Idaho’s Coroner System Is “Broken and a Joke.” Here Are 5 Ideas From Coroners on How to Fix It.
by Audrey Dutton ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week. Since last year, ProPublica has been reporting on the troubled system for death investigations in Idaho, where a person’s cause of death is determined by elected coroners with no oversight or state support and, often, little training or education. The failures documented by ProPublica left parents without answers in their baby’s sudden death and let clues vanish in the death of a woman whose family suspected foul play by her husband, a man later charged with killing his next wife. The Idaho Office of Performance Evaluations in January sent the state’s coroners a formal survey about their work, drawing responses from just over half. The office told coroners that it wouldn’t attach names to their responses when it made the survey results public, and some gave unvarnished critiques. “The coroner system in Idaho is broken and a joke,” one wrote. They also took the opportunity to plead for help, for changes they believe could transform Idaho into a place where death investigations consistently meet national standards. Idaho coroners are elected to an office under county government control and funded by county budgets. Idaho politics have traditionally held the independence of local government as sacrosanct. This year’s state survey — and subsequent interviews by ProPublica — revealed a twist: Many coroners believe the state’s hands-off approach is outdated and harmful, making the quality of a person’s death investigation vary based on the county. These local officials want the state to get involved, and they want it badly. Jimmy Roberts of Bingham County, an agricultural area in eastern Idaho, is one such coroner. He worked with two interns in his office to draft a 118-page white paper that highlighted failure points in Idaho’s coroner system and described how states like Indiana and Arkansas addressed the same problems. In Indiana, as in Idaho, the county coroner is a constitutional elected office. But coroners in Indiana are subject to a suite of state laws that spell out what they must do. The policies that Roberts highlighted from those states include creating a state training council for coroners, defining in law which cases must be autopsied, raising money for coroners through fees on death certificates or paying for toxicology costs through alcohol taxes, and giving coroners “first responder” status so they can access mental health care for themselves and get a supply of naloxone for reviving people who overdose. Still, it’s unclear whether ideas like these will gain traction in Idaho after nearly 70 years of warnings and inaction on coroners. Gov. Brad Little’s criminal justice commission has begun to take a look at the coroner system, via a subcommittee it created this year that includes coroners, the state police forensics lab director, a state legislator and others — but no county commissioners have joined yet, leaving the group without input from the people who control coroner budgets. The subcommittee so far has drawn up a list of problems and brainstormed solutions — none of which it has endorsed — such as a state fund to help pay for autopsies, a forensic center in eastern Idaho to ramp up autopsy capacity or mandating autopsies in some child deaths. Coroners are not united in how to make the system better and what it will take to get there. Roberts, the Bingham County coroner, sent his 118-page report to fellow coroners and state legislators by email in October. But Roberts told ProPublica his offer to help the leaders of the Idaho State Association of County Coroners work on reform was “met with silence.” Jimmy Roberts, Bingham County’s coroner, in his office. He drafted a 118-page white paper that highlighted failure points in Idaho’s coroner system. (Natalie Behring for ProPublica) Torey Danner, the association’s president and a member of the governor’s subcommittee studying the issue, told ProPublica that his focus this year is on “low-hanging fruit” rather than major systemic changes. Asked about approaches that have gotten results in other states, he said he wants to review the root causes of Idaho’s problems before committing to any specific reform ideas, so that Idaho doesn’t unintentionally implement “Band-Aid” solutions in haste. Danner said he didn’t see Roberts’ 118-page report come through his email inbox in October but plans to read it after being contacted by ProPublica. He has not deeply studied the reforms in other states. “I haven’t taken the time because I haven’t had the time,” said Danner, one of the few coroners in Idaho to hold the job full time. “I mean, I’m still trying to do this and run my office, too.” Here are five concrete steps other Idaho coroners have suggested. 1. More autopsies Idaho has among the lowest autopsy rates in the U.S., with even worse rankings for autopsies in homicides and unexplained child deaths — and money is a factor. About 1 in 4 coroner’s offices answering this year’s survey said their budgets affect their ability to do autopsies. Madison County Coroner Sam Butikofer told ProPublica that when he took office in 2019, the county’s budget for grooming snowmobile trails was larger than the coroner’s. (County budget records confirm that.) Under Idaho’s current setup, each county sets an annual budget for its coroner’s office that estimates how many autopsies the coroner will have to order in the coming year. An autopsy in most parts of Idaho costs at least $2,300. Small counties in Idaho budget for less than a dozen a year, and a backcountry plane crash, a few unwitnessed deaths on the river, a spate of sudden infant deaths or the rare multiple homicide can quickly eat up the money that was set aside. Lacking the kind of funding other states use to help cover the cost of autopsies, Idaho coroners must decide between forgoing autopsies or blowing the budget and having to justify it to a