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Why Modern Medical Examiners Don’t Hold Ancient Coroner Inquests

Modern death investigation techniques, modern medical knowledge, and modern forensic sciences (all used currently by forensic pathologists serving as medical examiners) long ago replaced the coroner’s inquest: Villagers standing around a dead body and being asked by a coroner if anyone knew who the dead person was and how the person came to his or her death.

Coroners are an ancient English institution, and Coroner Inquests became outdated centuries ago when the natural and medical sciences had developed to the point of having practical application to death investigations, and began being used in most societies (including Scotland - Scotland never had coroners) outside of England and the sphere of the British Empire/Commonwealth.

Coroners and coroner inquests were not put in place to determine if a death was or was not justified.

Corner inquests were intended to force members of the public to be available to the coroner for questioning (“inquest” means “making an inquiry” – not the holding of a trial), done to serve the interests of the King of England – particularly property interests of the King.

Inquests were always supposed to be about the finding of facts, not the finding of fault.

Washington State law restricts the verdict of a coroner’s inquest to answering the following questions regarding a death:

  • Who died – what was the person’s name, if known?
  • When did the death occur?
  • Where did the death occur?
  • What was the cause of death: What physical disease, physical condition, or physical injury (or combination of) caused death?
  • What was the manner of death: Natural, accident, suicide, homicide, or undetermined?

    [Together, the cause and manner of death constitute “by what means he or she came to his or her death,” with “homicide” being defined by law as the killing of a human being by the act, procurement, or omission of another].
  • Was the person killed or was the death occasioned by the act of another? If so, name the person whose act resulted in the death, if known.

    [Naming the person is fact finding only- the prosecutor has to decide whether or not to file criminal charges against someone, and all people are innocent of a crime until proven guilty in a court of law, which the coroner’s inquest is not. Being guilty of an act is not the same as being guilty of a crime.]

Modern forensic death investigations answer these questions - there is no valid use for an inquest jury.

Coroner inquest verdicts are not binding - they do not mandate or prevent any legal action.

The Washington State Supreme Court has addressed issues of the coroner inquest, including the following statements:

"A coroner's inquest is not a culpability-finding proceeding." - State v. Ogle

“The purpose of an inquest is to determine the identity of the deceased, the cause of death, and the circumstances of the death, including an identification of any actors who may be criminally liable.” - Carrick v. Locke

“…the proceeding at issue is a nonbinding factual inquiry and does not result in a determination of guilt or responsibility.” - Miranda v. Sims

Currently, in the State of Washington, there are no minimum requirements to be a coroner – just be a resident in a county that has a coroner, run for the elected office, and win the election. In the least populated counties the elected prosecuting attorney also serves as coroner. In Spokane County, the medical examiner is required by law to be certified as a forensic pathologist by the American Board of Pathology. Forensic pathologists are trained in all areas of forensic death investigation, from death scene investigation through court testimony – not merely the performance of autopsies, as is often claimed by coroners trying to protect their jobs and prevent being replaced by a modern medical examiner system.

The fact that some coroners, politicians, and attorneys ignore the history of the coroner, ignore existing law, and misuse inquests for political reasons and law-suit fishing expeditions, does not justify medical examiners turning back the clock a thousand years – should a patient with a medical problem be diagnosed by the vote of a panel of people selected from the court jury pool rather than by a physician? Should we return to bloodletting as the primary treatment of most diseases?

In medieval England what established the Coroners was Article 20 of the "Articles of Eyre" written in September 1194. The "General Eyre" was the periodic visitation of the King's itinerant Judges, who traveled slowly around the country dispensing what passed for justice in those days. The Eyre of September 1194 was held in the County of Kent, and Article 20 stated that:


The above words are the only official authority for the long-lived coroners system, and the coroners were ordered only to "keep the pleas of the Crown". This meant recording the pleas on parchments known as the "Coroners' Rolls." “Keeping the pleas” was different from “holding the pleas” which meant trying cases and passing sentence. “Holding the pleas” could only be done by the courts – County Court or General Eyre, depending on the seriousness of the offense.

Following Are More Lessons From History:

During the years 1348-1350, the head of the Catholic Church, Pope Clement VI, ordered autopsies on victims of the Black Death in an attempt to find a cause for the plague – autopsies, not inquests.

