Dr. Lester Simon: Undetermined Cause of Death Does Not End Coroner Investigations in Antigua and Barbuda

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By- DR. Lester Simon 

1. The following is a second attempt to outline the Coroner Case procedure in Antigua and Barbuda, which is similar to what obtains elsewhere in other Commonwealth countries.

2. This attempt does not refer to any singular case current or past in the country. This attempt is to try to demystify the Coroner case process. Nothing more.

3. Kindly find below a reprint of a related article written in 2023 on Facebook. To add to the reprint below I will expand on point # 16 in the previous article, which refers to autopsy findings.

4. When the autopsy findings are not clear enough to allow the pathologist to write a definitive cause of death, “Undetermined” can be written on the death certificate.

5. It does not mean that the case is over and done with. Quite the contrary. It signals the continuation of a series of all types of investigations and tests on a large number of tissue samples harvested from the body, as well as those from elsewhere.

6. With nothing else to be gained from the physical body, the death certificate, with or without an undetermined cause of death, allows for the burial of the body.

7. When additional information becomes available, the undetermined cause of death will be amended to record and register the determined cause of death, allowing the beginning, the beginning, of the final closure of the case.

29 November 2023.

Death and the Maiden

1. Death is a medical as well as a legal construct.

2. Only a medical doctor can certify death and write a death certificate but only a magistrate can issue a warrant for burial.

3. All unnatural or unusual deaths fall under the ambit of the coroner. It is reasonably argued by some that every single death, including those that are not unnatural or not unusual, every single, solitary death, is a coroner case.

4. The coroner is a magistrate. All roads to and from the coroner are travelled via the police. All.

5. Coroner cases may or may not be subjected to autopsy. The autopsy decision is based

on the coroner, with due regard to official and unofficial information.

6. For the purpose of autopsy, several requirements must be met. These include a relevant clinical summary by the doctor who looked after the patient before death, or which doctor was responsible for the care of the patient.

7. This clinical summary must be given to the coroner via the police. It should not be given to anyone else. The doctor who provides the clinical summary should not give the said summary directly to the doctor doing the autopsy. It has to go from the clinical doctor to the police, from the police to the coroner, back to the police, and finally to the autopsy doctor.

8. The public’s right to know must be balanced always against the sanctify of and respect for the dead and the unquenchable grief of the family and friends of the dead.

9. Even if the grieving relatives and friends run and fly in the air to the media to air their sorrow and concerns, clamoring and pleading for information, the media must act responsibly so as not to inflame the public or to worsen the very grief the family is trying so hard to endure and expunge. Or both. It is a very fragile family moment. Death speaks to tell us who we are.

10. How then can anyone, family, media, or public, get information regarding coroner cases?

11. The coroner may decide to hold an inquest ( a preliminary inquiry) to determine the circumstances surrounding the death. Such an inquest may or may not be an open court; and jurors may or may not be summoned.

12. The media, the public, and the family should be apprised of how the coroner system works.

13. The police officer in charge of the coroner case and other police officers gather all the relevant information about the case by way of detailed investigation and documentation. This takes time. The family should be kept informed as time goes by.

14. The relatives are told that if an autopsy will be done, it will be done by the pathologist who reports to the coroner (via the police). It is also noted that the family has the prerogative to have their own independent pathologist or independent medical doctor present at the autopsy.

15. Before the autopsy, there may be a need for X-rays. During the autopsy, all sorts of samples can be taken, documented and stored for testing, with the appropriate chain of custody.

16. The autopsy findings are usually clear, with few exceptions, so the areas of contention or concern for the relatives are almost always related to matters outside the actual autopsy findings. Hence a knowledgable and experienced lawyer for the family of the dead is often a good, sensible, and natural recourse.

17. There are many things wrong in Antigua and Barbuda. Some would say too many. But in our honest attempt to fix the wrongs, we should not allow our fixation on personalities ( justifiable or not) to erode and eradicate the fundamental principles, good practices, and technical procedures that are required to achieve the very end we seek.

18. It’s called shooting ourselves in the collective head. Bang! We are all dead.

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14 COMMENTS

  1. Who wrote this!!!??? This is babble!!

    I’m an MD shaking her head… get better pathologists in here to do the job!! I’ve done autopsies and wondering who all can perform one in this inquest!? Can i call in friends from other countries??
    Because it’s RIDICULOUS for this man to not have found a COD by now!! All this time!!??

