Journalism in the Public Interest

Civil Rights

How to Investigate Coroners and Medical Examiners

(Andres Cediel/Frontline)

Reporters covering the criminal justice system rarely look at coroners or medical examiners -- instead we focus on cops and prosecutors and defense attorneys and defendants.

I began to look more closely at the Tyvek-clad doctors who staff America's morgues when I started finding cases in which they made repeated errors, or failed to document obvious injuries or reached conclusions challenged by their peers.

The coroner or medical examiner in your area may merit the type of examination that could lead to stories.

Here are a few things I'd encourage you to scope out:

1. Look at the type of system in your area.

Death investigation systems falls into two broad categories. There are offices overseen by coroners, typically laypeople, who are often elected.

Coroners who don't have medical training rely on doctors to do autopsies for them. When the autopsy is complete, the coroner makes the final call on how somebody has died and signs the death certificate.

The other type of system is run by medical examiners. They play the same basic role as coroners, but are usually trained forensic pathologists who are appointed to their position by county or state government officials. Typically, chief medical examiners have experience doing autopsies.

If you're dealing with a coroner who doesn't have any medical experience, check if he or she is overruling or ignoring the doctors who do the actual autopsy work.

If you have an elected coroner, who supports the coroner come election time? Who does he or she rely on for endorsements, fundraising and getting out the vote?

It's important to remember that "controlling the determination of the cause and the manner of death gives you political power," as Jeffrey Jentzen, the author of Death Investigation in America: Coroners, Medical Examiners, and the Pursuit of Medical Certainty, told us.

2. Find out if your local morgue is accredited.

The National Association of Medical Examiners, a nonprofit group dedicated to improving the field of death investigation, inspects and accredits coroner and medical examiner facilities.

NAME has a long list of requirements for accreditation -- among them, that the morgue facilities have to be clean and functional and the doctors need to be properly trained.

Check to see if your local coroner or medical examiner operation is accredited. If it isn't accredited, find out why. Did the office fail its inspection? Does it have shortcomings that have kept it from even seeking accreditation?

For more information on accreditation, check NAME's site, at

3. See how many cases doctors handle at your coroner or medical examiner offices.

A key concern of NAME is how many autopsies doctors are doing. The worry is that doctors start making errors start when they try to work too fast, or for too many hours in a row. The association recommends that doctors do no more than 250 autopsies per year, and 325 at the absolute maximum.

But there are doctors who do 400 or more autopsies on an annual basis. Find out if doctors in your area are taking on more cases than NAME says is advisable.

Caseload information should be public record in your jurisdiction, but be aware: Some offices can't -- or don't -- track autopsies on a doctor-by-doctor basis. That could be worth exploring, as well.

4. Check if the doctors at your coroner or medical examiner's office are board certified.

Board certification is like accreditation for doctors. To become a certified forensic pathologist, a doctor must complete a three-to-four year residency, do a year-long fellowship in a coroner or medical examiner office, and pass the forensic pathology board exam administered by theAmerican Board of Pathology.

There are competent doctors who aren't certified, but experts in the field say certification helps to ensure that those doing autopsies understand the finer points of forensic pathology, the area of medicine that focuses on the mechanics of death. Some coroner and medical examiner offices won't employ physicians who lack certification.

For our Autopsies in the U.S.A. database, we asked large coroner and medical examiner offices whether the physicians were certified. The results were surprising -- even in these organizations, 1 in 5 doctors were not.

We also asked why doctors weren't certified. Some had just emerged from a training fellowship and hadn't had a chance to take the exam, which is only offered once a year. Others, though, had failed the test repeatedly. Others chose not to sit for the exam.

You can also ask the pathology board if a doctor is certified.

5. Make sure those doing autopsy work have medical licenses.

To perform an autopsy, a person must have a valid medical license, but I found cases in which non-doctors performed autopsies. Run names past the state medical board.

6. Look for errors and disputes.

Cases in which forensic pathologists' findings or diagnosis of cause of death become controversial can be great jumping off points for reporting.

There is no central place to find such cases, but there are plenty of ways to look for them. Talk to people in the legal community: prosecutors and defense attorneys, as well as civil lawyers -- particularly medical malpractice and civil rights attorneys.

Look for cases where defense lawyers hire experts to review autopsies or where civil attorneys bring in their own forensic pathologists to do second autopsies.

Also, check with independent forensic pathologists, those not affiliated with a local agency. Some offer private autopsy services, either examining bodies that have never been autopsied, or doing second autopsies on bodies that have already been dissected once. These doctors also sometimes review autopsy reports, photos, and slides, looking for errors or oversights. Keep in mind that paid experts typically are brought in by those on one side of a lawsuit -- their opinions should be considered in that light.

Another way to find disputes over autopsies is to check case law. If a judge or panel of judges finds fault with an autopsy, it may pop up in a search of court decisions using Nexis or Westlaw.

Related: Read our full series on death investigations in the United States.

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