CHAPTER 127
COUNTY MEDICAL EXAMINERS
[Prior to 7/29/87, Health Department [470] Ch 127]
641—127.1(144,331,691) Definitions.
“Autopsy” means the external and internal postmortem examination of a deceased person.
“Cause of death” means the disease or injury which sets in motion the chain of events which eventually result in the death of a person. The physician shall consider “but for” this injury or disease the person would still be living.
“County medical examiner” or “CME” means a medical or osteopathic physician or surgeon licensed in the state of Iowa and appointed by the board of supervisors to serve in this capacity.
“County medical examiner investigator” or “CME-I” means an individual appointed by a county medical examiner, with approval by the board of supervisors and the state medical examiner, to serve under the supervision of a county medical examiner to assist in death investigations.
“County of appointment” means the county which requests a medical examiner to conduct an investigation, perform or order an autopsy, or prepare a report(s) in a death investigation case. The request may be authorized by the county attorney or the county medical examiner. The county of appointment shall be the county in which the death occurred.
“Cremation” means the technical process, using heat and flame, that reduces human remains to bone fragments.
“Day” means calendar day.
“Death” means the condition as described in Iowa Code section 702.8.
“Death affecting the public interest” means any death of a human being in which the circumstances are sudden, unexpected, violent, suspicious, or unattended, including but not limited to those deaths listed at Iowa Code section 331.802(3) and described as follows:
	1.	Violent death. Violent death includes homicide, suicide, or accidental death resulting from physical, mechanical, thermal, chemical, electrical, or radiation injury. A medical examiner’s investigation and report are required irrespective of the period of survival following injury.
	2.	Death caused by criminal abortion, including self-induced.
	3.	Death related to disease thought to be virulent or contagious which may constitute a public hazard. Any such case investigated by a medical examiner shall be reported to the department and to the local health authority.
	4.	Death that has occurred unexpectedly or from an unexplained cause. This term includes the following situations:
	●	Death without prior medical conditions accounting for the death.
	●	Apparently instantaneous death without obvious cause.
	●	Death during or following an unexplained syncope or coma.
	●	Death during an unexplained, acute, or rapidly fatal illness.
	5.	Death of a person confined in a prison, jail, or correctional institution.
	6.	Death of a person when unattended by a physician during the period of 36 hours immediately preceding death.
	●	This term includes the following situations:
— Persons found dead without obvious or probable cause.
— Death when the person was unattended by a physician during a terminal illness.
— Fetal death unattended by a physician. A fetal death is a fetus born dead after a gestation period of 20 completed weeks or greater or a fetus which weighs 350 grams or more (Iowa Code section 144.29).
	●	This term does not include a prediagnosed terminal or bedfast case in which a physician has been in attendance within 30 days preceding the death.
	●	This term does not include a terminally ill patient who was admitted to and received services from a hospice program as defined in Iowa Code section 135J.1, if a physician or registered nurse employed by the program was in attendance within 30 days preceding the death.
	7.	Death of a person if the body is not claimed by a relative or friend.
	8.	Death of a person if the identity of the deceased is unknown.
	9.	Death of a child under the age of two years if death results from an unknown cause or if the circumstances surrounding the death indicate that sudden infant death syndrome may be the cause of death.
“Department” means the Iowa department of public health.
“Deputy county medical examiner” or “DCME” means an individual appointed by a county medical examiner, with approval by the board of supervisors and the state medical examiner, to assist the county medical examiner in the performance of the county medical examiner’s duties.
“External examination” means a close inspection of the exterior of a deceased human body for the purpose of locating, describing, and delineating any and all injuries or other abnormalities. External examination of a body does not constitute an autopsy, even if toxicology samples are obtained.
“Fee” means an amount to be paid to a county medical examiner’s office as determined by the board of supervisors of the county of appointment for completion of an investigation, autopsy, or report(s). Fees for services provided by the state medical examiner’s office are established at 641—126.3(691).
“Form ME-1” means the Preliminary Report of Investigation by Medical Examiner form.
“Form ME-2” means the Medical Examiner Embalming Certificate form.
“Form ME-3” means the Permit by Medical Examiner for Autopsy form.