    Chupz SMH!!!

  2. Grateful for your explanation Dr. Simon. With such high interest in this case, an explanation like this to the public, preferably at a news conference would have gone a long way in assuring and satisfying an anxious, tense and impatient public that the matter is still ongoing. It’s the lack of knowledge and clarity that makes everyone fidgety and nervous about the whole situation. As you have so beautifully done, this assurance could have been given via a news conference by the police.

  3. sounds like a bandaid. how many cases of inconclusive undetermined cause of death in Antigua have had a different result after the burial?

  4. If you’re a MD you lacks comprehension skills. The author of the article is spot on in-regard’s an inquest. The result was inconclusive and only a pathologist can confirm the cause of death. Common.Why?How do you get your degree?

  5. Lol at WHOEVER is “Gaston Browne” today!! 😆

    And Mr Philip must not realize how much of a JOKE this news post is. 😳 😆 🤣

  6. Well well ah wah yah tarl. During the covid 19 pandemic covid was blame for every death not only in Antigua but world wide. No autopsy, no coroner bullshit…just a simple swab to the nose and covid 19 was the cause of death…story done. Even when hit by a motor car or having your head remove from your body once you tested positive for covid 19 that was the cause of death. The medical fraternity was threaten by the political directorate that their license would be revoke if they go along with this narrative, the doctors dare not issued sick leave for anything else other than covid. The populace was told take the vaccine or stay home. TALK ABOUT LEGALIZE HIGH CRIMES

  7. (My 3rd attempt)
    This whole Investigation is going from bad to worse daily, and stinks to high heaven!!! Why???a few weeks ago we were told that an autopsy had been conducted. The father of the deceased publicly aired some rambling nonsense no doubt handed to him by the authorities. Absolute silence about this publicly announced followed. In his muttering, the father claimed that there were no signs of mutilation visible on the body. Excuse me??? A body that had just undergone an autopsy bore no signs of mutilation. How could this layman distinguish between incisions made during an autopsy and those that might have been made for other purposes by some other person(s). The only odd sign he noted was “sunburn” on her skin!!!! Nothing from the authorities fir days. Stone cold silence. And then a flurry of activity. Well – attended candle light vigil (attendees and general public appear pleased AND appeased). Then the nation lays to rest a highly trained female poli ce officer – a death ruled a suicide, an officer highly trained in the field of forensics whose skills might have been contributing or contributed to the preliminary investigation of the Chantel Crump abduction and murder case, gone. Dead men or women tell no tales. Next came the announcement of the date for Chantel Crumps funeral, and now this latest Installment. AUTOPSY INCONCLUSIVE. Well,well well. This poor.child of ignoble birth, just another child from the ghetto will be buried along with the files of all those guilty of her murder as well as those allegedly responsible for covering it up. The pretty, littl senorita will be freed on the basis of mental illness and probably institutionalized for a year or two. The sailorman who has mot been charged to date and probably never will. CASE CLOSED.
    KARMA, however, IS REAL!!!!

  8. For the record, a highly respected external forensic pathologist handled this case and operated and reported by all standard international procedures and protocols.

    Kindly stop ransacking the mind of the members of the family.

  9. @ drop the mic
    If you are really a MD and have done autopsies, you should know better.
    It is foolish statement like yours that lead to more public misinformation.