The first constitution of the American Medical Association (AMA, 1847) devoted an entire section to forensic medicine and the responsibilities of the physician in death investigations.

In 1857 a committee of the American Medical Association (AMA) recommended the complete abolition of the coroner’s office, separation of medical and legal duties in criminal cases, elimination of the coroner’s inquest, and cessation of political appointments of coroners. Maryland, in 1860, became the first U.S. state to require coroners to be physicians.

Boston lawyer Theodore H Tyndale, addressing the Department of Health of the America Social Science Association in the spring of 1877, called for the abolition of Boston’s coroners. He identified the office of coroner as archaic and corrupt. Among the complaints regarding coroners of the time (and still true to this day) was that “the coroner frequently determined the outcome of jury deliberations by asserting his influence in subtle or not-so-subtle ways.

In 1889 S. Squire Sprigge wrote the Life and Times of Thomas Wakely. A chapter discussing the old-fashioned English coroner’s inquests, which were commonly held in “Public Houses” (taverns), included the following depiction.

The tint of the tavern-parlour vitiated the evidence, ruined the discretion of the jurors, and detracted from the dignity of the coroner. The solemnity of the occasion was too generally lightened by alcohol or entirely nullified by the incompetency of the judge. In short, the tribunal designed by Edward I. to be one of the most important in his kingdom… had been universally degraded to a dreary farce, …a thing proverbially to be laughed at, and where the majesty of death evaporated with the fumes from the gin of the jury.

In 1904 the Elsberg Bill passed the New York state legislature, abolishing the office of coroner and creating an office of medical examiner.

In 1911 a special committee of the Chicago Bureau of Public Efficiency made a comprehensive examination of Chicago’s government offices. The committee recommended that “the coroner ought not be an elected official.

In 1928 the National Academy of Sciences through the National Research Council’s (NRC’s) Committee on Medical Legal Problems addressed the state of death investigation. Committee members included Roscoe Pound, Dean of Harvard Law School, and John Henry Wigmore, Dean of Northwestern Law School. The NRC released a harshly critical report entitled The Coroner and the Medical Examiner. In its first four recommendations, the 1928 committee suggested the following: (1) that the office of coroner be abolished. It is an anachronistic institution which has conclusively demonstrated its incapacity to perform the functions customarily required of it; (2) that the medical duties of the coroner’s office be vested in the office of medical examiner; (3) that the office of medical examiner be headed by a scientifically trained and competent pathologist, selected and retained under civil service, and compensated by a salary which will attract men of genuine scientific training and ability; and (4) that the office of medical examiner be provided with the services of a staff competent in toxicology, bacteriology and other sciences necessary in the scientific investigation of causes of death.

The committee found that coroner inquests “frequently did not follow the required legal procedures, often used quasi-professional witnesses, and many cases reached unrealistic, politically influenced conclusions.

In 1947 the City and County of Denver (Colorado) converted from a coroner to a coroner-medical examiner system and coroner inquests stopped. In the 1990’s, following a series of police-involved shootings in Denver, a commission was formed to examine the problem. The Erikson Commission published a report in 1997 making no mention of “coroner inquests,” but reached the conclusion that “The criminal law, by its very nature, can never be as effective a mechanism for shaping police behavior and limiting the use of deadly force in law enforcement as internal policies, administrative regulations, and training programs that reflect the values and priorities of the community.

In 1954 the National Conference of Commissioners on Uniform State Laws issued the Model Post-Mortem Examinations Act (the Model Act). The Act stated the following: The purpose of the Post-Mortem Examinations Act is to provide a means whereby greater competence can be assured in determining causes of death where criminal liability may be involved. Experience has shown that many elected coroners are not well trained in the field of pathology, and the Act should set up in each state an Office headed by a trained pathologist, this Office to have jurisdiction over post-mortem examinations for criminal purposes. The Office would supersede the authority of Coroner’s Offices in this field.

In 1958, the American Board of Pathology formally identified Forensic Pathology as a subspecialty. The Board began issuing certificates of special competence in Forensic Pathology (i.e. “Board Certified”) to qualified pathologists in 1959.

