Who probes suspicious deaths? It may not be who you think

(Photo by Mathew Schwartz, Unsplash)

A chronically underfunded system riddled with egregious conflicts of interest. That's one way to describe the state-by-state system that governs U.S. coroners, reports Samantha Young of Kaiser Health News. The meshwork is so sticky, one physician shared this observation with Young: "If you ever want to know when, how — and where — to kill someone, I can tell you, and you’ll get away with it. No problem."

Nancy Belcher, chief executive officer of the King County Medical Society in Seattle, told Young that in Washington, "A coroner doesn’t have to ever have taken a science class in their life. These are the people that go in, look at a homicide scene or death, and say whether there needs to be an autopsy. They’re the ultimate decision-maker."

How suspicious death is investigated varies from state to state, and even within states. "The job can be held by an elected coroner as young as 18 or a highly trained physician appointed as medical examiner," Young reports. "Some death investigators work for elected sheriffs who try to avoid controversy or owe political favors. Others own funeral homes and direct bodies to their private businesses. . . . It’s a disjointed and chronically underfunded system — with more than 2,000 offices across the country that determine the cause of death in about 600,000 cases a year."

The cost to hire medical examiners or properly train coroners is disproportionately difficult for rural areas, Young reports: "Many Illinois counties also said they would shoulder a financial burden under legislation introduced last year by state Rep. Maurice West, a Democrat. His more sweeping bill would have replaced coroners with medical examiners. Rural counties, in particular, complained about their tight budgets and killed his bill before it got a committee hearing. West told Young, “When something like this affects rural areas, if they push back a little bit, we just stop."

Dr. Jeffrey Jentzen, a former medical examiner for Milwaukee, told Young, “When you try to remove them, you run into a political wall. You can't kill them, so you have to help train them." Young notes that a 2011 study by the National Association for Medical Examiners "found that 82% of the forensic pathologists who responded had faced pressure from politicians or the deceased person’s relatives to change the reported cause or manner of death in a case."

Lawmakers have made some progress by allowing counties to "pool their resources and hire shared contract coroners in exchange for ending the dual role for prosecutors by 2025," Young writes. Belcher told Young, “We were just trying to figure out a system that I think anybody would agree needed to be overhauled."

Many coroners lack training, raising doubts in Pennsylvania on whether the local office should still be an elected one

Many of Pennsylvania's county coroners and medical examiners "lack adequate funding, transparency, and training," Ashad Hajela reports for Spotlight PA, in the latest of many such stories from many states over many years. Most Pennsylvania coroners, are elected but only five of the state's 67 counties have an accredited coroner or medical examiner. In many rural counties, "challenges are exacerbated because many coroners don’t have access to the labs and specialists who help investigate deaths," Hajela writes.

The rural coroners are less likely to have accreditation than their urban counterparts, a study from the state-run Center for Rural Pennsylvania finds. Those rural coroners also often have to "bear the burden of additional costs of transportation and lack of personnel because of their location," Hajela writes. 

Experts have long debated whether coroners should be elected. Christina VandePol, a former coroner and one of the study's authors, said elected coroners are able to work independently from counties so they're not always at the whim of district attorneys or county officials. "This autonomy can be important for investigating deaths like those in county jails. VandePol explained that because of her office’s independence, she was able to release the names of nursing homes that had more Covid-19 deaths while she was under pressure not to," Hajela reports. Conversely, elected coroners may be unqualified for the job. If a medical examiner was hired in they wouldn't have to meet residency requirements needed to run for office, "which allows counties to attract applicants beyond the county’s boundaries."

Rural coroner made the tough call on local opioid epidemic

Coroner Steve Talbott, in his funeral home
(Photo by Michael S. Williamson, The Washington Post)

How many rural coroners, witnessing death after death from opioid overdoses, would call police in an effort to see how their county was being inundated by the misused prescription drugs? We don't know the answer to that question, but we do know what funeral director Steve Talbott, the elected coroner of Clinton County, Kentucky, for the last 25 years, did. He made the calls, and one result was the conviction of a local physician who shared a building with the pharmacy that dispensed more opioids per person per county in 2006-12 than any in the U.S.

