In accordance with Emergency Support Function (ESF) #8, Public Health and Medical Services, the Office of the Chief Medical Examiner (OCME) was designated by the Mayor as the lead agency for the District’s mass fatality management and mass fatality incident response through a statutory amendment in 2017. Under the District Response Plan (DRP), OCME coordinates all mass fatality efforts, including investigating, establishing a temporary morgue(s), coordinating transportation of remains, performing postmortem examinations and identifications, securing evidence, certifying cause and manner of death, and releasing remains. The OCME also coordinates with District area hospitals for examination and storage or release of remains and deputize hospital physicians pursuant to D.C. Official Code § 5-1404 to allow in-house hospital examinations on behalf of the Chief Medical Examiner (CME).
12.2.1 Mass Fatality Incident
“Mass fatality incident” is a situation resulting in more human remains to be investigated, recovered, and examined than can be managed using routine District resources, or any other exceptional circumstance that results in the inability to process human remains under routine conditions. Chief Medical Examiner Amendment Act of 2017 (D.C. Law 13-172, as added Dec. 13, 2017, D.C. Law 22-33).
12.2.2 Mass Fatality Management
“Mass fatality management” is the training of, and cooperation among, governmental and nongovernmental agencies, organizations, associations, and other entities to ensure the following after a mass fatality incident: 1) the proper recovery, handling, identification, transportation, tracking, storage, and certification of cause and manner of death of victims; and 2) the facilitation of access to mental and behavioral health services to family members, responders, and survivors. Chief Medical Examiner Amendment Act of 2017 (D.C. Law 13-172, as added Dec. 13, 2017, D.C. Law 22-33).
12.3 Mass Fatality Incident Management
12.3.1 Conditions that Exceed Routine Office of the Chief Medical Examiner Operations
The following conditions trigger OCME mass fatality incident operations:
- The issuance of a public health emergency executive order by the Mayor. D.C. Official Code § 7-2304.01.
- The issuance of a public emergency executive order by the Mayor. D.C. Official Code § 7-2304.
- A situation resulting in more human remains to be investigated, recovered, and examined than can be managed using District resources that may include:
- Any confirmed incident associated with five or more fatalities tied to a single event;
- Any confirmed incident with the potential for mass fatalities (i.e., five or more deaths), such as a mass casualty incident; or
- Multiple, simultaneous incidents that produce any number of fatalities, and have the potential to be man-made, coordinated or terror-related, such as complex coordinated attacks (CCAs).
- Anticipated events such as:
- Impending or predicted natural disasters; and
- National security special events (NSSEs), or any large gatherings greater than 100,000 persons.
- Credible knowledge of a perceived threat as determined by law enforcement, the District of Columbia Homeland Security and Emergency Management Agency (HSEMA), DC Health or any entity with authority to issue threat alerts to the District government.
- Events that exceed OCME’s routine operational capacity, which includes:
- Greater than 20 fatalities in a single day;
- Pandemic-related or highly infectious deaths;
- Remains contaminated with any hazardous material or exposed to a Chemical, Biological, Radioactive, Nuclear, or Explosive (CBRNE) agent;
- A single event that produces multiple highly fragmented remains; and
- Protracted and/or complex fatality scenarios (e.g., building collapse, water recovery).
OCME has a number of resources to support its role in mass fatality incident management, including National Capital Region (NCR) assets, a Medical Examiner Transport Team (METT) that has a fleet capable of recovery and removal of decedent remains; and a Memorandum of Agreement with the Defense Health Agency, National Museum of Health and Medicine, for forensic anthropological consultation services, training, and collaboration on medical education activities.
12.3.2 Identification of Victims
When there is a mass fatality incident, the OCME may stand up the OCME Disaster Victim Identification (DVI) Service to provide accurate and timely identification of victims for the rapid return of decedents to their legal next of kin.
In mass fatality incidents, normal identification protocols through visual identification may not be possible or desirable. Therefore, alternate means of identification may be used, including scientific (e.g., fingerprints, radiograph comparison, DNA); and circumstantial (e.g., tattoos, scars, and clothing). Depending on the nature of the incident, OCME may request family who believe their next of kin is a victim of a mass fatality incident to complete the OCME “DNA Evidence Collection Consent Form” for collection of a DNA sample to test to aid identification of the victims.
