Thu June 14, 2012
Coroners: Inside The Lives Of Death Investigators
Originally published on Thu June 14, 2012 1:29 pm
NEAL CONAN, HOST:
This is TALK OF THE NATION. I'm Neal Conan in Washington. After 32 years, the mystery has been solved. A coroner in the fourth inquest into the death of an Australian couple's baby declared the dingo did in fact take the baby. You know a bit about the case if you saw the Meryl Streep movie "Cry in the Dark."
The murder conviction of the baby's mother was overturned after she served three years in prison, yet previous examinations were unable to reach a conclusion on the cause of the baby's death. Public officials have the responsibility to establish the cause and manner of every death. They're called coroners, medical examiners or forensic pathologists.
In recent years, new technology has allowed investigators to re-examine some old cases and sometimes answer lingering questions. We want to hear from coroners, medical examiners and forensic pathologists today: What don't we understand about your job? Give us a call, 800-989-8255. Email us, firstname.lastname@example.org. You can also join the conversation on our website. Go to npr.org.
Later in the program, Ben Zimmer on dictionaries and the evolution of the definition of marriage. But first, John Kades joins us from our studios at NPR West in Culver City, California. He's captain with the Los Angeles County Coroner's Office, where he's in charge of the Operations Division. And it's good of you to come in today.
JOHN KADES: Good morning.
CONAN: And I know you're a long way from Australia's Northern Territories, but do you know how the coroner there reached a definitive conclusion after all these years?
KADES: No I do not. I'm not familiar with that case.
CONAN: Not at all. So is it common, four inquests? Four inquests, is that unusual?
KADES: Well, the inquest system is something that is not really used that much in the United States, much more prevalent in Australia and in England. But inquests are something you don't normally see in the United States.
CONAN: The responsibilities for death investigators differ, of course, not just from country to country but in this country from state to state. In L.A. County as a coroner, what are you and your colleagues responsible for?
KADES: Well, we're responsible for investigating the cause and manner of any sudden unexpected or unnatural death that occurs in our jurisdiction. In Los Angeles County, of a population of about 10 million, every year we can expect to see about 60,000 of us die. Whether we like it or not, that's a statistical imperative. And any of the deaths that are sudden, unexpected or unnatural are reported to us, and those are primarily your cases of homicide, suicide, drug overdose, traffic accidents.
And we also investigate any death occurring from apparent natural causes where there is no doctor in attendance. Those are cases where people pass away. If they haven't seen a doctor within the past 20 days, and there's no doctor to sign their death certificate, they are referred to us, and we will perform an investigation.
And that can include autopsies and scene investigation, toxicology and other testing. And ultimately at the end of the day, what we're trying to figure out is the cause and manner of death, and we want to come to an informed medical opinion as to what that is.
CONAN: And obviously the circumstances of each death will determine how many of those tests and procedures you perform.
KADES: Exactly. We don't necessarily have to do an autopsy on every case that's reported to us, but we will, you know, look at the scene and the circumstances. We work with all the local law enforcement agencies to collect evidence and gather information so that we can ultimately speak intelligently about the cause and manner of death.
CONAN: And obviously there's a great concern. Of course there are - there's a homicide, well, there's issues there, but families are involved, too.
KADES: That's correct. You know, when a death occurs, it's very traumatic for family members and friends, and if the death happens to be sudden, unexpected or unnatural, that just obviously can really compound the family's loss and their emotions. And, you know, we're very mindful of that when we conduct our investigations because ultimately what a coroner or medical examiner is doing is being an advocate for the dead.
Because they can't speak for themselves anymore, we are their champion, and we want to find out exactly what happened and ultimately convey that information to the families so that hopefully they'll have some closure.
CONAN: And can you give us a description of what you actually do if a body is found, and the police call and say we've got something suspicious here?
KADES: Well, the field investigators for a coroner's office are responsible for responding to a scene where a death has occurred, and we work very closely with law enforcement. And I try and describe my job to the public similar to what a paramedic does or how a paramedic system functions.
Everybody seems to know what a paramedic is and what they do. And a paramedic has a very close working relationship with a doctor in an emergency room, who will ultimately - you know, the paramedic will transport to an emergency room for a higher level of care, and the paramedic is the hands, eyes and ears of the doctor.
