Two San Joaquin County, Calif., medical examiners have resigned in the past two weeks, alleging that Sheriff-Coroner Steve Moore pressured them to change their autopsy results for deaths in police custody. In other instances also involving deaths at the hands of police, they say, the sheriff ignored their conclusions completely.

Bennet Omalu, the chief medical examiner for the county, tendered his resignation on Nov. 28, as did a colleague, Susan Parson. (Notable aside: Omalu is the medical examiner who exposed the degenerative brain condition found in many former NFL players and was the inspiration for the movie “Concussion.”) Omalu was hired in 2007 to help professionalize and modernize the county medical examiner’s office. In his resignation letter, he said that Moore “has always made calculated attempts to control me as a physician and influence my professional judgement.”

Following her resignation last week, Parson sent copies of emails, notes and other correspondence to the San Joaquin County district attorney and the board of supervisors to support both doctors’ claims.
The documents, obtained by KQED, included memos written by Omalu that raised serious questions about the integrity of investigations of people who died in the custody of law enforcement officers who used Tasers or other types of force.
Omalu wrote that the sheriff’s interference in death investigations had “gotten even worse” over the last two years . . .
In March 2017, Omalu and Parson began documenting incidents they believe show wrongdoing by Sheriff Moore. The two doctors allege the sheriff labeled certain deaths as “accidents” rather than “homicides” to shield from prosecution law enforcement officers who were involved.
In the Aug. 22, 2017, memo, one of several he drafted over the past nine months to document his concerns, Omalu wrote: “The Sheriff does whatever he feels like doing as the coroner, in total disregard of bioethics, standards of practice of medicine and the generally accepted principles of medicine.”

Among the specific incidents the two doctors cite:

— Omalu cited the case of Daniel Humphreys, a father of two who died on a Stockton freeway median in 2008 after crashing his motorcycle as he fled arrest.
In a deposition for a lawsuit brought by Humphreys’ family, Omalu said he was told by investigators that a California Highway Patrol officer had used a Taser on Humphreys once or twice. But when Omalu asked to see a computer record that the weapon automatically generates when fired, he was told there was no report to see. In his autopsy report, Omalu attributed Humphreys’ death to a head injury from the accident . . . Two years later, a deputy district attorney shared the Taser report with Omalu. It showed that the CHP officer in fact fired the Taser at Humphreys 31 times. A source close to the sheriff’s office said that the sheriff had access to the Taser report since the day after Humphreys’ death.
— One case involved Abelino Cordova-Cuevas, 28, who died in a March 7, 2016, confrontation with Stockton police.
Police told The Stockton Record that officers used a stun gun to subdue Cordova-Cuevas. An attorney representing the family alleged the officers used an illegal chokehold.
Omalu found that the man had died from asphyxiation and blunt force trauma and that his death was a homicide; the sheriff certified the manner of death an accident.
— The autopsy of Samuel Augustine Jr. concluded that he died June 7, 2016, of a traumatic brain injury and a spinal cord injury during arrest by Stockton police — and that the manner of death was homicide. Omalu wrote that the sheriff told him that his findings were wrong and should be changed.
“This is simply daylight corruption and nothing else,” Omalu wrote in a memo dated the day after he alleges the sheriff approached him. “He is using his office and powers to protect police officers.”
Omalu came to the conclusion that Sheriff Moore “seems to believe that every officer-involved death should be ruled an accident because the police did not mean to kill anyone.”

Omalu and Parsons are both board-certified forensic pathologists. Moore is not. So why can Moore overrule these two doctors on whether a death was an accident or a homicide?

As it turns out, this is a fun little artifact of the coroner system, which the United States inherited from Britain. Coroners are often confused with medical examiners, but they are two very different positions, and they rarely overlap. A medical examiner is a doctor who performs autopsies after suspicious deaths. The county coroner is an elected position. In most states, you don’t need any medical training, police training or crime investigation training to run for the office. There are only a few states where the coroner must be a physician, and even in those states there’s a big loophole — if no doctor wants the office, anyone can run for it.

