by Benjamin Tschirhart

A medieval system: historical and modern coroners and death investigations

If there is one thing which most sets us apart as humans, it must be our answer to death. We are not the only creatures who mourn our dead, but we are among the only ones who perform such elaborate rituals upon them, for their sake or for the sake of those still living. These rituals serve various purposes, some ancient and some new, from memorializing the deceased to discovering the cause of their death. Sometimes this is done to avenge the death and give the survivors satisfaction.

Today, this is accomplished by a process beginning with the autopsy — the death investigation. Normally reserved for deaths which are mysterious, whose causes are sudden, violent, or otherwise unknown, the death investigation is traditionally performed by a coroner, who aims to establish the cause of death and, where possible, to discover evidence which might be used to find a killer. 

For this reason, even those autopsies where the cause of death seems obvious must be carried out with care and deliberation. Often, the death investigator bears responsibility for determining that what may appear to be an accidental death is in fact a murder. Even for deaths resulting from natural causes, the autopsy can be crucial — for example, discovering whether the deceased carried a transmittable disease which may pose a danger to others.  In modern times, the death examination has become more scientific in nature, and medical examiners — usually physicians with training in forensic pathology — have begun to assume the responsibility for this task.

As humans, we live in stories. We create narratives for ourselves and one another to determine and understand our place in the world and in time. Death is, to our knowledge, the final chapter of this story for each of us. We wish to know the truth about the deaths of those we love and for our loved ones to know the truth about us. The final examination is, in our time, a large part of how we write this ending. For this reason, it is essential that it be accomplished with care, dignity, and honesty to ensure that the death has meaning and justice is served in whatever ways are possible.

Historical background and current system

The original coroners were agents ofthecrown — hence the name. They were charged with investigating deaths where the sovereign might stand to gain by the forfeit of land or property. In the case of a violent death, the murderer might have his property seized by the king. This institution was also heavily interwoven with the ecclesiastical rules prohibiting suicide, since a suicide was denied a Christian burial and certain other posthumous rights like inheritance. Therefore, the ruler had a vested interest in ascertaining the cause of death.

In Norman England, the Sheriff was the agent of the king; the power of this office was easy to abuse and often led to rampant corruption. As a check on the power of the Sheriff, Henry II (1154-1189) created the office of Coroner (literally “crowner”). The Coroner had authority to relieve the Sheriff of his office if he showed good cause. Thus, the Coroner’s office originated as a sort of watchdog, empowered to pursue investigation into murders if the Sheriff was deemed insufficiently aggressive in his pursuit of justice.

The Coroner was ultimately established in English common law as an oversight officer; traditionally, the Coroner has had power to issue arrest warrants — even to arrest and assume the office of the Sheriff, should it be necessary. This authority was largely usurped by the Justice of the Peace in the 16th century, relegating the Coroner to a role primarily concerned with death investigation, with a minor concern in keeping other officials honest. It was in this form that the office was imported to the New World and put into practice in several colonies of Great Britain. 

While the attributes and responsibilities of the coroner have evolved over time, certain qualities have remained stable. The coroner has generally been an elected position, usually filled by a layman — that is, not a physician. This fact is extremely significant to the topic at hand. The early primacy of coroners over death investigation in the early United States was challenged by the growing involvement of licensed physicians in the medicolegal institution. This trend foundered however, as the physicians encountered problems including a lack of deference to their expertise from legal authorities, and difficulty obtaining reimbursement from local governments for their services. Physicians assumed a secondary role, performing examinations only at the request of coroners.

The 19th century saw a renewed effort by civic leaders to replace coroners with physicians in response to political corruption and bungled inquests under the traditional model. Physicians began to aggressively pursue inclusion into the legal arena. By the mid-1900s, a handful of states had begun to use medical examiners to regulate and codify the disorganized patchwork of regulations and institutions in place across the various states and municipalities. By this time, coroners, having managed to solidly entrench themselves in the legal apparatus surrounding deaths, as the “pawns of political patronage and influence” proved predictably resistant to reform.

