The Education of a Coroner Page 2

  THE CORONER’S OFFICE

  It’s in this setting that the coroner’s office in Marin County operates. Throughout Holmes’s career, it was on the second floor of the Marin Civic Center in San Rafael, the county seat. The building was the last one designed by famed architect Frank Lloyd Wright and features a roof the color of the sky, scalloped balconies, and pink stucco walls, all intended to blend into the surrounding environment.

  The office, which has since moved, isn’t what one might expect. Before I interviewed Holmes the first time, in 2010, I envisioned it to be part morgue with shrouded bodies laid out on stainless steel tables, waiting to be autopsied, and part laboratory with slides being inspected under microscopes. Like many small counties, however, Marin doesn’t have a morgue because it’s too expensive. Instead the coroner’s office contracts with local mortuaries and private physicians to receive the bodies of dead people and conduct autopsies when warranted. The county also doesn’t have a lab for analyzing specimens that are collected at a death scene. Fingernail scrapings, pubic hair samples, vaginal swabs, and the like are sent to outside labs. There are only a handful in California that specialize in this kind of analysis, with the primary one operated by the state Department of Justice. Samples from any case that might go to court—particularly homicide cases—are sent there. The DOJ lab doesn’t handle body fluids, though, so blood, urine, and gastric samples are sent elsewhere.

  Employee offices look the same as the offices of any other business with a modest budget—older desks and chairs, older computers and phones, and bookcases crammed with special texts, trade journals, binders, and miscellaneous papers. For all of Holmes’s thirty-six years, there was a staff of seven. Six employees—the coroner, assistant coroner, three death investigators, and a secretary—were full-time. One position—the medical transcriber—was part-time. He or she took the voice recordings of forensic pathologists during autopsies and turned them into written summaries.

  The common areas are more distinctive. There are evidence lockers, an old bank safe to store money that is collected at a death scene, refrigeration units to store specimen samples, and dozens of four-drawer metal file cabinets that are filled with case files, some of which date back more than 150 years, to the time when California became a state.

  The role of the coroner originated in twelfth-century England. “Crowners,” as they were known at the time, conducted inquests on behalf of King Richard I to identify the deceased, determine how they died, and—most important—collect death taxes on their estates. It was the height of the Crusades, the Catholic Church was trying to restore Christianity in and around the Holy Lands, and money was needed to finance numerous campaigns.

  Coroner’s offices today are vestiges of this royal system. Coroners are either elected by the populace or appointed by designated entities, with the requirements varying state by state and oftentimes county by county. In the highest form, coroners are medical examiners, meaning they are licensed physicians who are trained and certified in forensic pathology. Most people assume that all coroners are MEs, but this isn’t the case. Many coroners are licensed physicians who have no training in forensics, while in hundreds of communities across the country—including Marin County—the coroner isn’t required to have any medical training at all, much less a medical degree. He or she just needs to have a clean record, meaning no felony convictions, be twenty-one or older, and have a high school diploma. Some counties don’t even require that, however. One county in Indiana elected a coroner who was eighteen and still in high school.

  A 2015 review by the National Academies of Sciences, Engineering, and Medicine compared county coroners and medical examiners. The biggest benefit of county coroners, according to the review, is that they reflect the will of the people. In American political culture, elected officials represent a community’s needs and values better than anyone else because they are chosen by voters. In addition, county coroners have equal footing with other locally elected officials—members of the board of supervisors, sheriffs, judges, and district attorneys—which enables them to operate independently from these entities. The main drawback is that the coroner may not be medically proficient since it’s not a requirement of the job.

  On the medical examiner side, the major advantage, according to the review, is that the overall quality of death investigations is better. In addition, there is more uniformity. For statewide medical examiner offices, there are the added benefits of centralized administration, which is expensive to start but less expensive to sustain, and improved service to rural areas, which often don’t have the capacity to operate coroner offices on their own.

  Nineteen states—in general, the smallest ones—have a state medical examiner system. The largest states, including California, Texas, New York, Illinois, Pennsylvania, Ohio, and Georgia, have a mix of medical examiner and county coroner offices.

  As the most populous state, California is unusual—but not unique—in that the coroner’s office is combined with the sheriff’s department in forty-nine of fifty-eight counties. In these areas the sheriff serves as coroner, too—despite having little or no medical training—and appoints another law enforcement person to oversee the day-to-day duties who, in all likelihood, has no medical training, either. The result is that the work of the coroner’s office is controlled by the sheriff, which can create problems. Because sheriffs focus on criminal activity, the emphasis of the coroner’s office in these counties is to support homicide investigations. Less time is spent delving into deaths by accident, suicide, or natural causes, and frequently in these instances autopsies aren’t conducted, in order to save money. Cases in which the manner of death is undetermined, but clearly isn’t homicide, also get short shrift, leaving families in the dark as to what caused their loved one to die.

