What’s death got to do with it? Sheriff-Coroners

Newsletter for April 20, 2021

One day, I was just doing my thing, cruising the latest sheriff news when something caught my eye. The Placer County, California, Sheriff Devon Bell posted that a man died “hours” after getting the COVID-19 vaccine. (Yes, it’s the same county that just got rid of the noose in the county’s logo. Obviously, PC culture finally infiltrated.) Bell posted a correction a week later that was still pretty vague.

That’s strange, I thought. I knew that a bunch of California sheriffs were busy on an anti-science campaign to talk trash about mask-wearing and vaccination. Sheriff Bell had already said he wouldn’t enforce mask-wearing mandates and business closures. I assumed there was more to it.

And, indeed. Lucky for me, the Sacramento Bee dug into the story. Turns out it’s NOT the case that Sheriff Bell has a secret graduate degree in immunology, but rather that he refused to listen to county health officials who begged him not to post misleading and false information. According to the Sac Bee investigation, Placer County health officials begged the sheriff not to post about this individual’s death because they feared fueling the already ongoing vaccine conspiracy theories. (The health department managed to talk the sheriff down from some of the more bizarre proposed statements.) In fact, the sheriff posted the death notice before the autopsy had even been completed. And, to make matters worse, the sheriff’s office responded to Facebook comments with snippy remarks, telling one person, “Accuracy trumps instant gratification here” and “If you’re unhappy with the set of information we have provided, feel free to unfollow this page.” Totally normal government office-type stuff.

The sheriff’s office has objected, unsurprisingly, to the Sac Bee reporting, claiming some top-secret medical information they have, but cannot release.

But, why is Sheriff Bell even involved in this in the first place? It’s because in about 2/3 of California counties, sheriffs are also coroners.

Coroners are basically in charge of investigating, determining, and recording deaths. They serve as both medical investigators who determine the cause of death and the identity of the deceased and as public health officers who track deaths, maintain records, and handle the deceased’s personal inventory and family notification (as well as the actual body). Sometimes, coroners assess deaths through what is called a coroner’s inquest, which is a bit like a mini-trial where witnesses present facts to help come to a conclusion about how a person died. And in some states, coroners also have the power to civilly commit people.

Just as law enforcement is splintered and decentralized, so is death. There are over 2,300 separate death investigation jurisdictions, which can include a combination of elected coroners and medical examiners (ME) at both the local and state level. As usual, this hampers information-gathering and comprehensive reform. There’s no central database on elected coroners that I could find. And many states, like New York, have some counties with MEs and some with elected coroners (and some with district attorneys who are also the coroner!). Sometimes those MEs are part of the district attorney’s office; sometimes they are independent. It often happens that rural counties are more likely to have elected coroners, and big cities have ME offices. So, it turns out that the rural/ urban divide exists in death, too.

Sheriff-coroners exist in smaller counties in Nevada and Montana, but I haven’t found a comprehensive list. (Clark County, Nevada, which is where Vegas is, for example, uses a ME.) Sheriffs in California must be certified peace officers (although this is under reconsideration), but there’s no requirement that sheriffs have any medical experience (not even EMT training) nor, say, have taken basic chemistry or biology.

Placer County’s COVID boo-boo is not the first known hiccup for California’s sheriff-coroners. San Joaquin County separated its sheriff and coroner roles after the then-sheriff Steve Moore (voted out of office after this scandal broke) was caught making questionable calls about the cause of death, causing the chief medical examiner and a forensic examiner to quit. Moore was accused of, on more than one occasion, overriding the cause of death determined by the actual scientists, especially in cases where the individual has died in custody. In multiple cases, Moore changed the cause of death from “homicide” to “accident” when the deceased was killed by sheriff’s deputies using excessive force. In one case, the sheriff’s office withheld information about taser use, instead claiming a man being chased by deputies died from a motorcycle crash. From a news article:

The forensic pathologists raised other concerns, including months-long delays in getting written reports from sheriff’s investigators that the pathologists needed to complete their cases. And, in several instances, they say they discovered that a sheriff’s deputy who oversees coroner operations ordered technicians to cut the hands off bodies, without the knowledge, consent or supervision of the physicians.

You can see how this matters. The coroner is the person who fills out the death certificate, writing down either “natural causes,” “excited delirium” (which isn’t real), or “homicide” when a person died in jail custody. The coroner also decides if an autopsy is even necessary. If someone who is in the throes of opioid withdrawal dies, is that an accident? Homicide? Negligence? Natural causes? People who die usually have more than one thing wrong with them – the primary problem being mortality itself – and the idea of having a law enforcement person, one who a) runs the jail and b) is elected (and therefore concerned about bad press), seems perfectly ridiculous. Yet, it stands.

