If you happen to catch me testifying, perhaps in court, or in an old case from Court TV, you may notice how very precise – finicky, even – I am in the words I use. In court, every word counts – every sentence is transcribed, kept forever in a searchable database, pored over and used to attack or support opinions as the trial or legal process continues, sometimes for decades.
Largely because of this, forensic pathologists are very specific in their language; our terminology is consistent throughout the forensic community, with some definitions that don’t necessarily translate cleanly into the civilian arena. For example, an emergency room physician examining a man with a slashed throat might describe the injury as “a transverse 5 inch laceration below the level of the thyroid cartilage”. For forensic pathologists, the term “laceration” refers exclusively to tearing of the tissues caused by blunt trauma; we would say the man with the cut throat had a “5 inch incised wound”.
We’re also specific in how we describe ourselves professionally. I’m a forensic pathologist, a New York City medical examiner for over 20 years now: I am not a coroner. The positions are fundamentally different and have a very different history.
The word coroner (from the Latin corona, “crown”) is a title that goes back to medieval England, to just after the Norman invasion in 1066 (illustration below: King Harold dies at the Battle of Hastings, nailed by an arrow in the eye). The coroner was the King’s agent, originally responsible for protecting the crown’s interest in legal matters. England still has a coronial system; English coroners hold both medical and law degrees. The coroner considers all the information from the investigation, and then decides if there are grounds for a legal trial. The evidence is presented in a court-like setting in a procedure known as an inquest, over which the coroner presides.
By contrast, in the US, most communities consider the basic facts of a murder in a Grand Jury, in which the prosecutor has a series of witnesses testify to civilian jurors who must then decide whether or not to indict a suspect on the basis of the evidence presented. In some areas, prosecutors have a larger amount of discretion in deciding whether a prosecution will go forward, and gather evidence in a series of depositions.
In contrast with England, where the court appoints the coroner, the American coroner is an elected official. Because this country is vast, with huge, sparsely populated rural areas, which see few deaths each year, local counties may not be able to adequately fund medicolegal death investigation. The quality varies widely across the nation – I highly recommend the recent NPR series about the state of death investigation in the US; if you’ve been bred on a diet of CSI and The Forensic Files, I think you’ll find it quite an eye-opener. There may be a slight bias towards the sensational, focusing almost exclusively on epic failures in the system, but I think it’s great that someone’s shining a light on a critically neglected issue.
As the NPR report indicates, both coroners and forensic pathologists vary widely in competency and experience. Medical examiners must be pathologists formally trained in forensic pathology; coroners don’t have to be medical doctors – indeed, in some jurisdictions, the coroner may be the guy with a truck large enough to move a body. The coroner often has a tightly limited budget, and with each case, he must decide whether he can afford to pay for an autopsy; the financial and political pressures can be extreme.
In situations where he or she deems an autopsy necessary, the coroner refers the autopsy to a local or regional pathologist. Again, the amount of forensic training that coroner’s pathologists have had is very variable; the worst-case scenario involves doctors with minimal experience forced to rely on pictures in forensic textbooks.
If you’re reading this blog, you probably know this, but I suppose I should go over some basic definitions. A pathologist is a physician who makes diagnoses by examining specimens taken from patients. A surgical (aka an anatomic pathologist) is the person who examines the biopsy of that arrestingly odd-looking growth on Aunt Tillie’s face; surgical pathologists also do autopsies. An autopsy is an examination of the body after death performed in order to get as much information as possible about the cause and circumstances of that death. The body is examined externally for evidence of disease or injury, and then is opened, and examined internally. Further studies may be performed, and when the pathologist has enough information about the cause of the death, they’ll issue an autopsy report.
Forensic pathologists practice a subspecialty of pathology. For the most part, we do autopsies in cases of violent, unnatural, suspicious or unexpected death. Because of our expertise in the evaluation of trauma, we may be called on to examine living victims of assault, prisoners who complained of brutal treatment, victims of sexual assault, abused children, etc. Properly, the evaluation of injuries in living victims is referred to as forensic medicine, whereas autopsy work is forensic pathology.
