What Are the Differences Between Coroners and Medical Examiners?

When a person dies violently, unusually, or unexpectedly, challenging questions are sure to arise.

What exactly happened? Was it avoidable? Is there foul play involved? Was there a crime? Should we be concerned?

These are the kinds of questions that coroners, medical examiners, and forensic pathologists tackle daily. They are the ones responsible for seeking answers for the living.

"Morally, I believe our society can be evaluated by how we treat the deceased," says Gary Watts, the coroner of Richland County, South Carolina. "We discuss this often. It doesn't matter if we're dealing with someone found under a bridge or in a $5 million mansion. We'll treat them with respect and dignity. We'll care for their families."

However, many of America's death investigators — especially medical examiners and coroners, whose work is funded by taxpayers — struggle with a shortage of personnel, ongoing underfunding, and a general lack of appreciation for their work.

Regardless of whether people want to acknowledge it, these real-life Quincys are vital. Death investigators not only uncover potential foul play, but they can also identify infectious diseases and are often the first to detect epidemics and other public health threats.

Medical Examiners vs. Coroners

In May 2019, John Oliver, the host of HBO's 'Last Week Tonight with John Oliver,' delivered a 22-minute monologue addressing the state of death investigations in the United States. The focus was primarily on those responsible for investigating unusual deaths: coroners and medical examiners.

Although many people mistakenly use the titles of coroners and medical examiners interchangeably, they are not the same. A 2003 workshop by the U.S. Institute of Medicine (now called the National Academy of Medicine) explains the differences.

"Many people wrongly believe that death investigations must rely on either coroners or medical examiners," says Watts. "I believe it’s essential that all death investigators be professionally trained, no matter the system in place, whether it’s a coroner system or a medical examiner system."

Watts, who has a 40-year career as a coroner and a background as a police officer and EMT, explains that, in some areas of the U.S. — though not everywhere as John Oliver pointed out — the Richland County coroner's office employs medical examiners (usually physicians) to conduct autopsies. Deputy coroners handle the fieldwork, including death scene investigations, gathering medical records, and interviewing witnesses.

"We depend on the expertise of the medical examiner, the forensic pathologist, to provide us with the medical cause of death," he explains. "They establish the cause of death from a medical perspective. We, on the other hand, determine the manner of death through a detailed investigative process."

Consider, for example, a victim of a gunshot. Is it a homicide, suicide, or accident? Can we figure it out?

"You can't necessarily conclude that solely based on the autopsy," Watts states. "You need experienced investigators, death investigators, on the scene to assist with the process. Their work ensures not only the correct cause of death but also the correct manner of death."

How Death Investigations Differ by State

The Centers for Disease Control and Prevention report that states have a variety of systems in place to handle death investigations. Some states operate with a centralized medical examiner system, while others use a county or district-based approach, and some incorporate coroners in different ways.

The roles of coroner and medical examiner vary from state to state. In West Virginia, for example, a medical examiner doesn't necessarily need to be a doctor. In Georgia, it's possible for someone to serve as both mayor and coroner in towns with populations under 5,000. In Nebraska, the county attorney takes on the responsibilities of the coroner. Meanwhile, in Texas, justices of the peace are responsible for handling coroner duties.

Each state has its own criteria for determining when an autopsy or death investigation should take place. These differences contribute to a confusing and sometimes inconsistent system for managing death investigations across the country.

"On one side of the border, there is a state-run medical examiner and a well-organized death investigation system," said Ross Zumwalt, a medical examiner from Albuquerque, New Mexico, in a 2011 investigation by NPR, PBS and ProPublica. "On the other side, a small county coroner with limited resources and training may be in charge of the process."

One common issue across the board seems to be a lack of funding. This financial shortfall makes it difficult to attract qualified medical examiners or forensic pathologists (who can often earn better salaries outside of government work), and it’s becoming increasingly challenging to retain professionals with expertise in the field. Watts emphasizes that both are necessary for proper handling of death investigations.

"The medical examiner or forensic pathologist is only one part of the equation," Watts explains. "The field investigators are the other crucial piece. It’s not a matter of choosing one or the other; it’s an 'and' situation."

A Dysfunctional, Impaired System

In a 2012 report, the Scientific Working Group on Medicolegal Death Investigation highlighted several contributing factors to the shortage of forensic pathologists. Estimates suggest that fewer than 500 are currently practicing in the U.S. The reasons for this shortage include the scarcity of specialized training centers, inadequate funding to support these educational programs, high dropout rates, strained state and county budgets, and the resulting low salaries that discourage young people from pursuing this career.

This shortage may be leading to some concerning issues. A 2011 investigation by NPR, PBS, and ProPublica revealed that some jurisdictions were reducing the number of autopsies conducted when the cause of death appeared to be clear. Craig Harvey, a retired death investigator from the Los Angeles County Coroner's office, stated at the time, "We can't examine every case we should; when we're only looking at one-third of cases, the likelihood of missing a homicide increases significantly."

For Watts, who has personally participated in over 32,000 death investigations throughout his career, the root of these systemic issues always traces back to funding. If states fail to provide adequate resources to hire the right experts, these problems will continue to worsen.

"Death investigation offices are typically the last to receive funding," he explains. "It’s a problem that people either avoid, ignore, or simply don’t consider—until it directly impacts them. And then, suddenly, everyone demands answers and wants to know exactly what happened."