See Appendix 6.0 for an example of this form.
Victim identification will also inform the order of priority for the release of remains to control decedent disposition and any District notification obligations in the event of mandatory mass burial, mass cremation, or other executive directive that affects the disposition of the decedent’s remains. D.C. Official Code § 3-413.
12.3.3 Subpoena Authority
The OCME has broad subpoena authority with respect to confidential medical records and relevant information from physicians, hospitals, nursing home, residential care facilities and other healthcare providers as they deem necessary for investigating deaths. D.C. Official Code § 5-1407. Use of this subpoena authority, in connection with a death investigation, may be used to help identify victims in a mass fatality incident.
The identification of the victim may also impact the court when determining standing, resolving disputes, and any civil considerations resulting from the District’s action that affects the decedent’s remains and next-of-kin rights.
12.4 Professional Licensure and Mass Fatality Incidents
The OCME staff includes board certified forensic pathologists who determine cause and manner of death. In mass fatality incidents, the OCME may utilize non-staff physicians to assist with these functions. D.C. Official Code § 5-1410.
There may be a need to waive licensure requirements for the following individuals:
- Funeral directors; and
- First responders.
See sections 11.2 and 11.3 of the Manual for information regarding scope of practice, licensure portability, and volunteer health practitioners.
12.5 Decedent Disposition and Storage
The District has locations to accommodate burial of human remains; however, due to space limitations and locations, such sites may not be suitable for mass burial of infected or contagious remains. The District currently has no crematorium; therefore, all human remains to be cremated must be transported out of state.
In the event decedent remains require direct transport outside of the District (e.g., in cases of Ebola or other infectious diseases), or for other purposes, licensure requirements for non-District licensed funeral directors may need to be modified or waived to effectuate out-of-state transfers of human remains. See section 11.2 of the Manual. Under District law, the provision of funeral, cremation, cemetery, or other mortuary services by an individual who is authorized to provide such services under Chapter 23C of Title 7 is not prohibited while an emergency declaration is in effect. D.C. Official Code § 3-411(h).
During the West African Ebola epidemic in 2014, DC Health determined that, in the event of a death in the District in which Ebola may be the cause or suspected cause, the OCME would assume all control and management of disposition of the involved human remains. It was decided that all human remains of Ebola patients would be promptly cremated. All funeral directors were notified of this protocol. A plan was adopted, the Interim Draft Concept of Operations for the Management of Decedents with Confirmed or Suspected Viral Hemorrhagic Fever (ConOps Plan), that was consistent with CDC Guidance for Safe Handling of Human Remains of Ebola Patients in U.S. Hospitals and Mortuaries.
12.5.1 Special Rules Regarding Decedent Disposition When Death Caused by Certain Diseases
Special rules apply in cases of death from the following diseases:
- Plague (bubonic and pneumonic);
- Smallpox; or
- Louse-borne typhus fever.
When death is caused by one of the diseases listed above, the physician issuing the certificate of death must give immediate notice by telephone of the death to the DC Health Director. 22B DCMR § 214.1. Certain steps must be taken with the body of a person who died from one of the diseases listed above. In addition, the body of a person who died from one of the diseases listed above may not be moved from the place of death except after issuance of a permit by the DC Health Director. 22B DCMR §214.2.
A public funeral service for a person who has died of any of the diseases listed above must not be held in the presence of the body unless the body has been embalmed and placed in a hermetically sealed casket.
See section 7.5 of the Manual regarding special reporting requirements for deaths from these diseases.
12.6 Mutual Aid Agreements
The District may enter into Mutual Aid Agreements with neighboring jurisdictions in the NCR for cremation and/or mass burial in the event of a mass fatality incident. These agreements are authorized through Emergency Management Assistance Compact (EMAC) and various Mayor’s Orders, including:
During the West African Ebola epidemic in 2014, Maryland’s Board of Morticians and Funeral Directors and Maryland’s Secretary of Health and Mental Hygiene’s Office agreed that it was acceptable to transport any infected decedents from the District to Maryland for the purposes of cremation. Transportation plans in that incident included details for postmortem preparation of the infectious remains.
See section 4.10.2 for more information about EMAC.
If a mass fatality incident overwhelms District resources, aid can be requested via the National Disaster Medical System (NDMS). See section 4.11 of the Manual.