In 1857, a committee with the American Medical Association recommended abolishing the elected coroner’s office and replacing it with a system of appointed medical officials.
“This method of filling the office will be more successful in securing the selection of one having the special attainment demanded for the faithful and intelligent performance of its duties than by popular election,” the committee wrote.
But 163 years later, a system created in old England and called archaic before the Civil War remains in place across Colorado and in a handful of other states, driving one lawmaker and some death investigators to consider how the state can up its standards for an industry that few people want to talk about.
The elected position tasked with investigating the cause and manner of death of everyone from those who die in police custody to people suffering opioid overdoses has virtually no prerequisites in Colorado, leading to situations where 22-year-old recent college graduates can run for the office in major metropolitan areas. And the job still comes with duties left over from medieval England, such as when an Eastern Plains coroner four years ago was unwittingly thrust into the county sheriff’s role.
“In Colorado, essentially our mortuaries and coroners are not regulated,” said Matt Soper, a Republican state representative from Delta.
Colorado’s coroner system gained newfound attention earlier month when authorities raided a Leadville funeral home owned by the Lake County coroner, finding unrefrigerated bodies, unlabeled cremains and mounds of paperwork strewn across the floor. The coroner, Shannon Kent, previously had been indicted on charges he sent his wife out to death scenes in his place, and later was also charged with perjury.
State lawmakers over the years have slowly added more training for coroners after they win election, but the will to overhaul the entire system has been minimal. Now Soper and a handful of industry professionals are taking another stab at bringing Colorado’s coroner and mortuary practices into the 21st century.
“We need to set the standards higher so we don’t get people with little or no credentials into this office,” said Jill Romann, Douglas County’s coroner. “All they do is make us look like we’re not professionals.”
But not everyone in the industry feels the need for drastic change, particularly in rural areas where recruiting trained forensic pathologists is nearly impossible.
“At this point, the way our state has it set up seems to be working fairly well,” said Randy Keller, Fremont County’s coroner and president of the Colorado Coroner’s Association. “We don’t get a lot of problems or complaints.”
Colorado’s coroner system goes way back
Colorado’s elected coroner system has been in place since 1876, the year the Centennial State entered the union, but the practice goes back to ninth century England, when the position was created to represent the crown and it dealt with all sorts of things on top of investigating suspicious deaths.
The state Constitution enshrined into law that all 64 counties have an elected coroner, and the requirements are limited: The person must be 18 or older, a U.S. citizen, a resident of the county he or she serves and have no felony convictions. There is no requirement to have a medical degree or any previous training related to death investigations.
In Pitkin, Denver and Weld counties, however, the coroner or medical examiner is appointed, and all three currently have medical degrees.
Colorado has come a long way from even a decade ago, said Dr. Steven Ayers, Pitkin County’s medical examiner and one of three appointed coroners or medical examiners in the state. His previous experience came in Oklahoma, where doctors conducted death investigations. And for the first 20 years here, the “coroner system had zero qualifications.”
“It is an antiquated system,” Ayers said. “However, Colorado coroners have come a long way in trying professionalize and standardize it.”
New coroners are required to take a one-week, 40-hour training course and within a year become a certified death investigator. Coroners must also complete yearly continuing education requirements. But a 9News investigation in 2017 found at least a dozen counties where deputy coroners, who often have to step in when the coroner is unavailable, aren’t certified.
While the position has been updated over the years, Colorado coroners can still occasionally be thrust into strange roles, such as when the former Sedgwick County coroner became the temporary sheriff in 2016 through a seldom-invoked provision in state law after the sheriff was charged with felony sex assault.
Douglas County Sheriff Tony Spurlock spoke to the County Sheriff’s of Colorado at the time about changing the law.
“Nothing came of it,” he said. “We could never find the legislators to do it.”
Why does Colorado still elect coroners?
While the state has added additional requirements after one gets elected to be a coroner, there’s still nothing to stop virtually any adult from running.
Two years ago, Sydney Ludwick wanted to show just how easy it was to run for coroner in Colorado. So the 22-year-old environmental activist, who had recently graduated with a biology degree, decided to challenge Romann for her coroner seat in Douglas County.
“I knew I was unqualified,” Ludwick said. When she talked to voters, Ludwick realized that “the vast majority of people didn’t know people elected coroners. Even fewer people knew you only had to be 18 and not a felon.”
Running as a Democrat in right-leaning Douglas County, Ludwick figured it was pretty unlikely that she’d win.
“If I did win, I’d do my best to fulfill the duties,” she said.