“Form ME-4” means the Preliminary Report of Child/Infant Death Scene Investigation form.
“Form ME-5” means the Cremation Permit by Medical Examiner form.
“Form ME-6” means the Iowa State Medical Examiner’s Office Personal Effects form.
“Form ME-7” means the Medication List form.
“Form ME-8” means the Body Identification Record form.
“Manner of death” means the circumstances under which the cause of death occurred and may be specified as follows: natural, accident, suicide, homicide, undetermined, or pending.
“Medical care provider” means an individual licensed or certified in any medical profession, including but not limited to a physician, physician assistant, nurse, emergency medical care provider, certified nurse’s aide, pharmacist, physical therapist, and medical technologist.
“Medical examiner” means the state medical examiner, deputy state medical examiner, county medical examiner, or deputy county medical examiner.
641—127.2(331,691) Duties of medical examiners—jurisdiction over deaths which affect the public interest.
	127.2(1) Jurisdiction. Upon receiving notification of a death which affects the public interest, a medical examiner shall notify any appropriate law enforcement agency not otherwise notified and shall take charge of the body of the decedent. The body shall not be disturbed or removed from the position in which it was found without authorization from the medical examiner except for the purpose of preserving the body from loss or destruction or permitting the passage of traffic on a highway, railroad, or airport, or unless the failure to remove the body might endanger life, safety, or health.
	127.2(2) Investigation. A county medical examiner shall conduct a preliminary investigation of the cause and manner of death and shall utilize the investigative protocol outlined in the most current edition of the County Medical Examiner’s Handbook, available from the state medical examiner’s office. A medical examiner may perform or authorize performance of any scientific study to assist in identifying the cause, circumstances, and manner of death. A medical examiner shall cooperate with other investigating officials and agencies involved and shall share reports, information, and conclusions with these officials and agencies.
	127.2(3) Reports required.
	a. 	Form ME-1.
	(1)	Preparation and filing. A county medical examiner shall prepare a written report of the examiner’s findings on the Preliminary Report of Investigation by Medical Examiner, Form ME-1. A county medical examiner shall file the original Form ME-1 with the state medical examiner’s office within 14 days of the date of death and shall file a copy of the Form ME-1 with the county attorney within 14 days of the date of the death and shall retain a copy for the medical examiner’s records.
	(2)	Content. Form ME-1 shall be completed as fully as possible in light of all available information and may be signed by either a county medical examiner or a county medical examiner investigator acting under the supervision of a county medical examiner. If the cause or manner of death, identity of the decedent, or other information is unknown or pending at the time of filing, “unknown” or “pending” may be written in the appropriate area of the form. If additional information becomes available, this information shall be forwarded to the state medical examiner in written form at such time as it becomes available to be added as a supplement to the file.
	b. 	Jurisdiction declined or terminated. A form designated by the office of the state medical examiner shall be completed and filed in accordance with subparagraphs (1) and (2) of paragraph “a” above in cases reported to the county medical examiner where jurisdiction is terminated or declined.
	127.2(4) Disposition of body. After an investigation, including an autopsy if one was performed, the body of the decedent shall be made available to the funeral home designated by a relative or friend of the decedent for burial or appropriate disposition. A medical examiner shall not use influence in favor of a particular funeral director or funeral home. If no one claims a body, it shall be disposed of as provided in Iowa Code chapter 142.
	127.2(5) Coverage.
	a. 	When an individual is required to report a death to a medical examiner and the county medical examiner cannot be located or is not available, the individual shall contact a county medical examiner from any adjacent Iowa county to perform those duties outlined in this chapter. The responding medical examiner shall have full authority to conduct any procedures necessary to the investigation of the cause and manner of death. If an adjacent county medical examiner is not available, the state medical examiner shall be contacted and may act in the capacity of a county medical examiner.
	b. 	The responding county medical examiner shall be reimbursed by the county for which the service is provided for all fees and expenses at the rate which is customarily paid by the county for which the service is provided or at a rate agreed upon by the medical examiner and the board of supervisors of the county for which the service is provided.
641—127.3(331,691) Autopsies.