Created a century earlier in 1847, the American Medical Association (“AMA”) had attempted to create a physician-led medical examiner system; however, the westward expansion of the population made this difficult, as the informal law enforcement role of the coroner found more fertile ground in the less than organized social environment of the frontier. The AMA focused its efforts in four major cities: Boston, New York, Chicago, and Cleveland. But it would be almost 40 years before the coroner system was abolished in New York City.

Coroners

The next 50 years saw an ongoing effort by academic and philanthropic figures to improve the death investigation system nationwide; such efforts by the Rockefeller Foundation resulted in the Harvard University Department of Legal Medicine. And while these efforts may be seen largely as being professionally motivated, a persistent undercurrent continued to feed the wellspring of public efforts at its source: fear of crime.

While this may seem insignificant to the larger picture (after all, who cares what motives drive improvement, so long as it happens?). This motivation does not guide progress down the same paths as an objective, unbiased drive to improve the field of science. Where it leads is, in fact, quite different — as has become all too apparent. The coroner was originally a watchdog. But the intervening centuries have brought the dog indoors where it now shares a roof with the very figures it was once charged with keeping an eye on.

For most of the almost 8,000 people who die every day in the U.S. in 2023, death is a matter of routine. That is to say, no crime or scandal accompanies their death. There is, however, a minority of these which cannot be resolved routinely. Deaths which are in any fashion suspicious or violent will (ideally) earn the scrutiny of the coroner. The official responsibility of the coroner is to examine the court’s postmortem or to employ another expert who is qualified to do so in order to ascertain the manner of death and ideally the cause.

While the medical profession has consistently pressed for oversight of the death investigation by a trained professional, this campaign has met resistance from legislative bodies and from law enforcement. The coroner is not necessarily a medical professional, and in many places, this role is filled by a sheriff. Even where the coroner is not a law enforcement officer, their offices are often so closely associated with law enforcement that they are viewed (indeed, often viewed by themselves) as part of the prosecutorial team. When the coroner’s office is located in the police station, sheriff’s department, or courthouse and when an officer or deputy is present for an autopsy giving advice, direction, or blatantly instructing the examiner what to look for, the prospect of an objective or balance inquiry is little more than a naive fantasy. This is especially true if police or deputies were involved in the death themselves even when such an obvious conflict of interest does not exist, this situation can and does often preclude any hope of a balanced and objective investigation.

Fortunately, the lay coroner is not the only option for an autopsy or death investigation. Often, a medical examiner performs this duty at the behest of a coroner. In some states, the entire office is held by a medical examiner who is a physician, and in some districts, that person must be a qualified forensic pathologist.

Medical examiners

Where the medieval system of the coroner’s office has been brought into the 21st century, the result is almost always some variety of a forensic pathologist medical examiner. A coroner is a political animal. Considering that a coroner is elected — beholden to constituents instead of to science — it is not difficult to understand why certain elements of government wish to see the perpetuation of the outdated system which serves the political process, often at the expense of the truth. Often, it’s only after a personal tragedy that individuals discover that the criminal justice system’s goal of simply obtaining a conviction is not always the same as that of victims and their loved ones who want the truth.

Television and movies frequently provide an unrealistic depiction of American forensic science. Death investigation is only one part of the forensics that is portrayed on television and movies as a science-based toolkit, deployed by educated, highly trained experts who have no motivation other than truth and justice. Indeed, medical examiners represent a step toward modernity, transparency, and competency. For a start, they are not elected. They are medical professionals hired or appointed by the relevant government body. This fact alone is sufficient to weigh in favor of a transition to their use over exclusive use of coroners as the final authority in death determinations.

