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Idaho has known for at least 73 years that its pioneer-era coroner’s system isn’t working. For an equally long time, the state has been unable to make any meaningful changes to it.
ProPublica examines legislative records and news archives dating back to 1951, uncovering a pattern in which reform-minded lawmakers, industry groups, the public, doctors, lawyers, and even some coroners sought to change the state of Idaho. (recurs approximately every 10 years). In charge of death investigation.
ProPublica reported last month that a medical examiner in eastern Idaho failed to follow national standards to determine why 2-month-old Onyx Cooley died in his sleep last winter. As the coroner later told ProPublica, Idaho law says nothing about following standards. The law does not provide oversight, a state medical examiner, or other resources to ensure counties have adequate access to autopsies.
The law, which has remained largely unchanged since the late 1800s, simply states that Idaho coroners are responsible for accounting for the state’s most mysterious deaths.
But Idaho has a patchwork of 44 coroner’s offices, and for decades it has been well known that some parents grieve without answers after their child’s death. There are disparities in the coroner’s investigation depending on where the person died. And it may even be possible for murderers to escape prosecution.
“The whole system needs complete reform,” former Ada County Coroner Dottie Owens told ProPublica earlier this year.
Following Onyx’s death, the coroner decided not to order an autopsy on the baby, not to go to the scene, and not to speak to the family. Instead, the emergency room doctor’s diagnosis of Sudden Infant Death Syndrome (SIDS) was deferred. Frustrated, detectives called the coroner in a neighboring county and asked if they could intervene.
In an interview with ProPublica last month, Coroner Rick Taylor defended his handling of the death, saying he spoke with doctors and police at the scene and reviewed Onyx’s medical records. “We basically did what I call a ‘paper autopsy,'” he said.
Onyx died weeks before state officials released a report to state lawmakers warning of structural flaws in Idaho’s medical examiner’s system. Lawmakers said they were stunned by the findings.
Diamond and Alexis Cooley hold a photo of their son Onyx, who died in his sleep in February in eastern Idaho. Credit: Natalie Behring for ProPublica
Idaho continues to delegate death investigations to elected coroners, who have no oversight, few rules to follow, and whose budgets rise and fall at the whims of other county politicians. Possibly — unlike in places like Washington, where state funding provides some stability.
There is no central agency that families and prosecutors in Idaho can sue if coroners do not follow standards. And because nearly every county in Idaho lacks the facilities or pathologists to perform their own autopsies, coroners must drive bodies to a morgue several hours away each time they order an autopsy. have to be carried.
Idaho child death investigator points out coroner system
There is one group that works across the state, and its sole purpose is to find patterns in deaths and safety gaps that could help save children’s lives in the future.
The Child Death Investigation Team is one of several teams that have been pointing out flaws in Idaho’s coroner system for decades.
“Something needs to happen,” said Tana Barton, the team’s current president.
In its annual report on child deaths, the team cited inconsistent work year after year by coroners who lacked adequate funding, staffing, experience and training.
The team’s 1997 report “strongly urges the introduction of new legislation to establish a national medical examiner system.”
No major reforms have been made since then.
In 2012, the team released a “controversial” document detailing how one infant’s body was not autopsied until after it had been embalmed and how another infant’s death certificate did not match the autopsy results. He announced that he had received a document from the coroner.
The team said nine years ago that Idaho’s booming population was putting a strain on the medical examiner’s office, which had “historically operated under a small staff and budget to support an ever-increasing number of cases.” “We have not received any additional funding to do so.” Since then, the state has consistently ranked as one of the fastest growing states in the country, but most coroners’ budgets have not kept pace.
The Child Death Investigation Team’s latest report on deaths in 2021 said the problem remained, with too many cases and not enough time or funding.
Reforms fail as authorities refuse to monitor and spend
At every juncture over the past 50 years, those with a vested interest in keeping Idaho’s coroner’s system as unregulated as possible have halted efforts to change it.
It often comes down to money.
In Ida, it is up to each coroner to decide whether to follow national standards, and it is up to each county to decide whether the coroner has the funds to do his or her job properly. Owens, a former Ada County coroner, said nothing will change as long as the state continues to take a hands-off approach, as it has for decades.
“We need a state law that outlines the fact that infants should be autopsied unless there is a medical diagnosis. The question is, if we go ahead with this and make it mandatory, who’s going to do everything? I We don’t have the resources to do it all, but that’s half the problem,” Owens said.
That tension has hampered reform efforts since the last century.
In January 1975, as reformers were working on drafting a bill that would change Idaho from an elected coroner system to one led by the state medical examiner, funeral directors organized a preemptive strike. A local funeral director warned commissioners in Idaho’s northernmost rural county that lawmakers could approve reforms that would create “exorbitant” costs for local governments. A local newspaper reported that members “voted in favor of submitting a letter of opposition to members of Congress during a legislative committee meeting.”
It worked. A few weeks later, the legislator who supported the proposal withdrew it, a state senator told the county’s local newspaper.
A group of law enforcement officials, attorneys, and a doctor who also served as the county medical examiner met again in November 1975 to prepare for a new trial.
There needs to be a state law outlining the fact that unless there is a medical diagnosis, infants should be autopsied. The question is, if we go ahead with this and make it mandatory, who will do everything?
—Dottie Owens, former Ada County Coroner
The group has developed a proposal to eliminate the elected coroner system and replace it with a full-time forensic pathologist as Idaho’s state medical examiner. A part-time physician will be appointed to head the regional office, and a medically trained assistant will assist them. Gov. Cecil Andrus “supported the concept,” according to a Telegraph report at the time. This proposal never received attention. According to news reports, this required both an act of Congress and a constitutional amendment.
Around the beginning of the 21st century, legislators again attempted to improve the system in Idaho.
Two bills in 1999 and 2000 created a state medical examiner’s office to oversee autopsies and support and train medical examiners, creating what Idaho had never done before: a “uniform system” for death investigations. protocol” was to be provided.
Two other bills, in 2003 and 2004, sought to address a narrower scope, establishing autopsy requirements for sudden unexplained infant deaths.
No one passed.
One of the bill’s sponsors, a Democratic congressman from North Idaho, testified before a House committee in 2003 that his baby’s death was determined to be SIDS without an autopsy, committee records show. It became. “She said parents have a right to know whether their infant died of SIDS, and an autopsy could relieve some of the parents’ guilt.”
An Idaho woman whose grandchild’s sudden death was attributed to SIDS also supported reform, saying SIDS is “a terrible thing to explain to parents and grandparents.” It’s like having your child kidnapped and having no idea what happened,” she wrote to lawmakers. “Discovering the cause began with the autopsy. Standards need to be set so that we can identify the cause to prevent this death from occurring. No one should ever experience the pain of losing a child, especially the pain of not knowing why. You shouldn’t.”
The reform had support from local and national organizations, including the American Academy of Pediatrics, the American Association of Physician Examiners, state pediatric associations, and firefighters associations.
The bill died under pressure from local governments and individual coroners. The State Medical Examiners Association and the State Association of Counties made contradictory claims. Because the Idaho coroner already performed autopsies on SIDS deaths, there was no need for autopsies on SIDS deaths. But a mandate to do so would “require an increase in the budgets of all coroners.”
According to ProPublica, which analyzed death certificate data from around the country, Idaho ranks last in the nation in the number of autopsies for SIDS deaths. Idaho also has the lowest autopsy rate of any state for children who die from unknown or unnatural causes.
And in February of this year, Onyx Cooley became part of that statistic.