Romann felt the race encapsulated a problem with how Colorado chooses its coroners. She has over two decades of experience as a board-certified medicolegal death investigator, conducting some 50,000 death investigations and participating in thousands of autopsies.
“It’s very concerning,” Romann said of the last election. “That’s why I believe standards have to be raised. The public doesn’t deserve to be put in the middle of someone’s inexperience.”
The problem, Romann said, is that more and more people are voting straight-ticket down the ballot for one party or another — regardless of their qualifications.
Ludwick received 36% of the vote — not enough to seriously challenge Romann, but significantly more than Kanye West-level support.
“I think everyone should be worried,” Ludwick said about people like her winning a coroner election.
Medical examiner system
There is another option for investigating deaths, one that has been recommended by medical associations for more than 150 years.
In 1928, the National Research Council released a report that recommended coroners be abolished and replaced with a medical examiner’s office “headed by a scientifically trained and competent pathologist.”
And in 2009, the National Academy of Sciences recommended Congress provide funds so state and local jurisdictions could switch to a medical examiner system.
These systems are already used in some places, but not others. Without a national mandate, cities and states around the country have a patchwork of 2,300 different death investigation systems, said Dr. Sally Aiken, president of the National Association of Medical Examiners.
“The thing about death investigations in the modern era is that a lot of the decisions are medical decisions,” she said.
Coroners who are not forensic pathologists cannot perform autopsies, so they are required with certain deaths to outsource the work to an outside pathologist. And that could be hours away in rural Colorado.
That’s how it is for Jerry Gray, who’s been coroner in tiny Hinsdale County since 2002.
Gray, who has a background as an EMS director, has never been challenged for the job, and deals with only four or five deaths a year.
The medical examiner system simply isn’t possible for a place like Hinsdale — year-round population of 850 — considering the doctor who staffs the clinic in Lake City commutes in from Gunnison, 55 miles away, Gray said.
“It might be fine in the Front Range with doctors all over the place,” he said. “But here it just doesn’t fly.”
A nationwide shortage of forensic pathologists makes staffing every county with one impossible, Aiken said. But there are regionalization models that are possible solutions, she said.
As the medical examiner for Spokane County, Washington, Aiken and her staff do autopsies for 14 surrounding counties. And in New Mexico, counties send bodies to Albuquerque from around the state, where a chief medical examiner is tasked with investigating all reportable deaths.
Romann said she recognizes that issue for rural Colorado, but says the large metro areas have no excuse. She’s been conferring with other coroners in the area, she said, as they have general discussions about what they want to push for as a larger Colorado Coroners Association — which would then bring it to the legislature.
“Personally, I believe that metro coroners should meet the higher standard of board-certification as professional medicolegal death investigators,” Romann said.
Keller, the Colorado Coroner’s Association president, said there may be a future need in larger communities for slightly more stringent requirements, but that he trusts voters to look at experience when they go to the ballot box.
“A lot of the time — specifically in more rural counties — it’s harder to find people with that experience,” Keller said.
Is change on the horizon?
Soper, the Delta lawmaker, become more attuned to laws and regulations surrounding the death industry after the Sunset Mesa case, in which the owners of a Montrose funeral home allegedly chopped up and sold body parts around the world without families’ consent.
After hearing from hundreds of victims, Soper spearheaded a bill to make it a felony in Colorado to abuse a corpse. Since then, he has found regulation and requirements on both coroners and the funeral home industry to be inadequate, he said. And seven months after Sunset Mesa’s owners were indicted by a federal grand jury, news broke of the alleged practices conducted by the Shannon Kent-owned funeral homes in Leadville and Gypsum, another indication for Soper that there’s a need for more legislation.
A month before November’s elections, Soper met with lobbyists for coroners and morticians to discuss a comprehensive bill that would add further regulations to those industries.
The legislative process is in its early stages, Soper cautioned, as coronavirus issues figure to dominate January’s General Session. But the lawmaker hoped to address a number of concerns in a possible bill, including: clarifying who has the authority to investigate coroners and morticians, adding a test — on par with what prospective lawyers have to take — to show someone is qualified to be a coroner, and adding more teeth to the Department of Regulatory Affairs to handle unlawful funeral homes.
“Everyone I talked to wants change,” Soper said. “They would like to regulate the professions, but it’s having that person who knows the industry help with the law-making process that makes it a real struggle.”
Another problem: Lawmakers don’t seem to be passionate about the topic, Soper has found.
“There’s the classic line in my profession,” said Aiken, the Washington medical examiner. “The dead don’t vote.”
This content was originally published here.