Coroners in Washington manage to investigate deaths despite untenable conditions
It isn’t often a coroner gets to deliver good news. Last week was an exception for Hayley Thompson.
The Skagit County coroner learned her office was awarded a $250,000 federal grant, seed money that will eventually fund a renovation to bring all of her operations under one roof.
Thompson told KNKX Public Radio that this will offer the county consistent control of death investigations. And it’s long overdue.
A year ago, I stood inside a cramped space that Thompson rents from Skagit Valley Hospital. In 2010, six years before she took over, the coroner’s office started using this former closet as a makeshift morgue. A decade later, it’s still the place Thompson uses for storing bodies and performing exams on those bodies.
It’s small, but it took an hour to finish the tour, with Thompson rattling off a long list of grievances:
The autopsy table “looks like something that came out of the 1950s,” and the nearby garbage disposal doesn’t work a majority of the time. A single outlet limits how many tools can be used during an autopsy. And one of those tools is either a fan or a heater, because temperature control is lacking. “We’ve had doctors that have come close to cutting themselves, because they can’t feel their hands.”
Lighting in the exam room is inadequate and awkwardly arranged, in part because of exposed pipes — some of which are used to hold tools, because of a lack of storage. The pipes sometimes shake when too much equipment is running at once.
Security is substandard. A single locking cabinet stores evidence, such as blood samples, alongside personal protective equipment. If supplies aren’t secured, they sometimes disappear. And there’s no way to track who at the hospital is coming and going.
The refrigeration unit is shared with the hospital and limited to storing a handful of bodies at a time. Unsecured, untreated plywood shelves that hold those bodies pose contamination risks — which could jeopardize the integrity of an investigation. And it’s unclear where any extra storage would come from in a mass-casualty event.
Above a loading dock outside, a pipe roughly 20 feet above the ground is aimed directly at the elevated entrance to a group of offices.
“Who knows if it’s contaminants or things like that,” Thompson said of the air coming from the vent.
Despite all those flaws, this morgue is an upgrade from what Skagit County used before. And if Thompson has her druthers, another upgrade will be underway by fall of next year.
Thompson is a proactive coroner. She has 15 years of experience as a trained death investigator, with a background in forensic anthropology. It’s why she’s advocating to move this space into her main office 10 minutes down the road. She understands the better the morgue, the better she can do the job voters elected her to do.
In the meantime, Thompson is stuck with the substandard facility she pays the Mount Vernon hospital $12,000 a year to use. Autopsies that should take about an hour end up taking at least twice as long in this space.
A setup like this, Thompson stressed, presents challenges that waste precious time.
“I would much rather spend my time working on the cases,” she said. “Every time we hit a roadblock, where we have to fix some minor thing, it gives us time to forget about something else that we need to be doing on that case.”
MORGUES ON ROTATION
Most of Washington’s coroners don’t even have what Thompson has: a dedicated space. If they’re lucky, they live close enough to one of six counties with a medical examiner’s office. Those offer fully stocked facilities with a full staff that sometimes extend space and help to under-resourced coroner offices. Spokane County is the only medical examiner office in Eastern Washington.
But if that’s not an option, those coroners are left cobbling together whatever space and resources they can find. And most of the time, all they have available is the local funeral home.
“When you don’t have a place of your own, and the funding isn’t available for it, you can’t even have your own staff to make removals, the funeral homes are the most sensible and likely choice,” said Roger Smith, a funeral home director at Coleman Mortuary in Hoquiam.
This story is the second in a three-part series examining the system of death investigation in Washington state. Read and listen to Part 1 here.
Coleman is one of three funeral homes in Grays Harbor County. All of them rotate on a monthly basis to assist Coroner Bob Kegel with transporting bodies, storing them, and providing space for autopsies to be performed.
Between the three facilities, there’s usually enough room.
“And then sometimes, we’ll call these folks — generally, as we say, after 5 o’clock and on a weekend — and they’ll say ‘We’re full,’” Kegel said.
When all of the on-call funeral homes are full, it’s a scramble to find space in a neighboring county. In one rare case, a family wanted to use the services of a funeral home in Olympia. But the need for an autopsy complicated things, Kegel said. The funeral directors there didn’t want the exam done in their facility, so the body was examined in yet another neighboring county.
“So the body went from the Elma area, to Olympia, down to Chehalis for the autopsy, and then back to Olympia for the final disposition,” Kegel said.
That meant the body traveled nearly 90 miles before it was laid to rest.
Kegel recognizes the monthly rotation is far from perfect. But he hasn’t been able to find a dedicated space, like the one in Skagit County. And building one isn’t cheap.
“We’re talking millions of dollars to build something from scratch,” Kegel said. “Grays Harbor is far from a wealthy jurisdiction.”
Kegel says it would only be feasible to build a dedicated facility if it was bundled with another county project, or in partnership with neighboring counties. With the economic fallout from the COVID-19 pandemic, a proposal like that is even further out of reach.