History of the Coroner’s Office

Coroners (or “crowners”) actually were mentioned in the Magna Carta, which is a fun fact, and got their start in Medieval England. Basically, when someone died, the coroner gathered the villagers together and asked who knew the deceased and what happened. They also made sure to collect the dead person’s taxes and any hidden treasure, since, obviously. This was the beginning of the “coroner’s inquest.” There was, of course, not much by way of science or medicine, never mind autopsies. The inquest was how people figured out what happened. The purpose was not to determine if the death was justified or not, just to establish what happened. Inquests were held for a number of different crimes, like arson, burglary, and assault, as well as in the event of unnatural or natural deaths. (There is some evidence that in medieval days, coroners also heard criminal cases; one historian argues that coroners in essence took over part of the sheriff’s job and were intended to serve as a check on sheriff powers. In some states, the only person who can arrest the sheriff is still the coroner.)

A lot of American colonies, which became states, established elected or appointed coroners without any definition of the term or what the office required. In places with elected coroners, there are no requirements other than being of voting age and a resident of the county. In 2018 Indiana, a high school senior became a deputy coroner by passing the exam. She probably does better than others.

As people discovered, you know, medicine, most jurisdictions turned to medical examiners for the actual autopsy part. MEs are far from lacking in controversy, of course, especially since the fields of forensic science is not prestigious nor is it a focus of many medical schools since doctors generally like to focus on the living, not the dead.

For the most part, medical experts critique the coroner system for lacking scientific rigor. This is an old argument that has been made since the mid-19th century. The 1928 The National Research Council’s Committee on Medical Legal Problems, which included two law school deans, issued a report saying that coroners should be abolished. Between 1960 and 1979, a dozen states converted to MEs in lieu of coroners. But the momentum stopped. A dozen states haven’t made any changes at all since their formation. It will not surprise anyone that when California tried to change the law and shift death investigations to MEs, the state sheriff’s association lobbied to prevent the bill from being passed.

Another extremely relevant controversy centers on the connection between elected coroners and the criminal justice system. Let’s take some of the police murders after Hurricane Katrina. One man was attacked and beaten by officers in the Superdome. The coroner ruled the man’s death an “accidental fall,” then an “allergic reaction.” Finally, an autopsy found that he had actually been beaten to death.

And this persists. When there’s, say, an epidemic, does it make sense to have a law enforcement officer make health decisions?

And of course, what about killings committed by law enforcement officers or correctional staff? One recent study conducted by Justin Feldman at Harvard found that coroners didn’t classify police killings as such in over half of all cases because of “errors.” some states were worse than others. In Oklahoma, none of the 30 police killings were classified as such by coroners. (To my knowledge, there isn’t a specific study of such by sheriff-coroners.)

Just last week, the Caddo Parish Coroner found that a man who died in the jail died a “natural” death even though he was obviously very sick before his death, complained of feeling unwell, and was found unresponsive in his cell.

Other Reading

This week, Supreme Court Justice Sonya Sotomayor wrote a scathing dissent against a SCOTUS denial of cert in a case against Polk County, Wisconsin’s jail.  The Petitioner, Sharon Lynn Brown was arrested for shoplifting and, after being booked in the Polk County jail for pretrial detention, was searched for contraband (drugs) both by an ultrasound, which showed nothing, AND physically. The physical inspection involved a doctor using a speculum to look in both her vagina and anus. The only basis for the search was a rumor from other people being held in pretrial detention.

Ms. Brown argued the case violated her 4th Amendment right because the “reasonable suspicion” requirement the jail relied upon as the basis for the search didn’t justify such an extreme and painful measure. Sotomayor’s dissent argues, in essence, that vastly less painful and invasive measures were available. Yes. AND this case represents the dangers and dehumanization of pretrial detention. Had Ms. Brown not been booked into jail, she would not have endured such a search, which was totally unrelated to the charges against her (never mind what the shoplifting charge was for etc). Jail policies like these are set by the sheriff and once you are booked, there’s no recourse to object. A whole new set of rules and regulations come into play. Ms. Brown’s only opportunity was to sue after the search happened. Again, reasons to think there should not be jails.

The Southern Poverty Law Center brought a lawsuit against the Jefferson Parish, Louisiana, Sheriff’s Office over the release of records related to a decade of brutality, murders, and excessive violence by the department against community members. In May 2020, Jefferson Parish deputies killed Modesto Reyes at a traffic stop. There’s no video of the incident although the deputies claim he was armed. An independent autopsy showed that Mr. Reyes was shot in the back. This is just one example of what is a decades-long reign of terror by the department.

Los Angeles Sheriff Alex Villanueva, the new self-appointed king of victims; rights, says he has no working relationship with the newly-elected district attorney George Gascon and somehow thought it was appropriate to speculate on how Gascon’s office would treat protestors who have not yet been arrested and sex workers who haven’t been charged. Talk about a moral panic with no basis in fact.