  10. I never doubt the result of the Pathologist. It is not the first time in history, that a result from an autopsy return inconclusive. This is just one test. There are many more test to be done to determine the cause of death but only the autopsy can be done in Antigua. The other test can be carried out in a foreign country with the appropriate Laboratory. Ticks remain in the mortuary for over 3 years because his cause of death was inconclusive. When the father said his daughter body was intact when he saw her, thst is when he was called to identify the body and not after the autopsy. Faithful national is a snake in a green grass. Audley Phillip, a man of integrity, you must be careful of what you write after reading the Pathologist comments. A toxicology test is yet to be carried out and many more. AS the Pathologist said, all the necessary samples were taken from the body and nothing left to be done on the body so her body can be buried. All the samples taken will be sent to a highly sofisticated Laboratory where the cause of death will be determined. The Pathologist is now going as far as asking for her medical history before death. That is to show it is not over yet. The parson who identified his or her self as a MD is nothing but a QUACK doctor. Facebook followers must be careful of you all conduct on Facebook and try not to jepodized the investigation into Chantal death. Chantal remain everyone of us daughter and Justice she will get. My advice to all the Pathologist in Antigua, whenever there is another murder whether young or old, refuse to do any autopsy and allow the government to go down by the market, Graysfarm or Point and pick up a Pathologist on the street to tell them what they want to hear. All of a sudden, every body in Antigua is a Pathologist, a Doctor, a magistrate or a Judge. Very Lawless people.

  11. All of this talk is gibberish , an inconclusive Autopsy means the pathologist was unable to determine the exact cause of death or how she died , this is a child that went to school for hours and was returning home no sickness doctors report is not necessary at this point. It seems like Antiguans
    allegedly first idea that body parts was taken from this child was correct.”No need for pacifying”
    Antiguans are not idiots .you’re coming out acting as if you’re giving a truthful statement but are just rumbling . Chantel Crump parents may not know their legal right, but they have the right to Obtain a pathologist at the expense of the government of Antigua so they can obtain an autopsy/ coroner report.

  12. …DR. SIMON-FORENSIC PATHOLOGIST: …PROFESSIONALLY COMPETENT: …METICULOUS

    This commenter’s ‘…WORD IS LAW.’

    ***
    Who doesn’t like it, may complain to the ‘…CHIEF JUSTICE.’

    ***
    ‘…No blame of ‘…PROFESSIONAL INCOMPETENCE’ shall be attributed to the ‘…PATHOLOGIST’ IN THESE ‘…MOST VEXING DEVELOPMENTS.’

    ***
    BENEFIT OF KNOWLEDGE:

    It shall be known that:

    (i) ‘…CRIMINAL INVESTIGATIONS: and

    (ii) …CORONER’S INQUISITIONS:’ are two distinct processes.

    ***
    (a) ‘…THE FORMER PRIMARILY SPEAKS TO:

    (i) ‘…THE COLLECTION OF EVIDENCE:

    (ii) …APPREHEND THE ‘…MURDERER/S: and

    (iii) …MAKE CRIMINAL PERPETRATORS AMENABLE TO LAW:

    ***

    THE LATTER SPEAKS TO AN INQUISITION INTO:

    (i) ‘…UNNATURAL DEATHS: (Pathologist to provide ‘Cause/s): and

    (ii) …ASCERTAINING ONE OF THESE:- CULPABILITY OR MISADVENTURE.

    (a) ‘…MURDER (Culpability):

    (b) …INVOLUNTARY MANSLAUGHTER (Culpability): and

    (c) …INFANTICIDE (Killing of Infants-babies- Culpability):

    (d) …MISADVENTURE (Climbing roof/tree/driving recklessly and killing oneself/commit suicide ‘….Suspected: Iao Merchant-Malone).’

    ***

    PASSED CORONER’S STAGE:

    NOW:

    (i) ‘…THIS CASE IS NOT ONE FOR ‘…DISTRICT CORONER, HER WORSHIP, NGAIO EMMANUEL:’

    (b) …CRIMINAL INVESTIGATORS HAVE ALREADY ‘…PASSED THAT STAGE.’

    (b) …THIS IS NOT AN INQUISITION INTO THE ‘…CIRCUMSTANCES SURROUNDING DEATH:’

    (C) …THIS IS A CASE FOR ‘…DETERMINING CAUSE/S OF DEATH.’

    DEVELOPMENTS: …TALKINGLY WRONG

    The developments, as reported in this case, should prove ‘…RADIO TALK SHOW HOST, DANE KNIGHT, …TALKINGLY WRONG.’

    ***

    The ‘Talk Show Host continues to speak to ‘…USEFUL IDIOTS.’

    ***

    Seemingly, however, not ‘…ALL IDIOTS’ are ‘…USEFUL.’