That’s true even for counties that are actively working to improve their existing coroner facilities. Nearly 100 miles away in Cowlitz County, the coroner has proposed upgrading his small facility to a brand new one. Construction and equipment costs for that project are estimated at $4.3 million — roughly $100,000 more than the anticipated budget deficit facing the county as a result of the pandemic.
So for now, coroners like Kegel in Grays Harbor and others across the state will keep sending bodies to be examined at funeral homes, even though they admit it’s not ideal.
“Those spaces were designed for embalming bodies, not doing autopsies,” Kegel said.
RACKING UP MILES
But where the autopsies are happening is only part of the problem. In Washington state, coroners are elected officials who aren't required to have medical training — meaning they can't perform autopsies. So coroners like Kegel have to rely on a handful of people who do have the training — traveling pathologists, who spend a lot of time in their cars driving across Washington state.
When I visited Kegel in his office at Grays Harbor Community Hospital in Aberdeen, he had finally scheduled an autopsy for a death that happened eight days earlier.
The reason for the delay? The doctor Kegel normally hires was on the road — a lot: “We were speaking and he says, ‘I just traded in my car. It had 300,000 miles on it.’”
Kegel was talking to Dr. Sigmund Menchel. He’s among the handful of traveling doctors who have crisscrossed the state, sharing autopsy work in coroner counties. That means driving hours from where they live, hauling their own equipment in pickup trucks to facilities that are too small, and lack sufficient lighting or storage.
These doctors serve a population of 2.5 million people across a large swath of Washington state. And in the past year, more than half of the traveling pathologists have retired — including Menchel.
Before he did, state records show Menchel was the second most active traveler between the summers of 2017 and 2019. He performed more than 250 autopsies in 11 counties. The work took him from Grays Harbor County near the coast, to Ferry County in northeast Washington, all the way down to the Tri-Cities and Walla Walla. It’s not unusual for a coroner to call their preferred pathologist and find out they’re on the opposite side of the state.
Now, the few remaining travelers are picking up slack for Menchel and others. But there’s an added complication, as a result of the pandemic.
Kegel says Dr. Eric Kiesel — one of his other go-to doctors, who traveled almost as much as Menchel in that two-year period ending in 2019 — will no longer come to Grays Harbor County to perform autopsies.
“He wants to work in facilities with proper ventilation and infection control,” Kegel said, something funeral homes can’t offer. “We don’t have that down here.”
Kegel now relies on First Call Plus, a Kent-based funeral transport service, to move bodies to the King County Medical Examiner’s Office for exams. That means bodies in the care of the Grays Harbor County coroner now travel 200 miles roundtrip when they require an autopsy.
“On the whole, it’s taking longer than it did before,” Kegel said of the new system.
COURTROOMS AND DEATH SCENES
Wahkiakum County has it a little easier. The preferred pathologist there — who is based over the border in Oregon — does most of his work in Southwest Washington. That means it’s more likely he’s around when he’s needed. And he has access to a small morgue facility in neighboring Cowlitz County.
But before Wahkiakum’s coroner can even call the doctor for an autopsy, he faces an additional challenge: simply getting to the death scene.
“If I’m in the middle of a jury trial, then it has to be somebody else or that scene with that dead body on it has to be held until I get there,” Dan Bigelow said, in an interview at his office in Cathlamet.
Bigelow wears a lot of hats. He’s the prosecutor in Wahkiakum County. When he’s not trying cases, he’s on call as a volunteer EMT. And — like 15 other prosecutors across the state — he’s also the county’s coroner. Sometimes, Bigelow will be called to a death scene in the middle of the night, hours before he’s due for an early-morning court appearance.
Despite the odd hours, Bigelow likes the job. But he says only about half of his colleagues feel the same.
Bigelow understands why. It’s not practical for a prosecutor to leave in the middle of a trial to respond to a death. And it’s not ideal for a death scene to sit for hours awaiting a coroner who is tied up in court.
“You can’t just slot another attorney in on the second day of a jury trial,” Bigelow said. “There’s only one person who can do that case. And that person can’t be in two places at once.”
With a population of about 4,000 people, and relatively few deaths to respond to as a result, Bigelow says it’s a much more manageable job in Wahkiakum than elsewhere in the state. He’s only had to leave death scenes a few times, and he says he’s left them in good hands — fellow EMTs and police officers.
“In other (prosecutor/coroner) counties with higher populations, they have an awful lot greater workload than I do,” Bigelow said. “And that means a lot more sleepless nights.”
KNKX reached out to prosecutors who also serve as ex officio coroners to get an idea of the number of autopsies performed on average each year in their respective counties (not all death investigations require a full autopsy). Of the 16 counties with the dual role, 10 responded with rough estimates*: Asotin: 4 Clallam: 60 Columbia: 2 Douglas: 10-15 Ferry: 5 Jefferson: 10-20 Klickitat: 24 San Juan: 12 Skamania: 15-20 Wahkiakum: 3-6 *Adams, Garfield, Lincoln, Okanogan, Pacific and Pend Oreille counties either didn't respond or couldn't provide an accurate estimate.
