Perceived Strengths,Limitations,and Needs of Death Investigation Systems in States that Lack a State Medical Examiner

Abstract

Based on a one-month online survey that was announced to 640 subscribers of the National Association of Medical Examiners’ NAME-L listserv, perceived strengths, limitations, and needs of death investigations systems were obtained for the 25 states that lack a state medical examiner. Forty-one persons responded to the survey and at least one response was obtained from each of the 25 states. Overall, strengths could be summarized into categories that include the local nature of death investigation (e.g., items related to coroners, medical examiners, forensic pathologists, and accreditation and certification) and issues related to finances, organization, and system oversight. Perceived limitations fell into similar general categories but the largest group of comments consisted of coroner-related concerns. Needs could be categorized into issues which relate to facilities and death investigation system features; finances; coroners, forensic pathologists, and accreditation and certification; standards, training, and education; and research and technology. Specific strengths, limitations, and perceived needs are summarized in tables showing the states citing those features. We hope these data will be useful to those who wish to further study death investigation systems in the various states.

Keywords

Forensic pathology Medicolegal death investigation systems Coroners Medical examiners

Introduction

A separate article in this issue of Academic Forensic Pathology reports the strengths, limitations, and needs of death investigation systems in those states with a state medical examiner or state agency head with a similar title (1). This article describes the perceptions of persons who work in states that have county, district, or regional based death investigation systems but which lack a state medical examiner regarding the perceived death investigation system strengths, limitations, and needs in those states.

Methods

On November 25, 2013, a message was posted on the NAME-L Listserv soliciting input from persons (primarily forensic pathologists or other NAME members) who work in the 25 states that lack a state medical examiner system. Responders were asked to indicate their perceptions about the strengths, weaknesses/limitations, and needs for improving the death investigation system in their state. The survey was open for a four-week period until December 25, 2013. During the four-week period, two additional reminder emails were sent to NAME-L subscribers (N=640). Comments from persons in each state with a response were summarized in general terms and tabulated for each state.

Results

Responses were received from 41 persons with at least one response from each of the 25 states ( Table 1 ). The number of responders from each state ranged from one to four and averaged 1.64 per state. There was one responder from 14 states and 11 states had more than one responder. States with multiple responders included South Carolina (4), New York (3), California (3), Indiana (3), Wisconsin (2), Washington (2), Texas (2), Ohio (2), Minnesota (2), Colorado (2), and Alabama (2).

Table 1

States Included in This Study, With Type of Responder(s) From Each State

State	Type of Responder
AL^*	2 Forensic pathologists
AZ	1 Forensic pathologist
CA^*	3 Forensic pathologists
CO^*	2 Forensic pathologists
FL	1 Forensic pathologist
HI^*	1 Forensic pathologist
ID^*	1 Physician coroner
IL^*	1 Forensic pathologist
IN^*	3 Forensic pathologists
KS^*	1 Forensic pathologist
LA^*	1 Forensic pathologist
MI^*	1 Forensic pathologist
MN	2 Forensic pathologists
MO^*	1 Forensic pathologist
NE^*	1 Forensic pathologist
NV^*	1 Nonphysician coroner
NY^*	3 Forensic pathologists
OH^*	2 Forensic pathologists
PA^*	1 Forensic pathologist
SC^*	2 Forensic pathologists, 2 nonphysician coroners
SD^*	1 Forensic pathologist
TX^*	2 Forensic pathologists
WA^*	2 Forensic pathologists
WI^*	2 Forensic pathologists
WY^*	1 Nonphysician coroner
Total	41 Responders total; 4 nonphysician coroners, 1 physician coroner, 36 forensic pathologists

States That Have at Least Some Coroners.

Overall, strengths could be summarized into categories that include the local nature of death investigation; items related to coroners, medical examiners, forensic pathologists, and accreditation and certification; and issues related to finances, organization, and system oversight ( Table 2 ).