	127.3(1) Autopsy required. A county medical examiner shall perform an autopsy or order that an autopsy be performed in the following cases:
	a. 	All cases of homicide or suspected homicide, irrespective of the period of survival following injury.
	b. 	All cases in which the manner of death is undetermined.
	c. 	All cases involving unidentified bodies.
	d. 	All deaths of children under the age of two when there is not a clear cause of death, including suspected cases of sudden infant death syndrome. A summary of the findings of the autopsy shall be transmitted by the physician who performed the autopsy to the county medical examiner within two days of completion of the report. Autopsies performed on children under the age of two when the circumstances surrounding the death indicate that sudden infant death syndrome may be the cause of death or the cause of death is not clearly explained by known medical history shall conform to Form ME-4.
	e. 	All work- and farm-related deaths unless there is an obvious natural cause of death.
	f. 	All drowning deaths.
	g. 	All deaths of commercial vehicle drivers that occur during the performance of their job duties.
	h. 	Deaths due to poisoning.
	i. 	Deaths of airplane pilots who die as a result of an airplane crash. The National Transportation Safety Board and the Federal Aviation Administration should be contacted prior to the autopsy to request specimen kit(s).
	j. 	Deaths due to a natural disaster, including tornadoes and floods.
	k. 	Deaths in a prison, jail or correctional institution or under police custody, where there is not a natural disease process that accounts for the death.
	127.3(2) Autopsy recommended. It is recommended that a county medical examiner should perform an autopsy or order that an autopsy be performed in the following cases:
	a. 	Deaths of adolescents less than 18 years of age when there is not a natural cause of death.
	b. 	All cases which involve a motor vehicle crash, unless it is a single motor vehicle accident with no potential for litigation and there is an obvious cause of death or the injuries have been clearly documented by hospitalization.
	c. 	Rescinded IAB 3/29/06, effective 5/3/06.
	d. 	Deaths from suicide.
	e. 	All pedestrian, bicycle, motorcycle, snowmobile, boating, watercraft, three- or four-wheeler or all-terrain vehicle fatalities.
	f. 	Deaths due to failure of a consumer product.
	g. 	Deaths due to a possible public health hazard.
	h. 	Deaths due to drug or alcohol abuse or overdose.
	i. 	Electrical- and lightning-related deaths.
	j. 	Deaths from burns or smoke or soot inhalation.
	k. 	All deaths related to exposure, such as hypothermia and hyperthermia.
	l. 	All sport-related deaths, including but not limited to deaths from auto racing and deaths resulting from injuries sustained in football, basketball, baseball, softball, soccer, or other games or sports.
	127.3(3) Other deaths. For those deaths not listed in subrule 127.3(1) or 127.3(2), a county medical examiner shall determine whether the public interest requires an autopsy and may perform an autopsy or order that an autopsy be performed. A county medical examiner may consult with the state medical examiner to assist in determining the need for an autopsy.
	127.3(4) Performance of autopsy.
	a. 	Who may authorize. Autopsies may be authorized by the state medical examiner, the county medical examiner for the county in which the death occurred or the county where any injury contributing to or causing the death was sustained, or the county attorney who would have jurisdiction in any criminal proceeding related to the death.
	b. 	Who may perform. An autopsy shall be performed by a pathologist trained or with experience in forensic pathology, licensed to practice medicine and surgery or osteopathic medicine and surgery in the state of Iowa and board-certified by the American Board of Pathology, or under the direct supervision of a physician with these qualifications. If an autopsy is performed by a physician who does not satisfy these criteria and who is not performing under the direct supervision of a physician who satisfies these criteria, the physician shall submit a supplemental report with the Permit by Medical Examiner for Autopsy, Form ME-3, which details the specific training, education, and experience which qualify the physician to perform an autopsy. The following cases/types of deaths shall be transported to the office of the state medical examiner for autopsy unless otherwise approved by the state medical examiner:
	(1)	Deaths of adolescents through 18 years of age when there is not a known or preexisting natural cause of death.
	(2)	All cases of homicide or suspected homicide, irrespective of the period of survival following injury.
