Coroners in Washington lack clear oversight, leaving some families without closure | KNKX

Coroners in Washington lack clear oversight, leaving some families without closure

Oct 26, 2020

Nicole MacMaster remembers her mom, Frankie "Ellen" Schmitz, as a doting grandmother who loved to crochet. Christmastime was her favorite, and she always kept her house spotless. Nicole says she can practically smell bleach just thinking about her mom’s home, even all these years later. 

“She had a really good heart,” she said. 

Mother and daughter had their ups and downs, but they spent time together right up until the end. Nicole says she wouldn’t trade her for anything. 

But those happy memories are set against a backdrop of chronic pain. Ellen suffered from fibromyalgia for years. Doctors prescribed morphine to help her cope. 

“I guess we never really took the time to understand some things that she was going through,” Nicole said, holding back tears. 

In July 2012, Nicole’s time with her mom was suddenly cut short. 

Ellen, who was only 53 at the time, called her sister to tell her she was struggling to breathe. “She was out on their front porch slumped over and blue,” Nicole recalled. 

Paramedics revived Ellen at home and several more times on the way to Central Washington Hospital in Wenatchee, where she was placed on life support. At the time, the family didn't have many answers. Soon Nicole had to make the difficult decision to give her mom a large dose of morphine, to help make her as comfortable as possible. Ten minutes after Nicole told her mom it was OK to let go, Ellen died. 

This is the final story in a three-part series examining the system of death investigation in Washington state. Read and listen to Part 1 and Part 2.

That moment is still raw for Nicole. But many of her most painful memories from that time came in the weeks that followed. Those memories are the result of what can happen when families are left navigating Washington state's patchwork system of death investigation.

It started with a phone call from the Chelan County coroner. The family hoped he could offer some answers about Ellen's death. Instead, the conversation ended with more questions and, they say, a disregard for their grief. 

“All my mom’s sisters were there and my dad, and we got the call from Wayne Harris so I put him on speaker phone,” she said. “And he proceeded to say, ‘Your mother died of a drug overdose, you need to get over it.’” 

Coroner Wayne Harris declined an interview for this story, after several requests for comment. In an email response to KNKX Public Radio, Harris said he did recall speaking to Nicole on the phone that day. “I told her I would pend the death certificate until after testing of her admission blood comes back, which I did,” he wrote. “She didn’t seem at all surprised about my initial revelation to her.”

Harris added that there’s “not a chance in hell” he told the family to “get over it.” 

“I’ve never used those words in my 39 years of working with grieving families,” wrote Harris, who is a funeral home director by trade. 

Harris is one of 33 coroners in Washington state, elected officials who aren't required to have medical training or other relevant experience to investigate deaths in their counties. Coroners like Harris not only respond to death scenes, hire out for autopsies and sign off on death certificates, but a key function of the job is sitting down with families and carefully walking them through an investigation’s findings so they understand how a cause of death was determined. 

Nicole says she has no idea how the coroner reached his conclusion that day, even now. Nothing about the way her mother was found, or the days leading up to her death, pointed to drug abuse. Harris didn't order an autopsy to be performed. Toxicology results were still pending when he made that initial phone call to the family. Ultimately, Nicole and her family knew it was wrong for the coroner to seal Ellen's final chapter with a cause of death that painted her as an addict. 

For weeks, her search for answers resulted in lots of paperwork that didn't add up. “I have multiple different causes of death,” she said. “And none of them make sense.” 

I have multiple different causes of death. And none of them make sense.

In the days after Ellen died, the family says Harris never made an effort to talk to them about her medical history. Records show he didn’t investigate the scene where Ellen was found slumped over. Nicole also describes an unsympathetic encounter she had with Harris when she went to retrieve the records the coroner did have. He taunted her.  

Harris disputes those claims, too. He told KNKX in his written response that investigating the scene would have been useless, because he took over Ellen’s case days after she was found unresponsive. And he says he reviewed records released from the hospital.  

“Ms. Schmitz died in the hospital a day after being taken there," Harris wrote. "I did in fact have her records faxed to me. I have them in the file. (Two) days after she was transported from the scene by EMS, what information could I have gained by going to a scene that was most likely cleaned up by then?”

