For Decades, Calls for Reform to Idaho’s Troubled Coroner System Have Gone Unanswered

Idaho has known for at least 73 years that its frontier-era coroner system does not work. For just as long, the state has failed to make meaningful changes to it.

In a review of legislative records and news archives going back to 1951, ProPublica found a pattern — repeating almost every decade — of reform-minded legislators, trade groups, members of the public, doctors, lawyers and even some coroners pushing to change how Idaho handles death investigations.

ProPublica reported last month how a coroner in eastern Idaho didn’t follow national standards to figure 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 following any standards. The law provides no oversight, no state medical examiner and no other resources to ensure each county has adequate access to autopsies.

Almost unchanged since the late 1800s, the law does little more than say Idaho’s coroners are responsible for explaining the state’s most inexplicable deaths.

But for decades, it’s been well known that Idaho’s patchwork of 44 coroner’s offices leaves grief-stricken parents without answers in their children’s deaths; creates disparities in coroners’ investigations based on where a person dies; and may even allow murderers to escape prosecution.

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

In the death of Onyxx, the coroner decided not to order an autopsy for the infant, go to the scene or talk with the family. Instead, he deferred to an emergency room doctor’s diagnosis of sudden infant death syndrome, or SIDS. Frustrated detectives called a neighboring county’s coroner to see if he could intervene.

In an interview with ProPublica last month, the coroner, Rick Taylor, defended how he handled the death, saying he talked with doctors and police on the scene and looked at Onyxx’s medical records. “We did basically what I call a ‘paperwork autopsy,’” he said.

Onyxx died weeks before a state agency issued a report to state legislators that warned them of structural failures in Idaho’s coroner system. Legislators said they were stunned by the findings.

Idaho continues to entrust death investigations to elected coroners, who have no oversight and few rules to follow, and whose budgets can rise and fall on the whims of other county politicians — unlike in places such as Washington, where state funding helps provide some stability.

There’s no centralized authority to whom Idaho families or prosecutors can appeal when a coroner doesn’t follow standards. And nearly all of Idaho’s counties lack the facilities and pathologists to do their own autopsies, so a coroner must drive a body to a morgue hours away every time they order an autopsy.

Idaho Child Death Reviewers Point to Coroner System

There is one statewide group whose sole purpose is to find patterns and safety gaps in deaths that may help save children’s lives in the future.

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

“Something needs to happen,” the team’s current chair, Tahna Barton, said.

In its annual reports on child deaths, the team pointed year after year to the inconsistent work by coroners who lack sufficient budgets, staffing, experience and training.

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

There have been no significant reforms since then.

In 2012, the team said it received “problematic” documents from coroners detailing how one infant wasn’t autopsied until after its body was embalmed and how another’s death certificate didn’t match what the autopsy found.

Nine years ago, the team said Idaho’s population boom put a strain on coroner’s offices, which “historically operated with small staff sizes and lean budgets and have not received additional funding to support ever-increasing caseloads.” Since then, the state has consistently ranked among the fastest growing in the U.S., while few coroners’ budgets have kept pace.

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

Reforms Fail as Officials Refuse Oversight and Spending

At every turn in the past 50 years, people with a vested interest in keeping Idaho’s coroner system as unregulated as possible have halted efforts to change it.

It often comes down to money.

Idaho leaves it up to each coroner to decide whether to follow national standards and up to each county to decide whether the coroner has the funds to do the job right. As long as that hands-off approach by the state holds, as it has for decades, nothing will change, said Owens, the former Ada County coroner.

“We need to have state statutes that outline the fact that, you know, infants should be autopsied unless there’s a medical diagnosis. The problem with that is, if we go ahead and we mandate that, who’s going to do it all? We don’t have the resources to do it all, which is half of the problem,” Owens said.

That tension has thwarted reform efforts since last century.

As reformers worked in January 1975 to draft legislation that would have changed Idaho from an elected coroner system to one headed by a state medical examiner, funeral home directors organized a preemptive strike. A local funeral director warned commissioners of a rural county in northernmost Idaho that lawmakers might approve reforms that would create “prohibitive” costs to local governments. The commissioners “voted to write their legislators opposing this while it is still in legislative committee,” the local newspaper reported.

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

A group of law enforcement officials, attorneys and a physician who doubled as county coroner met again in November 1975 to gear up for another try.

We need to have state statutes that outline the fact that, you know, infants should be autopsied unless there’s a medical diagnosis. The problem with that is, if we go ahead and we mandate that, who’s going to do it all?

The group wrote a proposal to scrap the elected coroner system and instead hire a full-time forensic pathologist to serve as Idaho’s state medical examiner. Part-time physicians would be appointed to head district offices, with some medically trained assistants to help them. Gov. Cecil Andrus “endorsed the concept,” according to wire reports at the time. The proposal never gained traction; news reports said it would have required both an act of the Legislature and a constitutional amendment.

Lawmakers again tried to improve Idaho’s system around the turn of the 21st century.

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

Two other bills, in 2003 and 2004, tried to take a narrower scope: setting an autopsy requirement for sudden unexplained infant deaths.

None passed.

One bill sponsor, a Democrat from North Idaho, told a House committee in 2003 of her own baby’s death being ruled SIDS without an autopsy, the committee records show. “She stated that parents deserve to know if the infant died of SIDS and autopsies could relieve some guilt for the parents.”

A woman whose Idaho grandson’s sudden death was attributed to SIDS also supported reform, saying SIDS “is a horrible explanation to give a parent or grandparent. It is like having your child kidnapped and never knowing what happened to them,” she wrote to lawmakers. “One beginning to find the cause is through autopsies. We need standards set so that a cause can be found to help prevent this death from occurring. No one should experience the pain of losing a child, and especially not knowing why.”

The reforms had support from local and national groups, including the American Academy of Pediatrics, the National Association of Medical Examiners and the state pediatric and firefighters’ associations.

The bills collapsed under pressure from local governments and individual coroners. The state coroner’s association and state association of counties made a contradictory argument: that the mandate to autopsy SIDS deaths was unnecessary because Idaho coroners already were doing autopsies in those deaths; but a mandate to do so would “require an increase in every coroner’s budget.”

Idaho is at the bottom nationally for autopsies in deaths attributed to SIDS, according to a ProPublica analysis of nationwide death certificate data. Idaho also has the lowest rate of any state for autopsies performed in child deaths from unknown or unnatural causes.

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