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.