To become a forensic pathologist, I went to medical school in England at the University of London. In England, medical school takes five years, and I did an honors year in addition to that. (Below, a photo of St. Thomas’s Hospital, my alma mater – an august institution, described as already “ancient” in 1215 AD, it’s mostly cool because that was where that dude wakes up at the beginning of the zombie movie 28 Days Later.)
After graduating, I did internships in medicine and surgery before moving to the United States. I did a three-year residency in anatomic pathology at Boston University Medical Center and then moved to Miami to train in forensic pathology. I was an Associate Medical Examiner for Dade County for one year prior to taking my current position as a medical examiner for New York City. New York has been great, but Miami was insane – it was while I was working in Florida that I thought of the story that would become A Hard Death.
I’ve been extremely lucky in my training, working with two of the greats of American forensic pathology—Dr. Joe Davis in Miami, and Dr. Charles Hirsch in New York City. My 20 years in New York City have been a fantastic experience working with devoted, super bright, super-competent colleagues.
Reading this over, I’m alarmed at how harsh I sound on coroners. Most coroners do great work with very limited resources. Just as with medical examiner systems, the quality of death investigation in coroner systems ultimately depends upon the people who do the work, and I’ve encountered many superb coroners and coroners investigators who go the extra mile in really difficult conditions to make sure they get it right. Just recently, working with a team to refine our approach to deaths among the elderly in NYC, I was really struck by the excellence of the Sacramento Coroner’s office. And last month I reviewed a very difficult case from a rural jurisdiction in Pennsylvania and was completely blown away by the quality of the investigation, by the thoroughness of the autopsy report, and by the self-critical, carefully circumspect approach the investigator and coroner took to their own conclusions. Because, pathologist or coroner, you want someone who is willing to question their own results.
New York is actually a hybrid state with co-existing systems, specifically coronial systems in the more rural areas, and medical examiner systems in the more populous ones. Since full-time medicolegal death investigation is an expensive proposition, and more readily bankrolled where there’s an adequate tax base, if you live in a big city, you probably have an ME office, rather than a coroner’s office.
At the end of the day, though, even forensic pathologists can be pretty inconsistent – this morning I was reading Michael Jackson’s autopsy report (knowing L.A. County autopsy reports are public record, I just Googled it), and noticed that the autopsy report is signed by Dr. Lakshmanan Sathyavagiswaran, the office’s chief. The title he uses? “Chief Medical Examiner-Coroner”…
But I suppose the coroners in L.A. have always been a little bit different…
So – what do you have in your region? Do you know if you have a medical examiner system or a coronial system? How much do you know about your Chief ME or Coroner? Here’s a hint: generally, the less you hear, the better the system…
Great post, Jonathan. Given my books are actually set in the US, I haven't done much research on my local situation, although I do speak to a Melbourne forensic pathologist to check a few facts when I'm writing. She officially works for the Victorian Institute of Forensic Medicine but I assume she presents her findings in the Coroners Court of Victoria. And Victoria is a state in Australia.
PS I was a HUGE Quincy fan!!!!!
Excellent post!
As with P.D., I'm living in Australia – South Australia – and we also have a coronial system. We hear very little about it, so I'm assuming all's good!
P.S. And yeah, another big Quincy fan here too.
Oops! Sorry about the video clip malfunctioning at the end, there – thanks to Zoe for picking up on it!
I think Australia has a generally very good system – one of the advantages of a low homicide rate is that when murders occur, a lot of resources are thrown at their investigation.
It's funny, but I've never watched an episode of QUINCY, M.E. in my life. My colleagues tell me it's surprisingly good.
In my region? I have you!
Helpful post!
Hi Jonathan
Glad the video clip's up and working now!
Great post – hugely informative. You've about covered the UK angle. How DO you carry out a post-mortem examination on a zombie, by the way?
I spent some time attending a few inquests in the UK into road traffic accidents for a previous book and found it enormously interesting. The coroner's opening statement would have made a terrific opening line for the book, but the story just wouldn't allow it, dammit.