This is not to say that an education in forensic pathology is sufficient to ensure objectivity or dedication to truth, but the chances are certainly better than under the coroner system. For one, a forensic pathologist is a licensed physician, with years of secondary education and medical school, residency, and specialized training in the field of death investigation. For instance, the additional education and training enables medical examiners to identify suicides at a rate up to 16% higher than coroners, according to research on the issue. Being able to accurately and consistently identify when a crime has not occurred is vital because a suicide misidentified as a homicide results in police hunting for a suspect despite the fact there isn’t one. 

We must also acknowledge that no amount of training can overcome the effects of systemic, fundamental corruption that inevitably results from the profound conflict of interest which seems to be baked into much of the system as it currently exists. Currently, only four states require coroners to be physicians. Out of the 28 states which elect their coroners, only 17 require additional training on death investigation.

In 1954, the Model Post-Mortem Examinations Act was passed to ensure greater competence in determining the cause of death in cases of criminal liability. Although it was never codified into state law or administrative code, it did result in a swap of about half of U.S. coroner positions to medical examiners. Had it been fully implemented, the Act would have established a state office of medical examiner, headed by a forensic pathologist who would have jurisdiction over — and supersede the authority of — coroner’s offices in the case of criminal death investigations. In the 21st century, we have a patchwork of centralized and decentralized systems in the U.S. Some states have a state office which oversees all medical examiners, while others delegate this authority to the county or parish level.

In 2006, the National Association of Medical Examiners (“NAME”) developed an accreditation program for promulgating a definitive set of Forensic Autopsy Performance Standards for use across the country, which was intended to establish official consensus on the standardization of  “histology, radiology, toxicology and written reports.” The need for such a system was brought into the public consciousness by the COVID-19 pandemic in 2020, prompting the cooperation of the Centers for Disease Control (“CDC”) and the National Center for Health Statistics (“NCHS”) to assemble a reporting system for epidemiology data from all 50 states. This provided a possible model from which a more centralized and standardized system of forensic pathologists and medical examiners might be created. Before something like this can happen however, certain fundamental conflicts of interest and perverse incentives will need to be addressed.

Problems with the system

Even the most outspoken advocates of the current system readily concede that there are flaws. There is a lack of standardization across states and jurisdictions, with some regions employing a central medical examiner office, yielding relatively objective and unbiased reports, while others use a medieval system where the sheriff himself is the coroner. The result is perverse situations where, for example, the suspicious death of a prisoner in custody is investigated by the very person under suspicion for having caused it.

No national standard currently exists for licensing and accreditation, although the National Science and Technology Council (“NSTC”) has published a report establishing certain best practices for the NAME in developing a standardized accreditation and licensing system for the field. This lack of standardization is only one of the shortcomings that currently plagues the field of death investigation. Underlying the haphazard organization of the field is the widespread shortage of qualified personnel to fill the vacant positions across the country. This shortage results in the adoption of relaxed standards for the sake of expediency, resulting in less-qualified occupying positions which already experience heavy workloads and challenging working conditions.

And these are just the innocent problems. The more serious faults in the system are the result of deliberate absorption of the coroner’s office by the law enforcement agencies, which are supposed to work in parallel with medical examiners, but who instead manage to absorb the office into the hierarchy of law enforcement investigation and deny defense counsel access to information which could help defendants. These conflicts of interest will be solved only with fundamental systemic change to the death examination field to establish the office as an institution separate from police and prosecutors.

Expertise

The problems with much of the country’s coroner and medical examiner system run deep. Certain problems are plain to see. The most obvious is the worrisome lack of subject matter expertise required of and possessed by officials who exercise enormous influence over the lives of others with their decisions.

Many coroners currently working in the U.S. have no medical training at all. Until recently, a county coroner in South Carolina was not even required to have a high school education. Yet, these officials are empowered to determine whether a death was an accident or a homicide. Their decisions have serious financial, legal, and personal ramifications. Often, their conclusions can have life-altering ramifications, e.g., whether charges will be pressed against police who kill a person in their custody or whether a family will collect life insurance money after the death of a loved one – a suicide ruling by the coroner means delayed payment or often none at all.

