Coroner and Medical Examiner

James Claude Upshaw Downs. Handbook of Death and Dying. Editor: Clifton D Bryant. Volume 2: The Response to Death. Thousand Oaks, CA: Sage Reference, 2003. 

Show me the manner in which a nation cares for its dead and I will measure with mathematical exactness the tender mercies of its people, their respect for the laws of the land, and their loyalty to high ideals. — Sir William Gladstone (quoted in Rostad 2000)

Origins of Death Investigation

The origin of official death investigation is traced to at least 44 B.C. with the Greek Physician Antistius’s examination of Julius Caesar (Fisher 1993; Gawande 2001). The history of the office of coroner extends well over a millennium and has seen major evolution. A British creation, the office carried to other countries under English influence, including the United States where the position was modified, improved, and at least partially supplanted by its own progeny, the office of medical examiner.

The Office of the Coroner


“The office of the coroner is the oldest administrative office evolving from the development of the Anglo-Saxon common law system of government” (Allegheny County Coroner 2003). The coroner originated in the period A.D. 871 to 910 in pre-Norman England and, although likely involving functions later performed by the office, the exact duties at that time are unclear. The first identified coroner was St. John of Beverly in the Chart of Privileges in A.D. 925 (Fisher 1993). The complicated basis of the office of coroner is inextricably tied to the origins of the English legal system. The essence of the office (as some might say of the legal system) is monetary. The development of the medieval British system of justice necessitated the creation of a coroner to keep the king’s financial books in order.

The Eyre and the Origins of Common Law

From its beginnings, civil (also known as common) law has centered on monetary matters. The first laws, dating to circa 3000 B.C., involved property and marriage. The Code of Hammurabi in 2200 B.C. added laws involving injury and trade. Anglo-Saxon feudalism vested rights in the lords, the holders of land (O’Conner 2002) “as a means of consolidating power, feudal lords began requiring that dispute be submitted to a local ‘court’ for settlement” (Unnever 1999). By the Norman conquest in 1066, the ongoing evolution of Britain from a feudal society had resulted in an eight-kingdom territory composed of numerous counties with further subdivisions of the latter into governmentally independent “hundreds” (Unnever 1999) “The English legal system was a complex one, and remained in a continual, and rather chaotic, process of evolution throughout the medieval and early modern period” (Phillips 2000). Under Saxon law, local matters were dealt with in local courts, run by the king’s local agent, the sheriff, who was the ranking authority in the county (Edwards 1906). Problems arose with corruption, and “in 1170, after an ‘inquisition of the realm,’ which was the medieval equivalent of a modern Royal Commission, all the Sheriffs were sacked and many heavily fined for malpractice” (Knight 1999a). By the late 12th century, the central king’s court (curia regis) was composed of the Bench(or Court of Common Pleas) charged with the civil law and the King’s Bench (or coram rege), which handled criminal and certain civil matters. Finally were the eyres (also known as the general eyre or wanderings), which were traveling royal courts covering a defined circuit in an average 7-year span (Unnever 1999). Eyre derives from the latin iter (a journey) and, in the language of the day, referred to “the right of the king (or justices acting in his name) to visit and inspect the holdings of any vassal…. Done periodically, usually at irregular intervals of a few years” (Harbin 2002). The kingdom was divided into six circuits and held an eyre “in each county of the circuit of the justices not more than once every seven years” (Edwards 1906). “This body took so long to return to each county that, unless careful records were kept, many cases never came to trial and much revenue was lost to the crow” (Knight 1999b).

It was the duty of the judges in eyre to insure that the king received his portion of forfeited property from any such offenses [as felony] occurring in the various county and hundred jurisdictions. “Law and order on the national scale were first expressed in terms of revenue.” (Unnever 1999)

The justices in eyre (justiciarii itinerantes or judges in eyre) were basically the equivalent of modern circuit judges and the eyre the equivalent of circuit court. A major difference is that unlike modern circuit courts, which are usually of little de facto public interest, the visits of the eyre were an infrequent occurrence directly affecting the lives of many within the community. As such, the eyre was a tremendously significant event that was treated with much fanfare (Knight 1999a). The eyre functioned with a jury of 12 local residents who determined for the traveling justices in eyre what was the local custom (Brown-Syed 1999). This combination of local input with an overall consistent application of legal doctrine from prior cases (case law) served as the foundation the English system of common law. “The legal rules thus elaborated by the king’s courts were applied by the justices in eyre were-ever their circuits took them, and became in time the common law of England, common because it admitted no local bars and no provincial prejudices” (Pollard 2002).