Between 1960 and 1979, 12 states converted from coroners to medical examiners. Also during that time, Texas Code was change to include: “Subject to the provisions of this Act, the Commissioners Court of any county having a population of more than one million and not having a reputable medical school as defined in Articles 4501 and 4503, Revised Civil Statutes of Texas, shall establish and maintain the office of medical examiner, and the Commissioners Court of any county may establish and provide for the maintenance of the office of medical examiner.”

During the period of 1969 to 1987, the Washington State counties (in chronological order) of King, Whatcom, Pierce, and Snohomish converted under “Home Rule” from coroner to medical examiner.

1999: Spokane County and Clark County convert by popular vote of the people each county from coroner to medical examiner under RCW 36.24.190.

2009: The National Research Council published the report of its Committee on Identifying the Needs of the Forensic Sciences Community titled Strengthening Forensic Science in the United States: A Path Forward. Included in the recommendations is the statement “Congress should authorize and appropriate incentive funds to the National Institute of Forensic Science (NIFS) for allocation to states and jurisdictions to establish medical examiner systems, with the goal of replacing and eventually eliminating existing coroner systems.

In 2012, the U.S. Department of Justice identified only Clark County Nevada, King County Washington, and the counties of the State of Montana as jurisdictions that routinely held coroner inquests in cases of fatal officer-involved shootings. That represented only 58 of 2,342 death investigation jurisdictions in the U.S. It is of note that King County has a medical examiner system that replaced the coroner in 1969, but the coroner inquest authority was given to the elected County Executive, not to the medical examiner, making the inquests political, not investigatory.

In 2013, Nevada’s Clark County (Las Vegas) Commission voted to do away with the county’s controversial coroner’s inquest process (legal challenges went all the way to the State Supreme Court), introducing a new fact-finding process into fatal officer-involved shootings. The board approved a new “police fatality review process” that streamlined the incident review process, including doing away with a panel of members of the public that had acted as a “jury” during inquests, and moved the hearings out of courtrooms.


  • Commission shelves coroner’s inquests for new ‘police fatality review process’
    Las Vegas Sun, January 7, 2013
  • Report: Collaborative Reform Process
    A Review of Officer-Involved Shootings in Las Vegas Metropolitan Police Department
    Community Oriented Policing Services, U.S. Department of Justice
    CNA 2012
  • Katherine D. Watson
    Forensic Medicine in Western Society: A History
    Taylor and Francis, 2011
  • Denver Office of the Medical Examiner Annual Report 2011
  • Jeffery M. Jentzen
    Death Investigation in America Coroners, Medical Examiners, and the Pursuit of Medical Certainty
    Harvard University Press, 2009
  • Committee on Identifying the Needs of the Forensic Sciences Community,
    National Research Council
    Strengthening Forensic Science in the United States: A Path Forward
    National Academies Press, 2009
  • Stefan Timmermans
    How Medical Examiners Explain Suspicious Deaths
    The University of Chicago Press, 2006
  • Ruth Richardson
     Death Dissection and the Destitute, 2nd Ed.
    The University of Chicago Press, 2000
  • Ian A. Burney
    Bodies of Evidence Medicine and the Politics of the English Inquest, 1830-1926
    The Johns Hopkins University Press, 2000
  • Bernard Knight
     History of the Medieval English Coroner System, LLC, 1999
  • Bernard Knight
     Simpson’s Forensic Medicine, 11th ED
    Arnold, 1997
  • Robert Wilkins
     Death A History of Man’s Obsessions and Fears
    Barnes & Noble Books, 1996
  • Kenneth V. Iverson
     Death to Dust
     What Happens to Dead Bodies?
    Galen Press, 1994
  • Lester Adelson
     The Pathology of Homicide
    Charles C Thomas, 1974
  • Werner U. Spitz and Russell S. Fischer, Eds.
     Medicolegal Investigation of Death
    Charles C. Thomas, 1973
  • R. B. H. Gradwohl
     Legal Medicine
    C.V. Mosby, 1954
  • Thomas A. Gonzales, Morgan Vance, Milton Helprin, and Charles J. Umberger
     Legal Medicine Pathology and Toxicology
    Appleton-Centrury-Crofts, 1954.
  • RCW 36.24.070 Verdict of the jury [RE: Coroner Inquest Jury – the law dates to 1854]

This document was prepared by John D. Howard, M.D.
February 2013