In Sandusky Ohio on March 02, 2012, 19 year-old Jacob Lamberios was reported dead due to a gunshot wound to the head. The county elected coroner, John Wukie, was called and certified the death based on verbal reports from on scene sheriff deputies. No scene response from the coroner or medicolegal death investigators. It was ruled a suicide. The evidence was later lost and the decedent buried. No autopsy.
The death was certified by the coroner as “Reason for death: Suicide. Gunshot wound to head. Deceased shot self in head, may not have realized the gun was loaded.”
The press is calling this an 'Accidental Suicide'. Like 'Suicide by Cop' - 'Accidental Suicide' is a non-existent manner of death and is purely an emotional conclusion.
You can follow the details of this story at http://www.sanduskyregister.com/limberios-shooting-saga
Our agency is not attempting to opine on if this death is 'Suicide' as ruled, or 'Accident' as determined by a grand jury following an investigation by the Ohio Attorney General; or ‘Homicide’. Cases like this have such an impact on families and society, and such misunderstandings, that we thought it would be useful to share some professional insight into these types of cases.
First, based only on press reports, here is what is wrong:
-- No scene response, no autopsy and no toxicology. The role and function of the coroner's office is to independently investigate deaths. Not all deaths require or should be autopsied - this is one that should have been.
Would this change the ruling? That question may not be answerable – it likely would not, and by some accounts would not; but it would answer questions of the family, and either support and/or refute the law enforcement investigation. The most important function of the coroner's office is independently determine the cause and manner of death, to provide answers to the family.
-- A grand jury investigates for felony criminal charges, such as if this were a homicide. They do not determine cause and manner of death.
A coroner's inquest serves that function. In the event that it is determined to be a homicide, then it may be sent to a grand jury for consideration of criminal charges. In addition, grand jury proceedings are secret - they provide no answers to the family.
Next, based only on press reports, here is what has been determined:
-- The decedent's parents sued, resulting in the AG investigation, because they did not want the legacy of their son to be suicide to their (then) two-year old granddaughter.
Death investigations cannot be based on emotions and desires of the family. This does not conform to the death investigator’s creed of 'To the living we owe respect, to the dead we owe the truth.'
-- The decedent's parents were concerned, but not solely, about an insurance payout.
Many life insurance policies have suicide clauses - from no payout to a payout only after a period of time from activating the policy (often two years). In addition, it is common for life insurance policies to have a double indemnity clause for accidental deaths (payout of double the policy value), as well as other insurances (i.e. accident policies, firearms policies, etc.). Finally, a death determined to be an 'Accident' may have civil remedies that 'Suicide' cannot.
Next, based only on press reports, these are the reported facts:
-- The decedent was not suicidal per his family.
-- The handgun was a .357 magnum revolver holding six rounds in the cylinder.
-- (from an independent source) the handgun had been fired five times, those spent shells removed, leaving the sixth live round in the cylinder.
-- (from an independent source) in testing by the AG’s office, the handgun would misfire three times of ten attempts. This ‘misfire’ is not detailed.
-- Three other persons were present and reported to scene sheriff deputies that the decedent shot himself.
-- The witnesses reported the decedent shot himself in the right temple, scene sheriff deputies reported the left temple, the first post-exhumation autopsy reported a distant gunshot with no stippling (homicide), and the second post-exhumation autopsy report a contact gunshot with stippling (suicide). In our experience, it is not unheard of for law enforcement or others not specifically training in injury causation to misidentify an entrance from an exit wound.
Next, let's define 'Accident' and 'Suicide' in death investigation:
-- Accident - Deaths other than natural, where there is no evidence of intent: an unintentional event or category of chain of events.
-- Suicide - Death as a purposeful action set in motion (explicit or implicit) to end one’s life. Suicide is a ruling that is to the exclusion of all other Manners of Death and is presumptive to the decedent having not committed suicide. This manner is not used as a fallback when the other manners are inconclusive. For example, if not Accident or Homicide, it must be Suicide is an unfounded conclusion.
Specific to 'Suicide' - the investigation should not try determining the person’s “final thoughts” - only their final actions. It is difficult to believe a person could be 'suicidal' and there need not be premeditation or history of suicidal ideations or attempts. The coroner violates this important protocol - and possibly adds to confusion and familial emotional distress by stating, “...may not have realized the gun was loaded.” Unless there is specific evidence to support this, it is inappropriate to add conjecture to a cause of death statement.
There are four elements to Suicide:
1. Intent to commit the act knowing that it may result in their death;
2. Knowledge of the instrument used and that it may cause death;
3. History of attempts, ideation or documentation of evidence supporting Suicide; and
4. Evidence of contributing factors to the act.
Finally, based only on press reports, each of the elements exist. However, two private post-exhumation autopsies and review by independent forensic pathologists differ from the official findings. If the gunshot wound were not consistent with being self-inflicted, elements one and four are removed. That would leave 'Accident' or 'Homicide' as considerations. In the complete absence of sufficient evidence or information, especially about intent, to assign another manner - 'Undetermined' may be ruled.
This example is exactly why we support trained medicolegal death investigation, appropriate protocols and scene response to such deaths. It is why we are publishing our latest book, “A Survivors' Guide to Death Investigations” (www.UnderstandingDeathInvestigations.com). It is also why we have developed our distance learning and continuing education “Death Investigation for Investigators” death investigation course (www.MedicolegalDeathInvestigations.com). Neither of these are intended to enable a lay person to investigate deaths, but only to understand what protocols should and do exist, and what options exist in equivocal deaths. It is why we do what we do at www.IsItSuicide.com.
Associates in Forensic Investigations, LLC
Expert Consultants and Legal Investigators
Personal Injury, Negligence & Death in Civil, Criminal and Probate Litigation
Dean A. Beers, CLI, CCDI and Karen S. Beers, BSW, CCDI
Colorado Licensed Private Investigators Nos. PI-503 and PI-502
Board Certified Legal Investigator / Expert
Board Certified Criminal Defense Investigators
Certified Death Investigators / former Deputy Coroners
www.DeathCaseReview.com ~ beersda@DeathCaseReview.com
(970) 480-7793 Office (Dean x1 / Karen x2) and (970) 480-7794 Fax
'Quaero Indicium' - To Find The Evidence
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