The office of coroner was formalized in September 1194’s Article 20 of the Articles of Eyre (from the general eyre in the County of Kent), which proclaimed (in toto) that “in every county of the king’s realm shall be elected three knights [coroners] and one clerk, to keep the pleas of the crown” [“crowner” or in Latin custos placitorum coronas, later corrupted to coroner]. “And that [article 20] is the only statutory basis for the Coroner” (Knight 1999a).

King Richard the Lionheart’s ransom from near Vienna and subsequent departure from England forced the de facto head of state, Hubert Walter (the Archbishop of Canterbury), to revive the office in order to generate funds. The county sheriffs (shire-reeves) were known to be corrupt and had “an evil reputation for extortion and embezzlement.” The “new” law enforcement office of crowner attempted to keep in check the sheriffs’ corruption and was, in fact, empowered to arrest the sheriff. To keep the coroner’s office untainted, officeholders were elected by their county’s freemen and had “no need of further wealth” and thus were unpaid and unrewarded public servants. The standards were later (in the 1200s under Kings Edward I and II) relaxed a bit, requiring the crowner to be “knights or of the most meet and lawful men in the country” (Fisher 1993; Knight 1999a). (Thus the crowner began as an untainted steward of the public trust, unsullied by monetary concerns, a far cry from the present day.)


The crowner’s duties were myriad and centered on monetary matters, including those related to deaths. In 1275, the De Officio Coronatis continued the crowner’s protection of crown financial interest in the duty to conduct inquests in cases of the finding of treasure troves. Other fiduciary responsibilities included the scene investigation and valuation of property in nonfatal fires and in whale and sturgeon (royal fish) catches. In fact, on request from the crown, a sheriff, or justices in eyre, the crowner might become involved in any investigation, including determination of sanity in a suicide, commission of a burglary, and the legality of free-roaming livestock (Knight 1999e).

Although not charged with hearing crown pleas, the crowner held the pleas by keeping the records for the justices of the general eyre, who completed their circuit about every 7 years. The crowner held fines (amercements) and sureties (attachments) in all felonies (defined at the time as any capital offense, including theft of 1 shilling or more). The judges in eyre actually determined fines to be paid and if items were to be forfeit to the king. The primary function of the crowner was death investigation, including murder, manslaughter, accidents, suicides, and natural fatalities. The crowner’s record-keeping duties were of paramount importance, particularly noting all the parties involved (witnesses, residents, etc.) and property in question (goods and chattel). These were important, for if the complex and arduous rules were not followed explicitly, fines would be levied on individuals and communities (Knight 1999b).

Residents avoided the bodies of the dead for fear of personal financial loss through amercements. The unfortunate “first finder” of the body had to raise “the hue-and-cry” forcing immediate neighbors to join in the search for a possibly nonexistent murderer. The residents had to protect the body at the scene until such time as the coroner arrived (which might be a week or longer). “The burying of stinking bodies before the arrival of the Coroner” was illegal and could be severely amerced. As a result, the populace was disinclined to assist with death investigation (Knight 1999b). (This, it could be argued, laid the foundation for the present lack of public funding support for the office.)


A hearing or inquest could be convened by the crowner in any case before the office. The crowner’s inquest originally required a jury composed of “all males over the age of twelve years from the four nearest townships,” but in 1259 this was reduced to a “sufficient” number and eventually to 1 or 2 dozen town representatives. The attendance of the masses (including potential witnesses) ensured the best possibility that information would be forthcoming at the hearing. The individual verdicts rendered by the populace of each of the four townships did not matter to the crowner, who recorded the results for the eyre, where the matters were settled. In addition, the body was required either to be present at the inquest or to be viewed by the jurors prior to same. Old traditions die hard; as recently as 1961, skeletal remains were produced in court in Wales (Knight 1999c). (The author has presented into evidence portions of human skull in a capitol murder case in the United States within the past decade.)