Back in medieval England, the office of “coroner” originally had nothing to do with death. The coroner’s responsibility for investigating suspicious deaths came about almost by accident. The background on how all of that happened is pretty fascinating, but a bit too involved to get into here. (You can read all about it in my forthcoming book, “The Cadaver King and the Country Dentist.”) The office of coroner was essentially a catch-all position for the crown, but that didn’t neatly fit under any other office (“coroner” comes from “crowner,” or an agent of the crown). You can still see vestiges of the coroner’s utility function in the United States. In some states, the county coroner is responsible for auctioning off unclaimed property. In others, he or she is the only public official with the power to arrest the county sheriff. Until the 1990s, coroners in Mississippi had two responsibilities: investigate suspicious deaths, and round up any stray livestock and return it to its rightful owner. A call in the middle of the night could have been to investigate a murder, or it could have been to catch some pigs.

In much of the country, the office of coroner is part time and low paying. It’s sometimes an entryway into politics, but more often it’s held by the local funeral home director. It’s a popular position for people in the mortuary industry, not because embalming bodies confers any relevant skills to investigating deaths, but because being the first at the scene of the death usually gives them first crack at selling funeral and body transport services to the families of the deceased.

By the early 20th century, the office of coroner grew to be quite powerful, particularly in large cities. It also had a reputation for corruption. A coroner’s determination about cause of death could determine whether or how much a life insurance company had to pay out. It could swing the outcome of a lawsuit in a factory death or negligence case. A bribed coroner could also help a rich or powerful family avoid public embarrassment when a relative committed suicide. Coroners could paper over mob hits, or exonerate a parent of child abuse. (If you’re interested in all of this, I highly recommend the book Death Investigation in America: Coroners, Medical Examiners, and the Pursuit of Medical Certainty, by Jeffrey Jentzen.)

For much of the past century, coroners played a shameful but often unnoticed role in facilitating lynchings, assassinations and other racial violence. Too often, coroners’ juries determined an obvious lynching to be a suicide or natural death. Even in cases in which they did determine a death to be homicide, they made little to no effort to ascertain the identities of the culprits, as they did in other cases.

As far back as the Progressive Era, groups such as the American Medical Association, the Municipal League and other civic and professional organizations have tried to get states to ditch the coroners for a more modern death investigation system. The coroners proved to be a political powerful lobby and were able to consistently push back reform efforts until the last 20 years or so of the 20th century. A few states did eventually abolish the coroner position, but many didn’t. Most that tried any reform at all ended up creating some sort of hybrid system in which a medical examiner performs the autopsies, but an elected coroner still has final say over manner of death. That often made things worse.

Allowing the official in charge of death investigations to be beholden to political forces is a bad idea, for lots of reasons. There are the obvious ones, like those already mentioned — coroners could be susceptible to influence by powerful interests that may have a stake in the outcome of a death investigation. As the story that kicked off this post illustrates, you also want the person in charge of determining cause and manner of death to be as insulated as possible from pressure by law enforcement officials. Deaths in police custody are the obvious concern here, but we’ve also seen examples where law enforcement pressure resulted in a homicide determination in cases where a child may have died accidentally, such as with shaken baby syndrome. The reverse can be a problem — sometimes, a sheriff or prosecutor may not want to deal with another unsolved murder and might pressure a coroner to rule an obvious homicide to be an accident, a suicide or a natural death. While this obviously isn’t the norm, it isn’t unheard of, and it tends to happen most often when the deceased is part of a marginalized community — where the death isn’t deemed “important.”

To some extent, a prosecutor or police chief unhappy with a cause of death determination will always be able to apply some pressure, no matter who is doing the determining. (See John Edland, the heroic medical examiner who autopsied the bodies after the Attica prison uprising.) But a medical examiner appointed by an official outside of law enforcement will be less susceptible than a low-level elected official.

