Glitches in state’s death-investigation system
February 14, 2011
The bumper sticker says it all.
Foreboding red letters etched on a black background beside a crime scene body outline read, “Our day begins when yours ends.”
Creepy? Maybe. But for Summit County Coroner Joanne Richardson, who picked the sticker up on a trip to Las Vegas, the words cut to the root of the problem with Colorado’s messy death-investigation system.
A coroner’s workday begins when someone dies. Coroners are responsible for determining time and manner of death, deciding whether an autopsy will be performed, assisting law enforcement in investigations – and breaking the news to family members. So why are a high school diploma, a background check and a short training course Colorado’s only qualification requirements for individuals entrusted with such important work?
“This is not on the forefront of people’s minds unless they have been directly affected by … a botched investigation,” Richardson said. “People just don’t want to think about it.”
But this year, state Rep. Rhonda Fields (D-Aurora) is asking people to think about it.
On Jan. 21, she introduced a bill calling a review commission to take a hard look at Colorado’s death-investigation system. The commission would look at the lack of qualification requirements for coroners, whether the coroner should be an elected position and if a medical examiner system might be better for Colorado.
“We’re not specifying what the options might be,” said Rep. Su Ryden, a co-sponsor on the bill. “We want (the commission) to investigate that.”
Richardson said she supports the concept of the commission and has even testified on behalf of the proposed legislation.
“The coroner system is, I don’t want to say broken, but it could be better,” Richardson said. “The public really should be demanding more.”
Coroners in Colorado are officials elected at the county level. Because state qualifications standards for coroners are so low and it is an elected position, the office of the coroner can be filled by candidates with little or no background in death investigation.
“The public doesn’t always look at experience in candidates for any position,” Richardson stated. “They may vote for a friend or for somebody they like. In this business, experience matters and the voters should not have to tolerate a coroner who has to obtain training after they take office at taxpayer expense.”
As coroners in Colorado go, Richardson is fairly well qualified. In addition to several years’ experience working in the business prior to her election, she holds a master’s degree in forensic science and a master’s certificate in grief and bereavement counseling.
She is also the only coroner in Colorado with board certification from the American Board of Medicolegal Death Investigators, the only official certification program available for coroners nationwide.
Death investigators, particularly those who lack the proper training and qualifications, can and do make mistakes, according to Richardson. She recalls two separate instances of big ones made in recent years.
In the first case, a hospital pathologist concluded abuse was involved in the death of a child. Local law-enforcement agencies began looking into the child’s parents and home life and soon realized the situation was not indicative of child abuse. The child was re-autopsied and it was later determined abuse had not factored in the death.
In another botched investigation, a forensic pathologist ruled the death of a young woman – who had died from blunt force trauma in a park – a homicide. Later investigation of the scene and the context of the incident revealed she had simply tripped and hit her head on an exposed sprinkler head.
Coroners are charged with ruling a death a homicide, suicide, accident or natural death. In some cases, the cause of death cannot be determined.
Elected coroners with little qualification are required to undergo some basic training in legal death investigation, though they do so at the taxpayer’s expense.
But in many small counties in Colorado, the position of coroner is a very part-time gig, and there is little time or incentive for individuals in the position to get any training beyond the minimum requirements. Coroners in rural counties may hold other jobs, handle as few as five deaths a year and make no more than $1,200 annually.
“The smaller counties have a hard time getting anybody to run for the position,” Richardson stated in an e-mail.
The answer to the messy coroner system in Colorado, some argue, is to have medical examiners handle death investigations.
Richardson calls Colorado a “pseudo-medical examiner state.” There are medical examiners, but they are only asked to investigate some cases, as decided by the coroner.
And though they have higher qualification standards than coroners, many medical examiners are physicians who have no background in forensics. There is also an extreme shortage of medical examiners. In Colorado, their caseload is heavy enough that the results of their tests can take several weeks.
Sponsors say the commission proposed in Rep. Fields’ bill would look at the glitches in Colorado’s death investigation system and report back to the Legislature with policy recommendations.
But Richardson says fixing the system will take time and money and is somewhat concerned about who will be appointed to sit on the commission.
“You need the right people sitting on a committee,” Richardson said. “You need people that are in this business, know what’s going on in this state, have the experience and understand that training is needed.”
If passed, the commission would spend the next several years researching the existing system and come back with suggestions in 2013.
Richardson will term out as coroner at the end of her current term. She says she is currently grooming one of her deputies to run for the position when she leaves office.