Table 2

Summary of Perceived Strengths of Death Investigation Systems

Local Nature of Death Investigation	State
Local autonomy and control	MI, MN, SC
Work is done locally	NY
Trained local investigators	CO, NY, WA
Coroners are locals	SC
Investigators
State patrol are trained in death investigation and are interested	NE
Coroner-Related
Elected coroner not subject to pressure	OH
Strong coroner association that educates, trains, and monitors	OH
Strong coroner authority	SD
Education/training required for coroners	CO, ID, IN, SC
Some coroners are very good and interested	CO, WA
Sheriff-coroner works well if adequately funded	CA
Sheriff-coroner is eligible for law enforcement grants to help fund office	CA
Coroners assist in death notifications for other jurisdictions	SC^*
No coroners	AZ
Medical Examiner System-Related
There are at least some well-established medical examiner systems	CA, MN, NY, PA, TX, WA
Most homicides investigated by medical examiner offices (not coroner)	MO
Forensic Pathologist-Related
Large counties must have forensic pathologist medical examiner	WI
All cases are done by a forensic pathologist	ID, OH, NV, TX, WA
Good forensic pathologists	IL SC
Forensic pathologist is coroner	SD
Forensic pathologist completely in charge of cause/manner	HI
Forensic pathologist medical examiners	AZ
Investigators and coroner determine manner of death, not the forensic pathologist	SC^*
Accreditation and Certification
Largest coroner office in the state is accredited	NV
Almost all investigators are American Board of Medicolegal Death Investigators (ABMDI) certified	NV
Financial
Reasonable system funding	OH, WI
Per case fee for forensic pathology cuts costs	SC
Good forensic pathologist salaries in low cost of living areas	AL
System costs are relatively inexpensive	NY
Working of per case fee increases flexibility and reduces time on job	CA
Flexibility for forensic pathologists	HI
Funds from death certificates help fund operations	WA
Competition among private pathologist contractors may be efficient and promote autonomy	KS
Organization and Oversight
System is separate from law enforcement or judicial system	NY
Strong state influence to foster uniformity	NY
State technical team assists with child fatalities	MO
Written guidelines	FL
District flexibility	FL
Good interactions with users	SC, WI
Close affiliation with the forensic sciences/criminalistics	AL
State toxicology and crime lab provides free services	WA
Forensic investigation council provides guidance	WA
State medical examiner system is in our code (but not implemented)	IN
State association of coroners and medical examiners	WA
U.S. senators and representatives are well informed and helpful	WA

This is probably not true in all jurisdictions in the state.

Perceived limitations were diverse in scope and fell into general categories similar to those of system strengths ( Table 3 ). The largest group of comments had to do with coroners, with coroner limitations being reported by 18 of the 22 states with coroners. The most often cited limitations had to do with possible conflicts of interest, too much coroner discretion regarding when to autopsy or providing information, and the fact that many coroners are elected nonpathologists or nonphysicians. A variety of other coroner-related limitations were reported by some states.

Table 3

Summary of Perceived Limitations of Death Investigation Systems

Coroners	State
Lay coroners or nonpathologist coroners, or elected coroners	PA, SC, WI, WY
Too much discretion in deciding when to autopsy, or in providing information	AL, OH, SC, TX
Death certificate sometimes not completed based on forensic pathology input	AL, CA, SC
Qualifications or experience vary widely	AL, IN, MN
Potential conflicts of interest as Sheriff, prosecuting attorney, or funeral director	AL, IN, MN^*, NE, NY, SD, WA
Coroner investigators are not trained	CA
Sheriff duties are given priority in regard to effort and funding	CA
Non-medical people certifying cause and manner	CO
No policing of mandated training	CO, IN
Coroner turnover can result in loss of seasoned investigators	CO
Some are unwilling to use protocols	CO
Police are coroners in some counties	HI
Inconsistent reporting of cases to coroners	HI, OH
Political motivations can be a problem	IN, SC, SD
Coroners have no supervisors and/or audits of performance are lacking	IN, PA, SC
Many are part time (ID) and/or give priority to their main job (IN)	ID, IN, SC
Rely upon toxicologists to interpret toxicology data	MO
Training is inadequate	IN, SD
Systemic and Administration
Emphasis is on criminal or suspicious deaths	AL
No statewide law and/or standards for investigations types or criteria for autopsy	AL, NY
Highly political involvement of district attorneys and pro-prosecution	AL
Lack of forensic pathologist oversight of entire system	AL
De facto regional centers have little control and local information is hard to get	AZ
Large areas and/or sparse population impact on transport and ability to autopsy	ID, MN, NV
Unequal/inadequate geographic distribution of medical examiner offices	MN
Disparity in quality of facilities	OH
Inadequate availability of toxicology and other special studies	PA
Inadequate communication/cooperation among offices	MN, TX
Forensic Pathologists
Some are marginally trained, qualified or not boarded	AL, KS
Are often viewed as just “cutters”	CA
No autonomy in directing investigation, forensic pathologists rarely called to scene	HI
Shortage of forensic pathologists, or none in the state (WY)	IN, WY
Inability to financially support forensic pathologists	KS
Lack of peer review in some areas	MO
Investigators and Investigations
No medical examiner investigators, just police	HI, MN^*
Investigative information is hard to get	HI, MN, NY, OH
Investigations need improvement	IL, PA, WA
Investigation scope and quality vary considerably from place to place	KS, MI, TX, WA
Autopsy
Some are done by nonforensic pathologists	CA, IN, KS, NY, PA
Some are done for very cheap rates which impacts quality	CO, MO
Variation in types of cases which are autopsied	MI, NY
Financial
Inadequate resources and funding	AL, CO, MO, NY, OH, SD, WA, WI
Pay for contract forensic pathologists is inconsistent Discrepancies in funding and support	CA FL, OH
Small counties cannot afford a medical examiner system	AZ, NY
Training
Limited opportunities for, or insufficient training of law enforcement and/or coroners	CO, NE, NV, NY, OH, SC, WI
Guidelines and Standards
Difficult to enforce	IN, FL
Accreditation/Certification
Accreditation is difficult to attain based on current status of system	AL
State control of accreditation and certification are needed	MN

