Observing the role of a coroner in court during a trial is a great way to learn about medicolegal death investigation. Coroners are responsible for critical evidence that often ends up at a murder or drug delivery resulting in death trial.
Whatever the staff of the coroner’s office sees, hears, smells, photographs, or does—from the time they receive a dispatch about a death until the time the body is released to a funeral home—is evidence. That evidence must be able to meet forensic standards of evidence in a court of law.
Often that evidence determines whether or not someone will be charged with and perhaps convicted of murder. A murder trial, like one I attended recently, is a good place to see why coroners’ death investigation evidence is critical to our justice system.
Other English-speaking countries—the United Kingdom, Canada, Australia, New Zealand—have a well-established coroner inquest system with special Coroners’ Courts. This article is about the very different courtroom role of the American coroner. That role diverges significantly from that of coroners in those other countries. Jeffrey Jentzen, a forensic pathologist and science historian, has written extensively about the evolution of death investigation in America.
Note: Part 1 of this series will only look at the role of coroners—not medical examiners—in the courtroom. Most medical examiners are forensic pathologists. Their role in the courtroom may differ from that of most coroners.
Basics of the Role of the Coroner in Court
The documents
Three core documents produced by or for the coroner’s office form the basis for court testimony: the coroner’s report, the autopsy report, and the toxicology report. The coroner’s report is the narrative report usually initiated by the deputy coroner responding to the dispatch. The court may also review the document recording the coroner’s final decision on the cause and manner of death. In Pennsylvania, that is not the death certificate but a View of Form or Verification of Death form.
Fact witnesses and expert witnesses
The prosecution or defense is most likely to call the deputy coroner who went to the scene, the forensic pathologist who performed the autopsy, the toxicologist from the forensic laboratory, and the coroner to the witness stand. If called, the deputy coroner is almost always a fact witness, while the forensic pathologist and toxicologist are expert witnesses. The role of the coroner in court can be either a fact witness or expert witness. It depends on their qualifications and what they are testifying about.
A fact witness is someone with first-hand knowledge—meaning they saw, heard, smelled, touched, photographed something relevant to the legal case. A fact witness may or may not have formal credentials. What matters is their credibility: are they believable, are they impartial (no personal interest in the case). A typical question for a fact witness is “what did you see?” The prosecution or defense may or may not pay fact witnesses nominal fees for their attendance.
An expert witness is someone with specialized knowledge or skills in a particular field relevant to the legal case. The prosecution or defense usually asks an expert witness for an opinion based on their expertise. “What do you think?” Part of the expert witness’s role is to interpret findings for the jury, so communication skills matter.
Expert witnesses are usually paid very highly. A forensic pathologist not testifying as a public official (a state or municipal medical examiner for instance) may charge as much as $400-$500 per hour for their services. Either the prosecution or defense pays these fees, not the coroner’s office.
The coroner’s case
Let’s see how these documents and witnesses played a part in the murder trial I observed this month.
First, the major events of the case from the coroner’s viewpoint: a dispatch sends the deputy coroner on duty to a local hospital for the suspicious death of a woman in her early twenties. The deputy coroner takes photographs, examines the external body, and arranges for its transport to the morgue. She then files a narrative report describing what she saw and heard, including what police, medical personnel, or anyone else on the scene told her. In this case, police tell the deputy that the decedent’s live-in boyfriend claims he found her dead when he woke up this morning. She also learns that police doubt his story because the young woman, who had no health problems, is covered with bruises.
The coroner then requests the contracted forensic pathologist to perform an autopsy. The forensic pathologist, the coroner, and the autopsy assistant are present for the five-hour autopsy. Subsequently, the District Attorney’s Office asks the coroner to view security camera footage, obtained through a search warrant, from the home where the woman was found dead. It shows the boyfriend physically assaulting the woman on multiple occasions, including hours of beatings the night of her death.
The coroner enters the cause of death on the death certificate exactly as written on the forensic pathologist’s autopsy report. Based on the entirety of the evidence available to them (autopsy, toxicology, and video), the coroner and pathologist agreed that the manner of death was homicide. The District Attorney’s Office then charges the boyfriend, already in prison on lesser charges, with murder.
The murder trial
The District Attorney’s Office sent subpoenas to five people from the Coroner’s Office: the coroner at the time of the death, the coroner who signed the death certificate two months later, the deputy coroner, the autopsy assistant, and the forensic pathologist. In addition, the prosecution issued a subpoena to a forensic toxicologist from the forensic laboratory contracted by the coroner’s office. In the end, the prosecution elected to call only the deputy coroner, the forensic pathologist, and the toxicologist to the witness stand.
The deputy coroner is a “fact witness.” She describes the body of the victim as she first saw it, the information she obtained from the police, and the procedures she followed in examining and photographing the body.