	(3)	Deaths of children under the age of 2 years if death results from an unknown cause or if the circumstances surrounding the death indicate that Sudden Infant Death Syndrome may be the cause of death.
	(4)	All suspicious suicides.
	(5)	All high-profile deaths including, but not limited to, deaths of elected officials in municipal, state or federal government.
	(6)	All deaths of inmates occurring in any institutions under the department of corrections as outlined in Iowa Code section 904.102, excluding those deaths that result from a pre-existing medical condition.
	c. 	Permit required—Form ME-3. A medical examiner shall complete the Permit by Medical Examiner for Autopsy, Form ME-3. All reasonable efforts shall be made to complete the Form ME-3 prior to the performance of an autopsy and to submit the form with the body of the decedent or to submit the form via facsimile to the state medical examiner.
	127.3(5) Autopsy report. A complete record of the findings of the autopsy shall be submitted to the state medical examiner’s office, the county attorney of the county where the death occurred and the county attorney of the county where the injury contributing to or causing the death was sustained within 90 days following the date of death, unless unusual circumstances requiring further investigation or testing exist. The report filed shall include all diagrams, transcriptions of the autopsy observations and opinions, and toxicology reports.
	127.3(6) Out-of-state autopsy. The body of a decedent may be sent out of state for an autopsy or postmortem examination only if the county medical examiner certifies in writing that the out-of-state autopsy or examination is necessary for any of the following reasons:
	a. 	A forensic pathologist practicing in the state of Iowa is unavailable;
	b. 	Requiring an in-state autopsy would cause financial hardship; or
	c. 	Requiring an in-state autopsy would delay the funeral or burial more than three days.
	127.3(7) Retention and disposal of tissues, organs, and bodily fluids. The office of the state medical examiner shall retain tissues, organs, and bodily fluids as necessary to determine the cause and manner of death or as deemed advisable by the state medical examiner for medical or public health investigation, teaching, or research. Tissues, organs, and bodily fluids shall be retained at a minimum for the time periods established by the National Association of Medical Examiners and may be retained for a longer time period at the discretion of the state medical examiner. Tissues, organs, and bodily fluids retained under this subrule shall be disposed of without the specific consent or notification of the legal next of kin and in accordance with applicable federal and state regulations including but not limited to OSHA-recommended biohazard and blood-borne pathogen standards. The anatomical material shall be removed from the laboratory premises through use of a contracted, licensed, and bonded medical waste removal service to a medical waste processing center for final disposition.
641—127.4(331,691) Fees.
	127.4(1) Payment of fee and expenses.
	a. 	A medical examiner shall receive from the county of appointment a fee for each preliminary investigation and report submitted in a case in which a death affects the public interest. A county medical examiner shall also receive from the county of appointment the examiner’s actual expenses.
	b. 	A pathologist or other physician who performs an autopsy under medical examiner authorization shall be paid for the services by the county of appointment.
	127.4(2) Reimbursement.
	a. 	County of residence different from county of appointment—Iowa resident. The county of the decedent’s residence shall reimburse the county of appointment for the fee and expenses paid by the county of appointment.
	b. 	Death caused by criminal defendant. If the person’s death is caused by a criminal defendant who has been convicted and sentenced for murder, voluntary manslaughter, involuntary manslaughter, or homicide by vehicle, the county of the person’s residence may recover from the defendant the fee and expenses.
	c. 	Out-of-state resident—law enforcement involvement. The fee and expenses of a county medical examiner who performs an investigation or autopsy of a person who dies after being brought into the state for emergency medical treatment by or at the direction of an out-of-state law enforcement officer or public authority shall be paid by the state. A claim for payment shall be filed with the department.
	d. 	Out-of-state resident—no law enforcement involvement. The fee and expenses of a county medical examiner who performs an investigation or autopsy of an out-of-state resident shall be paid by the county of appointment.
	e. 	Child under the age of two. If the death of a child under the age of two results from an unknown cause or if the circumstances surrounding the death indicate that sudden infant death syndrome may be the cause of death, the department shall reimburse the county of appointment up to $400 toward the expense of the autopsy. A county auditor may submit a copy of the bill and the autopsy report to Iowa SIDS Program, Department of Public Health, Lucas State Office Building, Des Moines, Iowa 50319. A request for reimbursement shall be submitted within one year after the date of death.
