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The Daunting Task of Strengthening Medical Examiner and Coroner Investigations Across Hundreds of Jurisdictions

After a five-year fact-finding mission, a multi-agency working group has identified a host of problems in the U.S. medical examiner/coroner system, but solutions remain elusive.
Date Published
April 24, 2024

Perhaps it started in 1976 when actor Jack Klugman first appeared on TV screens across the nation in “Quincy, M.E.,” a first-of-its kind show that critics described as, “the cases of a brilliant, if irascible, coroner who investigates suspicious deaths that usually suggest murder.” “Quincy, M.E.” was a hit and began a years-long parade of death investigation-as-entertainment shows that have included everything from “CSI: Crime Scene Investigation” to “Forensic Files.”

Yet as these types of shows continue to garner high ratings, the real-life sleuths — currently between 5,000 and 8,000 death investigators working in more than 2,000 medical examiner and coroner offices across the country — struggle with chronic shortages in funding, a lack of forensic pathologists and technical staff, outdated equipment, and inconsistently implemented standards from jurisdiction to jurisdiction.

Federal efforts to improve the medical examiner and coroner systems, collectively referred to as the medicolegal death investigation system, have been ongoing for more than a decade. But these federal solutions have proven difficult to even identify because the offices are local and, depending on the location, under the control of states, counties, or cities. Improving the system is made more challenging because many coroners are elected and may not be required to be medical professionals. Medical examiners, by contrast, are physicians who specialize in pathology and are typically appointed to direct the system or organization in their jurisdiction.

In 2013, federal efforts to improve the system began in earnest with the National Commission on Forensic Science, a joint effort between the Department of Justice and the National Institute of Standards and Technology, to “enhance the practice and improve the reliability of forensic science.” The commission highlighted the need for more consistent and reliable data from medical examiners and coroners.

A follow-on report by the National Science and Technology Council in 2016, Strengthening the Medicolegal-Death-Investigation System, focused on improving data and reporting systems, and a report by the council later that year explored how to improve accreditation and certification of coroners and medical examiners.

Jonathan McGrath, a former senior policy analyst with the National Institute of Justice (NIJ), observed the growing concern over the medicolegal death investigation system. He joined with forensic policy experts in 2017 to synchronize federal efforts to strengthen medicolegal death investigation practices nationwide.

“We knew what the community needed, and we knew we could accomplish big things at the federal level,” said McGrath, now an advisor with U.S. Customs and Border Protection. “We put our heads together and communicated with our federal counterparts everything that was going on in medicolegal investigations so we could identify ways we could better contribute individually and collectively to improve the quality of what happens at the state and local level.”

The discussions led to the creation of the Medicolegal Death Investigation Working Group, a joint effort led by NIJ and the Centers for Disease Control and Prevention (CDC) that has been striving to improve medicolegal investigations nationwide since 2018. Other federal partners in the group include the National Transportation Safety Board, Drug Enforcement Administration, and the Consumer Product Safety Commission.

“There has been a movement from within the federal government to solve medicolegal death investigation issues,” said Lucas Zarwell, co-chair of the working group and director of NIJ’s Office of Investigative and Forensic Sciences. The working group, with about 30 members, “is a federal interagency group to exchange information about what we know about what’s going on in the field in terms of resources and research, to coordinate agency programs, and strengthen the system overall.” 

A key issue is sharing data, Zarwell said, and that underscores the difficulties of gathering comprehensive information. “If you think about particular mortality systems, you realize the CDC is concerned with public health data, such as drug overdose data, while the criminal justice system might want firearms and violence data. The Veteran’s Administration is interested in suicides, while Customs and Border Protection wants to know how many people die trying to cross the border.” 

To deal with the data issue, the NIJ-funded Forensic Technology Center of Excellence formed a related working group with the CDC’s National Center for Health Statistics to study how to classify illicit drugs, particularly emerging drugs. The group also wanted to study how best to exchange investigative and mortality data between public health and safety systems such as prescription drug monitoring and overdose mapping programs. Much of the work to identify the composition of new drugs appearing on the streets is done by NPS Discovery, an NIJ-supported organization that specializes in rapidly identifying emerging illicit drugs and alerting health and law enforcement officials in affected areas.

The CDC’s Collaborating Office for Medical Examiners and Coroners (COMEC) is another new effort to bring together information from the thousands of medicolegal death investigators across the country. Established in 2022 as a result of CDC’s discussions spurred by the Medicolegal Death Investigation Working Group, COMEC uses CDC resources to support medical examiners and coroners in investigating everything from drug overdoses to sudden unexpected infant deaths.

A key difficulty in trying to set standards of practice across medicolegal death investigation systems is the many different ways such investigations are conducted, Zarwell said. He noted that in big cities, such as New York or the District of Columbia, “you have medical examiner systems, and their mortality findings are very different than in rural states or other small jurisdictions.” According to Zarwell, it is possible that a funeral home director or someone with no medical experience may be determining the cause of death in small jurisdictions, and they may not have the skills or resources to conduct forensic autopsies. “So, if they discover a decedent with a syringe nearby, it might be ruled an overdose just based on the circumstances,” he said. No further testing is completed because of the lack of funds to pay for the toxicology testing. “They may not contract out an autopsy because they can’t afford that either,” he said. In addition, some under-resourced offices do not keep electronic records of their work, making it difficult for them to share files and keep the national mortality statistics accurate and up to date.

Zarwell contrasted that with the County of Los Angeles Medical Examiner-Coroner’s Office where, according to their website, they investigate the “circumstances, manner, and cause of all sudden, violent, or unusual deaths.” “There are different levels of training, resources, and different governmental structures,” Zarwell said. “There are states with their different needs, and then there are the national needs [for comprehensive and consistent data].”

He noted that the alarming rise in the national mortality rate is an impediment to improving the medicolegal investigation system. Zarwell cited the increase in deaths from the opioid crisis, the COVID-19 pandemic, and firearms-related deaths, particularly among children. He pointed out that with accurate and timely data, the medicolegal system can better anticipate both the volume and types of cases it must deal with.

Improving the system is not just a matter of money. He noted, “The federal government can never just write a blank check and say, ‘let’s improve the system.’ It’s always more complicated and challenging because, again, state and local jurisdictions have diverse needs and improving the quality of these services relies on many moving parts, including developing and retaining a qualified workforce and building robust facilities and infrastructure.” 

McGrath observed that the Paul Coverdell Forensic Science Improvement Grants, administered by the Bureau of Justice Assistance, are used to increase the quality of forensic science services by allowing state and local governments to address personnel, accreditation, education, certification, and training needs. Grants under the program, funded at $35 million in 2023, also allow for the purchase of new equipment.

For the past five years, McGrath said, the Medicolegal Death Investigation Working Group has been on a fact-finding mission: pulling together data, identifying gaps and weaknesses in the system, and creating a network of medicolegal people to identify and address problems. “We now know so much more about what the needs are in the medicolegal death investigation community,” he said. “NIJ captured that knowledge when it published a review that was reported to Congress in 2019

Date Published: April 24, 2024