Because of the enormous influence which coroners wield within the criminal justice system and due in no small part to their portrayal on television and film, the public assumes that the coroner is an expert. That is, if coroners are not full-fledged forensic pathologists, then at least they’re some manner of doctor. But that simply isn’t true. As mentioned above, a coroner is often an elected position, meaning that their dedication to performing objective work is in fundamental conflict with their need to pursue a political agenda. Even in places where the coroner designates a forensic pathologist to perform the actual examination, the lack of expertise and training mean that the coroner is ill equipped to judge the qualifications of the person they hire.

Certain states like Louisiana make a sort of perfunctory (but ultimately empty) gesture by requiring that a parish coroner be a physician except when “no licensed physician qualifies to run for office” — a caveat which renders the requirement somewhat toothless. In the U.S., about 20% of all deaths are due to “violent or external means,” e.g., homicides, suicides, overdoses, and car accidents. These are the deaths which are subject to investigation by coroners who make up about 80% of death investigation offices. This means that a significant portion of deaths are at risk of misclassification under this system due to a lack of expertise. A 2018 study found that opioid related deaths are undercounted “most years by 20 to 35 percent.”

These numbers are concerning enough in the abstract. But to see a real-life example of the sort of person who makes these errors, consider John P. Goble, longtime coroner for Scott County, Kentucky. Goble served as county coroner for about 20 years after serving in the U.S. Marine Corps and completing 20 years with the Kentucky State Police as a state trooper. In 2001, he was elected to the Georgetown City Council and after serving two years there won the election to become county coroner in 2002. Although he was popular (with almost 5,000 Facebook friends), this popularity did not translate to accountability. In 2018, Goble was indicted in state and federal courts on seven counts, including receiving stolen property, abuse of public trust, and possession of a controlled substance. Former employees sued him for retaliation after they reported having seen him steal drugs from a death scene; one of his criminal charges alleged that he illegally possessed 90 tablets of oxycodone. The same lawsuit accused him of labeling most deaths as heart attacks “as a way to reduce paperwork.” The fact that hundreds of people relied on the integrity of people like Goble in their time of crisis is chilling.

Conflict of interest

The architecture of the death investigationsystem is, like so much of the legal and the justice system, not so much vulnerable to corruption as designed for it. The patchwork of various authorities and offices developed piecemeal, assembled ad hoc by a population expanding into empty or hostile lands as the U.S. fulfilled its flawed manifest destiny. This expansion was  concerned more with expedient measures than with any sort of ideal. The ideals were applied retroactively, and this makes it difficult for many people today to see the profound shortcomings of the system that now perpetuates itself, stubbornly resisting any attempts at reform.

Professor Justin Feldman (epidemiology, NYU School of Medicine) writes in the Washington Post that “coroners and medical examiners throughout the U.S. routinely report findings that minimize the responsibility of police” in autopsies and death investigations. He points to the preliminary findings of Hennepin County Medical Examiner Dr. David R. Fowler in the death of George Floyd — they blamed “underlying health conditions” and “potential intoxicants” before footage of the event made it impossible to pretend that police had not killed him by kneeling on his neck. As professor Feldman writes, “there is evidence that law enforcement agencies pressure medical examiners to minimize culpability when investigating deaths and custody, even to the point of withholding evidence.” 

This tendency is exemplified by the “excited delirium” diagnosis — a theoretically fatal condition with vague symptoms and non-explicit causes, (but which seems to have something to do with being restricted while intoxicated) and according to the American Medical Association is “disproportionately cited in cases where Black men die in law enforcement custody.” After the embarrassing publicity of the George Floyd case, a committee of forensic pathologists reviewed over 1,300 autopsies performed by Dr. Fowler and his team on people who died while in law enforcement custody. They looked for any evidence that he made errors caused by obvious bias. Of the 1,300 autopsies reviewed, the committee recommended that Maryland officials reinvestigate 100 cases, focusing on those that involved restraint.