As for the taunting, Harris says that’s “patently false.”  

Five months after her mother’s death, Nicole received toxicology results that she says Harris either misinterpreted or ignored when he concluded her mother died from accidental drug intoxication. She asked someone at the lab in Seattle if the levels of morphine in her mom’s system were consistent with a fatal overdose. 

“The lady stated ‘no, there’s more people driving on the streets with the amount of morphine in their system that your mom had,’” she recalled. “It was not enough to kill her at all.” 

Today, Harris doesn’t dispute that he got it wrong. And Nicole says she has a stack of death certificates — six versions in total — that suggest he was never really sure what happened to her mom.

“I have one from 8-14-12, and then I have one from 1-16-2013, and I have another from 1-22-2013,” she said, rattling off dates listed on the amended death certificates. “They’re all a little different, but they’re all from Wayne Harris.” 

Nicole MacMaster sifts through some of the records she gathered in a thick binder after her mother's death in July of 2012. Tucked inside the binder are six different versions of her mother's death certificate, all issued by Chelan County Coroner Wayne Harris.
Credit Parker Miles Blohm / KNKX

A SECOND OPINION

Eventually, Nicole decided to take her mom’s death investigation into her own hands — and she’s got the binder showing her work. 

All six versions of her mom’s death certificate are tucked inside hundreds of pages of medical records. The binder captures years of documented treatment and an extensive medical history that Nicole says Harris failed to consider when he investigated her mom’s death. A copy of the coroner’s report obtained by KNKX doesn’t indicate he reviewed any records beyond those he retrieved from Ellen’s final hospital stay. 

So, Nicole decided to gather the fruits of her own investigation and seek a second opinion. 

“I took the binder and I shipped it to Carl Wigren,” she said. “He went through the entire thing and came up with a different death for my mom.” 

KNKX has reviewed the records Nicole sent to Dr. Carl Wigren, a forensic pathologist we met in Part 1 of this series. He worked on the case pro bono, after it was referred to him by a toxicologist at the state lab in Seattle — the one who previously talked to Nicole. The binder is still heavily marked up with post-its, scribbled with detailed medical notes from Wigren. He determined Ellen Schmitz likely died of natural causes: a blood clot to the lung. 

Dr. Carl Wigren sits in his office at his Renton-based private practice.
Credit Parker Miles Blohm / KNKX

Wigren took his findings to Harris. The coroner consulted a different forensic pathologist, and eventually changed the cause and manner of death — pulmonary thromboembolus, natural — one last time. 

“I feel like Carl helped seal my hurt,” Nicole said. 

That second opinion, which ultimately led to a resolution Nicole could live with, helped provide her family some closure. But help like that isn’t always available to other families across Washington state who are facing similar situations. 

If they believe a coroner botched an investigation, it’s not obvious where they can go to seek justice. These elected officials are beholden to voters, and to some extent their county governments — which are run by other elected officials who don’t have expertise in the field. Beyond ballot boxes, there’s no clear pathway to accountability and oversight for the state’s 33 coroners. 

And if a family manages to seek a second opinion from someone with more training who comes to a different conclusion, like Wigren did in Ellen's case, the coroner still has the final say on a person’s cause of death. The coroner may or may not choose to change the death certificate, even after that professional reaches a different determination. 

“I just don’t understand how you can elect someone into a position that has no medical background whatsoever and let them do an investigation on a body,” Nicole MacMaster said. 

OVERHAULING THE SYSTEM

This is just one case out of hundreds that are investigated across the state every year. And not all cases end the way Ellen’s did. But some officials are concerned that the system is prone to leaving families with questions — and nowhere to go to find answers.

State Rep. Tina Orwall is one of those officials. The Democrat from Des Moines has worked on legislation related to suicide prevention and data collection. It’s how she dipped her toe into the world of death investigations. 

“Families need answers, our community needs answers, and it really alarms me that something this important isn’t done in a way that’s consistent and uniform in our state,” Orwall told KNKX. 

She admits she still has a lot of research to do, and the learning curve is steep. But she knows enough to know the system needs help.