641—127.5(144,331,691) Death certificates—deaths affecting the public interest.
	127.5(1) Completion. The funeral director to whom the body is released shall complete the personal data on the death certificate. The medical examiner shall complete the manner of death and cause of death sections of the death certificate within 72 hours after determination of the cause of death. If an autopsy is performed by the state medical examiner, the death certificate shall be submitted to the state medical examiner’s office for completion. All information included on the certificate shall be typewritten.
	127.5(2) Filing. The funeral director shall file the certificate with the county registrar in the county in which the death occurred. A death certificate shall be filed prior to the issuance of a burial transit permit and prior to disposal of the body.
	127.5(3) Extension of time. If a medical examiner is unable to complete the manner of death and cause of death sections of the death certificate within the 24-hour time period, the funeral director shall file a death certificate form completed with all available information. Such certificate shall be authority for the issuance of a burial transit permit. Within 15 days, a supplemental report shall be filed with the local registrar which provides the information missing from the original certificate.
	127.5(4) Additional standards. Additional rules relative to death certificates may be found at 641—Chapter 101.
641—127.6(331,691) Cremation.
	127.6(1) Permit obtained prior to cremation—Form ME-5. A permit for cremation shall be obtained from a county medical examiner prior to cremation of a body of a decedent. For purposes of this requirement, a facsimile or electronic copy of the cremation permit has the same legal effect as the original. Cremation permits shall be issued on the Cremation Permit by Medical Examiner, Form ME-5.
	127.6(2) Requirements for issuance of permit. A county medical examiner shall direct an inquiry into the cause and manner of death and shall determine whether the death is one which affects the public interest prior to issuing a cremation permit.
	a. 	Death which affects the public interest. If the death occurred in a manner specified in Iowa Code section 331.802(3) or if reasonable suspicion that the death occurred in such a manner exists, a medical examiner shall view the body, make a personal inquiry into the cause and manner of death, and complete or cause to be completed all necessary autopsy or postmortem examinations prior to issuing a cremation permit.
	b. 	Death which does not affect the public interest. If, following an inquiry into the cause and manner of death, the county medical examiner determines that the death did not occur in a manner specified in Iowa Code section 331.802(3), a medical examiner is not required to view the body prior to issuing a cremation permit. A county medical examiner shall certify on the Cremation Permit by Medical Examiner, Form ME-5, that the medical examiner’s inquiry into the cause and manner of death did not disclose evidence that the death occurred in a manner specified in Iowa Code section 331.802(3).
	127.6(3) Fee. A fee for the Cremation Permit by Medical Examiner, Form ME-5, shall be paid by the family, next of kin, guardian of the decedent, or other person authorized to act on behalf of the decedent.
641—127.7(331,691) County medical examiner investigators.
	127.7(1) Appointment. A county medical examiner may appoint one or more county medical examiner investigators upon approval by the board of supervisors and the state medical examiner.
	127.7(2) Qualifications.
	a. 	Prior to appointment, a CME-I should possess a minimum of two years of experience as a licensed or certified nurse or medical care provider. A certified peace officer may be appointed to the position of CME-I if a nurse or medical care provider is not available.
	b. 	A CME-I shall satisfy the following criteria:
	(1)	Prior to or within two years of appointment, attend the St.	Louis University School of Medicine Basic Medicolegal Death Investigation Course or its state medical examiner-approved equivalent; and
	(2)	Prior to or within five years of appointment, obtain certification at the registry-level as a death investigator by the American Board of Medicolegal Death Investigators.
	c. 	A CME-I is not required to meet the requirements of paragraph “a” or “b” if the individual has functioned in the capacity of a CME-I for a period of five years as of January 1, 2002.
	d. 	If a CME is unable to appoint a CME-I who possesses the qualifications required by paragraph “a,” “b,” or “c,” the CME may request a waiver. Waiver requests shall be submitted in writing to the state medical examiner and shall include the efforts undertaken by the CME to locate a CME-I who meets the above qualifications; the qualifications of the individual willing to serve in the capacity of CME-I; and the period of time for which the waiver is requested, not to exceed two years. The state medical examiner has sole discretion to waive the requirements of this rule and may withdraw or modify a waiver request upon a finding that the CME-I has failed to adequately perform the duties of the position or for other good cause.