In one medical examiner office in the state.

Needs could be categorized into issues which relate to facilities and death investigation system features; finances; coroners, forensic pathologists, and accreditation and certification; standards, training, and education; and research and technology ( Table 4 ).

Table 4

Perceived Needs of Death Investigation Systems

Facilities/Systems	State
Three to four regional offices with local American Board of Medicolegal Death Investigators (ABMDI) certified	WI
Regional medical examiner system with one overseeing chief medical examiner	NY
Regional system	CA, CO, IN, MI, TX, WA
State medical examiner system to serve smaller counties	AZ, NY
Different model for frontier counties	MN
State wide supervision by a forensic pathologist	AL, SD
Fewer part-time and more full-time workers	IN
Centralized case referral system	IN
More offices run by trained and qualified personnel	PA
Freedom to hire and fire based on competence, not union rules	IL
More cooperation and will to work together among offices	MN, TX
More statewide oversight and assistance from the state to districts	FL
Pool human resources to allow similar services for the whole state	KS
All cases need to be reviewed by a physician	CA
Elimination of police as primary investigators	HI
Qualified person to oversee state system	AL
Develop as an organized system with a good law	AL
Consider having death investigation be run by the pathology departments in Birmingham, AL Huntsville, Mobile	AL
Compare costs of coroners with a regional medical examiner system	WA
Autopsy facilities need to be updated	IN
Financial
Increase budget for all counties	SC
Published minimal level funding	OH
Sliding scale for National Association of Medical Examiners (NAME) accreditation fees	OH
State assistance to help small counties	MN
More funding for staff/operations	AL, NV, SC
Additional funding for ancillary tests such as radiography	HI
Coroners
Have no lay coroners	NY
More coroner and/or law enforcement education (county attorneys in NE)	NE, WA
More stringent requirements for coroners	SC
Cease having the coroner as an elected position	SC
Encourage coroners to consult with forensic pathologists when necessary	IN
Forensic Pathologists
Ensure all autopsies can be done by board-certified forensic pathologists, using state funds if needed	CA, IN
More qualified forensic pathologists	AL, MO
Reinstate medical school associated forensic pathology fellowship	IN
More medical examiners	SC
Put medical examiners in charge of systems, make decisions about autopsies and cause/manner of death	IN, SC
Forensic pathologists need better and independent access to medical, police, dental, emergency medical services reports, etc.	SC
More autonomy for forensic pathologists with fewer decisions based on financial constraints	HI
Accreditation/Certification
Accreditation and certification requirements are needed	AL, NM, SC
More ABMDI-certified investigators	SC
Standards / Training /Education
More standardization of death investigation practices and procedures	MI
Statewide protocols for identification, personal effects management, toxicology, sample collection and processing	IN
Mandated list of cases, or guidelines about which should have an autopsy, with methods to enforce	IN, SC
Unified report system and minimum standards	ID
Minimum performance investigative guidelines	LA
Better coroner standards and training	IN, SC
No or low cost training, or more training in general	AL, OH
Education for field workers	WI
Education of supervisors about costs of good systems	WI
Parameters about which cases could remain rural and which need to be sent in	CA
Dedicated and trained investigators to attend scenes	HI
Education about what cases to report and how to report them	HI, IN
Centralized person at the state level to ensure good death certificates and proper notification of coroner	SC
Educate coroners that non-forensic pathologists may not be aware of important forensic issues	IN
High quality work is needed regardless of whether the system is coroner or medical examiner	SC
Educate general pathologists about important forensic issues, documentation, and procedures	IN
Research and Technology
Advanced imaging equipment and molecular testing	MN
Broader use of tissue and research applications	MN