Never a big Quincy fan, sorry, and although I do admit to CSI and NCIS, I watch purely for entertainment, not for research ;-]
In the "other" Washington (State, that is) we have a mixed system. My county has a coroner who contracts with a pathologist to come in for the post mortems. In some counties here, the even smaller ones, the deputy prosecutors are also the deputy coroners.
Huh…this turned out to be really interesting! I knew we had a Medical Examiner here, but wasn't sure how the system worked or if we also had coroners.
Turns out we have a centralized ME office and trained medical personnel from the OCME "assess the scene and circumstances surrounding the death, confer with family members of the deceased and/or witnesses to the fatal event and other agency responders such as law enforcement and emergency medical personnel. They then present the case to the Chief or Deputy Chief Medical Examiner who makes one of the following dispositions: 1) jurisdiction declined 2) issuance of a death certificate based on history, circumstances of death and external examination of the body or 3) transfer of the remains to Concord for complete autopsy" (NHBA Journal).
The journal article also mentioned that the first modern system with a non-political appointee was in NY (go NY!), that our Chief and Deputy Chief hold academic appointments at Dartmouth Medical School and the Massachusetts College of Pharmacy and Health Sciences (competence is good), and included the following line that made me laugh:
"Today’s clinician, on a short leash held by a large HMO or other such entity, is loath to leave his or her office to attend a traffic fatality on SR101 that could tie him or her up for hours."
I wasn't expecting that bit of snark in a legal journal article.
Was that this article, Karin?
http://www.nhbar.org/publications/archives/display-journal-issue.asp?id=31
I'm not surprised by the snark – the piece is by my friend and former colleague Tom Andrew; your Chief Medical Examiner is a fantastic forensic pathologist, a superb cook and possessed of a very dry wit. Dr. Andrew has been very influential in spreading the word about fatalities in kids due to "the Choking Game", and about rising trends in prescription drug abuse, particularly with regard to methadone. He's definitely one of the good guys.
Anyone wanting more detail about this subject will find the article well worth a read, btw.
Kathy, Washington has traditionally been well-served by its ME's; for years, Seattle was one of the great training programs, and training in Seattle meant rotating out through the rural jurisdictions.
There's a really incredible difference between forensic pathology in cities and out in the country. The former is characterized by a lot of natural deaths, deaths by handguns, and construction site deaths. The latter is more likely to involve deaths by long arms (hunting weapons like rifles and shotguns, which aren't common in cities) and farm or forestry deaths. One of the great things about working in Miami was that the county was so vast that it covered both urban and rural areas, plus there was plenty of water around – the sea, lakes, ponds and reservoirs. For a trainee, this means variety, experience in a lot of different arenas.
Zoe – we can't do autopsies on zombies. As I said, the autopsy is performed on a *dead* body, and zombies are technically undead.
In Canada we have the coroner system, though in some provinces they have to be doctors, while in others, like Saskatchewan where I'm from, they could have a legal or other background.
The downside of having a low murder rate can be having experts that aren't very expert. In Ontario, there was a pathologist that specialized in child deaths and a lot of innocent people ended up in jail because he found murder where there wasn't any.
Great post!
San Francisco has a Medical Examiner system – I have no idea who the Chief ME is now, but during my funeral director days in the mid 80s and early 90s, I worked pretty closely with coroners' offices throughout the Bay Area. Dr. Boyd Stevens was the CME in San Francisco, and he and his staff were great.
To your point about budget, I spent some time running a funeral home/cemetery/crematory in Santa Rosa, in Sonoma County. The county had no money for a central morgue, so there was a ‘rotation’ among funeral homes; we each took a month at a time acting as the county morgue. It was super interesting, and the local ME would let us observe autopsies. The system there was that there was an elected office, County Sheriff/Coroner, and the ME was hired by the county but reported into the Sheriff. On the other side was a Chief Deputy Sheriff, who had come up through the ranks and was not an elective position. I thought it worked pretty well, although I wasn’t privy to what must have been some pretty entertaining internal politics.