Fines and Fees

The Normans continued the Dutch law of murder (lex murdrorum), which imposed a murdrum fine on the locals for their deaths. Eventually, by the 13th century, this included even accidental and natural sudden, unexpected deaths. In the 12th to 14th centuries, the inquest was charged with “Presentment of Englishry” based on the Norman conquerors’ policy that anyone found dead was assumed to be Norman, unless proved otherwise by the deceased’s relatives’ testimony. The community was penalized for Norman deaths, but not necessarily for those of their own. (Thus a stigma of family’s adversary was attached to the function of the office). Clearly, the residents also had incentive to not become involved in death investigation because it might prove costly, and thus they would be motivated to remove or bury any stray bodies. It took the death of some 20,000 Britons in the famine of 1257-58 to eliminate the need for the crowner’s inquest and viewing of the body before burial. In 1259, the murdrum fine was limited to felony deaths, and in 1340, the fine was eliminated (Knight 1999c).

In addition to fines, the crowner made certain that properties were seized. The basis for forfeiture of goods was religious. Only by the act of Deo damdum (giving to God) could an object causing death (such as the murder weapon) be purified. In the middle ages, the church’s role became that of the crown. Anything imaginable, including livestock and vehicles (even steamships and locomotives), might be declared responsible for the death (the deodand) and held for the next eyre where it was subject to forfeiture the crown or possibly the victim’s family. This practice continued unabated until its cessation in 1846 (Knight 1999c).

Miscellaneous Duties

Religion and the crowner also intersected in sanctuary, whereby a suspect could claim the right to 40 days of safety by reaching church property. Only “some felons, such as habitual robbers and night thieves” were unable to invoke the right to sanctuary (King James I revoked the concept of sanctuary in 1623). After the specified time, the felon was forced to flee, surrender, or abjure the realm. Abjuration required the criminal to confess his felony to the crowner and swear to “leave the realm of England and never return without the express permission” of the king. The crowner gave detailed instructions on how the process was to be carried out and then determined if any properties were to be forfeited to the crown (Knight 1999c).

Among the many other duties, crowners witnessed and recorded a subject’s guilt or innocence through impossibly difficult ordeals. The ordeal of fire required prolonged contact with red-hot metal, with the absence of burns proving innocence. The ordeal of water required complete submersion, with the lack of resurfacing (i.e., drowning) demonstrating innocence. These latter ordeals were abolished in 1215; however, the ordeal of combat continued until 1818. In this trial, the suspect or his hired agent would battle the accuser (Knight 1999c). (Obviously, the impossibility of success would tend to further stigmatize the office.)

The crowner also served as a medicolegal examiner in documentation and detailed description of nonfatal wounds. For example, in rape cases the crowner acted “as a corroborator of the ravishment.” The crowner also interpreted the potential effects of wounds for the court, with potentially fatal wounds resulting in a subject being incarcerated until the next eyre. Sureties (bail) were held by the crowner pending trial in nonfatal cases. The crowner recorded the declarations of subjects who failed to appear at four consecutive county courts as outlaws, who could thus lawfully be killed on sight. In cases where a suspect turned state’s evidence (approver’s appeal), the crowner heard and recorded the confession implicating co-conspirators (Knight 1999d).

Decline of the Office

The Norman-French sitting court (the Assize court) in the late 14th century, combined with the ascent of the office of the justice of the peace, eliminated many of the duties of the crowner. Furthermore, the office lost its aura of wealth while, at the same time, the officers became more corrupt.

In 1483, an Act was passed limiting the Coroner’s involvement with the forfeiture of property….By the 16th century, almost all that he was left with was the investigation of sudden death and even that was done in a desultory manner, there being no real support from the legal system. It became difficult to get men to take on the job of Coroner, as it was such an unrewarding appointment (Knight 1999e). No doubt the many negatives described above played a major role in this situation.