Discussion

A limitation to this study is that in states lacking a state medical examiner, no single person can provide a first-hand overview of administrative, managerial, and operational aspects of death investigation for the entire state. Further, as shown in Table 1 , the great majority of responders were forensic pathologists even from those states that have coroners. This is not unexpected, since the survey was conducted through the National Association of Medical Examiners (NAME), an organization comprised predominantly of forensic pathologists. Thus, the perspectives expressed in our data may represent the opinion of only one, or just a few people who work in a given state and who may work only on a county or regional level within the state, and coroner input is undoubtedly under-represented in the data. We can only hope that the viewpoints of responders are tempered with knowledge of how things operate in the respective states. The best way to study the strengths, limitations, and needs of death investigation systems in the various states is for them to be thoroughly studied on the state level by people who work in the state, in conjunction with state associations of medical examiners, coroners, and death investigators where they exist. Our study might be useful as a springboard for further surveys of coroners (perhaps through the International Association of Coroners and Medical Examiners), investigators (possibly via the American Board of Medicolegal Death Investigators and/or the Society of Medicolegal Death Investigators), and even other users such as law enforcement entities that are engaged in death investigations.

Although Table 2 shows all of the perceived strengths reported by the various states, some overall trends stand out. First, the local nature of death investigation is valued by some. Second, positive aspects are reported for coroner systems. Third, formal medical examiner systems and forensic pathologists are valued as strengths. Fourth, an appreciation of the need for some state oversight, guidance, or guidelines is apparent.

In addition to the coroner-related deficiencies, other distinguished limitations followed generally applicable themes. Those cited by the most states had to do with inadequate resources and funding, insufficient training of law enforcement scene investigators or coroners, autopsies being performed by nonforensic pathologists, variation in quality and scope of investigation from place to place, and difficulty in obtaining needed investigative information from other agencies.

Among the perceived needs, some common themes deserve mention. The development of regional centers, more cooperation among offices, centralized reporting systems, more state oversight, and conversion from part-time to more full-time personnel were noted by multiple responders. The need for more funding and operational support was noted, as was the need for more forensic pathologists, medical examiners, accreditation, certification, standards, training, and education. It should be noted that these are all needs identified in the National Research Council report regarding death investigation systems (2).

Of the 25 states in this study, 22 have coroners in at least some counties. A perceived need to abolish lay coroners or elected coroners was mentioned by only two responders (NY, SC) and the lack of coroners was cited as a strength by just one responder (AZ), although the need for improved coroner education and training was a common theme. This is an interesting observation in the context of the National Research Council's report, which recommends that coroner systems eventually be replaced with medical examiner systems (2). However, the data in our study seems to indicate a feeling that coroner systems can be functional with adequate funding, training, education, and medical input, and that the replacement of coroner systems is not a pressing issue among those who responded to the survey. Rather, the emphasis seems to be on needs to improve those systems. Of the states from which comments about coroners were received, only Ohio requires the coroner to be a physician, and in nearly all, the coroner is elected. Thus, in general, comments about coroners should be regarded as being directed at nonphysician (sometimes called “lay”) coroner systems in which the coroner is elected. It is also important to realize that some systems that retain the word “coroner” in the system leader's title actually operate as a medical examiner system, such as the medical examiner/coroner office in Denver.

In one state (SC), there was an obvious difference of opinion among responders, which included both medical examiners and coroners. While the strengths of coroners and weaknesses of medical examiners were cited, sentiments that the coroner system needs to be replaced and more authority and records access needs to be provided to forensic pathologist/medical examiners was indicated. In light of the aforementioned bias in this survey toward forensic pathologist respondents, such a divergent viewpoint likely exists in other states as well, such that more focused study is probably advisable in any state considering implementing major changes.

Not unexpectedly, the scope of comments reported in this study was larger or more diverse in nature compared with comments received from state medical examiner states, as reported elsewhere (1).

Conclusions

Recognizing that the opinions about strengths, limitations, and needs for death investigation systems in a given state may reflect the views of only one person working in that state, we have documented viewpoints about 25 states that lack a state medical examiner. The data may be useful for specific individual states to review and critically analyze to verify or identify additional needs in the state. Such reviews should be conducted by state associations of medical examiners, coroners, and death investigators where such organizations exist. Collectively, these data may also be useful as they include a wide scope of strengths, limitations, and needs that can guide further study.

Authors

Lead Authors:

Randy Hanzlick MD - Chair

Christopher Boden BS

Committee Members:

Steven Clark PhD

Joseph Prahlow MD

Kathryn Haden-Pinneri MD

Karen Gunson MD

Tracey Corey MD

Erin Presnell MD

Footnotes

Acknowledgements

The authors wish to thank all of those who responded to the survey. Participants were told that data would be reported anonymously, so we cannot thank them by name here.

The comments in this article are those of the National Association of Medical Examiners ad hoc Data Committee authors and do not necessarily reflect the opinions, viewpoints, or position of the National Association of Medical Examiners.

The authors, reviewers, editors, and publication staff do not report any relevant conflicts of interest.

References

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