The education of a coroner

The education of a coroner, lessons in investigating death by John BatesonThe title The education of a coroner, lessons in investigating death by John Bateson was enough to make me buy the book. Which crime writer cannot use some lessons in death investigations?

The first half of the book is filled with those lessons. The author explains that he is interviewing and reviewing the career of Ken Holmes, the now retired coroner from Marin County, California.

The first case already holds a detail that I wish I could see one day. In the case of Ana Valiente (Dec 6, 2006) the Novato Fire Department uses a compressed-air separator to pull apart a smashed up car to search it for evidence. They find it.

Two Questions

On page 7, the author writes that he didn’t know much about death investigations and asked himself:

  1. How do coroners approach a death scene and what do they look for?
  2. How has the world of forensic pathology changed with advances in technology?

These are excellent questions. Alas, I did not get my answers in this book.

Bateson wrote a good book but it is about the career of Ken Holmes when he was the Marin County coroner. The author goes over many cases and indeed, Holmes does explain how he approaches a death scene and what he looks for. I will get into this below. But question number 2 remains unanswered.

There is nothing in this book that describes the advances made in forensic sciences and pathology. There is nothing about the new DNA technology or the advances in medical sciences that allow for better and more accurate descriptions of what caused a person’s death. In this aspect, the book disappoints.


Holmes explains a lot about the politics of being a coroner. Coroners are either elected or appointed depending on county and it can vary per county in one state. In other words, there is no uniformity. I asked some questions to my forensic friends on Twitter and even in procedures such as toxicology tests, there is no federal guideline or standard minimum procedure.

Ideally, coroners have some medical degree however, that is not a requirement. It would help raise the overall quality of death investigations with uniformity in reporting and archiving. You can think of centralized administrations by state, improving services in the more rural parts of a state, shared databases, and even spreading costs that may be initially high to set up such an office.

Why does this matter? Think about all the instances where you need a death certificate: life insurance pay outs, law suits, finalizing deeds, the execution of last wills and testaments, cancelling Social Security payment, canceling health care policies, arranging for a burial service, transporting the deceased across state lines, etc.


Holmes points out that a coroner must have a good understanding of medicine and forensics. This is an acquired skill. Second, you need to have compassion for the grieving family and circle of friends. This is an innate skill. Last, you need to be a skilled investigator. This is a skill that can be developed.

California does not require that their coroners are physicians but they are required to complete the same 22-week course that police officers must take to qualify. That is why coroners are often seen as an extension of law enforcement. Their investigations support police and in emergencies, they are to provide backup for police. As a result, California coroners are armed while on duty and must annually pass their proficiency test at the range.

Cause and manner of death

There is a huge difference between the cause and the manner in which someone died.

The cause of death is the physical reason why a person is dead e.g. gun shots, stab wounds to the heart, drug overdoses, blunt-force trauma, hanging, drowning, etc.

The manner in which a person died is one of five:

  1. Homicide: for a coroner these death investigations are the most intense as the autopsies require more work and depending on the progress police make new issues can pop up in such investigations. The coroner isn’t done until the police investigation is complete.
  2. Suicide: once this is established it stops all police involvement and the death investigation is done once the coroner is satisfied they have retrieved from the body all evidence to substantiate their findings. According to the book, in only 20% of all suicide cases there is a note.
  3. Accident: the premise is that the decedent could not prevent their own death so it might mean a less intense police investigation but only after everyone is satisfied that no other person’s blame was overlooked. The reports will note the decedent’s own carelessness or ignorance as it is a contributing factor in their death.
  4. Natural: according to the book, 60% of these cases are based on diseases.
  5. Undetermined: this may be the most frustrating category. Often there is not enough evidence to call it a homicide, etc. These cases can be re-examined if new evidence pops up but note this: the category of undetermined can be changed only once.

The author points out that on TV the manner of death is often called suspicious. Holmes says that they do not use that word. The word suspicious includes a weighing of facts and adding an opinion that something is wrong. Holmes would call something unusual meaning he would need to research and investigate indicating he doesn’t have all the facts yet on which to base his opinion.


Decomposition of the body starts at the moment you die. It is the breaking down of internal chemicals and bacteria that affect the body’s tissue and that starts the decaying process. The phase of decomposition helps the authorities establish the time of death.

Approaching a death scene

This part is answered in detail by Holmes and it is a treasure trove for writers. Holmes walks you through everything. Here goes:

After he has spoken to the first officer at the scene in private, he observes the death scene from a distance. He doesn’t immediately go to the deceased. He observes the structure/building they are in, watches and talks to family and friends who may be there, compares what he sees and hears to what the first officer on the scene said, and then starts his routine. Is there a pulse? If not, he nods at the family that it is true, their loved one is gone. Then he checks for signs of foul play. His initial inspection on the scene is as follows:

  • he pulls down the lower lip: if someone suffocated the skin may have been chewed up.
  • is the frenulum ripped, has the tongue been bitten? If so, it may be a sign of suffocation, a seizure or, of strangulation.
  • any broken fingernails? Possible signs of struggle.
  • check the eyes for petechia hemorrhages: these are little dots that form because blood vessels are broken in the white of the eye. They are small. In case of strangulation, we have a lack of oxygen and a cut off blood flow. The blood cannot flow back to the heart, starts backing up above the strangulation point, that pressure ruptures tiny arteries and petechia hemorrhages appear.
  • if people say the victim had a heart attack he lifts their shirts to check the skin colour. In case of a heart attack there is a slight difference between the skin colour from the heart down (normal) and from the heart up (now darker).
  • are the hands and fingers relaxed or cramped: cramped would show that shortly before the victim died they knew something was about to happen, so fear or pain. The same counts for the toes.

Holmes continues our lessons by explaining lividity, rigor mortis, and how temperatures affect the dead body. Then it is time to cover the autopsy. The importance of an autopsy goes beyond telling police how someone was killed. Examining every death expands our knowledge about the body, the trajectory of hereditary diseases, the age of onset for genetic malformations, environmental hazards that affected this person’s life, the competence of the medical care givers, the effectiveness of medications, etc.

Holmes describes his procedure, the tell-tale signs of the stomach content, and more (but not nearly enough for me) before the author switches back to cases again. He includes some experiences and cases Holmes investigated in San Quentin and explains the pull of the Golden Gate Bridge as the world’s top suicide spot.


The author’s writing style is informative but not engaging. It hinders the pace of the book.

As this book, contrary to the title, isn’t about death investigations in general but Holmes’ career, it is striking that the author never once questions or challenges Holmes. He never disagrees, never wonders what else could have been done, etc.

Bateson wrote an excellent book about Holmes’ career. But, as noted in the beginning, question number 2 is not discussed in this book. Holmes’ long career would have been perfect to compare advances in forensic sciences and especially, disputed sciences such as bite marks. It would have made the book complete.

Recommended reading for those starting to read up on death investigations.