For at least 73 years, Idaho has known its coroner system was dysfunctional. For the same amount of time, the state was unable to make significant changes to it.
In a review of legislative documents and news archives dating back to 1951ProPublica uncovered a pattern that repeats itself nearly every decade as lawmakers, trade groups, public representatives, doctors, lawyers and even some reform-minded coroners seek to change the way deaths are investigated in Idaho.
ProPublica reported last month how coroner in eastern Idaho did not meet national standards to find out why 2-month-old Onyxx Cooley died in his sleep last winter. As the coroner would later tell ProPublica, Idaho law says nothing about meeting any standards. The law provides no oversight, state medical examiner or other resources to ensure each county has adequate access to autopsies.
Virtually unchanged since the late 1800s, the law says only that Idaho coroners are responsible for explaining the state’s most unexplained deaths.
But it has been well known for decades that Idaho’s ellipsis of 44 coroner’s offices leave grieving parents without answers when their children die; creates disparities in coroners’ inquests based on where a person died; and may even allow murderers to escape prosecution.
“The system needs total reform as a whole,” Dottie Owens, a former Ada County coroner, told ProPublica this year.
After Onyxx’s death, the coroner decided not to schedule an autopsy on the infant, travel to the scene, or speak with the family. Instead, he deferred to the emergency room doctor’s diagnosis of sudden infant death syndrome, or SIDS. Frustrated detectives called the coroner of a nearby county to see if he 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 Onyxx’s medical records. “We’ve done basically what I call an ‘autopsy,'” he said.
Onyxx died weeks before a state agency released a report to state lawmakers warning them about structural failures in Idaho’s coroner system. Lawmakers said they were stunned by the findings.
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By Natalie Behring for ProPublica
Idaho still entrusts death investigations to elected coroners, who have no oversight and no rules to follow, and whose budgets can rise and fall at the whims of other county politicians — unlike places like Washington, where state funding helps ensure certain stability.
There is no centralized authority that Idaho families or prosecutors can turn to when the coroner fails to meet standards. And nearly every county in Idaho lacks the facilities and pathologists to perform their own autopsies, so whenever they order an autopsy, the coroner must take the body to the morgue.
Idaho child death experts look to the coroner’s system
There is one nationwide group whose sole purpose is to find patterns and gaps in the safety of deaths that can help save children’s lives in the future.
The Child Mortality Review Group is among those who have flagged problems with Idaho’s coroner system for decades.
“Something has to happen,” said current team chairman Tana Barton.
In its annual reports on child deaths, the team has year after year highlighted the inconsistent performance of coroners who are underfunded, understaffed, under-trained and under-funded.
“We urge new legislation to create a statewide medical examiner system,” the group’s 1997 report said.
Since then, there have been no significant reforms.
In 2012, the team said it had received “problematic” documents from coroners detailing how one infant’s autopsy was performed only after his body had been embalmed, and how the death certificate of another did not match the autopsy.
Nine years ago, the team said Idaho’s population boom was putting a strain on coroner’s offices, which have “historically operated understaffed and on lean budgets and received no additional funding to support ever-increasing caseloads.” Since then, the state has consistently ranked among the fastest growing in the U.S., while few coroner’s budgets have kept up.
The group’s latest report on child deaths in 2021 says the problem remains: too many cases, not enough time and money.
Reforms fail because officials abandon control and spending
At every turn over the past 50 years, people interested in keeping Idaho’s coroner system as unregulated as possible have stopped attempts to change it.
It often comes down to money.
Idaho leaves it up to each coroner to decide whether to follow national standards, and to each county to decide whether the coroner has the means to do the job properly. As long as the state’s laissez-faire approach is in place, as it has been for decades, nothing will change, said Owens, the former Ada County coroner.
“We need state laws that outline the fact that, you know, babies should be autopsied if there’s no medical diagnosis. The problem is, if we go ahead and give it, who’s going to do it all? We don’t have the resources to do it all, and that’s half the problem,” Owens said.
This tension has hindered reforms since the last century.
When in January 1975 reformers worked to draft legislation that would change Idaho from an elected coroner system to one headed by the state medical examiner, funeral directors staged a preemptive strike. A local funeral director has warned commissioners in a rural county in northernmost Idaho that lawmakers could approve reforms that would result in “unincreased” costs for local governments. Commissioners “voted to write their legislators against it while it’s still in legislative committee,” a local newspaper reported.
It worked. A few weeks later, the lawmaker behind the proposal backed down, the state senator told the county’s local newspaper.
A group of law enforcement officials, attorneys, and the acting county coroner met again in November 1975 to prepare for another attempt.
We need state statutes that outline the fact that, you know, babies should be autopsied if there’s no medical diagnosis. The problem is, if we go ahead and give it, who’s going to do it all?
— Dottie Owens, former Ada County Coroner
The group wrote a proposal to eliminate the elected coroner system and instead hire a full-time medical examiner as Idaho’s state medical examiner. The part-time doctors will be appointed as District Heads with some medically trained assistants to assist them. Governor Cecil Andrus “supported the concept,” as reported at the time. The proposal never gained traction; news reports stated that this would require both an act of the legislature and a constitutional amendment.
Lawmakers tried again to improve Idaho’s system at the turn of the 21st century.
Two bills, in 1999 and 2000, created a state medical examiner’s office to oversee autopsies, support and train coroners, and provide what Idaho had never had before: a “unified protocol” for death investigations.
Two other bills, in 2003 and 2004, attempted a narrower scope: requiring autopsies in the case of sudden unexplained infant deaths.
None passed.
One of the bill’s authors, a Democrat from North Idaho, told a House committee in 2003 that her own child’s death was ruled SIDS without an autopsy, committee records show. “She said the parents deserved to know if the baby had died of SIDS, and an autopsy would relieve the parents of guilt.”
A woman whose grandchild’s sudden death in Idaho was attributed to SIDS also supported the reform, saying SIDS “is a terrible explanation for parents or grandparents. It’s like having your child kidnapped and never knowing what happened to them,” she wrote to lawmakers. “One start to finding the cause is exposure. We need standards set in such a way that a cause can be found to prevent this death. No one should have to feel the pain of losing a child, especially not knowing why.”
The reforms have received support from local and national groups, including the American Academy of Pediatrics, the National Association of Medical Examiners and state pediatric and fire associations.
The bills collapsed under pressure from local authorities and individual coroners. The State Coroners Association and the State Association of Counties made conflicting arguments: that the SIDS autopsy mandate was unnecessary because Idaho coroners were already performing autopsies on those deaths; but a mandate to do so “would require an increase in the budget of each coroner.”
According to a ProPublica analysis of nationwide death certificate data, Idaho ranks first in the nation in autopsies for SIDS-related deaths. Idaho also has the lowest rate of any state for autopsies performed on child deaths of unknown or unnatural causes.
And this February, Onyxx Cooley became part of that statistic.
