In turn, these policies can be used to reduce the number of preventable deaths and improve the overall health of the community we serve.

0 0

2

0 0

1

2

0

2016 2017 2018 2019 2016 2017 2018 2019Accident Suicide

Horseshoe Bend Deaths by Manner 2016-2019