'A challenging way to practice medicine': Death investigation in Washington faces grim reality
Dr. Carl Wigren could stand in for just about any medical examiner as seen on TV. He’s witty, a fast talker who knows a lot about investigating deaths.
In fact, Wigren has been on TV, after testifying as an expert witness in high-profile criminal cases. He’s the guy you call when a death investigation furnishes more questions than answers.
And, Wigren says, that happens a lot more than you think.
“It’s the image that’s popularized on television crime shows,” Wigren told KNKX Public Radio, “that whoever is doing that autopsy really knows what they’re doing.”
But reality is a lot more complicated.
In Washington state and many states like it nationwide, the system of death investigation is a patchwork led by professionals with wide-ranging experience.
Only six counties in the state’s most populous areas rely on the work of medical examiners, doctors who specialize in forensic pathology. That means they are highly trained — even more than the average primary care provider.
Medical examiners manage a staff of investigators, perform autopsies and interpret toxicology results, among other medical duties necessary to determine causes of sudden, unnatural or suspicious deaths.
This story is the first in a three-part series examining the system of death investigation in Washington state. Read and listen to Part 2 and Part 3.
The remaining 33 counties, covering a population of about 2.5 million people, depend on elected coroners. In 17 counties, candidates only have to check two boxes to make it onto the ballot: they must be 18 years old and have a clean criminal record.
And in the state’s 16 least populated counties, prosecuting attorneys investigate deaths when they aren’t trying cases. In other words, they split their time between courtrooms and death scenes.
In all coroner offices, those elected officials are administrators who manage the death investigation process with little or no support staff, minus medical duties — because they often don't have the training.
While some coroners in Washington have prior experience related to death and medicine, such as mortuary work and nursing, others don’t have any relevant experience at all. Wigren says at one point, Eastern Washington’s roster of coroners included a former chimney sweep and a farmer.
That mixed bag can result in shoddy work, he says, which has consequences.
Death determinations inform what we know about rates of suicide and murder. They affect decisions on public policy and life insurance claims. They help public health officials identify clusters of deadly disease, or trends in drug overdoses.
On a more personal level, though, this work provides closure to families who are left with questions about the sudden death of a loved one. It helps children learn about previously unknown medical conditions in their parents, potentially preventing similar deaths for other family members. It even helps prosecutors determine whether police killings are justified.
And any mistakes or substandard work by untrained professionals has potential to disrupt that important public service. Missteps could interfere with homicide investigations or insurance payouts. Right now, it can affect data used to inform our response to the COVID-19 pandemic.
More simply, though, this work seals the final chapter of someone’s life.
“These are the individuals who are responding to your family’s death,” Wigren said, often under traumatic circumstances.
So, where you die determines a lot, including who responds and where they take your body for an autopsy. If you live in Pierce County and die unexpectedly more than 120 miles away in Wahkiakum County, your body and death certificate will be handled by an elected official you didn’t vote for.
Hayley Thompson, the coroner in Skagit County, doesn’t sugarcoat the problems facing her industry. She understands the weight of the job — a public service to the voters who elected her.
“As much as we don’t like to talk about death, it allows us to understand more about what we can do about the people who are living,” Thompson said during an interview at her office in Mount Vernon.
Thompson is among the more experienced coroners. She’s a trained death investigator with a background in forensic anthropology. She’s worked under medical examiners in Snohomish County and in Arizona’s largest county.
In both offices, she assisted with autopsies. But she can’t perform those exams in the office she holds now.
So, Thompson and 32 of her fellow coroners scattered across Washington have to rely on outside help. A small cohort of traveling forensic pathologists — highly trained, contracted doctors — crisscross the state year-round, performing hundreds of autopsies that elected officials can’t do themselves.
Wigren, who now owns a Renton-based private practice that consults on cases here and across the country, used to be one those travelers.
“I would pack up the back of my Toyota 4-Runner with a bunch of cases,” Wigren said. “And then bring that to the funeral home, and create a morgue that I could literally work out of.”
Right now, only a few of these pathologists are actively traveling in Washington. Each county has its go-to doctors, and many of them overlap.
“Our pathologists that contract for us, they also work for two or three other coroner offices,” Thompson said. “So, when we call them to ask for their assistance on a case, sometimes they already have plans to help another office out with a case.”
Thompson’s not kidding when she says they get around. State records show the most active traveling pathologist in 2019 was Dr. Emmanuel Lacsina of Tacoma. He performed more than 600 autopsies over a two-year period, billing more than $520,000 in fees.