I have a similar relationship with the doctor, who happens to be a medical examiner who will ultimately do an autopsy on a person. I am the hands, eyes and ears of the pathologist in the field, gathering evidence, collecting information, interviewing witnesses and directing the transportation of the body to coroner's office.
CONAN: Let's bring another voice into the conversation. Joining us now from member station WCVE in Richmond is Dr. Marcella Fierro, retired chief medical examiner for the state of Virginia, a post she held for 14 years, and it's good to speak with you again.
MARCELLA FIERRO: Nice to be here.
CONAN: And as you just heard John Kades described his duties, I assume that's pretty similar to what people do in Virginia, as well.
FIERRO: Yes, we have medical investigators who go to the scenes of death, who assess the scene, look and see what the relationship is of the body to these - its surroundings, look for evidence of medications that could be either under-taken or over-taken, and look for evidence that might suggest the death is something other than a natural death or if it is clearly an unnatural death safeguard that evidence that's related to the body.
CONAN: What is it, do you think, that most of us don't understand about what you do?
FIERRO: Well, I think there's confusion in this country because there's confusion about systems, whether or not we have competency in training at the level of, say, the scene of death and then the levels of competency at the level of the examination of the body and then at the level of certification, which is the documentation of the cause and manner of death.
Determining the cause and manner of death is the major mission of both coroners and medical examiners. In each state, and sometimes even within a state, in the different counties, there are different types of systems, and that I think leads to confusion as to who does what.
CONAN: John Kades, I assume Los Angeles County being so populous and large, that seems to be one big system there.
KADES: Yes, it is a big system.
CONAN: And as you deal with - do the other neighboring counties do it the same way? Is it standard in the state of California?
KADES: Well, it's done a little differently as you go from jurisdiction to jurisdiction. And in the state of California, you have 58 counties. And the vast majority of those counties are sheriff coroner counties, where the sheriff is also the coroner for that county, and that's because that county boards of supervisors decided once upon a time that the coroner would also be the sheriff.
Six of the counties in California are coroner counties, like Los Angeles. And the system when you look at it, the question is it a coroner county or a sheriff coroner county or a medical examiner county, what you're saying is, well, who is the ultimate shot-caller at the end of the day to say what the cause and manner of death is. Do you want that to be a medical examiner who is a doctor? Do you want that to be a coroner? Or do you want that to be the sheriff for that county?
CONAN: So obviously they all have different training and different specialties.
KADES: Well, the training and specialties are pretty uniform and across the board. The duties, the responsibilities, the job description is pretty much the same. We're all responsible for investigating the cause and manner of any sudden, unexpected or unnatural death.
But as you go from jurisdiction to jurisdiction, it's handled a little differently, but the laws of the state of California apply equally to all jurisdictions, and there's actually more similarity as you go across the United States from jurisdiction to jurisdiction.
CONAN: Dr. Fierro, would you agree? Were there standards in - was it a standard system in Virginia?
FIERRO: Well, there's a standard system in Virginia because it's a statewide system. But I think the differences are the qualifications of the people who are making the decision on the cause of death. And the question then becomes: What are the competencies that are required to make a medical determination of a cause of death, cause of death being the disease, the injury or poison that has accounted for the death of the person?
And that requires specific medical training. That may or may not be present depending on the jurisdiction where the death occurred. The higher the level of training you have to make medical determinations, to sort out medical mysteries, to carry out examinations that will reveal those medical causes of death, generally the better off you are.
Ultimately, as previously said, there is somebody who is responsible for actually preparing a document called the certificate of death that assigns the cause of death and the manner of death. And I think what you want is you want the highest level of competency making a medical decision.
CONAN: When you say poison, I assume that would include drug overdoses and drug combinations?
FIERRO: It would include any substance, which if ingested or inhaled or received say through the skin could account for a bad effect upon the body that would actually poison. So it could be a drug. It could be a street drug. It could be an environmental toxin. It could be a prescription.
CONAN: And that is, I've read, has become an increasing problem.
FIERRO: It is because there are - especially with the analgesics, the painkillers, they seem to be rising in their incidence of causing death. We've had in Virginia large numbers of death due to some opioids that previously were not on the market, say, 20 years ago. And these are prescription medications. People overdose on them accidentally, and they also of course overdose on them when they specifically to overdose. And they seem to make their way to the street so that people overdose on them in a drug abuse setting.
These opioids are an increasing problem.
