When someone dies unexpectedly in Pennsylvania, authorities launch a death investigation. A quality investigation is important; it can be an effective tool to protect public safety and health.
In Pennsylvania, the person in charge of determining the cause of death and issuing a death certificate is either the county coroner or medical examiner. A 2003 report by the Institute of Medicine, Medicolegal Death Investigation System, described the difference between the two death investigation systems: “Coroners are elected lay people who often do not have professional training, whereas medical examiners are appointed and have board-certification in a medical specialty.”
There are 67 counties in Pennsylvania, of which, 62 elect a coroner, two appoint a coroner, and three appoint a medical examiner: Allegheny, Delaware, and Philadelphia.
All three PA medical examiners are physicians. PA coroners have a variety of backgrounds, including: physician, nurse, paramedic, police officer, and, most commonly, funeral director.
These are the requirements to become a coroner in Pennsylvania:
- 18 years or older
- A resident of your county for at least one year
- The most votes in the election
- Complete a one-week certification course within six months of your election
The coroner system has its roots in Colonial America. A coroner was the Crown’s representative responsible for investigating death. In 1877, Massachusetts became the first in the U.S. to replace the elected lay coroner with a physician medical examiner. New York City followed in 1918.
In 1951, Philadelphia was the first PA county to replace the coroner with a medical examiner. Delaware County was next in 1979, and after decades of failed reform attempts, Allegheny County got a medical examiner in 2005. Nationwide, 27 states, including Pennsylvania, still have coroner systems.
The coroner system is steeped in the vagaries of history rather than in a forward-looking, planned system that capitalizes on professional depth and knowledge.Medicolegal Death Investigation System, 2003
Overall, there is near unanimous consensus among the medical and legal communities that medical examiner systems are far better than coroner systems at protecting public safety and health. The National Academy of Sciences published its first recommendation on this subject in 1928, The Coroner and the Medical Examiner, recommending that, “the office of coroner be abolished. It is an anachronistic institution which has conclusively demonstrated its incapacity to perform the functions customarily required of it.” Since then, similar recommendations have been made in 1932, 1954, 1968, 1985, 2003, and 2009.
And yet, despite nearly a century of calls for reform, the vast majority of PA counties (95.5% of counties containing 73.9% of the population) still elect coroners. So why then do we still elect coroners instead of simply hiring a qualified medical professional? Ohio Coroner Carl Parrott, MD and Texas Medical Examiner Vincent DiMaio, MD argued: “The endurance of the coroner system is best explained by voter inertia, lack of awareness of the problem, and high capital expenditures for [medical examiner] system start up.”
Funding especially can be a major problem for a county-level death investigation system. As of the 2010 census Philadelphia and Allegheny counties were first and second in population with 1.5 million and 1.2 million. Delaware County is the fifth-most populous with 558,979. By contrast, Cameron, Sullivan, and Forest counties each have less than 8,000 people. It might not make sense to invest in county medical examiner systems in those areas due to high per capita cost and low demand for the service.
Professional medical examiner offices need a fair amount of public investment to function. Both Allegheny and Philadelphia’s medical examiners are the second-highest paid public employees in their counties with salaries of $187,391 (Karl Williams, MD, MPH) and $254,386 (Sam Gulino, MD).
But in Pennsylvania, the question is not if we should spend taxpayer money for professional death investigations, but if we’re spending taxpayer money well. In an attempt to professionalize the coroner system, the state requires that all elected coroners attend a taxpayer-funded one-week, 40-hour training course. That is still far less than the years of medical school and specialized training for professional forensic pathologists. Out of 64 coroners, only one is certified to conduct autopsies. The other 63 counties must hire physicians to conduct autopsies. So although the counties can hire coroners for about $100,000 less than a medical examiner, they still have to hire or contract with additional highly-skilled support staff to do the tasks that a coroner can’t. It’s not clear that system actually saves money.
Montgomery County’s elected coroner, Walter I. Hofman, MD, is the only coroner in Pennsylvania who is also a licensed forensic pathologist, and therefore the only coroner in the state who is certified to conduct autopsies. For years, Dr. Hofman has been critical of the system that has elected him. He recently announced his retirement after 50 years in forensic pathology, and told the Philadelphia Inquirer that Pennsylvania should end the political office of coroner and replace it with medical examiners who are hired based on their qualifications.
It seems clear that there is a huge gap in training and skill between most coroners and medical examiners, and the county-based system makes it difficult for smaller counties to hire professional medical examiners. Roughly half of the state’s population resides in nine counties (Southeastern PA and Allegheny County), and the other half spread out through the other 58 counties.
There is another problem with the county system. Lehigh County is home to two regional trauma centers, which serve much of the Northeast region of the state. As a result, a person who had an accident in Northampton County, just northeast of Lehigh, may be transported to Lehigh County for medical care. If that person dies in the hospital, the Lehigh County Coroner is now responsible for the death investigation. Recently Lehigh County Coroner Scott Grim has complained for years that Lehigh County taxpayers are paying for accident and criminal investigations that occurred in ten other PA counties. Lehigh County has been sending invoices to neighboring counties for 24 years, but they rarely receive a response.
It is possible to ensure that everyone in the state has access to the same service at a fair cost. Pennsylvania may be able to accomplish that through a regional or centralized statewide system.
The situation in Lehigh is already a quasi-regional death investigation system. Lehigh taxpayers are subsidizing investigations for ten of their PA neighbors. With a change in state law, those counties could reach an agreement to abolish all 11 offices of coroner and establish a regional Lehigh Valley Medical Examiner’s Office with full-time forensic specialists. Pooling money in this way could allow for a more centralized and professional office than any one county could afford on its own, and a similar concept is already practiced in the state with regional police departments. Many rural PA towns are too small to afford a professional police department, and in response have formed and empowered a regional policing authority. These offices are responsible for more territory, but the collective funding allows departments to hire more staff and more specialists including detectives and forensic experts. There are 19 regional police departments in Pennsylvania.
Sixteen states have centralized medical examiner offices. Forensic Pathologist Marcella Fierro, MD, said: “The major advantages of a statewide medical examiner system are the quality of death investigations and forensic pathology services and their independence from population size, county budget variation, and politics.”
The problem with both these statewide fixes is that they require changes in state law, and it isn’t a priority for Harrisburg. As the system stands, the quality of Pennsylvania’s death investigation varies from county-to-county. It seems clear that the county coroner system does not always work well, and it only requires the political will to fix it.