  The lack of national standards for coroners is hard to understand inasmuch as a death certificate is one of our most important documents. It is used by families to collect life insurance, file for payment from special funds for certain types of deaths, such as mesothelioma, and change names on deeds, trusts, and other valuable assets. Death certificates also are used by the government to stop Social Security payments, by businesses to change or eliminate pension payouts and health care coverage, by various public and private agencies to inform current funding decisions and future policies, and by researchers to track how society is changing.

  In Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner, author Judy Melinek talks about the value of a death certificate. “It’s no big deal if you don’t have a birth certificate,” she says. “Other forms of identification will suffice to secure a job, open a bank account, even file for Social Security. However, if your survivors cannot produce a death certificate after your demise, they will descend into bureaucratic purgatory. They can’t bury your body, transport it across state lines, liquidate your investments, or inherit anything you have willed them.”

  Coroners aren’t the only people who are authorized to sign death certificates. Depending on the state, a primary care physician, attending physician, nonattending physician, or nurse practitioner can sign. Most of the time, these signatories confirm a death by natural causes where no investigation is needed. In homicides, suicides, and accidents, coroners typically sign the certificate after an autopsy has been performed.

  CAUSE AND MANNER

  The results from an autopsy and the findings of toxicology tests help the coroner determine the cause and manner of someone’s death. Although cause and manner seem like the same thing, they are, in fact, different. Cause refers to the physical reason why a person died. A gunshot to the head, an overdose of drugs, blunt-force traumatic injuries such as those resulting from a vehicle accident or a fall, sharp-force injuries like stabbings, inhaling a deadly gas like carbon monoxide, and asphyxiation due to drowning, hanging, or strangulation are examples of cause. Deaths from heart attacks, strokes, seizures, and other diseases also are examples of cause.

  Manner refer
s to the way in which a person dies. There are five recognized categories in the United States: homicide, suicide, accident, natural, and undetermined. Each one has legal implications for law enforcement and can have financial consequences as well.

  A ruling of homicide means that there is likely to be a police investigation. Detectives collect evidence of criminal activity and present it to a district attorney, who decides whether or not to prosecute. If the case goes to trial, the coroner is called to testify, but only to the extent of explaining how a determination of cause was reached. Inasmuch as coroners’ rulings are fact-based and unbiased, there are occasions when the explanation is as helpful to the defense—mainly by discouraging the district attorney from trying the case—as it is to the prosecution.

  A ruling of suicide usually ends any police involvement. In some instances, this is welcome news for family members who otherwise might be implicated for murder. Other times, a determination of suicide can end up voiding a decedent’s life insurance policy if it was taken out or renewed within two years of the person’s death (beyond two years, the policy can’t be nullified). In addition to the possible financial impact, a death by suicide can be stigmatizing and cause family members to feel guilty, embarrassed, or angry on top of the other emotions that a loved one’s death tends to generate, such as sadness, depression, loneliness, and despair. For this reason, family members may push hard for the coroner to rule that the death was accidental rather than a suicide.

  If a death is determined to be accidental, it means that there was little if anything the decedent could have done in the moment to prevent it. A woman falls off her horse, lands on her head, and fractures her skull. A boat capsizes and someone drowns. An apartment building catches on fire and one of the tenants dies from smoke inhalation. Sometimes blame may be placed on another person, such as the driver in a fatal vehicle collision whose inattentiveness, recklessness, or drunkenness caused the accident. Alternatively, the victim’s own ignorance or carelessness may play a major role. A man is swept off a rock while fishing and is washed out to sea. A homeowner who is trimming trees on his property touches a high-voltage wire with his saw and is electrocuted. A farmhand loading bales of hay into an auger feeding wagon falls into the wagon and is mutilated. Each of these is among the many deaths that Holmes investigated in his career, and each was avoidable, but not in the instant that it happened. At that moment it was too late.

  As for natural deaths, which typically comprise about 60 percent of the deaths a coroner’s office handles, these are the result of a disease rather than an injury. This doesn’t mean that the person died of “old age,” since young people can have a known or unknown health problem that isn’t treated or ends up being mistreated. Rather, it means that the person suffered from a heart condition, tumor, seizure, or aneurism that proved to be fatal.

  Sometimes it’s impossible to determine the manner in which someone died. When a car goes off the road and hits a tree or catapults off a cliff, did the driver fall asleep at the wheel, swerve to avoid an animal, lose control, or intend to die? If the person had a stroke or heart attack there will be forensic evidence, but otherwise, in the absence of skid marks, it may not be possible to tell. Similarly, if someone is found dead in bed due to a drug overdose, was it accidental or intentional? A suicide note might provide the answer, but only 20 percent of suicide victims leave a note, so oftentimes the coroner has little to go on. Is a patient’s death during surgery merely unfortunate or is there evidence of medical malpractice? Every medical procedure has risks; the question is whether doctors bear any responsibility for the outcome.

