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Coroners Don't Need Degrees To Determine Death

by Sandra Bartlett

February 2, 2011

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EnlargeJohn W. Poole/NPR

The medical examiner's office in New Mexico is considered the gold standard that all medical examiners should meet because it employs enough staff to investigate and autopsy all sudden or violent deaths.

John W. Poole/NPR

The medical examiner's office in New Mexico is considered the gold standard that all medical examiners should meet because it employs enough staff to investigate and autopsy all sudden or violent deaths.

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February 2, 2011

This is our second report in the NPR News Investigations series Post Mortem: Death Investigation in America in partnership with ProPublica and PBS Frontline.

When someone dies unexpectedly or in suspicious circumstances it is the job of a coroner or medical examiner to investigate what caused the death. We rely on these death investigators to provide the autopsy report and a death certificate to settle estates, insurance claims and bring murderers to justice.

More From Our Series

The Real CSI: Death Detective Dysfunction

The reality of diagnosing death is drastically different from what we see on TV.

Flawed Autopsies Send Two Innocent Men To Jail

In Mississippi, two men spent a combined 30 years in jail for crimes they didn't commit.

Discuss Post Mortem: Death Investigation In America

Reporters from NPR, ProPublica and Frontline discussed their investigation.

How Is Death Investigated In Your State?

Did you know a coroner doesn't have to be a doctor? Learn more about investigating death in the U.S.

In the United States there isn't just one system. Coroners can be elected or appointed. Some are also sheriffs or funeral home directors. But many coroners aren't doctors.

There are also medical examiners, who usually are medical doctors but may not be forensic pathologists trained in death investigation.

But no matter what form it takes, the death investigation system in the U.S. is in trouble. A yearlong investigation by NPR, PBS Frontline and ProPublica has found a dysfunctional system short of qualified people, squeezed for resources and lacking in oversight.

Two years ago a blue ribbon panel created by the National Academy of Sciences pointed out the lack of mandatory standards for autopsies and the absence of oversight into the performance of coroners and medical examiners. It recommended that the goal of every state should be to move away from a coroner system, which is not based on medicine, and instead hire board certified forensic pathologists and put them to work as medical examiners.

The Coroner System

The coroner system was imported from Britain where it was originally a method for the king to be informed of deaths so he could extract one last round of taxes. Now, most of the states in the U.S. rely on this system.

During the recent midterm election campaign some of the political candidates knocking on doors asking for votes were the people responsible for signing death certificates.

In an affluent Denver suburb, Mike Dobersen's first task while campaigning was to get past people's surprise that coroners are elected.

"The first thing they say is, 'What do you mean I have to vote for the coroner?' The second thing they usually come out [and say] is, 'You mean you don't have to be a doctor?' " says Dobersen, who has been the coroner in Arapahoe County, Colo., for 17 years.

He is a rarity among coroners not only because he is a medical doctor but also because he's a board certified forensic pathologist, which means he's formally trained to perform autopsies after many years of schooling.

Each election, he is in danger of losing his job to someone with no medical training. In many states, the only requirement to get the job is to be of legal age and have no felony convictions.

"A lot of people don't really understand what the coroner does and tend to vote their political affiliation," Dobersen says.

When Election Day arrived, Dobersen, who ran as a Democrat, barely managed to keep his job in the Republican surge, winning 51 percent of the vote.

A Need For Trained Practitioners

Marcella Fierro, who retired as chief medical examiner in Virginia in 2008, says the autopsy is the cornerstone of death investigation. It was her job to decide which cases to autopsy.

EnlargeJohn W. Poole/NPR

Dr. Marcella Fierro, the former chief medical examiner in Virginia, is a member of the National Academies of Science panel that issued a report recommending an overhaul of the country's death investigation systems.

John W. Poole/NPR

Dr. Marcella Fierro, the former chief medical examiner in Virginia, is a member of the National Academies of Science panel that issued a report recommending an overhaul of the country's death investigation systems.

"Most errors are buried," she says. "If a death isn't recognized as being suspicious or is suspicious, say, for violence and it's released as natural death, [then] it's buried or cremated, whatever the family wishes, never to rise again."

Fierro sat on the blue ribbon panel when the National Academy of Sciences took a look at the death investigation system. The panel described coroners as the weak link.

"On their best day, if they do not have the training, the skills, the infrastructure, the facility, the access to forensic science, they can't do a good job. It's a question of competency. How can you train someone who is not a physician?"

The Medical Examiner System

Medical examiner systems are operating in 16 states and the District of Columbia. Medical examiners are appointed to their position and almost always are physicians.

Ross E. Zumwalt, a medical examiner in Albuquerque, is proud of his new state-of-the-art office, which serves all of New Mexico.

EnlargeJohn W. Poole/NPR

Ross E. Zumwalt, a forensic pathologist, is the chief medical examiner in New Mexico.

John W. Poole/NPR

Ross E. Zumwalt, a forensic pathologist, is the chief medical examiner in New Mexico.