Hi Jonathan. Wonderful post.
As I'm here in San Francisco, I'm in the land of criminal crime lab analysts, not underperforming medical examiners.
New York is lucky to have you.
That was the article, Jonathan. I thought about putting the link in but realized I had no clue how to do that here. (And at this moment, somewhere out there, my two sons are involuntarily wincing without knowing why.)
Glad to know Dr. Andrew is one of the good guys!
The Chief ME in San Francisco is Amy Hart – another of my alumni (in this case, an alumna).
This should tell you two things: 1. that the NYC OCME runs an excellent training program! and 2. That the world of forensic pathology is a fairly small one. There are only about 500 board-certified forensic pathologists in the country. One problem with forensic path is that it's the one medical subspecialty training that guarantees you less money than if you hadn't had the training…
We're also dependent on county budgets, so are vulnerable to economic swings and political shifts.
Larry: there are some great forensic pathologists in Canada, many of whom trained in the (more violent!) US. What's more, Canada is an attractive place to practice, since the salaries are very good.
Charles Smith, the pediatric pathologist you're talking about, represents part of the problem: he was a hospital pathologist who kind of "taught himself" by interpreting the autopsies he did at Toronto Sick Kids. As I understand it, he didn't have formal training in forensics, but kind of grandfathered himself into the position. From what I've read, he was very successful and very prominent because he very much supported the prosecution side, which made him a useful witness. An interesting fact about Smith: he was a foundling, an abandoned baby who in later life became an advocate for children.
And I know this will sound odd, but in the justice system, the advocates you really need are the advocates for truth.
Which is tragic, because child fatalities are among the most challenging cases we do.
Also: I think that in an ideal situation, the medical examiner's office shouldn't report to the Sheriff's Office or the Police Department. It should be a freestanding institution – the better situation is the increasingly common pattern of the ME office being a part of the Department of Public Health.
When I testify, one of the first questions the DA will ask is "Do you work for the police?", to which the answer is, no, I work for the Department of Health. I don't for a second believe that ME's who report to the police hierarchy are in any way more corrupt than those that don't, but, particularly in officer-involved fatalities, the appearance of possible conflict of interest can be really problematic.
Per Rae, we have a medical examiner and I was told by one of their young (female) doctors that works for Amy Hart and they still use old porcelain tables from the 20's or thereabouts (I don't have my notes here). What I loved about that was one of books takes place in the late 50's in SF so I can describe the tables (because they are still there).
Another book was set in Mendocino County up north and there they share a medical examiner with Sonoma County and the sheriff's deputy can be a coroner if needed. Sometimes they use contract medical examiners for the reasons you stated, they can't afford someone on staff full time.
What a group. We know a lot of death here. Are you going to let us ask you pointed questions for our books?
It's funny that you should mention the Michael Jackson autopsy. In my research for Boulevard I cold-called the Chief Coroner Investigator at the L.A. Coroner's Office and asked for an interview and tour of the place. He was wonderfully gracious and gave me the tour himself, as well as the interview. We've stayed friends over the years, but there was about a year when we hadn't talked or emailed. One day I had a quick question for him – I wanted to know if there were X-ray machines at the Coroner's office and what they were used for. He got right back to me on email with an answer. We went back and forth on email a couple times that day. As I was driving home from work I heard his name announced on the radio and he gave a short speech that began like this – "We won't have the toxicology reports for Mr. Jackson for another two weeks…" I couldn't believe it. When I got home I emailed him again – "I can't believe you took the time to email me when you were doing Michael Jackson's autopsy today!" He wrote back – "Don't forget, I was here during the O.J. deal. I've seen this circus before."
Your blog today is incredible, Jonathan. You've answered a lot of questions for me. I wish I could be a fly on the wall of your life for about a month.
"Zoe – we can't do autopsies on zombies. As I said, the autopsy is performed on a *dead* body, and zombies are technically undead."
Ah, so that probably counts as vivisection, then?
Really, Zoey, it's a grey area.