Performance standards set by the National Association of Medical Examiners recommend forensic pathologists perform no more than 250 autopsies in a year, to minimize mistakes. Between the summers of 2017 and 2019, records show Lacsina’s average exceeded that standard. In that time, the work had him traveling between six counties spanning the length of the Olympic Peninsula: from Jefferson County to the north, down to Lewis County, and west to Grays Harbor County.
It’s not a glamorous gig. Burnout is common. In any given year, the most active travelers in Washington spend more time driving from county to county than they do performing autopsies.
And their workload is increasing. As of 2019, roughly a half dozen pathologists were doing all of the autopsies in a majority of Washington’s 39 counties. In the past year, more than half have retired or scaled way back, including Lacsina.
Dr. Eric Kiesel is among the few who remain active. In that two-year period ending in 2019, Kiesel performed more than 230 autopsies in 13 counties. The work had him traveling as far west as Clallam County and as far east as Adams County, roughly 400 miles apart. Now, Kiesel's distance traveled and volume of autopsies is likely to increase, as he and few others pick up the slack left behind by their retired colleagues.
Attracting people to replace outgoing travelers isn’t easy. The country’s pipeline of forensic pathologists is drying up. Only about 500 practice nationwide, and recruiting efforts are stagnant.
Becoming a forensic pathologist requires additional education beyond what’s standard for other medical specialties, which often pay at least double the average medical examiner salary. Additionally, only some counties — like King and Pierce — hire forensic pathologists to work in well-equipped facilities with a full staff.
Those who choose to take their work on the road, like the handful of doctors in Washington, can make a lot of money. But they must cover their own malpractice insurance and benefits. And they have to haul their own equipment to substandard or makeshift facilities, sometimes hours away from where they live.
That’s a hard sell for newbies coming into the business, says Wigren, who stopped traveling for this kind of work about five years ago.
“When I was really actively doing this, I would get a call from Benton County, which is the Tri-Cities,” Wigren said. “I would drive three and a half hours out, perform the autopsy, and then drive three and half hours back to Seattle.”
And sometimes, after walking in the door from that seven-hour road trip, Wigren would get another call from Benton County — looking for him to perform yet another autopsy.
“So then I would hop back in the car and drive all the way back, do the single autopsy, and then drive back to Seattle,” he said. “It’s a challenging way to practice medicine.”
A BREAKING POINT
So, elected officials and prosecutors are not cutting open dead bodies. But they are struggling to find people who can.
Wigren says that means some coroners, who lack medical training, sometimes draw blood and attempt to interpret toxicology results using textbooks and supplies they buy online.
“There are literally, in Washington state, people who are elected officials who are drawing blood on decedents,” Wigren said. “Some of them have some training or they've watched that happen. But I would say that most of them don't have any understanding of the anatomy of the body and where certain organs are.”
Wigren has firsthand experience with coroners playing doctor. He cites one case in Central Washington in 2012, in which a coroner incorrectly interpreted toxicology results for the sudden death of an elderly woman. The coroner determined the woman died by accidental drug intoxication. Wigren, who worked with the family to review the case, determined the woman likely died from natural causes.
There are literally, in Washington state, people who are elected officials who are drawing blood on decedents.
But examining a body is only half the job. If the death scene isn’t properly investigated, Wigren says, a traveling pathologist is at a disadvantage even before performing an autopsy.
“I would argue that the scene investigation of where that person died is critical in understanding how the death came to be,” Wigren said.
Often, he says, a traveling pathologist is forced to perform an autopsy in a vacuum of information, because a coroner didn’t take photographs or collect medical records. “So there is no context to understand the death scene,” Wigren said. In that 2012 case in Central Washington, the records Wigren used to reach his determination were never reviewed by the coroner he says got it wrong.
Experts say these gaps are bad news for public health data, which begins with forensic work and passes through state, national and even international health organizations.
A key function of death investigation is learning from the dead to help the living. That’s especially important now — in the middle of a pandemic. These frontline workers provide some of the most timely data to help public health officials better understand and respond to COVID-19. Gaps in coroner training and experience limit what we can learn.
“I’ve spent a lot of time, I’ve had my boots on the ground,” Wigren said. “I just don’t think the system that we have now works.”
With fewer boots on the ground, fanning across the state to assist coroners and prosecutors, the industry is at a breaking point.
That worries coroners, too, like Thompson in Skagit County. Despite its flaws, Thompson believes the system works. It just needs reforming to make it work better, she says.
“One of the hard parts of my job is trying to find people that are going to do a good job, care about what they do, and provide us the information that we need for the family, community and also to make the death certificate as accurate as possible.”
This story is the first in a three-part series examining the patchwork system of death investigation in Washington state. In Part 2, we’ll visit coroners in Skagit, Grays Harbor, Cowlitz and Wahkiakum counties, and get an up-close look at the challenges the elected officials there are facing.