Jenn Abelson, Andrew Ba Tran, Beth Reinhard and Aaron C. Davis of The Washington Post reported the story last week, following the Post's publication of other stories drawing on the Drug Enforcement Administration database for those years. Their story is a look at the opioid epidemic from the bottom up, in Albany, Paintsville and Booneville, Ky.; Kanab, Utah; and Carthage, Tenn., where pharmacies were funnels for large volumes of painkillers.

When Talbott responded as coroner to an overdose death, the Post reports, "Friends and relatives of the dead rarely had answers to Talbott’s questions: What kind of pills did they take and where did they come from? A toxicology report often answered the first question. It was the second one that typically eluded Talbott. As overdose deaths soared, Talbott repeatedly called the state police, hoping they could identify the source of opioids poisoning his community."

Clinton County (Wikipedia map)

Since 2006, 41 people have died of prescription opioid overdoses in the county of 10,000. Talbott told the Post that law enforcement took far too long to pay attention. "The federal investigation began in 2015 after Talbott noticed multiple overdose deaths involving patients of a local physician, Michael L. Cummings, and the Kentucky Board of Medical Licensure expert found Cummings’s treatment of several patients fell below minimum standards of care, court records show," the Post reports. "In 2017, Cummings was charged in federal court with the illegal distribution of controlled substances, which resulted in the deaths of three patients." He pleaded guilty in March to 13 counts of illegally prescribing controlled substances, and was sentenced July 24 to 30 months in prison and fined $400,000. Cummings had his medical practice in the same building as Shearer Drug.

The Post reports, "The 6.8 million opioid pills bought by Shearer Drug from 2006 through 2012 accounted for 66 percent of the total ordered by the county’s five pharmacies, according to The Post’s analysis." When Talbott heard those figures from the Post, he told the newspaper: “It’s a lot of pain medication for this little town.”

"Talbott, who said he grew up with [pharmacist Kent] Shearer and attended the same school, hasn’t talked to the pharmacist in a few months," the Post reports. "Talbott said the overdose deaths have waned since Cummings was indicted in 2017, but the epidemic is far from over." He told the paper, “There were just too many people dying from these drugs in such a small place. I hate these drugs. They are awful.”

Kentucky partnership creates system to track drug overdoses, to help fight opioid epidemic

Kentucky has been hit hard by the opioid epidemic, but the state is trying to fight it with innovative efforts to gather more specific data about overdose deaths. The Kentucky Injury Prevention and Research Center, a partnership between the state Department for Public Health and the University of Kentucky College of Public Health, built a "drug-overdose fatality surveillance system" that combines information sources like death-certificate information, post-mortem toxicology analysis, and victims' prescription history to get a better picture of which drugs are killing people and under what circumstances.

"The efforts that KIPRC and the state have made to improve this data have led to crucial findings, including that Kentucky’s crisis isn’t one crisis, but many," Kathryn Casteel reports for FiveThirtyEight. "Different parts of the state are afflicted with different drugs. Northern Kentucky, for example, has a high prevalence of heroin and fentanyl — a synthetic opioid that is more deadly than heroin and other types of opioids — while in the eastern part of the state, prescription opioids are still the main concern.

KIPRC chart; click on the image to enlarge it.

"We’re not doing this for the sake of research," Svetla Slavova, a biostatistician with KIPRC, told Casteel. "We provide actionable data for policymaking, treatment and prevention. We’re trying to be responsive and provide data that will help make these decisions." Because of KIPRC's research, Van Ingram, the executive director of the Kentucky Office of Drug Control Policy, said he was able to push legislation increasing the availability of the anti-overdose drug naloxone.

One of KIPRC's biggest efforts is to make death-certificate information more uniform across the state, because "even the smallest differences in language can leave overdose deaths uncounted," Casteel reports. Sarah Hargrove, a data management analyst for KIPRC and former autopsy technician for the state, is spearheading the effort. It's tough going, since some coroners in the state's 120 counties, many of them small, have limited resources and funding, and many have little medical experience.

But KIPRC is making headway. "Researchers were able to determine the specific drugs that were involved in 97 percent of drug overdose fatalities in 2016; that’s compared with 82 percent using death certificates alone," Casteel reports. The also used the surveillance system "to find which drugs were most commonly involved in deaths linked to a combination of substances, as well as which drugs were involved in overdose deaths among people of different age groups and genders."