Resurrection in the New World and Advancement in the Old

For the next 4 centuries, the crowner’s office remained stagnant in the United Kingdom; however, the office showed significant maturation with the colonization of America in the early 1600s. The British crowner as it existed at that time came to the New World. The first coroner’s inquest was held in New Plymouth, New England, in 1635. The office of coroner was combined with that of sheriff in the state of Maryland, and although unsalaried, the officeholder (continuing the long tradition of the crowner’s fiduciary trust) was entitled to 10% of his collections of taxes and levies. Medical expertise was first associated with the office of coroner in Maryland in 1860, which required “the attendance of a physician in cases of natural death.” In Britain, the crowner’s office became salaried in 1860 (Fisher 1993). In 1868, Baltimore, Maryland, had a physician appointed as coroner, later termed medical examiner in 1877 (Hanzlick 1998). In England in 1877, the crowner was granted authority to hold inquests in cases of unnatural, violent, or unknown cause of death; in 1888, the position became appointed by the local government. In Boston, Massachusetts, the coroner was replaced by the medical examiner, a physician charged with investigation of deaths by suspected violence. In 1890, Baltimore appointed physician medical examiners to autopsy bodies as requested by the coroner or state’s attorney. The modern medical examiner system began in 1918 (Fisher 1993; Hanzlick 1998), when New York City replaced the coroner with the office of medical examiner charged with the modern duties of investigation of deaths resulting from criminal violence, casualties or suicide, or suddenly while in apparent health, or when not attended by a physician or imprisoned or in any suspicious or unusual manner. The medical examiner was granted the authority to make a decision as to the necessity of an autopsy. (Fisher 1993:7) Minimum British qualifications were first established in 1926 and included “five years experience as a medical practitioner, barrister, or solicitor” (Fisher 1993:5). Harvard Medical School created the subspecialty of forensic pathology in 1937. In 1939, Maryland established the first statewide medical examiner system, although it was not for another 50 years that the office had the powers that had been vested in the New York office (Fisher 1993).

Death Investigation: Coroners and Medical Examiners

The modern terms of coroner and medical examiner are thus inextricably linked and hopelessly overlapped, both in origin and in public perception (Geberth 1990:418). As used by the majority of people in the United States today, the offices are vastly disparate in required minimum qualifications and in duties performed. In general, the coroner is a politician and the medical examiner is a physician. There are differences between states: For example, in California the term coroner may refer to the sheriff, the forensic pathologist, or both; in Mississippi a lay investigator is called a medical examiner; and in many areas, a local physician performing the duties of the coroner may be called a local medical examiner, despite having no special knowledge in the medical practice of death investigation. In any event, the media and public routinely use the terms synonymously.

Correctly defined, and as the term is most often intended, the modern day coroner is an elected official, often requiring no education or specific training in order to be elected. Frequently, the coroner is a funeral home employee, tow truck driver, or possibly a nonforensic pathologist physician. Recently, medical support personnel such as emergency medical technicians and nurses have shown more interest in the office. In many areas, no minimum educational requirements exist; thus the only requirement is a majority of votes. Some locales do require or encourage at least basic education in performing death investigation, and board certification is available for trained lay coroners through the American Board of Medicolegal Death Investigation. The coroner typically serves as the direct interface between families and other investigators. In this capacity, the coroner may act as a gatekeeper, determining when cases falling under the office’s jurisdiction require autopsy. In contrast, the true medical examiner is a physician who has spent 4 years in college, 4 years in medical school, 4 to 5 years in pathology graduate medical education, and 1 year in a forensic pathology fellowship. Preferably, the medical examiner is a licensed physician who is board certified in forensic and anatomic pathology through the American Board of Pathology. The medical examiner’s primary function is to examine, either by record review and consultation, by external examination, or by combined external and internal examination, a deceased’s body to determine the cause and manner of death (see “The Autopsy,” pp. 523-533 in Volume Two of this handbook).

Death Investigation as the Practice of Medicine

The question is, When does the investigation of death become medicine? When is it necessary to have a physician specialist trained in death investigation to examine a case? Paradoxically, at least one state’s attorney general has determined that the performance of an autopsy by a lay coroner is not the practice of medicine, and thus the practitioner cannot be charged with practicing medicine without a license, whereas a licensed physician performing the same procedure is practicing medicine and thus subject to the State Medical Board requirements and scrutiny (Bonnell 2001). National professional medical examiner groups believe that the autopsy is the practice of medicine (Riddick et al. 2001), as is subsequent expert witness courtroom testimony (Reardon 1998). As such, the performance of both requires proper credentials by the practitioner.

Modern Failures in Death Investigation

The magnitude of the results stemming from the autopsy examination is immense and is predicated on the recognition of certain postmortem findings. “A dead body is extremely eloquent and honestly informative if one listens to the tales it tells” (Adelson 1974:13).

The whole of society benefits from a competent and timely study of how and why an individual died.

