It’s become a familiar scene in every police procedural: the solemn white-coated genius stares thoughtfully at the blood spatter on the wall, or the indentation of a footprint, or the scrap of DNA through the microscope. In a moment of epiphany, the mystery is solved.
That myth — of ingenious scientists using Sherlock Holmes-esque tactics to catch criminals and bring them to justice — doesn’t usually come with a campaign slogan.
On Tuesday, millions of Americans will go to the polls mainly thinking about who they want to occupy the highest office in the nation. But many of them will also elect a crucial official who often goes overlooked: the coroner.
In much of small-town America, the person who investigates death is determined by a political contest. More than 80 percent of U.S. coroners are elected. Their qualifications vary wildly from state to state — and very few places require coroners to have any medical background whatsoever.
About 36 percent of Americans live in areas where minimal or no special training is required to conduct death investigations, according to a comprehensive 2009 report by the National Academy of Sciences on the shortcomings of forensic science. One elected coroner in Indiana hired his 18-year-old daughter as a deputy after she passed a certification test.
“Typical qualifications for election as a coroner include being a registered voter, attaining a minimum age requirement ranging from 18 to 25 years, being free of felony convictions, and completing a training program, which can be of varying length,” the NAS report noted. “Coroners are independent of law enforcement and other agencies, but as elected officials they must be responsive to the public, and this may lead to difficulty in making unpopular determinations of the cause and manner of death.”
Look out for the boys in blue
Unlike medical examiners, who are appointed officials generally required to be physicians, coroner candidates are often former or current police officers who campaign on their law enforcement background rather than medical expertise.
That background can and does come into conflict with the job. Though their role tends to be behind-the-scenes, coroners wield a sizable amount of power in the criminal justice system. They decide if an untimely death in the community was the result of an accident or a crime. They also must rule if a death that occurred in police custody was a suicide or a murder.
One coroner in Dorchester County, South Carolina, even admitted to faking an autopsy result to help police officers. Coroner Chris Nisbet quickly ruled the 2015 police shooting of Shamir Palmer a “suicide by cop” before he had even watched all of the dashcam footage. A month later, Nisbet pulled a gun on his black neighbor and delivered a racist rant that got him ousted from office.
“You know I always got y’alls back. I look out for the boys in blue,” Nisbet told the police officers who came to arrest him. “Just like the last suicide by cop bullshit.”
Coroners are just one part of the often confusing patchwork of death investigators in the United States. Some states and larger cities appoint medical examiners, who are generally required to be physicians. Coroners also sometimes work with forensic pathologists and forensic laboratories — most of which also operate under zero oversight.
But the roughly 2000 coroner offices in the United States are on the front line of death investigations. It’s rare that anyone thinks to check their work.
And when someone does check their work, things start to unravel.
Coroner Frank Minyard, a trumpet-playing former gynecologist, was beloved in New Orleans. The city re-elected him over and over again for forty years, until he retired in 2014. Yet his office had a tendency to conclude that suspicious deaths in police custody were simply accidents or natural causes.
Minyard and a forensic pathologist who worked under him, Dr. Paul McGarry, determined a drug overdose had killed Cayne Miceli, a woman who died while restrained in jail. An independent autopsy found that not only did she not have any drugs in her system, but that she had had severe asthma, a condition that turned lethal once she had been strapped down flat on her back by guards.
The coroner’s office had a long history of looking away from evidence of police killings.
Almost two decades earlier, a man named Adolph Archie grabbed a gun from a security guard and killed a police officer. After broadcasting on police radio that they were going to mutilate and kill him for his crime, a mob of police officers ambushed Archie at the hospital and took him to a station house. By the time he returned to the hospital, he had been beaten to a bloody pulp.
Minyard decided that Archie had sustained the injuries from slipping and falling backward.
A second autopsy commissioned by civil rights attorney Mary Howell found far more extensive injuries than the ones detailed by Minyard’s office. Archie’s face had been kicked in, his skull was fractured, and he had severe hemorrhaging throughout his back and in his testicles.
Under public pressure, Minyard revised his determination to a homicide. But then he changed his mind again, saying Archie had actually died from an allergic reaction to iodine administered for X-rays at the hospital.
No one was ever charged or even disciplined for their role in Archie’s death.
A national math problem
A single coroner can cover up local cases of injustice. Two thousand offices, all with different qualifications and resources, are creating confusion on a national scale.
The lack of standards for coroners creates a mess of incomplete data and unanswered questions. Many coroners don’t even bother to order costly autopsies for the vast majority of deaths, relying on their own visual assessments instead.
An audit of Georgia’s 154 coroner offices found that a quarter of suicides went unreported to the state medical examiner, skewing vital public health data. A single coroner in upstate New York failed to investigate the deaths of more than 18 people at the local prison for years.
Federal prosecutors have also complained that coroners, particularly in rural areas, are standing in the way of efforts to research the true scope of the opioid epidemic and come up with solutions. Smaller coroner offices that lack technology and manpower are failing to turn over timely data on overdoses in their area, which then bogs down the whole system.
Ultimately, however, the elected coroner system is just one cog in a very dysfunctional machine. The state of forensic science in the United States is in far more chaos than shows like CSI or Law and Order would have you believe.
In September, a groundbreaking White House report formally acknowledged that many of the fields of forensic analysis used to convict people currently have no grounding in science. Thousands of wrongful convictions have been attributed to junk science masquerading as forensic expertise.
These techniques are not limited to small-town coroner offices. The FBI defended its use of microscopic hair analysis, which some scientists have derisively called “magic,” until last year. The Manhattan district attorney’s office has fiercely justified convictions based on bite mark analysis, another popular forensic technique that has been thoroughly debunked.
Many other forensic techniques, the White House report noted, depend on the subjective opinion of an expert. The lack of training or standards in the forensic science community makes the reliability of that analysis very shaky.
The report exposed the mythology that underlies death investigation and criminal justice in the United States. But the FBI and DOJ swiftly dismissed the report and said they would continue to use the debunked techniques.
The stubborn entrenchment of the coroner system demonstrates how slow progress can be, especially when it comes to forensic science.
A committee of the American Medical Association (AMA) was the first to call for abolishing coroner offices. It specifically recommended that coroners be medical officials appointed by courts, independent of law enforcement.
“This method of filling the office will be more successful in securing the selection of one having the special attainments demanded for the faithful and intelligent performance of its duties than that by popular election,” the committee wrote. “Amid the strife and excitement of politics and predilections of party, those special attainments cannot be expected to be regarded with sufficient care.”
That warning was written in 1857.
Aviva Shen, a former ThinkProgress editor, is now a freelance writer in New Orleans focused on criminal justice.