CONAN: We want to hear today from coroners, medical examiners and forensic pathologists. What don't we understand about your job? Give us a call, 800-989-8255. Email us, email@example.com. Stay with us. I'm Neal Conan. Our guests are John Kades, captain with the Los Angeles County Coroner's Office; and Dr. Marcella Fierro, retired chief medical examiner for the state of Virginia. It's the TALK OF THE NATION from NPR News.
(SOUNDBITE OF MUSIC)
CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan. TV dramas like "Bones" and "CSI" show us the fictional side of death investigations. Today we're talking about the real thing, the people who determine the cause of death, whether it's a stab wound or a heart attack, and we want to hear from coroners, medical examiners and forensic pathologists. What don't we understand about your job?
Give us a call, 800-989-8255. Email us, firstname.lastname@example.org. Our guests are John Kades, a captain with the Los Angeles County Coroner's Office - he runs the Operations Division there; and Dr. Marcella Fierro, she retired in 2008 as chief medical examiner for the state of Virginia.
Just mentioning those TV shows - here's an email from Ken in Fair Oaks, California: They don't have all the equipment you see on "CSI," and all tests are not as accurate and dependable as shown on TV. And well, John Kades, I know we've had prosecutors come on and complain about the "CSI" effect, where juries are expecting all of these fancy tests. I assume that affects your job too.
KADES: Absolutely. These television shows that are very popular now unfortunately give the public a misconception of what it is we can and can't do in the real world. And because these television shows are so popular, and they're always showing successful cases, the level of expectation of the public now is that we will be successful and we will answer all their questions, and they have a high expectation that a case will end in a conviction, and all questions will be answered.
And unfortunately, that's - you know, that's not the reality. My counterparts at the Clark County Coroner's Office in Las Vegas, which is the "CSI" television show...
CONAN: Where "CSI" is set, yes.
KADES: Yes, they are quick to remind the world that the operating budget for one episode of "CSI" far exceeds the real annual operations budget for the real Clark County Coroner's Office. So when you've got that kind of money being used on a television show, they can sure make it look really good.
CONAN: Let's see if we can get a caller in on a conversation. We'll start with Adele(ph), Adele with us from Nashville.
ADELE: Hi, yeah, I'm a medical examiner and a forensic pathologist here in Nashville, Tennessee. And one of the main things that I run into in my practice is that people don't really understand the difference between what is a coroner and what is a medical examiner.
And in general, a coroner is a person who needs to be 18 or 21 years old and have a GED, and in many jurisdictions they don't require any specialized training at all for a person to be a coroner. So that person is elected, and they may be more beholden to the electorate than they may be to the decedent.
I've run into problems where the child of a prominent family in a given jurisdiction turns up deceased under suspicious circumstances, and the coroner, because of that family's political prominence, decides not to order an autopsy and decides not to investigate that death. A medical examiner, on the other hand - and again, this is very generally speaking, and it depends from jurisdiction to jurisdiction - but a medical examiner is a person who goes to four years of college, has a Bachelor's degree, goes to four years of medical school, and then does at leave five years of extra training after that in order to become a forensic pathologist.
So the distinction is very large between a coroner and a medical examiner, and about 50 percent of the population of the United States is served by coroners and about 50 percent by medical examiners.
CONAN: Let me ask you, Adele, after all of that training, why did you decide to go into - become a medical examiner, forensic pathologist, and work for public money?
ADELE: You know, it's funny that you ask me that. Even - I did even more training than that. I started out training as a general surgeon and actually did a general surgery residency and a trauma surgery fellowship before I decided to go into pathology and forensic pathology.
It's a really fascinating field to be in. You're right, the pay is not nearly as good as being a private practice or a hospital pathologist, but it's absolutely fascinating and very satisfying to be able to give families and law enforcement some answers into what caused the death or injuries of their loved ones.
CONAN: Dr. Fierro, would you agree?
FIERRO: Oh, yes, I think the idea of the medical mystery is what appealed to me. And if you have a strong sense of justice, you would like the truth to be told. So solving a medical mystery, telling the truth about what happened to the patient is a very satisfying exercise. In all my years, I think most days I could say I actually had an eight or a nine day, you know, if I scored it on a score from one to 10.
There were a couple of ones in there, but most of them were nine or 10, and it's the medical mystery. It's sorting out what actually happened to the person. What does this mean? The dead person speaks to you in a special way, through the physical exam, through the autopsy, through the clinical testing, through the toxicology.