"This is such a pleasure to work in this spacious operating room type atmosphere," he says.

Zumwalt is a medical doctor with a specialty in forensic pathology. Like other medical specialties it takes about a dozen years of education and training.

He has been performing autopsies for 35 years, and his Albuquerque facility is one of the best in the country, not just because of the new building and its modern equipment, but also because he has enough staff to investigate and autopsy all sudden or violent deaths. The office currently has 12 forensic pathologists, seven who are board certified.

Around the country Zumwalt's colleagues see New Mexico as the gold standard that all medical examiner offices should meet, but only about a quarter of the offices reach a bar that high.

An investigation by NPR, PBS Frontline and ProPublica analyzed more than 60 of the nation's largest medical examiner and coroner offices. We found at least 100 doctors who are not board certified forensic pathologists.

Our investigation uncovered dozens of autopsies with serious mistakes in more than a dozen states. We read thousands of pages of records documenting how pathologists missed crucial evidence — such as a bullet hole in the neck, mucus in the lungs and signs of strangulation.

Analysis

Autopsy Data

Explore autopsy rates among 70 of the largest coroner and medical examiner systems in the country.

Zumwalt says where you die makes a difference especially when your death is unexpected or suspect.

"It's certainly incredible to think that just the space of a few yards may mean the difference between competent death investigation and incompetent death investigation," he says. "But it may be the difference between what side of a state [or] border you're on. On one side of the border you have a statewide medical examiner and competent death investigation; the other side of the border may be a small county coroner with few resources and little training."

The investigation across the country also found that it is not necessarily the poorest states or those states with smaller populations that fail to provide adequate death investigations.

Boston is home to some of the best medical facilities in the country. Like New Mexico, it is a state-run system. It was the first in the country to appoint a doctor to act as the medical examiner, back in 1877.

It's certainly incredible to think that just the space of a few yards may mean the difference between competent death investigation and incompetent death investigation.

- Ross E. Zumwalt

In 2000, an audit by the National Association of Medical Examiners found the agency was $10 million short of what it needed to do the job. The average salary for a forensic pathologist back then was $200,000 a year, but salaries in Boston were $95,000. That led to a chronic shortage of pathologists, most of them not board certified forensic pathologists. Those who are board certified have trained in what to look for in performing autopsies.

But the state had a series of serious mistakes that piled up over the years.

Even when funding began to improve in 2004, problems continued. The most recent audit in April of 2007 describes the office as being on the verge of collapse.

Henry Nields, the acting chief medical examiner, says he's doing his best to improve the office, but he highlights the budget shortfalls.

"Well, the place has already been fixed to some extent. I hate to come back to the money thing but we certainly need more funding to be at the level where I would like to be and I think it's a better place today than it was yesterday," he says.

Nields' budget in 2010 was still more than $3 million short of what the office needed to operate 10 years ago.

Curt Green (CurtGreen) wrote:

Fortunately Silke you were able to straighten out the folks who had questions about Medicolegal death investigations

I realize I couldn't possibly shed any light because I am just an elected Coroner.

By the way, I would put my staffs qualifications and experience against a majority of the ME's offices in the country.

I guess my years of experience working ER's, decades of prehospital care, over a decade of recovery and removal experience, formal education, thousands of death investigations, thousands of physical exams, 7 certifications, experience as a diener, membership in NAME, IACME, WCMEA, Board Certified F-ABMDI, attendance at numerous national training conferences in numerous states within the last several years, lecturing at our local tech college couldn't possibly qualify me to give an opinion.

And by the way, to the gentleman who stated that a Coroner wouldn't be able to find the cause of death for someone who may have died as a result of someone "shooting microwaves through a wall" and "waiting years for them to die" and suggesting this is a homicide... You're right, I haven't found one yet but I am certainly going to spend a lot of my time looking for a "Homicide by microwave". Thanks for the tip.

Wednesday, February 09, 2011 12:31:05 PM

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tanja minkkinen (dorsalfinn) wrote:

@Curt That may be. But I doubt they would've done any better putting it together had they spoken to you, given your emotional and staccato-like attempt to articulate the "system" in WI.

Wednesday, February 09, 2011 5:49:03 AM

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Curt Green (CurtGreen) wrote:

Perhaps a reasonably intelligent person could put it together.

The series reporters weren't able to. They were after sensationalism.

Tuesday, February 08, 2011 1:24:06 PM

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tanja minkkinen (dorsalfinn) wrote:

@Curt If the "other article" to which you refer is the one where she says "please do some research before making an entire profession look incompetent and lazy", which you quote as well, I found it.

As for "missing (your) point and hers (refer to her comment on the other article)", I don't find anywhere in that comment where she addresses the interrelationship between coroners and MEs. She details the education needed to become a forensic pathologist.

She doesn't say anything there about "Each state is different and within a state each county may be very different."