The problem is widespread. A report published in June 2021 by UCLA Carceral Ecologies Lab and Biocritical Studies Lab reviewed 59 in custody deaths from Los Angeles County jails between 2009 and 2019 revealed several disturbing phenomena. Of 59 deaths, 65% were Black and 23% Latin. While all these deaths were attributed to “natural causes,” 85% of the decedents were reported to have suffered from some sort of mental illness (which can include “aggressive behavior toward staff”).

The researchers concluded that “the majority of Black and Latinx men are not dying from ‘natural causes’ but from the actions of jail and carceral staff.” How are these misattributions taking place? According to lead researcher Dr. Terrence Keel, during 51 of the 59 “natural cause” deaths examined, there were “either detectives from the sheriff’s department or officers themselves that [were] in the room during the effort to actually do the autopsy and we see this as a conflict of interest.”

Of course, the Los Angeles County Department of Medical Examiner-Coroner denies that law enforcement has any influence on its decisions. Yet, it offers no alternative explanation to account for the errors which plague the autopsies of people who die in police custody. A study in The Lancet found that fully 55% of fatal encounters with the police between 1980 and 2018 were misclassified in the U.S. national vital statistics system. This is worse accuracy than would be expected from flipping a coin. The conflict of interest is there, and only those with a vested interest in concealing the truth would attempt to deny it.

Wrongful conviction and exoneration

Some of the errors that result from the outdated and byzantine death examination system are blatant and painfully obvious. More subtle and harder to spot (but no less outrageous) are the “innocent” mistakes caused by unconscious bias and other cognitive errors. Their subtle nature is probably no consolation, however, to the innocent people they send to prison. Without some rigorous statistical analysis, these errors will usually go unchecked. When the person making the error means well and is unaware of their mistake, they are prone to repeating it acting as they do in good faith.

A 2021 study in the Journal of Forensic Science highlights just such a case. The researchers examined the effects of confirmation bias on the decisions of 133 medical examiners, all of whom were certified by the American Board of Pathology and members of NAME. Their input was a large data set: all the death certificates in the state of Nevada for children younger than six between 2009 and 2019. They noticed that for unnatural deaths (those which are usually examined) examiners were more likely to attribute the deaths of Black children to homicide and white children to accidents. When given hypothetical cases of children, the forensic pathologists displayed significant bias in their conclusions, revealing the contextual effect of information (the race of the deceased child) which should have been irrelevant to a strictly scientific examination.

They ruled the deaths of white children as accidental 27.8% of the time and homicide 13.2% of the time. As for Black children, they ruled 35.4% homicides and only 6.2% as accidents. This is a very large difference, considering that aside from race the information given across all the cases was the same. This is not to say that there was racial prejudice at work in these decisions.  The pathologists may have been allowing their past professional experience to influence their expectations. However, what the study does show is how easily irrelevant information can influence even a trained pathologist in their cognitive processes. The researchers argue for a death investigation system which is insulated from law enforcement and prosecutors — working only with relevant information to produce the most objective and unbiased conclusions possible. Objectivity and balance disappear quickly enough with innocent mistakes. Consider then how much will an investigation be influenced when police or prosecutors are actively attempting to steer the conclusions of the examiners?

The UCLA researchers who noted the presence of law enforcement officers in the autopsy room agreed that this resulted in autopsies which were heavily biased in favor of those parties — especially when officers have a personal interest in the outcome of the examination. According to Dr. Kathryn Pinneri, president of NAME, “the best system of death investigation is one in which medical examiners and coroners are independent from law enforcement.…”

This independence might have kept a grieving mother out of jail instead of being falsely charged with her baby’s death. Jocelyn McLean, 29, with two other children, was called a monster by the Assistant U.S. Attorney who had her charged with capital murder. She spent a year in jail before an autopsy review revealed that Dr. Davis, the forensic pathologist called to testify for the prosecution, had never reviewed the baby’s medical records or even spoken to the doctor who treated the infant before her death. Dr. Joyce Carter, civil rights advocate and forensic pathologist, arranged an autopsy review. When confronted with the prospect of facing Dr. Carter in court, Dr. Davis abruptly recanted, concluding that the infant’s injuries “were consistent with life-saving efforts” from her medical treatment — not from violent assault as he had first claimed. Fortunately for McLean, she had an advocate who supported her. But how many women are in the same position and are left to grow old in prison?