“Sadly I think it’s broken, and I feel so sad that it’s having impacts on families in our state,” Orwall said. “They deserve answers and accurate answers quickly.”

State Rep. Tina Orwall, D-Des Moines
Credit Parker Miles Blohm / KNKX

Industry leaders also want reforms. The Washington Association of Coroners and Medical Examiners acknowledges there are gaps in training. The group is working to create a statewide academy for coroners that would include 240 hours of hands-on training — significantly more robust than the 40-hour lecture course that exists now. President Tim Davidson believes the improved education will solve a lot of the problems that exist statewide.  

“We’re going to have role players. We’re going to have chaplains in there to help train our people on how to knock on that door at 2 o’clock in the morning to tell them that their child died in a car wreck on the way home last night," Davidson said. He added that the training would teach coroners how to properly go over findings with families and answer their questions.

But that plan isn’t off the ground yet, and it’s unclear how soon Davidson and his colleagues will gain traction in the Legislature in the midst of a pandemic and subsequent economic crisis. And a group of doctors in the state’s largest county says improved training, while important, isn’t enough. 

The King County Medical Society is lobbying state lawmakers, including Orwall, to establish a statewide medical examiner system. The group says the stakes are too high to continue under the status quo.

“The treatment and the care that a decedent receives throughout the state is inconsistent, and it wouldn’t be tolerated if the person was still breathing,” said Nancy Belcher, CEO of the medical society.

Belcher and her colleagues say many death investigations end before they even begin because of the way the system is designed. They argue death investigators are on the frontlines of justice, at a time when accountability for institutions is at the forefront of people’s minds. And they worry that the level of care exercised in these investigations depends too heavily on where someone lives. 

“The smaller the town, the less likely they’re going to receive the kind of death investigation that we should all have,” Belcher said.

Belcher says an ideal statewide system would provide well-equipped regional offices that guarantee uniform death investigations statewide. The plan is in the early stages of what is expected to be a long road toward overhauling the system, Belcher says, and the group faces the same obstacles in Olympia as the coroners association. 

The treatment and the care that a decedent receives throughout the state is inconsistent, and it wouldn't be tolerated if the person was still breathing.

But if Washington does forge ahead with a statewide system of regional medical examiner offices, it would join only a handful of systems like it in the country. The Pacific Northwest is home to just one statewide system, and it’s centralized not regionalized: Oregon’s medical examiner office is a division of the state police. Idaho, by contrast, has a system made up entirely of elected coroner counties. One effort to create a central forensic pathology department at the state level stalled earlier this year.

Gene Turley — the coroner in Twin Falls County, Idaho, who helped spur the effort — has stressed that any changes would still involve elected coroners.

“I don’t think switching to a state pathology department would change the coroner’s job,” he told KNKX. “It would only enhance the coroner system.” 

Belcher says her group’s plan wouldn’t necessarily exclude coroners from the death investigation process, either. They could play an important role in maintaining timely responses to death scenes, for example. What would change is the level of support and access to quality facilities that’s currently lacking.  

Belcher acknowledges something of this scale would be expensive to establish. But in the long run, she says, it translates to pennies on the dollar for counties that, in the meantime, will have to continue cobbling together whatever space and resources they can find.

James Paribello, a lobbyist for the King County Medical Society, is working to garner support for this overhaul from a growing list of lawmakers. Paribello says it’s hard not to sound hyperbolic when talking about what’s at stake. He says you can’t put a price on improving trust in a system that affects so many people — a system that’s reached a breaking point

“I think it’s a small price to pay in the grand scheme of things,” he said.

Nicole MacMaster says her family has already paid the highest price. 

“It’s still just confusing to me,” she said. “And I’ll never, ever know exactly what happened to her.”

What Nicole says she does know is that she’s one of the lucky ones. She got answers to some of her questions about her mother’s death, thanks to a forensic pathologist with the proper training to provide them.

Many in the industry say all families across Washington state deserve the same — no matter where their loved one dies.

And that type of investigation should be standard, not one that comes after mistakes have already been made. 

This is the final story in a three-part series examining the patchwork system of death investigation in Washington state. Read and listen to more in-depth reporting in Part 1 and Part 2.