While there may be some truth (have you now branched out beyond WI?) that "to provide answers to your questions would be impossible unless you are refering to a particular county within a state", I'll prefer her to give answers to my questions, thank you.

What I've learned from you is this: the system (at least in WI) of death investigation involving coroners and MEs is so convoluted that a layman like me shouldn't even begin to try to understand it. And it certainly does seem piecemeal and complicated, but I'm certain that a reasonably intelligent person can at least begin to put it together.

Monday, February 07, 2011 9:26:07 PM

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tanja minkkinen (dorsalfinn) wrote:

@Curt Please take note that I wrote to Dr Hummel, "...and I understand you may only be able to speak about the state in which you practice." So I didn't bring it down to a county level. Gee.

The tone of your initial post was, at minimum, aggressive. Furthermore, you blasted me for making statements that may not apply to WI's situation, while allowing that WI's system may be an 'anomoly'.

For the moment, I'm tempted to think the arrival of Dr Hummel here made you be a bit less cock-sure; clearly it made you cool down a bit.

Monday, February 07, 2011 8:59:10 PM

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Curt Green (CurtGreen) wrote:

Silke Lipp

My comment wasn't meant as an insult, I was pointing out that you were providing incorrect information based on the articles/series misinformation and extreme generalization that an ME is an ME and a Coroner is a Coroner. It all depends on where you are.

Jennifer's information is correct regarding the system she is familiar with but as you ask questions regarding specifics in relation to the roles and responsibilities of Coroners and ME's you seem to be missing my point and hers (refer to her comment on the other article). Each state is different and within a state each county may be very different. Therefore to provide answers to your questions would be impossible unless you are refering to a particular county within a state.

The article went for sensationalism.

They could have simply stated "Basic standards needed for Coroners and MEs and death investigators, and left it at that. Reviewing Jennifer's other comment regarding the series I would agree with her that the writers should "please do some research before making an entire profession look incompetent and lazy." I realize she was talking about pathologists but it applies to death investigators as well.

Monday, February 07, 2011 4:38:22 PM

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tanja minkkinen (dorsalfinn) wrote:

@Jennifer And two other questions... Is ever the coroner and ME one and the same person? Would a (non-ME) coroner ever perform an autopsy, whether legally-required (by statute) or not?

Sunday, February 06, 2011 1:22:08 PM

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tanja minkkinen (dorsalfinn) wrote:

@Jennifer Piecing it together, would I be correct to think that:

1) All counties have a coroner, elected or appointed, and
2) that office performs death investigations "in the field", both "cause & manner",
3) ultimately making a judgment whether the death requires, by statute, further investigation via autopsy performed by an ME, who may or not be based in that county? (I assume deaths deemed not to require an ME's autopsy can still be autopsied at a family's request, and by any board-certified pathologist.)
4) And coroners are peripheral to and not involved with in-hospital deaths?

Sunday, February 06, 2011 1:14:10 PM

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tanja minkkinen (dorsalfinn) wrote:

@Jennifer Thank you for weighing in with your unique expertise and for your close reading of my comments, correcting me as necessary and without the superfluous emotion expressed by the coroner. Some questions, and I understand you may only be able to speak about the state in which you practice:

What triggers a "routine hospital autopsy", other than at family's request? To clarify, one cannot own the title of Medical Examiner without residency training & board certification in both clinical pathology and forensic pathology (which, of course, presumes an MD or DO)? In counties that have an ME, is there only one? And she or he performs the autopsies on deaths which occurred under statute-defined, typically suspicious or unusual, circumstances including but not limited to the in-hospital cases you mentioned? Does every county have a coroner, regardless of whether it has an ME? If so, then in an instance where a rural county has no ME, who judges whether a death is an "ME case"? The coroner, who, in some cases, would be an elected official, such as @Curt? Would you agree with @Curt that "the most important part of any medico-legal death investigation is the field investigation"? Are coroners involved only with out-of-hospital cases?

Sunday, February 06, 2011 12:59:02 PM

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jennifer hummel (jmhummel) wrote:

SikeLipp, as a pathologist, thank you for your mostly accurate comments. This series of articles is so inaccurate, it's exhausting to read!

To answer someone's question about hospital autopsies: any board certified pathologist can do those, because they completed the required number during pathology residency, and subsequently passed the boards. If a death in a hospital is deemed to be a medical examiner case (a.k.a. a forensic pathologist with an M.D. or D.O. who has passed both the pathology boards AND the forensic pathology boards; no other degrees are acceptable/valid), usually the medical examiner will come to the hospital to do the case rather than moving the body. This includes cases where for example, someone checked in to the ER but died less than 24 hours later or cases where people die soon after surgery. If during the course of a routine hospital autopsy, some sort of medical negligence is suspected, risk managment is notified as well as the medical examiner.

If anyone has questions, let me know rather than referring to this series of articles. The issues regarding budgeting and thinly-stretched resources are spot on, but the description of those involved and thier roles is incorrect in many instances.

Sunday, February 06, 2011 11:47:50 AM

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