Examiner prejudice and bad forensic science 

There are people working on these issues. The Innocence Project investigates cases across the nation looking for dubious convictions which were railroaded or slipped through the cracks of the justice system. According to their findings, around 52% of these wrongful convictions were obtained, at least in part, by bad forensic science. Sometimes, this bad evidence is presented in good faith. Forensic pathologists and prosecutors may believe in the truth of what they present in court.

In some cases, bad evidence can be attributed to pure negligence on the part of a coroner or a lab worker. There have been cases of drug lab workers who stole the drugs sent for testing and then gave false positives, reporting (and billing for) drug tests which were never performed.

Dr. Leroy Riddick, former Mississippi State medical examiner, sent Tasha Mercedes Shelby to prison with his judgment that the death of her 2-year-old stepson in 1997 was not accidental but was in fact murder. Shelby is one of the 3,000 or more people who have been charged with murder or abuse based on diagnosis of “shaken baby syndrome” since 2015. After spending 18 years in prison, Shelby has been exonerated — at least in the opinion of Dr. Riddick who issued a public apology acknowledging his mistake after new science cast serious doubt on the existence of the condition.

This change in scientific consensus was enough to prompt a superior court judge in New Jersey to bar prosecutors from introducing the shaken baby syndrome diagnosis as evidence, calling it “an assumption packaged as a medical diagnosis.” Yet these developments were not enough to sway Mississippi Attorney General Lynn Finch, who opposed Shelby’s appeal, or Circuit Court judge Roger Clark who denied it.

In other cases, a law enforcement officer, death examiner, or prosecutor (or all of them together) give evidence which they know full well to be false. More than once, an innocent person has been sentenced to death in this fashion. Prosecutors’ willingness to pursue the conviction of a person they know beyond a doubt to be innocent is well-established. 

Minnesota teen Nicole Marie Beecroft was 17 years old. She had hidden her pregnancy and gave birth alone. She gave birth in secret and put the dead body of the baby in a trash bin, where it was later discovered bearing over 100 stab wounds. The question was whether the baby was stillborn or born alive and murdered. Beecroft insisted that she had not killed the infant. She did stab it, she said, but only after it was already dead. But Washington County Coroner Dr. Mills (and three other medical experts who testified for the prosecution) were convinced that the baby had been born alive and then murdered. They firmly believed Beecroft guilty of murder. The defense produced two experts who believed (and would testify) that the baby had been stillborn. One of these was Dr. Susan Roe, assistant medical examiner for Dakota County. She was a reliable and credible witness. So far, so good. Was Nicole Beecroft a murderer, guilty of infanticide, or a mentally unstable, traumatized teen in desperate need of help? It was now for the court to decide. But that was not to be permitted.

Not content to rely on the fairness of the justice system and the court, Dakota County Attorney Jim Backstrom took matters into his own hands. He contacted Roe’s supervisor in an email and explained what he would do if Roe went through with her plan to testify on behalf of the girl she believed was innocent of murder. When Dr. Roe saw his threats, she withdrew from the case. She also resigned from her position, moved out of the state, and hired a lawyer. Beecroft was convicted and sentenced to 14 years in prison. The American Bar Association Journal reports that Dr. Roe’s case is not unique.

Garrett and Neufeld in Invalid Forensic Science Testimony and Wrongful Convictions concur:  “To many medical examiners, the Beecroft case and Roe’s trepidation sound familiar. They say they’ve been called names behind their backs and have their professional reputations besmirched. They say they have been subjected to intimidation tactics — subtle and overt — and threatened with the loss of their appointed public positions. Their tormentors, they say, are police and prosecutors who criticize them for doing consulting work for the defense.”