The forensic pathologist is an “expert witness.” He testifies for approximately four hours, showing photographs and detailing the physical findings documented in the autopsy report. Using metaphors and lay language, the forensic pathologist interprets the impact of those physical findings for the jury. In so doing, he is giving his expert opinion on how the injuries caused the death. Finally, the prosecutor also asks his opinion of the manner of death. “Homicide,” he says.
The jury finds the defendant guilty of murder in the first degree after barely two hours of deliberation.
Policies, procedures, training: the role of the coroner behind the scenes
Sometimes the coroner is in the courtroom as a witness, but most often it’s the forensic pathologist who performed the autopsy. Someone attending a murder trial like the one described would not know about the background work done by the coroner. That invisible effort is essential to a credible and effective death investigation office.
Hiring and Training
The coroner is responsible for the most important evidence in a murder trial—the body of the victim. The coroner hired, trained, and supervised the deputy coroner who went to this death scene. If that deputy coroner had been unreliable, incompetent, or simply lacking death investigation expertise, she could have jeopardized the case from the start (she did not).
The coroner hired the forensic pathologist who did the autopsy and who eventually testified at the trial. The coroner must ensure these essential medical professionals are properly licensed, board-certified or eligible in forensic pathology, insured, and reputable. If the office seeks accreditation, it must track the number of autopsies its forensic pathologists perform annually and must require autopsy reports to be completed according to established standards and in a timely manner.
Written Policies and Procedures
Seemingly boring administrative tasks matter. Take the need for proper identification and storage of a dead body. It’s surprising that defense attorneys rarely question the issue of chain of custody or handling of a body or toxicological specimens from that body. The scandal at the Harvard Medical School morgue and elsewhere makes it obvious that malfeasance can and does occur in places where bodies are stored.
An accredited coroner’s office is required to have written and up-to-date policies and procedures in place. All coroners’ offices, whether accredited or not, should have these. Unfortunately, many do not. To be fair, neither do some medical examiners’ offices. Written policies should cover key processes like proper identification of the body, handling and storage of the body and retained specimens, and a description of which cases need autopsies.
I’ve rarely heard a prosecutor or defense attorney delve into the accreditation status of a coroner’s office or ask to review the policies they have in place. I suggest those may be relevant factors in criminal cases.
What can go wrong?
Consider the death investigation of Tamara Daybell, a 49-year-old previously healthy woman found dead in bed at her home in Fremont County, Idaho. The elected coroner and her appointed deputy coroner believed the information provided by the husband at the scene. Based on that, the coroner signed the case out as a natural death and did not order an autopsy.
Both the coroner and deputy coroner were part-time, had less than a year’s experience in death investigation, and had gone to no more than 25 deaths between them. It’s safe to assume this coroner’s office was not accredited and had no written policy on autopsies at the time of Tamara’s death.
After other murders were linked to the husband, a district attorney and medical examiner in Utah exhumed Tamara Daybell’s body. A forensic pathologist in that state conducted an autopsy and determined someone had asphyxiated Tamara, likely while forcibly restraining her. The husband’s murder trial is currently scheduled to begin in April 2024.
In murder cases, justice depends on the integrity, competence, and independence of the coroner (or medical examiner). All three qualities matter. In many jurisdictions it’s up to the voters to decide who’s going to be their coroner, assuming anyone wants the job, given its many challenges. In 2022, the citizens of Fremont County, Idaho, re-elected the coroner who handled this case.
What’s the role of the coroner in court if there’s no autopsy?
Deaths don’t always look “suspicious” at first. That’s why many coroners follow the rule that “all deaths are homicides until proven otherwise.” Still, some coroners’ offices, often for budget reasons, don’t do as many autopsies as they should. The Fremont County, Idaho, office, for example, had a total budget of $37,000 in 2020. If Tamara Daybell’s body had been cremated, as so many are, there would be no evidence, no murder trial, and no justice for the victim.
The shortage of forensic pathologists is as problematic for our justice system as the skimpy budgets of coroners’ offices. The state of Wyoming, for example, had no forensic pathologist approximately one year ago. Its coroners were (and maybe still are) transporting bodies needing autopsies to out-of-state facilities. That is probably one reason that fewer than 10% of coroner cases in Wyoming had an autopsy in 2021.
Jurisdictions with limited access to autopsies are particularly in need of more experienced medicolegal death investigators and physician-coroners, because they don’t have the expertise of a forensic pathologist to call on. The places that lack forensic pathologists, however, are also likely to lack physician-coroners or adequately trained and experienced death investigators.
The Role of the Coroner in Court: Part 2
Next month’s post will focus on the importance of an independent coroner’s office.