Who decides cause of death? It may be a business owner — or an 18-year-old

By Samantha Young, Kaiser Health News

When a group of physicians gathered in Washington state for an annual meeting, one made a startling revelation: If you ever want to know when, how — and where — to kill someone, I can tell you, and you’ll get away with it. No problem.

That’s because the expertise and availability of coroners, who determine cause of death in criminal and unexplained cases, vary widely across Washington, as they do in many other parts of the country.

“A coroner doesn’t have to ever have taken a science class in their life,” said Nancy Belcher, chief executive officer 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 that go in, look at a homicide scene or death, and say whether there needs to be an autopsy. They’re the ultimate decision-maker,” 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 job can be held by an elected coroner as young as 18 or a highly trained physician appointed as 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 businesses.

Overall, it’s a disjointed and chronically underfunded system — with more than 2,000 offices across the country that determine the cause of death in about 600,000 cases a year.

“There are some really egregious conflicts of interest that can arise with coroners,” said Justin Feldman, a 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 system when state lawmakers approved a new law last year, but efforts to reform death investigations in California, Georgia, and Illinois have recently failed.

Rulings on causes of death are often not cut-and-dried and can be controversial, especially in police-involved deaths such as the 2020 killing of George Floyd. In that case, Minnesota’s Hennepin County medical examiner ruled Floyd’s death a homicide but indicated a heart condition 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 kneeled on his neck and back.

In a recent California case, the Sacramento County coroner’s office ruled that Lori McClintock, the wife of congressman Tom McClintock, died from dehydration and gastroenteritis in December 2021 after ingesting white mulberry leaf, a plant not considered toxic to humans. The ruling triggered questions by scientists, doctors, and pathologists about the decision to link the plant to her cause of death. When asked to explain how he made the connection, Dr. Jason Tovar, the chief forensic pathologist who reports to the coroner, said he reviewed literature about the plant online using WebMD and Verywell Health.

The various titles used by death investigators don’t distinguish the discrepancies in their credentials. Some communities rely on coroners, who may be elected or appointed to their offices, and may — or may not — have medical training. Medical examiners, on the other hand, are typically doctors who have completed residencies in forensic pathology.

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

Massachusetts was the first state to replace coroners with medical examiners statewide 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 mix, 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 casualty of coroners’ political might in their communities and the additional costs needed to pay for medical examiners’ expertise.

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

“When you try to remove them, you run into a political wall,” said Dr. Jeffrey Jentzen, a former medical examiner for the city of Milwaukee and the 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 medical examiners to meet demand anyway, in part because of the time and expense it takes to become trained after medical school, said Dr. Kathryn Pinneri, president of the National Association of Medical Examiners. She estimates there are about 750 full-time pathologists nationwide and about 80 job openings. About 40 forensic pathologists are certified in an average year, she said.

“There’s a huge shortage,” Pinneri said. “People talk about abolishing the coroner system, but it’s really not feasible. I think we need to train coroners. That’s what will improve the system.”

Her association has called for coroners and medical examiners to function independently, without ties to other government or law enforcement agencies. A 2011 survey by the group found that 82% of the forensic pathologists who responded had faced pressure from politicians or the deceased person’s relatives to change the reported cause or manner of death in a case.

Dr. Bennet Omalu, a former chief forensic pathologist in California, resigned five years ago over what he described as interference by the San Joaquin County sheriff to protect law enforcement officers.

“California has the most backward system in death investigation, is the most backward in forensic science and in forensic medicine,” Omalu testified before the state Senate Governance and Finance Committee 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, spearheaded by state Assembly member Mike Gipson (D-Carson), cleared that chamber but failed to 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 after 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 has been rejected by the American Medical Association and the World Health Organization.

Lawmakers “didn’t want their names behind something that will get the sheriffs against them,” Collins said. “Just having that 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 “massive costs” to set up stand-alone coroner offices.

Many Illinois counties also said they would shoulder 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 about their tight budgets and killed his bill before it got a committee hearing, he said.

“When something like this affects rural areas, if they push back a little bit, we just stop,” West said.

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

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

So, lawmakers struck a deal with the counties to allow them to pool their resources and hire shared contract coroners in exchange for ending the dual role for prosecutors 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 had some hostile people that we talked to that really just felt that we were gunning for them, and we absolutely were not,” Belcher said. “We were just trying to figure out a system that I think anybody would agree needed to be overhauled.”

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KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.