Done properly, death investigations can ensure that the guilty are imprisoned, that the innocent are not, that negligence by caregivers is well documented. Investigations can bring closure to mourning families and determine life insurance payoffs. They can also detect important [public health] trends. (Cenziper and Mellnik 2002)

Regrettably, governmental and public inattention to the offices charged with death investigation have resulted in errors of commission and of omission. Because the untrained lay coroner is easily targeted and often a source of these errors, there has been a push (often by the medical community) to replace the “antiquated” office of coroner with a specialist in death investigation. “Problems with coroner systems have received much media attention over the years, and the natural trend and public attitude seem to favor medical examiner over coroner systems” (Hanzlick 1998:874). In arguing to abolish the office of coroner, one school of thought is a potential conflict of interest in determining how someone died. The thought is that the coroner interprets the data to facilitate reelection by not angering the voters.

Because the coroner is an elected official, it is not uncommon for his decisions to be influenced by political considerations. Not infrequently a suicide may be ruled an accident, or a death is ruled a homicide, because of pressure placed on the coroner. (Mavroforou and Michalodimitrakis 2002:20

The fallacy of this argument is that an appointed medical examiner, answering to an elected official, indirectly faces the same pressures for the same reasons. Furthermore, those who would abolish the office of coroner would create a medical examiner system in name only.

[Many areas have] launched [what they called] a medical examiner system on the gamble that doctors would take on the work because they considered it public service…. Some counties have had trouble finding any doctor for the job…. [M]any doctors don’t want the responsibility. (Cenziper and Mellnik 2002)

Some jurisdictions have attempted to establish a medical examiner system, only to find it too expensive to operate effectively in a rural community and return to an elected coroner system within 2 years. Governmental failure to deal with the chronic lack of funding ensures that the professionalism and education required for an effective death investigation will never be sustained.

Competent death investigation, as with any specialty, requires extensive training. The bestowing of the degree of Doctor of Medicine does not ensure any such level. The sad truth is that most medical schools spend negligible time in the education of students in the signing of death certificates and proper certification, let alone death investigation; the whole process is viewed by all too many physicians as a nuisance, at best. (Sadly, 80% of U.S. medical schools average a mere 3 hours in forensic pathology training [Fisher 1993:11].) As a result, too often, ill-qualified individuals (whether untrained lay coroners or physicians) inherit the job no one else wants.

Such pseudo medical examiners have numerous problems, including not recognizing homicides, necessitating exhumations (due to botched cases), jeopardizing hundreds of cases through documented errors, failing to visit scenes, failing to view bodies, obtaining insufficient medical history, failing to order necessary autopsies, having the wrong practitioners examining bodies (Cenziper and Mellnik 2002); all these problems are related to due lack of training in death investigation.

The truth of the matter is that a doctor who is not a forensic pathologist knows no more about determining the cause of death than a layperson….[They are] untrained, unqualified people to do death investigations….The fact that they are doctors does not matter. (Cenziper and Mellnik 2002)

Unethical pathologists have distorted the process by concealment and misrepresentation within the autopsy report for the purpose of protecting other doctors (Zarbo et al. 2002). Medical examiners have been sentenced to jail for criminal abuse of a corpse (Perry 2002). Lawsuits against a county medical examiner’s employer have been based on “the systematic failures of the county to control, supervise, and put in place sound policies and procedures [which] resulted…in deliberate indifference to the constitutional rights of others” (Stein 2001).

Present Status: A Balance between Offices

Despite the American trend since 1877 to replace the coroner with a medical examiner, such has reached an impasse, with few new medical examiner systems created in the past few decades (Hanzlick 1998; Jentzen and Ernst 1998). The stalled crossover to the medical examiner may reflect a “lack of effort, significant obstacles, a natural trend that has simply run its course, or a combination” (Hanzlick 1998:874) due to lack of pressing need, constitutional/home rule/referendum issues, local politics, physician apathy, inadequate populace to support office operations, overwhelming geographical constraints (sparse density), and insufficient numbers of trained personnel (Hanzlick 1998).