They tell you their story just as dramatically as if they were alive.
CONAN: John Kades, you're not coming to it from the medical side, but you had some decisions to make too, I'm sure.
KADES: Yeah, to - I got into the coroner business, if you will, because I was fascinated by the science and by the, you know, by the classic mystery and the challenges that you face. And you are - as I said before, you are an advocate for the dead now. You're the person who has to gather that information and solve that mystery, and there's something very personally satisfying about being engaged in that type of a career.
And for myself and I think most of the people who work with me, there's something about doing a job where others take a look at it and say, boy, I could - I could never do your job, and I wouldn't want to do your job, and that's something that you can take a lot of pride in.
FIERRO: And I think what's important to notice about this whole business is that - excuse me.
FIERRO: Is that you're figuring out the medical aspect of it. The forensic pathologist, the medical examiner, the coroner, we're not policemen, OK? What we're interested in doing here is bringing the body of knowledge of medicine to apply to the problem of why did this person die. The courts, the police, the attorneys, they're the ones who figure out who did it. That's not our issue.
Our issue is what happened to this person. Why are they dead? And there's a public health aspect to this too, because we need to know why people die if we're going to properly allocate our resources for prevention, our resources for intervention and our resources for, say, crime-solving too, in the civil and in the criminal courts.
So knowing why people died is the major issue here.
CONAN: Adele, thanks very much for the phone call, appreciate it.
ADELE: Thank you.
CONAN: Here's an email that we have from Kelly(ph) in Fort Myers: If I understood you correctly, if one is not an MD, how in the world can he or she determine the cause of death? Does that not put the accused at risk in a trial? And John Kades, you point out you're the eyes and ears for the pathologist.
KADES: That's correct. In Los Angeles County, the deputy coroners, who act as the investigators, do so under the direction of our chief medical examiner, Dr. Lakshmanan, who is also the coroner for the county of Los Angeles. By California state law, a coroner does not have to be a doctor, but here in Los Angeles he just happens to be.
So when I sign a death certificate, or one of my investigators signs a death certificate, it's because a board-certified forensic pathologist, a deputy medical examiner, has, you know, has taken a look at the case and provided all that information based on the totality of the circumstances and the evidence we've gathered, and that's how we close a case.
FIERRO: I think that's a real question: How can somebody without a serious medical credential decide how somebody died? I mean, if you consider that death is the ultimate disease, and you wouldn't dream of going to the coroner to figure out what's wrong with you when you're alive, why ever would you go to someone who has no medical credential to figure out why you died?
CONAN: Here's an email from Pascal(ph) in St. Peters, Missouri: Can there be a conflict of interest when the cause of death is not adjudicated by a separate medical unit that is distinct from the sheriff's office? John Kades, is there - does there need to be, should there be independence?
KADES: Generally speaking, there is independence, even in a coroner system or a sheriff coroner county. When a death occurs, you know, all the information is considered. Many sheriff coroner counties, if they have a death under their jurisdiction that might have been, say, at the hands of one of their deputies, or maybe it was an in-custody death where that sheriff, who is also the coroner, is responsible for the jails, they will seek the independent opinion from a medical examiner or a pathologist who may be from another jurisdiction or provides services to that county, or they may, you know, ship that body for an autopsy to the next jurisdiction over.
There's a memorandum of understanding so that they have transparency, and there's no, you know, accusations of a cover-up or any other problem. So that is something that is considered.
CONAN: And - go ahead, I'm sorry.
FIERRO: Ideally, a death investigation system should be independent administratively and financially from law enforcement or from the courts or from the attorney general or anyone else. If it has to report to someone, it should report to a health director.
CONAN: And have there been cases where - well, let me ask you, Dr. Fierro, were you ever stumped?
FIERRO: About one percent of the time we have to admit that we cannot figure out what happened. Either the cause of death is not clear - often this is clear with skeletons. With a skeleton you may not be able to determine a cause of death because there's no tissue left to show any injury. Or we couldn't sort out the manner of death - was the death an accident or was it a suicide - about one percent of the time.
CONAN: And those must be very frustrating.
FIERRO: Very frustrating.
CONAN: And John Kades, the same question to you.
