For decades, calls to reform Idaho’s troubled coroner’s system went unanswered

In a review of legislative records and news archives dating back to 1951, ProPublica found a pattern — repeated throughout most decades — of reform-minded lawmakers, trade groups, members of the public, doctors, lawyers and even some medical examiners pushing to change the way things are done in Idaho handles death investigations.

ProPublica reported last month that a medical examiner in eastern Idaho did not follow national standards to determine why 2-month-old Onyxx Cooley died in his sleep last winter. As the coroner later told ProPublica, Idaho law says nothing about compliance with any standards. The law provides no oversight, no state medical examiner and no other resources to ensure each county has adequate access to autopsies.

The law, virtually unchanged since the late 19th century, says little more than that Idaho coroners are responsible for solving the state’s most unexplained deaths.

But it has been known for decades that Idaho’s patchwork of 44 coroners leaves grieving parents without answers to their children’s deaths; creates inequalities in coroners’ investigations depending on where a person dies; and it may even be possible for murderers to escape prosecution.

“The system as a whole needs major reform,” Dotti Owens, former Ada County coroner, told ProPublica this year.

When Onyxx died, the coroner decided not to order an autopsy on the infant, go to the scene, or speak to the family. Instead, he left the diagnosis of sudden infant death syndrome (SIDS) to an emergency doctor. Frustrated investigators called the coroner of a neighboring county to ask if he could intervene.

In an interview with ProPublica last month, coroner Rick Taylor defended his handling of the death, saying he spoke to doctors and police at the scene and reviewed Onyxx’s medical records. “We basically did what I call a ‘paperwork autopsy,'” he said.

Onyxx died weeks before a state agency issued a report to state lawmakers warning of structural flaws in Idaho’s coroner’s system. Lawmakers said they were stunned by the results.

Idaho continues to entrust death investigations to elected coroners who have no control and few rules to follow, and whose budgets can rise and fall at the whims of other county politicians — unlike in places like Washington, where state funding provides some stability.

There is no centralized authority that families or prosecutors in Idaho can turn to when a coroner fails to adhere to standards. And nearly all Idaho counties lack the facilities and pathologists to perform their own autopsies. That’s why every time a medical examiner orders an autopsy, he has to take a body to a morgue several hours away.

Experts on child deaths in Idaho point to the coroner system

There is a nationwide group whose sole purpose is to find patterns and vulnerabilities in deaths that can help save children’s lives in the future.

The Child Fatality Review Team is among those who have been highlighting problems with Idaho’s coroner’s system for decades.

“Something has to happen,” said the team’s current chairwoman, Tahna Barton.

In its annual reports on child deaths, the team highlighted year after year the inconsistent work of coroners who lack adequate budgets, staff, experience and training.

“We strongly urge the introduction of new legislation to establish a state coroner system,” said the team’s 1997 report.

Since then there have been no significant reforms.

In 2012, the team said it received “problematic” documents from coroners outlining that an infant’s autopsy was only performed after his body was embalmed and that another’s death certificate was inconsistent with the results matched the autopsy.

Nine years ago, the team said Idaho’s population boom was placing a strain on coroners, who “historically operated with small staffs and tight budgets and were not provided additional funding to support ever-increasing caseloads.” Since then, the state has consistently ranked among the fastest-growing states in the U.S., while some coroner’s office budgets have kept pace.

The Child Fatality Review Team’s latest report on deaths in 2021 said the problem remains: too many cases, not enough time or money.

Reforms fail as officials refuse to control and spend

Over the past 50 years, people who had a vested interest in keeping Idaho’s coroner’s system as unregulated as possible have repeatedly abandoned their efforts to change it.

It often comes down to money.

Idaho leaves it up to each coroner to decide whether to meet national standards and to each county to decide whether the coroner has the resources to do the job properly. As long as the state’s heavy-handed approach continues, as it has for decades, nothing will change, said Owens, the former Ada County coroner.

“We need state laws that spell out the fact that infants should be autopsied unless there is a medical diagnosis. The problem is: If we go ahead and mandate this, who will do everything? We don’t have the resources to handle everything, and that’s half the problem,” Owens said.

This tension has thwarted reform efforts since the last century.

In January 1975, as reformers worked to draft a law that would have transformed Idaho from an elected coroner system to one with a state medical examiner, funeral directors organized a preemptive strike. A local funeral director warned commissioners in a rural county in northernmost Idaho that lawmakers could approve reforms that would impose “prohibitive” costs on local governments. The commissioners “voted to write to their legislators saying they oppose it while it is still in the legislative committee,” the local newspaper reported.

It worked. A few weeks later, the legislators behind the proposal backed down, a state senator told the county’s local newspaper.

A group of police officers, lawyers and a doctor who doubled as the county coroner met again in November 1975 to prepare for another attempt.

The group drafted a proposal to eliminate the elected medical examiner system and instead hire a full-time forensic pathologist as Idaho’s state medical examiner. Part-time doctors would be appointed to manage the district offices, assisted by a number of medically trained assistants. Gov. Cecil Andrus “supported the concept,” news outlet reports said at the time. The suggestion never gained traction; According to news reports, this would have required both an act of the legislature and a constitutional amendment.

At the turn of the 21st century, lawmakers again tried to improve Idaho’s system.

Two bills in 1999 and 2000 would have created a state medical examiner’s office to oversee autopsies, support and train medical examiners and provide something Idaho has never had before: a “unified protocol” for death investigations.

Two other bills from 2003 and 2004 attempted to have a narrower scope: They established an autopsy requirement for sudden, unexplained deaths of infants.

Nobody passed.

A sponsor of the bill, a North Idaho Democrat, told a House committee in 2003 that her own baby’s death without an autopsy had been ruled SIDS, according to committee records. “She explained that parents deserve to know whether the child died of SIDS and that autopsies could alleviate some of the parents’ guilt.”

A woman whose grandson’s sudden death in Idaho was attributed to SIDS also supported the reform, saying SIDS is “a terrible explanation to give to a parent or grandparent.” It’s like kidnapping your child and never find out what happened to him,” she wrote to lawmakers. “One way to find out the cause is through autopsies. We need to set standards so that a cause can be found that will help prevent this death. No one should experience the pain of losing a child, especially if they don’t know why.”

The reforms were supported by local and national groups, including the American Academy of Pediatrics, the National Association of Medical Examiners and state children’s and firefighters associations.

The bills failed under pressure from local governments and individual coroners. The state medical examiner’s association and the state county association made a conflicting argument: The mandate to autopsy SIDS deaths was unnecessary because medical examiners in Idaho already performed autopsies on those deaths. but a mandate to do so would “require an increase in each coroner’s budget.”

Idaho ranks last in the nation in autopsies for deaths attributed to SIDS, according to a ProPublica analysis of statewide death certificate data. Idaho also has the lowest rate of any state in autopsies performed on child deaths from unknown or unnatural causes.

And in February of this year, Onyxx Cooley became part of that statistic.

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