At present, overall death investigation in America is unstructured with medical examiners in many large cities (Fisher 1993; Geberth 1990:417). Twenty-two states have a medical examiner system without coroners, 13 states are mixed, and 15 have only coroners or justices of the peace (Hanzlick 1998). Noncoroner medical examiners investigate deaths for 48% of the U.S. population (Hanzlick 1998). One quarter of the U.S. population is served exclusively by law coroners (Jentzen and Ernst 1998). There are approximately 2,759 coroners (Hanzlick 1996a) and a total of 24,960 Anatomic Pathology board-certified pathologists in the United States; of the latter, only 1,107 are board certified in forensic pathology (William Hartmann, American Board of Pathology, personal communication, March 2002). Nationally, medical examiners and coroners investigate 20% of the roughly 2 million deaths each year, or approximately 400,000 cases per year. If all 1,107 forensic pathologists were practicing, that translates to over 361 exams per year per medical examiner and approximately 145 per coroner. In fact, only 400 forensic pathologists practice full-time, with only 30 additional medical examiners trained every year (Hanzlick 1996b), representing 1,000 bodies per practicing forensic pathologist per year. Thus, in addition to training concerns for coroners, the field of forensic pathology is woefully understaffed. The death investigation system candle is burning at both ends.

Modern Death Investigation

The Shakespearian adage “How sharper than a serpent’s tooth, to have an ungrateful child” could well be applied to the coroner’s progeny, the medical examiner. Unquestionably, the physician trained in general medicine and specializing in the investigation of sudden, unexpected death is better qualified to handle medical aspects of death investigation. This has led some medical examiners to call for the abolition of the office of coroner as an antiquated relic of a distant past. In many instances, some such criticisms were justified. Lost somewhere in this argument are the many shortcomings and failures by physicians and even less than optimal medical examiners. A large part of the process of death investigation is human interaction with surviving family, law enforcement, medical personnel, the justice system, and so on. Regrettably, even the best medical education cannot create empathy and compassion.

Finger-pointing and bellicosity has spawned heated controversy and turmoil between the two offices. Progressive communities have “moved past the decades-old debate pitting medical examiners against coroners and built stronger systems that borrow from both approaches. Trained laypeople do the field investigations. Doctors trained in violent death do the medical work” (Cenziper and Mellnick 2002). A model lay coroner would be

a trained investigator,…[who] visits death scenes, interviews families, and works with law enforcement, social services, and other agencies. Then he brings all unexplained, accidental, and traumatic deaths to forensic pathologists—doctors specially trained to analyze violent death—for a medical review and possible autopsy. (Cenziper 2001)

The overall investigation benefits from energetic, interested, and qualified lay and medical specialists working in synergy.

The Investigative Triad: Physician, Coroner, and Law Enforcement Cooperation

Physicians should be interested in coroners because there is some physician-coroner overlap, such as public health deaths, diagnosis/therapy-related deaths, and national mortality data (Hanzlick 1996b). There remains a need for coroner training in administration, basic death investigation, and continuing education, including advanced death investigation (Hanzlick 1996b). As demonstrated in Britain, a combined skilled coroner and medical examiner model can work; there, the coroner’s “autopsy rate approaches 100%. Only in rare cases, when the coroner is satisfied that the medical practitioner is confident about the cause of death, does the coroner decide to dispose of the case without a postmortem examination” (Mavroforou and Michalodimitrakis 2002:21]). An effective modern medicolegal death investigation system requires communication, coordination, and cooperation between the three major participants: the coroner, law enforcement, and the medical examiner.

The Coroner: The Death Call

The coroner’s work begins with the information that a subject has died. The coroner then sets about gathering pertinent information. In medical deaths, the patient may be hospitalized or an outpatient. In either, abundant independent information is easily obtained from medical records. Forensic cases add the nonpatient who dies suddenly and unexpectedly at home. In the latter cases, information may be exceedingly difficult to obtain because even the decedent’s identity may be in question. Much of medical diagnosis (including postmortem diagnosis) is based on history, thus the death investigator searches diligently for sufficient medical information to determine the extent of continued medicolegal services required. The coroner serves most effectively in this capacity—consulting with the pathologist and serving as a conduit for information.

The functions of the coroner would include interaction with surviving next of kin, obtaining medical records, securing hospital samples (such as clinical admission blood samples), tracking down X-rays, securing dental records, and visitation of the scene of death. All these responsibilities may be carried out by a lay forensic investigator or medicolegal death investigator in a pure medical examiner system. Typically, the lay investigator has little or no experience in the operations of the medical examiner’s office prior to employment but learns by on-the-job training and/or advanced training seminars in the subject. Certification as a medicolegal death investigator is available to forensic investigators and to lay coroners. Fundamental to the effective operation of any modern practice of death investigation—in either model—is the adequate training of a layperson to perform in an adjunct capacity for the forensic pathologist by acting as an extension of the medical examiner when the pathologist would otherwise be unable to visit a death scene, gathering baseline information pertinent to the case, and anticipating potential future questions to avoid difficulties later.

