The Evolution of the Coroner System: Examining the History of Death Investigations

Every year, roughly 10% of the US population passes away – which is a startling figure. A majority of those will die of natural causes, meaning they died of something as simple as old age or succumbed to a disease of some kind. But historically, 20% of deaths occurs in a way that is deemed “unnatural” and require an investigation to determine how that person died. Today, that means that before the body is released to the funeral home, it is going to make a visit to either the coroner or medical examiner’s office – depending on the jurisdiction – and it will undergo an autopsy by an experienced forensic pathologist who will scientifically determine the decedent’s manner, cause, and mechanism of death.

Death investigations have existed around the world for centuries, but the truly scientific approach to death investigations currently practiced is relatively new; this is due to the fact that there were not enough physicians trained in what is now known as legal or forensic medicine. The first medical school to teach legal medicine was Harvard, and active instruction in the discipline did not begin until 1938.

The coroner system has its origins in Medieval England, where a coroner was a royal judicial representative, and their primary duty was to collect money that was due to the monarchy. Usually, this was through the collection of taxes and fees. But if someone died in a way that was deemed “sudden or unnatural,” the coroner was called upon to investigate the death and determine whether it was a murder or a suicide. At this time in history, both murder and suicide were considered crimes against the crown. If a death was determined to be a murder, the murderer would be executed or imprisoned, and all their possessions would be forfeited to the crown. In case of suicide, all the deceased’s possessions would be forfeited to the crown.

The coroner performing these death investigations in Medieval England – through the colonial period when the coroner system was brought to North America – was not typically a trained medical professional. Investigations into unnatural deaths were not scientifically based, but they were required to observe the body of the deceased and hold an inquest. The coroner would bring together a jury of 10 to 12 men for the inquest. Most of these men were illiterate and knew the deceased, and some may have even witnessed the death they were called upon to investigate. The coroner and the jury would examine the body for signs of violence, note the presence of any wounds, and render a verdict regarding to the nature of the death by holding a vote. If it was decided that the decedent had been murdered, the inquest jury and coroner were required to name the killer, charge and arrest the accused, then bring them to the sheriff to await trial.  In some jurisdictions, the coroner and sheriff were the same person.

For nearly three centuries in early America, the methodology behind death investigations remained unchanged. Coroners were laypersons who had jurisdiction in a particular county or city and a person’s appointment to the position was inherently political. Sometimes the coroner was a sheriff or justice of the peace, but they could also be local woodworkers or farmers, and often it was the local undertaker who served as the coroner. Even as medical science began to progress, it was not required for a coroner to have medical training. If the individual in the position was in the good graces of the people in his community, he could remain the coroner almost indefinitely. The position was also prime for corruption—it was easy for a coroner to send a body to a particular undertaker who was willing to pay him more, and with investigations occurring at the coroner’s discretion, with the help of inquest jurors who were paid by the case, some early coroners found themselves with a key to the community chest and some sticky fingers.

The first law in the United States that required a medically-trained physician to participate in a death investigation was passed in Maryland in 1860. Eight years later, a physician coroner—which is a coroner with medical training, rather than a lay coroner with no medical training—was appointed in Baltimore County. In 1877, Massachusetts made history when it replaced the lay coroner’s office with a Medical Examiner—the first of its kind.

The office of the Medical Examiner emphasized the importance of forensic medicine in investigating unnatural deaths, especially unnatural deaths that were seemingly violent. At the time, most doctors were not taught much about death in medical school; after all, the patients they were going to be treating would, presumably, be living. The change in Massachusetts caused Harvard’s medical school to re-evaluate its offerings and begin hosting lectures by doctors specializing in forensic and legal medicine to teach the newest generation of doctors how to diagnose cause and manner of death. And while the medical school would not have a formal department of legal medicine until 1931, the topic had been part of its curriculum in the past and that curriculum was greatly shaped by the Boston Medical Examiner’s office.

This early office of the medical examiner sought to take death investigation in a more clinical direction, allowing the practice to evolve and match the state of modern medicine. The State of New York went on to revolutionize the role of the Medical Examiner even further and introduce a greater emphasis on the importance of forensic toxicology in death investigations. The New York City chief medical examiner’s office was established in 1918, and the legislation that created it required that the chief medical examiner be an expert physician in legal medicine to be chosen by a civil service exam rather than an election. The appointment of a medical examiner based on their expertise meant that the medical examiner did not need to gain the favor of the constituents in their jurisdiction to keep their position. In this way, the medical examiner took the politics out of death investigations, allowing for the medical examiner’s only duty to lie with the decedent.

To this day in the United States, the death investigation system is not universal. There is what many would call a “patchwork” system for death investigations that can vary from state to state and even from county to county. Some states continue to have coroners, while others have medical examiners. In many states that have coroners, the individual holding the office is not required to be a physician. The exceptions to this include coroners in Kansas, Louisiana, North Dakota, and Ohio . In these jurisdictions, if an autopsy is warranted, a pathologist or forensic pathologist will be consulted by the coroner. Additionally, many of these coroners are in elected positions, meaning that the public in their jurisdiction still votes them into office.

States with medical examiners typically appoint someone to that office and they are often required to be physicians. However, not every jurisdiction that has a medical examiner requires that physician to be specialized in pathology or forensic pathology. Also, the jurisdiction a medical examiner’s office is responsible for is not uniform from state to state. Some states have a centralized state medical examiner’s office, while others have medical examiners in each county, or districts that are made up of a collective of counties. Some states like Texas and California have both medical examiners and coroners depending on where you are in the state.

Additionally, the terminology that is used in the field of death investigations varies from state to state. In some states, like Michigan, the term “medical examiner” describes a physician appointed to the position, but they may not actually perform autopsies. In Kentucky, the terms “medical examiner” and “forensic pathologist” are interchangeable.

The debate over whether coroner or medical examiner systems are preferrable has been continuing since the 1870s when Massachusetts created the first medical examiner’s office. Questions about preferred training for individuals in both coroner and medical examiner systems are greatly debated, and organizations like the National Association of Medical Examiners (NAME) and American Academy of Forensic Sciences (AAFS) are at the forefront of nationwide advocacy to promote education, training, and funding for death investigation systems throughout the United States. It has been historically recognized by many jurisdictions that the major obstacles in the way of replacing coroner systems with medical examiner systems often come down to a lack of resources such as legislative limitations, geography, funding, and ultimately, manpower.

At the end of the day, death investigations in the United States have come a long way from the coroner system of Medieval England and the colonial period. Historically, the evolution of death investigation moves at a languid pace, but the professionalism shown by both modern coroners and medical examiners helps to serve those who die of unexpected circumstances and the loved ones that they have left behind.