KADES: Yeah, there are cases that do get closed from time to time that are left as undetermined or unknown. Similarly, cases where we may know medically what a person died from, say, a gunshot wound, and we have an overabundance of evidence and information that says, yes, this person died from a gunshot wound - but what was their manner of death? Can we conclusively say that they died at the hands of another, closing the case as a homicide, or was this a self-inflicted wound or an accidental discharge of a firearm?
And even with the best, you know, investigative techniques and application of science and investigation, sometimes we just cannot speak intelligently about the manner of death. So we'll close the case as cause of death gunshot wound, manner of death undetermined, and - because we don't have enough information to hang our hat on one or the other.
But when we leave a case as undetermined, that still leaves the door open for a future investigation, future prosecution. If more information comes forward, more witnesses come forward, then at least we've got - the door is open for a determination or an amendment to the death certificate. So if the coroner or the medical examiner says we don't know what this person died from or what the manner of death is, that leaves the burden on the law enforcement agency investigating that case, that it's still an open case. It hasn't come to a conclusion.
CONAN: John Kades, captain with the Los Angeles County Coroner's Office. He is with us from NPR West in Culver City, California. Also with us, Dr. Marcella Fierro, a retired chief medical examiner for the state of Virginia, with us from WCVE in Richmond. And you're listening to TALK OF THE NATION from NPR News.
And, Dr. Fierro, one thing we do see on all those TV shows is those zippy new machines. How much has technology changed the business?
FIERRO: Well, technology for the forensic pathologist has not changed as much as it has for the forensic scientist. But we still are having new developments I'd say on a yearly basis that are helping us do our job better. The idea of being able to make a molecular diagnosis is helping us with sorting out the various forms of heart disease that resulted in sudden death. We could - we'd be able to establish medically that perhaps the heart was large, but not be able to ascertain with certainty what in this specific large heart caused the death.
But now we know that there are some diseases only manifest at the - only identifiable at the molecular level. So great roads are being made in there. We also are aware of - more aware and are able better to develop, say, the chemical bases of some deaths that we previously were not able to do. For example, in infants, some of the metabolic errors that results in sudden death of infants are now known to us that were not known to us, say, 20 years ago. So we've made advances in that way. The use of particular stains, biological stains on the tissue to help us to identify various markers has also helped. So as medicine progresses in general, the tools available to the forensic pathologist improved too.
CONAN: As in - one of the health care issues, of course, is the number of tests and procedures that are now available to doctors who sometimes order them, at least we hear, to avoid the perception that they ignored them, that they were leaving themselves liable, the remote chance that one test or one procedure might come up with something, driving up costs. Is that the same case in - for medical examiners?
FIERRO: I think the cost of an autopsy has increased over the years as we've availed ourselves of modern technologies. As we have availed ourselves of, say, more a complete toxicology, that increases cost. As we avail ourselves of molecular testing, that's still very expensive. And so that has increased cost. The - in order to recruit and retrain - retain forensic pathologists, salaries have had to improve, so that increases costs. But in the main, this increase in cost has been more than matched by improved - improvements in quality.
CONAN: Mm-hmm. And, John Kades, let me ask you a question. You're in charge of the operations division. There have to be calls - yes, we're going to go look at this one. No, we're going to go look at that one.
KADES: Yeah, that's correct. The - we just do not have the resources to, you know, do an autopsy on every single death that occurs within the county of Los Angeles. We have close to 50,000 deaths a year in a population of 10 million, so we have to make a judgment call from time to time as to the circumstances of the death and what is being reported to us.
And certain cases will be closed from time to time without an autopsy where we are basically coming to an informed medical opinion that someone has died from something based on their age and their medical history and the information that was provided to us. And unfortunately we just do not have the resources to always, you know, do a full-court press on every death that occurs. We do the best we can with the information we have and try and provide some closure to the families and give them that diagnosis because when a coroner closes out a case, or a medical examiner closes out a case, they are expressing an informed medical opinion.
And same way that a private physician treating a patient who may pass away from a certain type of disease, their private physician is expressing an informed medical opinion if they were to sign their death certificate. And you can ask the question, well, who is more qualified to speak about the cause of death, the physician who knew the person in life or the coroner or medical examiner who saw them after they died and was only able to perform an autopsy?
CONAN: John Kades, thanks very much for your time today. Appreciate it.
KADES: You're quite welcome.
CONAN: And, Dr. Fierro, nice to talk to you again.
FIERRO: Bye-bye. Transcript provided by NPR, Copyright National Public Radio.