Courts are also to blame, as they enable and facilitate the deep prejudice which prevails in the U.S. justice system against defendants. By depriving defense counsel of equal access to forensic evidence and experts who are qualified to analyze it, courts ensure that they are “ill-equipped to effectively cross-examine the forensic science testimony that was offered by the prosecution.” In this way, prosecutors, with the tacit approval of the courts, work to steadily erode the Confrontation Clause of the Sixth Amendment. A defendant has the constitutionally guaranteed right to be “confronted with the witnesses against him.” It doesn’t require a constitutional law expert to recognize that this right is diminished when a defendant is denied access to the expertise required to conduct a meaningful examination of forensic evidence and the experts who present it.

The “prosecutorial team” is composed of elements which are theoretically independent and objective. The prosecutor is of course the central figure, but law enforcement agents and judges are parts of a mechanism whose purpose is to chase, capture, charge, convict, and confine as many defendants as possible. Short acquaintance with the criminal justice system will show that the independence of these offices is a legal fiction. In practice, the presumption of innocence is not even a pretext. Where they are not restrained, some of these officials, incentivized not to seek justice but only convictions, will develop and exploit “end runs” around constitutional limits on their powers. So long as the coroner or medical examiner perceives their office to be a member of the prosecutorial team, (or is an actual law enforcement agent), wrongful convictions will continue to occur because of faulty or deceptive forensic evidence.

  The National Research Council Committee on Identifying the Needs of the Forensic Sciences wrote in 2009 that medical examiners “should not be considered a servant of law enforcement and [should] not be placed in a position in which there is even an appearance of conflict of interest.” This is an ethical standard which is (for now, at least) completely beyond the reach of most parts of the U.S. criminal justice systems. To achieve substantial compliance with a rule like this will require changes so extensive and fundamental that they are unlikely to occur in the foreseeable future.

Changes to the system

The shortcomings inherent in death examination systems are well established. The lack of unified standards is one of the limiting factors, creating and exacerbating other problems. Because no overall authority exists to maintain compliance with best practices (or indeed, any practices) reform and improvement are necessarily an extremely localized endeavor. Any improvement applied in one county may meet with approval, but the next county retains its antiquated system until changes are made at the state level.

Certain improvements are visible on the horizon, though they remain tenuous and uncertain. In such a large country, with such a widely varied population, government, and culture, the challenges are also diverse and often unique. Still, there are certain steps which must be taken. These fundamental improvements will create a foundation upon which further reforms can be accomplished.

Based on the overwhelming evidence found in court cases, news articles, academic literature, and forensic industry publications, we can identify two indisputable goals for improvement. First, the creation of a national oversight authority for criminal forensic science, which would be charged with the development of regulations, training, and accreditation standards as well as review and inspection practices to identify problems and challenges as they emerge. This would serve the dual purpose of establishing a standard for forensic pathology where science is preeminent, while simultaneously reducing the potential for conflict of interest which is such a dominant feature of the existing field.

Second, the persistent and relentless separation of medical examiners and their responsibilities from the domain of law enforcement. These two objectives go hand in hand.

It is impossible to overstate the potential for corruption under the current death examination paradigm, due to a lack of consistency and oversight. Consider two cases that have gone to trial. The first case involves a forensic pathologist, who is a medical doctor and values objectivity and truth – and does not consider himself a member of the prosecution team with the goal of winning a conviction, and performs examinations and tests according to his education and training. The second case from a neighboring county involves a forensic report written by a sheriff with no medical training who also happens to serve as a coroner. While the reports from both cases are presented in court and both carry the same theoretical authority, it does not take an expert to see the vast gulf that separates the quality and objectivity of these two reports.