    Some appear not to know that:

    (a) ‘…ARRESTING: and

    (b) …CHARGING A SUSPECT’ with ‘…MURDER,’ before:

    (i) …AN AUTOPSY/POST MORTEM TO DETERMINE:

    (a) ‘…CAUSE/S OF DEATH: but seemingly

    (b) …ACTING ON SUSPICION: and/or

    (c) …AN ACCUSED CONFESSION: or

    (d) …AN ACCUSED ADMISSION;’ are evidentially

    (e) …NOT INDEPENDENT ‘…PRIMA FACIE EVIDENCE IN ANY CRIMINAL TRIAL.’

    ***

    CASE ON POINT:

    QUEEN v PHYLLIS TAYLOR (Cedar Grove), MAKES THE POINT’

    ALLEGED TO HAVE ‘…KILLED DAVID RAMSEY’ [DECEMBER 1, 2013].

    ONE MAY WISH TO ASK ‘…ATTORNEY JOHN ELI FULLER OR ST. KITTS DPP, ADLAI SMITH.

    ***
    IF NOT POSSIBLE, THEN ONE MAY READ:

    CASE NO: ANUHCR:2016/0007’

    END OF LESSON 1

    ***

    NOW:

    In professional Law enforcement capacity, worked with ‘…DR. LESTER SIMON.’

    ***
    In very close proximity at ‘Morgue/FUNERAL HOMES:

    (a) ‘…OBSERVED, WITH ‘BLOOD-CURDLING AND BODY TWINGING’ EXPERIENCE, DISSECTIONS OF:

    (a) ‘…BODIES: and

    (b) …CRANIA:

    ***
    The good Pathologist shall recall the high-profile ‘SUDDEN DEATH’ of:

    CLIMATOLOGIST- LEONARD FARQUHAR’ [1954-1995].

    ***
    SKILLFUL REMOVAL OF:

    (i) …CRANIA:

    (ii) …VITAL ORGANS: and

    (iii) …INTESTINES: and

    (iv) …PROVIDING SAMPLES FOR:

    (a) …TRINIDAD FORENSIC PATHOLOGIST AND HIMSELF.’

    ***
    ONE FOOT OR ONE LEG:

    ‘…A MAN IS A MAN’ (Calypso Rose).

    NOW:
    NOT SURE HOW MANY ‘…DR. SIMON MAY HAVE SEEN, BUT NEITHER FOR HIMSELF, NOR THE VISITING PATHOLOGIST’ DID HE REMOVE ANY LEGS.

    ***

    SIMILARITIES OF RESULTS

    Then ‘…ISLANDS AND MILES’ apart, both ‘…LABORATORIES’ came up with ‘…SIMILARITIES OF RESULTS.’

    ***

    PROFESSIONAL COMPETENCE:

    These are that which shall be said of this ‘…FORENSIC PATHOLOGIST:’

    (a) ‘…PROFESSIONALLY COMPETENT: and

    (b) …EXTREMELY CAREFUL: …METICULOUS: AND …THOROUGH.’

    ***
    NOW:

    Though not necessarily evidentiary deliverable by the ‘…CRIMINAL INVESTIGATOR,’ (as only the ‘…PATHOLOGIST- EXPERT WITNESS)’ shall so do, still having shown the ‘…AFFECTED ORGANS AND TISSUES,’ he offered very useful medical explanations.

    ***
    FURTHER SYMPATHIES TO ‘…BEREAVED AND MOURNING FAMILIES.’

    ***
    WALK GOOD, DR. LESTER SIMON.

    ***

    THIS IS NOT THE ‘…TRIBUTE’ OR THE ‘…SERMON’ FOR THE FINAL RITES, THOUGH.
    ***
    BE IT …HEAVEN: …HELL: OR …GLORY: LIKENED TO ‘…ATTORNEY CHARLESWORTH TABOR,’ GOT TO WAIT FOR THE ‘CALL.’
    ***

    THESE WORDS ARE LAW.
    ***

  13. @ doctor Lester Simon: I am getting a good salary from the government as a pathologist, if they want me to tailor a report of a cause of death to reduce emotional hysteria and perhaps civil disobedience I just do it because they paying me, when they instruct me to then release the report written in some highfaluted scientific semantics that create a benign atmosphere, people wouldn’t even understand how she died unless the report is interpret by a doctor. I will write the report in university language.

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