The Official Who Investigates Suspicious Deaths in Your Town May Be a Doctor — Or Not

(KHN) 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.