Law Enforcement: The Scene Investigation

Good results in death investigation always begin at the scene(s) of death or injury. “The proper evaluation of the death scene represents the single best opportunity to gain the most accurate, comprehensive, and timely collection of information regarding a death. Many cases have been jeopardized by incomplete or deferred death scene investigations” (Jentzen and Ernst 1998:302). The overall scene is fundamentally the province of the police agency charged with the case. Although not mandatory in all cases, a medical examiner’s presence at the scene enhances credibility and is recommended in multiple fatalities, high-profile deaths, custody deaths, undetermined cause of death, homicides, unusual deaths, time-of-death concerns, and hit-and-run fatalities (Jentzen and Ernst 1998:308). “Most materials required to document the death scene are inexpensive, but the lack of adequate documentation (measurements, photographs, and evidence) can and will jeopardize the overall success of the investigation” (Jentzen and Ernst 1998:316).

Competent, complete, and thorough scene investigation is essential to the justice system. The environment is analyzed by law enforcement and the body by the coroner or medical examiner. Often, there is no single “right” way to process a scene. The essential elements of evidence are proper recognition, documentation, collection, packaging, preservation, and chain of custody—including for the human body. Police are “trained to track criminals, not determine a cause of death….It’s the medical examiners who are responsible by law for taking the lead in death investigations” (Cenziper and Mellnik 2002). The forensic pathologist can assist law enforcement with information regarding cause of death, suspect weapon, wound consistency with the overall investigation, the fatal wound, the direction of forces, the relative positions of victim and assailant during the attack, foreign material such as trace evidence, time of death, and the survival time, as well as determining if the body was dragged, dumped, or both; if activity were possible following injury; if wounds are antemortem or postmortem; if sexual activity took place, and if drugs, alcohol, or both were involved (Geberth 1990:426-27). Forensic or medical examiner analysis is not a substitute for investigation—the old adage, “good police work solves cases,” is all too true.

The Medical Examiner: The Autopsy

The autopsy examination conducted in the morgue by the medical examiner is a detailed procedure (see “The Autopsy,” pp. 523-533 in Volume Two of this Handbook). Prior to the postmortem, the autopsist should be completely briefed by fully informed and involved scene investigators, both law enforcement and coroner. During the performance of the case examination, the pathologist (and coroner, for that matter) should guard against making the classic mistakes in forensic pathology, including missing the objective of the exam, performing an incomplete autopsy, embalming prior to exam, not examining due to mutilation and/or decomposition, missing postmortem artifacts, inadequately examining and/or describing, confusing subjective with objective, missing the scene examination, substituting intuition for science, insufficiently photographing, making errors in toxicology samples, and making minor errors that jeopardize the entire process (Moritz 1956). In the modern litigious environment, few death investigation cases can survive even one of these seemingly easily avoided errors.

The Certification of Death

With the examination completed, the forensic pathologist prepares a report describing the findings and informs the other members of the death investigation team of the results. The final step after the autopsy is the completion of the death certificate. Here, the cause and manner of death are certified. The cause of death is that disease process that terminated life; the manner of death is a description of the circumstances surrounding the death and may be homicide(death by the hand of another), suicide (death by one’s own hand), accident (death due to unforeseen and unforeseeable events), natural (unrelated to foul play or violence), or undetermined (insufficient data to assign manner). In general, the cause is determined by autopsy and the manner by investigation, although there is some overlap. In coroner jurisdictions, the coroner often completes the death certificate. With sufficient experience and training, many lay coroners do quite well with most death certifications; however, “the very nature of this key responsibility—lucid, incontrovertible expression of lethal physical or chemical damage—indicates that the physician best suited for this assignment [of cause and manner of death determination] is the anatomic pathologist” (Adelson 1974:6).


“As a result of the crisis depicted by recent national events involving high-profile murder cases, medicolegal death investigation—traditionally ignored, underfunded, and misunderstood—has begun to slowly receive the attention it deserves” (Jentzen and Ernst 1998:318). The evolution of the official governmental investigation of death has been and remains a laborious process. Tangible support must be given to whichever death investigation system exists if the dead are to be given the respect they deserve.