The official who investigates suspicious deaths in your city may or may not be a doctor

When a group of doctors gathered in Washington state for an annual meeting, one of them made a startling revelation: If you ever want to know when, how and where to kill someone, I can tell you, and you’ll be fine. . No problem.

Indeed, the expertise and availability of coroners, who determine the cause of death in criminal and unexplained cases, varies widely in Washington, as in many other parts of the country.

“A coroner doesn’t need to have taken a science class in their lifetime,” said Nancy Belcher, chief executive of the King County Medical Society, the group that met that day.

Her colleague’s startling comment launched her on a four-year journey to improve the state’s archaic death investigation system, she said. “These are the people who walk in, look at a homicide or death scene and say if there should be an autopsy. They are the ones who ultimately decide,” Belcher added.

Each state has its own laws governing the investigation of violent and unexplained deaths, and most delegate the task to cities, counties and regional districts. The position can be held by a coroner elected from the age of 18 or by a highly qualified doctor appointed as a medical examiner. Some death investigators work for elected sheriffs who try to avoid controversy or owe political favors. Others own funeral homes and direct bodies to their private companies.

Overall, it is a disjointed and chronically underfunded system – with more than 2,000 offices across the country determining the cause of death in around 600,000 cases a year.

“There are really glaring conflicts of interest that can arise with coroners,” said Justin Feldman, visiting professor at Harvard University’s FXB Center for Health and Human Rights.

Belcher’s crusade succeeded in changing some aspects of Washington’s coroner’s system when state lawmakers approved a new law last year, but efforts to reform death investigations in California, Georgia and Illinois have recently failed.

Decisions regarding causes of death are often unsettled and can be controversial, especially in deaths involving police such as the 2020 killing of George Floyd. In that case, Minnesota’s Hennepin County Medical Examiner ruled Floyd’s death as a homicide, but indicated heart disease and the presence of fentanyl in his system may have been factors. Pathologists hired by Floyd’s family said he died from lack of oxygen when a police officer knelt on his neck and back.

In a recent California case, the Sacramento County Coroner’s Office ruled that Lori McClintock, wife of Congressman Tom McClintock, died of dehydration and gastroenteritis in December 2021 following ingesting white mulberry leaves. , a plant not considered toxic to humans. The decision sparked questions from scientists, doctors and pathologists regarding the decision to link the plant to its cause of death. When asked to explain how he made the connection, Dr Jason Tovar, the chief medical examiner who reports to the coroner, said he had reviewed the literature on the plant online using WebMD and Verywell Health.

The various titles used by death investigators do not distinguish between discrepancies in their references. Some communities rely on coroners, who may be elected or appointed to their offices, and may or may not have medical training. Forensic pathologists, on the other hand, are usually physicians who have completed their residency in forensic pathology.

In 2009, the National Research Council recommended that states replace coroners with medical examiners, describing a system “in need of significant improvements”.

Massachusetts was the first state to replace coroners with statewide medical examiners in 1877. As of 2019, 22 states and the District of Columbia had only medical examiners, 14 states had only coroners, and 14 had a mixture, according to the Centers for Disease Control and Prevention.

The movement to convert the rest of the country’s death investigators from coroners to medical examiners is waning, a victim of the political power of coroners in their communities and the additional costs needed to pay for medical examiners’ expertise.

The goal now is to better train coroners and give them greater independence from other government agencies.

“When you try to suppress them, you hit a political wall,” said Dr. Jeffrey Jentzen, a former Milwaukee city medical examiner and author of “Death Investigation in America: Coroners, Medical Examiners, and the Pursuit of medical certainty. »

“You can’t kill them, so you have to help train them,” he added.

There wouldn’t be enough forensic pathologists to meet the demand anyway, in part because of the time and expense of training following medical school, said Dr. Kathryn Pinneri, president of the National Association of Medical Examiners. She estimates there are regarding 750 full-time pathologists nationwide and regarding 80 job openings. About 40 medical examiners are certified in an average year, she said.

“There is a huge shortage,” Pinneri said. “People talk regarding abolishing the coroner system, but it’s really not feasible. I think coroners need to be trained. This is what will improve the system. »

His association called on coroners and medical examiners to operate independently, without ties to other government or law enforcement agencies. A 2011 survey by the group found that 82% of medical examiners who responded had been pressured by politicians or relatives of the deceased to change the cause or manner of death reported in a case.

Dr. Bennet Omalu, California’s former chief medical examiner, resigned five years ago over what he described as interference by the San Joaquin County Sheriff to protect law enforcement.

“California has the most backward system in death investigation, is the most backward in forensic science and forensics,” Omalu told the Senate Committee on Governance and State Finance. in 2018.

San Joaquin County has since separated its coroner duties from the sheriff’s office.

The Golden State is one of three states that allow sheriffs to also serve as coroners, and all but 10 of California’s 58 counties combine the offices. Legislative efforts to separate them have failed at least twice, most recently this year.

AB 1608, led by State Assemblyman Mike Gipson (D-Carson), cleared that chamber but did not get enough votes in the Senate.

“We thought we had a modest proposal. That it was a first step,” said Robert Collins, who advocated for the bill and whose 30-year-old stepson Angelo Quinto died following being restrained by Antioch police in December 2020. .

The Contra Costa County Coroner’s Office, part of the sheriff’s department, blamed Quinto’s death on “excited delirium,” a controversial finding sometimes used to explain deaths in police custody. The finding was rejected by the American Medical Association and the World Health Organization.

Lawmakers “didn’t want their names behind something that would put sheriffs once morest them,” Collins said. “Just having this opposition is enough to scare a lot of politicians. »

The influential California State Sheriffs’ Association and the California State Coroners Association opposed the bill, describing the “huge costs” to set up stand-alone coroner’s offices.

Many Illinois counties also said they would take on a financial burden under similar legislation introduced last year by state Rep. Maurice West, a Democrat. His more sweeping bill would have replaced coroners with medical examiners.

Rural counties, in particular, complained regarding their tight budgets and killed his bill before it was heard by a committee, he said.

“When something like that affects rural areas, if they push back a bit, we shut down,” West said.

Proponents of overhauling the system in Washington state — where, in small rural counties, the local prosecutor also serves as coroner — faced similar hurdles.

The King County Medical Society, which drafted the legislation to divorce the two, said the system created a conflict of interest. But smaller counties worried they wouldn’t have the money to hire a coroner.

So lawmakers struck a deal with counties to allow them to pool resources and hire coroners on shared contracts in exchange for ending prosecutorial dual roles by 2025. The bill, HB 1326, signed last year by Democratic Gov. Jay Inslee, also requires more rigorous training for coroners and medical examiners.

“We’ve had hostile people we’ve spoken to who really feel like we’re shooting at them, and we absolutely weren’t,” Belcher said. “We were just trying to come up with a system that I think everyone would agree to review. »

This story was produced by KHN, which publishes California Healthline, an independent editorial service of the California Health Care Foundation.

This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health policy research organization not affiliated with Kaiser Permanente.