I'm happy to answer pointed questions, Allison. Just keep the questions distilled to their essence – I don't need the entire plot, just the specific question!
And thanks, Stephen. I think I'd like to have another life for a month or two, one which is a lot less fascinating…
Jonathan:
Great, lively, interesting post.
My county (Solano, northeast of San Francisco) operates the same as Sonoma, which Rae described, i.e., a coroner's officer run through the Sheriff's Dept., and they contract out for ME work.
The county coroner made news recently when one of the ME's at the firm the county contracts with for its autopsies was discovered to be a little less than up to snuff: http://californiawatch.org/dailyreport/solano-county-opens-review-autopsies-doctor-checkered-past-8894
My favorite section:
An autopsy assistant discovered a spleen left behind in a morgue sink after Gill finished autopsying the body of an inmate who died in the California Medical Facility, a prison hospital. The organ was intact and had not been cut, Stanton said.
But when Gill submitted his report on the death, the doctor wrote that he had dissected the spleen as part of his examination.
“I have a report that says he did,” [Sheriff] Stanton said. “I have a spleen that says he didn’t.”
Also, of relevance to what you cited about uneven standards:
Since entering forensic pathology in 1993, Gill faced little competition for autopsy jobs due to a chronic shortage of certified forensic pathologists. The absence of trained practitioners is so acute that many jurisdictions don't look closely at the doctors they employ.
On a completely different topic: Speaking of Michael Jackson and the Undead … Oh, never mind.
(I worked on the first MJ civil case. Don't get me started.)
Welcome aboard, homeboy!
Corbett
I live in WA state now, which has already been discussed here, but lived for a few years in north Idaho, Kootenai County, which has a coroner as an elected position, and also in Alaska for a while, which has a statewide ME.
I'm glad you posted about this. I did see the PBS series a while back, but reading here about the differences definitely makes an impression.
David, that NPR program that I posted a link to covers the Gill case. Rather unfortunately, one of my colleagues, a fantastic forensic pathologist named Jim Gill, had to answer a series of phone calls from families alarmed that the incompetent Gill had autopsied their relative after the show aired.
Apparently, things have changed in the nearly 25 years since I left England. A British colleague writes:
Sadly though English (&Welsh) coroners are not qualified in medicine as a rule, and the push is for them to be drawn entirely from the legal profession. Also, coroners don't decide on whether there are grounds for a prosecution, that is the function of the Criminal Prosecution Service. If the CPS go for a prosecution, the inquest is opened & adjourned (often indefinitely) until any trial is complete. Coroners are appointed by local authorities, not courts … And accountable to virtually no-one!
Yes, I too was a big Quincy fan … in fact, I used to want to be a forensic pathologist. Then I decided I'd much rather write about them 🙂
Great article. I believe in Sacramento we have a Coroner who's appointed by the board of supervisors, but we also have a chief medical examiner who oversees the forensic pathologists. It's a large county. If I remember right, the Coroner handles all the budgeting issues, political crap, media, etc. and the M.E. handles the forensics. There's also deputy coroners who go out to investigate death scenes and I think they have law enforcement powers. But I toured a few years ago and forgot pretty much everything I didn't need to know for the book I was writing at the time …
Sorry I missed you at Thrillerfest!
This was fascinating, Jonathan. Thanks! Pima County has an ME in Tucson. Don't know how the state works as a whole, but now I am motivated to check.
In TN, we have a long and storied history of malfeasance in forensic pathology:
Dr. Charles Harlan – http://bit.ly/q9j4Cq
Dr. Bruce Levy – http://bit.ly/nm9fKD
BUT – and this is a huge but – they are the exception. Our ME's are smart, caring, careful and utterly without ego, unlike the two yahoos above. All of my dealings with them have been great.
Yeah, well, the Small World thing continues:
The Deputy Chief ME in Pima, Eric Peters, is also one of my alumni. And JT! Bruce Levy is one of ours, too.