	e. 	If a CME-I is unable to meet the eligibility requirements for obtaining registry certification due to the small number of cases requiring investigation in the county of appointment, then a waiver shall be obtained from the state medical examiner in order for the investigator to continue his or her duties. The county medical examiner shall submit a request for a waiver in writing with documentation of the number of deaths occurring in the county of appointment which require death investigation. The waiver must be renewed every five years if the required number of investigations has still not been achieved.
	127.7(3) Duties. A CME-I shall assist in death investigations. A CME-I acting under the supervision of a county medical examiner may sign the Form ME-1. A CME-I shall not sign a certificate of death or a Form ME-5.
	127.7(4) Supervision. A CME-I shall serve under the supervision of a county medical examiner. A CME-I provides services under the direction of a county medical examiner or state medical examiner’s office. A CME-I shall at all times perform services in a manner which is consistent with the protocol outlined in the most current edition of the County Medical Examiner’s Handbook and any policies or protocols of the supervising county medical examiner.
	127.7(5) Fees. Fees for the services provided by a CME-I shall be paid by the county of appointment.
[ARC 8526B, IAB 2/10/10, effective 3/17/10]
641—127.8(331,691) Deputy county medical examiners.
	127.8(1) Appointment. A county medical examiner may appoint one or more deputy county medical examiners upon approval by the board of supervisors and the state medical examiner.
	127.8(2) Qualifications. A DCME shall be licensed in the state of Iowa as a medical or osteopathic physician or surgeon.
	127.8(3) Duties. A DCME shall serve at the direction of the county medical examiner and may perform any duty of a county medical examiner which is delegated by the county medical examiner to the DCME.
	127.8(4) Fees. Fees for the services provided by a DCME shall be paid by the county of appointment.
641—127.9(331,691) Failure to comply with rules. If a county medical examiner, deputy county medical examiner, county medical examiner investigator, pathologist, or other physician fails to comply with these rules, the state medical examiner may provide written notice of the failure to comply to that individual, the appropriate county medical examiner, and the appropriate county board of supervisors. Within 30 days of the date of the notice, the individual to whom the notice was provided shall submit a written response to the state medical examiner, outlining a proposed corrective action plan. If no response is received within the 30 days or if the proposed corrective action plan is unacceptable, the state medical examiner shall forward copies of the notice and all pertinent correspondence and information to the board of supervisors for the county which appointed the individual, notifying the board of the individual’s failure to comply with these rules.
641—127.10(331,691,22) Confidentiality. Records and reports of a medical examiner may be confidential records pursuant to Iowa Code sections 22.7(2), 22.7(5), and 22.7(41) and other provisions of Iowa law. Prior to releasing a medical examiner record or report to a member of the public, a county medical examiner may inform the appropriate law enforcement agency, the county attorney, and the state medical examiner to determine whether release is authorized under Iowa law.
641—127.11(331,691,670) Indemnification. A board of supervisors shall defend, hold harmless, and indemnify a county medical examiner and any properly appointed staff members to the extent provided in Iowa Code chapter 670.
These rules are intended to implement Iowa Code chapters 331 and 691.
[Filed May 10, 1966]
[Filed emergency 7/10/87—published 7/29/87, effective 7/10/87]
[Filed 11/19/01, Notice 10/3/01—published 12/12/01, effective 1/16/02]
[Filed 1/16/03, Notice 11/27/02—published 2/5/03, effective 3/12/03]
[Filed 3/9/06, Notice 2/1/06—published 3/29/06, effective 5/3/06]
[Filed 1/10/07, Notice 11/22/06—published 1/31/07, effective 3/7/07]
[Filed 7/10/08, Notice 5/21/08—published 7/30/08, effective 9/3/08]
[Filed ARC 8526B (Notice ARC 8162B, IAB 9/23/09), IAB 2/10/10, effective 3/17/10]