Medical examiners are also often the first to notice outbreaks of communicable diseases. They can be the first to notice patterns of deaths from environmental toxins, or trends in fatalities that come with the adoption of new technologies (Tasers, for example). Here, too, it seems wise to keep them insulated from political pressure.

So let’s go back to California. In 41 of that state’e 58 counties, the coroner’s duties are automatically assumed by the elected sheriff. (That’s according to the California Association of Counties. According to the KQED article, it’s 50 of 58 counties. The discrepancy is probably due to the fact that each county can set its own policies about the degree to which the sheriff oversees or takes over the coroner duties.)

This seems like the worst of all worlds. It’s bad enough to have police agencies investigating their own officers after an officer-involved shooting. It’s quite a bit worse to then give the sheriff the final say over whether a death in police custody was natural, accidental, or intentional. Because once a death is determined to be accidental or natural, there is no investigation.

Interestingly, several California counties where the sheriff also serves as coroner consistently rank among the highest in the country when it comes to the rate of deaths at the hands of police. That includes Kern County, which in 2015 was profiled by the Guardian as the county with the most police killings per capita in the United States. Ditto for San Bernardino County, which in 2015 ranked third. In Orange County, where the sheriff’s department is currently mired in a scandal of epic proportions, that same sheriff’s office has ultimate say over any suspicious deaths involving its own deputies. Riverside and Contra Costa counties also have some of the highest rates of police killings in the country, and each also has elected sheriffs who double as coroner.

Oddly, this all seems to be a relatively recent development. In Riverside, for example, the sheriff began overseeing coroner investigations in 1999. In San Bernardino, it was in 2005. In Marin County, two offices merged in 2011. Most of these mergers appear to have occurred for budgetary reasons, but it’s telling that few local officials apparently saw much problem with giving an elected sheriff the final say over what ought to be a medical determination.

This, from the KQED article, is telling:

Last year, California lawmakers increased the independence of the forensic pathologists working for a sheriff-coroner by defining autopsies as a medical procedure that may be performed only by a licensed physician and surgeon.
A key provision of Sen. Richard Pan’s bill, SB 1189, would have given forensic pathologists the authority to determine both cause and manner of death. However, it was opposed by the California State Sheriffs’ Association and the California State Coroners Association, and taken out. The final version of the bill, which took effect Jan. 1, 2017, upheld the sheriff-coroner’s authority to decide the manner in which people died, but added a requirement to do so “in consultation with” the forensic pathologist who performs the autopsy.

The solution here is pretty simple. It’s the same solution that groups such as the AMA have been recommending since the late 1800s: States need to abolish the coroner system entirely, and move to a medical examiner system.

To be sure, the states and cities that have adopted a medical examiner system aren’t without their problems. Two big ones: There are far too few certified medical examiners for the number of autopsies that need to be done, and there isn’t enough separation between medical examiners and law enforcement. But these problems, while important, aren’t endemic to the medical examiner systems. With some political will, they could be fixed, or at least improved.

The problems with the coroner system are more fundamental. The very act of electing someone to determine manner of death suggests that there’s room for political factors to guide or influence that determination. That shouldn’t be something we encourage. Put another way, we shouldn’t encourage the idea that there might be a Democratic or Republican way to determine whether someone died accidentally, committed suicide or was murdered.

Instead, let’s let each group of professionals do what they’re trained to do. Let medical examiners determine the cause of death. In cases in which a forensic pathologist has determined a death to be a homicide, let the police then investigate. If there was indeed a crime, let officials look for a suspect. If a suspect is arrested, let prosecutors determine the appropriate charges. Of course, we do elect sheriffs and prosecutors. Whether that’s a good idea is another debate. But it’s hard to see what good comes from adding another elected office to all of that — one that requires little to no specialized training.

The coroner system isn’t just an anachronism; it’s an anachronism that never made much sense in the first place. It’s well past time to get rid of it.