  In cases where the coroner doesn’t have enough information to make a definitive ruling, the official manner of death is “undetermined.” This can be altered if new evidence comes to light; however, it can only be altered once. The last thing anyone wants is for the manner of someone’s death to be perpetually changing. That would wreak havoc with law enforcement, the courts, health care providers, insurance companies, and families.

  Marin County has an average of 1,500 to 1,800 deaths per year. Roughly 300 of these require autopsies because the cause and manner of death aren’t clear. Trauma cases, accident cases, and other cases that are out of the ordinary or unusual end up in a pathologist’s hands.

  “On TV and in the movies they use the word ‘suspicious,’ ” Holmes says, “but that’s not a word we ever used. We said it was ‘out of the ordinary’ or ‘unusual.’ Not that it’s wrong to use ‘suspicious’—it might be part of the vernacular in other coroners’ offices—it just wasn’t part of ours. To say that a death is suspicious is to offer an opinion; something doesn’t seem right. Instead, we presented the facts and left the interpretation to others.”

  THE ROAD TAKEN

  Holmes was raised by his paternal grandparents in the Central Valley town of Fresno, California. His grandfather was the fire chief of Fresno and a huge influence on Holmes’s life.

  “He taught me morals, integrity, and work ethic,” Holmes says. “He also was a guiding light when it came to life in politics, which I didn’t fully appreciate until years later, when I entered the political arena.”

  Most boys Holmes’s age were passionate about three things: sports, guns, and the outdoors. Holmes was, too, but he also was transfixed by something that his friends had no interest in—anatomy.

  “I was the kid who tried to figure out how that bird died, or what happened to the jackrabbit,” he says. “When I first started hunting, at age eight, I was as interested in what happened to the bullet as I was in getting the animal ready to eat.”

  He remembers the first jackrabbit he ever skinned. “Once I skinned it I could see the shoulder and the foreleg, and I could work the shoulder and I could see the shoulder bone rotating in the socket because the muscle there is thin. I said to my granddad, ‘Gee, look at that.’ He said it was called a ball-and-socket joint. I kept working it, and in my mind I was struck by the fact that it was so simple yet worked so well.”

  Early on, Holmes’s grandmother determined that if an animal was wounded, her grandson was the one who would tend to it. One time someone’s collie got hit by a bus in front of Holmes’s house. Holmes was playing with three of his friends and witnessed the accident. He didn’t know whose dog it was, but he got a stick and two handkerchiefs and splinted the dog’s broken leg.

  In middle school, Holmes had to write a report describing three occupations he was interested in pursuing. Two choices—being a physician and being a veterinarian—seemed obvious. Both had a significant drawback, though—all of the additional years of study that were necessary. Holmes liked school, but not that much. Even so, he listed doctor and vet as two of his choices. He had no idea for a third choice, however.

  “You know, the coroner does autopsies,” his grandfather said. “That’s medicine.”

  Holmes perked up. “What are autopsies?”

  His grandfather explained that autopsies are postmortem examinations to determine how and why someone died. Usually they are done in a morgue, he said, but because Fresno County didn’t have one at the time, they were conducted at a local mortuary instead.

  “Do you want me to set up a meeting with the funeral director there?” he asked.

  Holmes nodded, instantly intrigued. He was even more interested when he saw the funeral director drive up in a big black late-model Cadillac. The man was wearing an expensive suit and equally expensive shoes. In addition, the funeral home was plush and quiet, the sort of place where Holmes could imagine himself working.

  The funeral director affirmed that all autopsies for the coroner’s office were done at his mortuary, and he explained the process and what the job entailed. By now Holmes sensed that he might have found his calling. There was just one more thing he needed to know.

  “How long does it take to be a funeral director?”

  “Three years after high school,” the man said. “One year of mortuary college and two years of apprenticeship.”

 
; That clinched it. Holmes wrote in his report that his third career choice was funeral director.

  From the outset, he knew that his real goal was to be a coroner, not a funeral director. “I just didn’t know how to get there,” he says.

  In school, his favorite subject was science. He also was enamored with mysteries, especially those that featured his namesake detective, Sherlock Holmes.

  After he graduated from high school, Holmes attended Fresno City College for two years and started an apprenticeship at the funeral home he had visited with his grandfather. In those days, a person didn’t have to go to mortuary college first. During the apprenticeship, Holmes learned two important things about himself.

  The first was that he had no qualms about death. On the contrary, when he watched his first autopsy, he was so enthralled that eventually his boss had to ask him to leave the doctor alone because he was asking too many questions. The person’s chest had been cut open, exposing all of the internal organs, and Holmes would point to various body parts and ask, “What’s that?” The doctor would explain, then remove the deceased’s heart, kidneys, and other organs and place them in Holmes’s hands.