In some of those counties, deputy prosecutors help lighten the workload, doubling as deputy coroners. But after juggling both roles, many of them are left with little time to get proper training. And in some counties, like Bigelow’s, deputies are turned off by the work.
“They’d be happy to do the same job at the same money if they didn’t have to go out in the middle of the night and look at dead bodies,” Bigelow said. “It’s not only a recruitment difficulty, it’s a retention difficulty. And that’s been causing a lot of problems statewide.”
Then, there’s the potential conflict of interest when prosecutors assume coroner duties. If Bigelow prosecutes a case that requires testimony from the local coroner, he can’t put himself on the stand for questioning. That could pose a problem in a lot of cases, such as police using deadly force. In a case like that, the person determining the cause of death would be the same person arguing whether the death was justified.
And in at least one county in Washington, that conflict goes a step further. James Kennedy, the prosecutor/coroner in Jefferson County, says his office has a close relationship with deputies in the sheriff’s office. Those deputies also serve as deputy coroners — further blurring the line between agencies that are meant to operate independent from one another.
“I don’t think there is a single prosecutor/coroner in this state that thinks this is an ideal set up,” Kennedy said in an email to KNKX.
I don't think there is a single prosecutor/coroner in this state that thinks this is an ideal set up.
That’s not lost on Tim Davidson, the coroner in Cowlitz County who also serves as president of the Washington Association for Coroners and Medical Examiners.
“The medicolegal community (has) always been established as a third, independent investigative body,” Davidson said.
His organization is considering eliminating coroner duties for the 16 prosecutors across the state, including Kennedy and Bigelow. But moving away from the dual role could take years, because of election term limits. Eventually, Bigelow expects the issue to be resolved by the state Supreme Court.
“And when it does, what WACME is thinking of doing may end up being forced on us before we’re ready,” Bigelow said.
Davidson, WACME’s president, says the problems with prosecutor/coroner counties extend beyond potential conflicts of interest. He acknowledges that the only way an elected official can effectively carry out the duties of both jobs is if they have adequate support staff, which rarely is the case. Some attorneys actively avoid applying for open positions in those counties solely because death investigations are part of the gig.
Even traditional coroners struggle to find enough hours in the day for basic responsibilities, Davidson stressed. He said it can sometimes take weeks just to notify next of kin. Add to the equation a John or Jane Doe and a prosecutor/coroner who has to be in court eight hours a day, and the competing roles can feel nearly impossible to manage.
“This job’s a 24/7 office,” Davidson said. “Just like the fire department, just like the hospital, just like law enforcement.”
And sometimes, the extra workload can take prosecuting attorneys by surprise. Bigelow recalls one phone call he received immediately after an election, from an alarmed prosecutor-elect who was blindsided: “I just found out I’m coroner. How do I get out of this?”
NO CLEAR SOLUTION
So prosecutor/coroners of all stripes — those who enjoy the extra work and those who would rather do without it — admit the system is flawed.
But Bigelow says the state hasn’t been able to come up with anything better since its founding, more than a century ago. He says any solution would likely involve a regionalized approach, which he fears would move the people tasked with responding to death scenes further away from the communities they serve. He says that would disproportionately affect places in his rural county, which is more than 30 miles from the Interstate 5 corridor.
“Regionalization has never been the friend of the outlying area,” Bigelow said. He worries a regional solution would put the nearest death investigator in Longview or Vancouver, more than an hour away.
Experts say a death scene yields the best information when investigators respond quickly. Bigelow says even if he’s stuck in court when a call comes in, at least he’s a short drive away once he’s freed up.
“What I would like to see replace me is somebody better than me who lives where I do,” he said.
What I would like to see replace me is somebody better than me who lives where I do.
It’s unclear when and how that will happen. Earlier this year, Davidson and his colleagues with WACME were inching toward progress on a handful of other reforms that take priority, including improved training and certification for all coroner offices.
Right now, training is limited to a 40-hour lecture course that’s encouraged, not necessarily required, for a position responsible for determining how people died and signing off on their death certificates. Davidson and others are hoping to establish a statewide academy to provide 240 hours of hands-on investigative and medical training.
“That way we can ensure that it doesn’t matter if you die in County A or County B, the people that are coming out and doing those investigations are trained and know what their jobs are rather than just showing up,” Davidson said.
Davidson believes better training will solve a lot of the problems that exist statewide.
But those changes rely on action in the Legislature. State lawmakers are facing the fallout from the COVID-19 pandemic — a public health crisis that is far from over, and an economic crisis that state officials say will stay with us long after the emergency ends. It’s unclear how that will affect existing efforts to reform the system.
And for some residents in Washington’s coroner counties, any improvements that might emerge from Olympia — now or in the future — are already too late.
In the final part of our three-part series examining death investigation in Washington state, we’ll meet a woman in Central Washington who is still grappling with her mother’s death eight years later — and the stack of death certificates that left her with more questions than answers.