Similarly, in a case where the sheriff has a personal, vested interest in the outcome — say a prisoner dies under suspicious circumstances in the sheriff’s jail — the district attorney requests an autopsy and considers whether to treat the death as a homicide. Would any reasonable person truly believe that the sheriff serving as coroner is capable of producing an objective and unbiased report? Yet this is what we naively expect in thousands of real cases every year across the nation where the person performing the death examination operates under a conflict of interest.   

Between 1980 and 2018, according to the federal government, police killed approximately 30,800 people. According to University of Washington researchers however, this number is 17,000 too low. The researchers attribute the discrepancy to the “substantial” conflict of interest that results when medical examiners “work for or are embedded within police departments” — to say nothing of those examiners who are themselves officers. Objective and honest reporting of killings by police will remain impossible as long as this arrangement persists.

Practically every study, review, or report written on the improvement of the medical examiner system in the U.S. advocates for a higher, consistent standard of regulation and governance. A federal oversight authority would assume responsibility for creating a nationwide training standard as well as certification and accreditation procedures. Some of these already exist on a smaller scale. The National Academy of Sciences has called for the creation of a federal body to oversee this vital and sensitive domain at the intersection of medicine and justice.  The American Board of Pathology already has extensive internal codes and standards which could easily be scaled and applied more broadly across the field. This federal body would also have responsibility for increasing recruitment for positions into the field of forensic pathology, which is currently far below the rate which is necessary to adequately fill medical examiner positions across the nation.

The National Science and Technology Council has published similar conclusions in its 2016 report, calling for federal support to implement accreditation and certification policies on a national scale. NAME already has such a program, established in 1999. The elements necessary for this reform are largely already present. It only remains for the nation to develop sufficient will to employ them. These measures are necessary to prevent abuses arising from the close association of medical examiners with law enforcement. Both the National Research Council and NAME insist in no uncertain terms on the necessity of this change. “Review of any medical examiner’s work by an outside expert represents the highest form of quality control.” Without this outside review and oversight, they warn, “if medical examiners are not independent from the law enforcement personnel they work with, they could be seen as just another branch of law enforcement.”

Conclusion

After a death, those left behind mustseek closure as best they can. While the impulse for vengeance can be overwhelming, it is important that our response be balanced and fair. The death examination must work in service of truth and of justice. When it is a tool for seeking retribution, its value is lost.

When innocent people are convicted of crimes they did not commit, there is a double injustice: not only does one person suffer for a crime of which they are innocent, but there is also a guilty party who goes free, potentially to offend again. We owe it to those we love to pursue justice with objectivity. Our treatment of death, including its investigation and the pursuit of justice, is the final chapter in the story of the life of someone’s child.

Sources: National Academy of Sciences, Strengthening Forensics in the United States: A Path Forward; Locke, P. (2013), Death Investigation in the U.S. – Medical Examiner or Coroner; Jentzen, J., Death Investigation in America: Coroners, Medical Examiners, and the Pursuit of Medical Certainty; Thompson, et al., The Real CSI: How America’s Patchwork System of Death Investigations Puts the Living at Risk; Jonas, J., The Independence for Medical Examiners Equals Due Process for Criminal Defendants and More Efficiencies in the Criminal Justice System; Robbins, I., A Deadly Pair: Conflicts of Interest Between Death Investigators and Prosecutors; Dewan, S., Failed Autopsies, False Arrests: A Risk of Bias in Death Examinations; Fernandez, J., The Political Economy of Death: Do Coroners Perform as Well as Medical Examiners in Determining Suicide?; Felder, R., A Coroner System in Crisis: The Scandals and Struggles Plaguing Louisiana Death Investigation; Jones, J., Medical Examiners Have Undercounted Thousands of Police Killings, Study Finds; Carter, et al., Cognitive Bias in Forensic Pathology Decisions; The New York Times; The Washington Post; kktv.com; usatoday.com; kxan.com; innocenceproject.com; knkx.org; inquirer.com; cdc.gov; vdh.virginia.gov; thename.org.

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