I haven't followed his career closely, but I must say that I was fascinated by what happened to Bruce – his career was destroyed when he was busted for pot, something that would be a misdemeanor up in NYC, the equivalent of a parking ticket. I wondered about the politics of that – my understanding was that he put into effect a number of changes that didn't sit well with the police, who had been very pally with Harlan, who Levy replaced. But I'm sure you have a clearer sense of all this. What, other than pot-smoking, was his major transgression? I know he also agreed to let a reality show film in his facility, which was, I think, a mistake.
Allison! Bouchercon? You can hang out with JT and me…
PS Reine, when I passed through Tucson last month on the A HARD DEATH road trip, Eric and I had fantastic breakfast at a place called, IIRC, Frank's and Francesca's. Do you know it? Breakfast burritos and OJ were just perfect.
Lord, what a smorgasboard of information. Jonathan, you and your words are absolutely fascinating. Do you find most authors correctly use the correct information? I clung to the section about the preciseness of your vocabulary. What an interesting twist it would make in a story.
Why couldn't the cause of death be determined in the Anthony case?
And have you come to terms with the cat and the cost of the piss stains?
Judy (sorry it's so late there, but still early here in sunny California.
David, you must get Jonathan on staff at Book Passage next year. Judy
Actually, I think most authors get things wrong. Even when they do their research really thoroughly, the way they articulate the issue doesn't ring true. The one striking exception to that is Chelsea Cain – she was describing extreme situations, but I thought she was remarkably accurate, as did my ex, another forensic pathologist, after I'd insisted she read HEARTSICK.
Determining a cause of death depends upon having enough material to examine to be able to make a diagnosis. The amount of tissue, the portion of the body necessary to make a diagnosis depends upon the method of killing; for example, in a case of poisoning, you might be able to make the diagnosis from a single hair. (Theoretically!). For violent deaths, though, generally you need to be able to examine the part of the body that is wounded.
Most wounds are inflicted on soft tissues; some – stab wounds where the blade strikes a rib, or gunshot wounds where the bullet perforates the skull, for example – will leave a trace in the bone. A strangulation can leave purely soft tissue traces.
This soft tissue findings are what we use most of the time to make our diagnoses. If there's a delay between the death and the time the body is discovered, the decedent will start to decay. In the early stages of decay, we can still see the soft tissue injuries – the cuts and the bruises. However, as the flesh melts away, and there's nothing left but the skeleton, any cut, and stab wound, any bruise is lost.
For this reason, determining a cause of death on a skeleton can be very difficult. Sometimes we might find sharp wounds or bullet wounds of bone – a bullet rattling around in a skull is a pretty easy cause of death call. However, sometimes we find skeletons where there is no trace of trauma on the remaining bones. At that stage, we can no longer say whether the victim was stabbed, shot or strangled.
In situations where a skeleton is found in circumstances which indicate foul play – naked and bound, for example – we can conclude that the person was murdered, but we can't say exactly so. In those situations (and you might be surprised at how common they are), each jurisdiction has its own fallback term to classify the death. In New York City, we typically say the Cause of Death is "Homicidal violence of unknown type", and the Manner of Death is Homicide.
By the time Caylee Anthony's body was recovered, she had been skeletalized. Apparently, there was no evidence of injury on her bones, and so the Medical Examiner classified her death as a Homicide because of the circumstances (the skeletalized remains of a 2 year old who'd been missing for months, found in a swampy area in plastic garbage bags with duct tape wrapping on her face), and used her generic term "Homicide by Undetermined Means".
Oh, and re: Petey: He comes home tomorrow. The stains weren't a problem, as he was going mostly in the bathroom and the kitchen. The cost of the vet visits, ER, surgery, hospital stay, convalescent stay etc is really mind-blowing!
But I'm glad he's in one piece.
Yeh, you mean Francisco's (Frank's) I think – the outdoor place . . . best breakfast in Tucson fer sure.
Glad Petey's OK.
That was quite a trial . . . Anthony.
Jonathan, that's a conversation we should have in person. But what is on the record: the pot was stolen from the evidence locker…..
We shall indeed have it in person. I know there were rumors about that at the time, but I don't think for a second it was true – I'll need a cite to believe that!
i would like