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Democrat-Gazette investigation: State's fractured coroner system creates uneven reporting

by Ginny Monk | December 26, 2018 at 4:30 a.m.

Arkansas' fractured county coroner system creates uneven, and often incomplete, reporting on unusual or suspicious deaths, an Arkansas Democrat-Gazette investigation found.

State law requires coroners to determine the manner and cause of death and to issue a final report describing findings, but many coroners skip writing descriptions of the death scenes and only fill in death certificates.

Coroners who do write death investigation reports vary in their methods. Some provided handwritten documents in response to the newspaper's requests for their reports on child deaths. Others typed their reports. Some reports included descriptions of the death scenes, while others did not.

Coroners' death investigation reports help various state and federal agencies determine causes and manners of death, gather statistical data, and plan health programs to prevent more deaths.

Some state agencies are working with the Arkansas Coroner's Association to make reports uniform and more streamlined.

Sometimes, coroners are called as witnesses during murder trials. They have the power to request autopsies and issue affidavits.

"In Arkansas, the coroner has ultimate responsibility over the death of an individual," said Kermit Channell, the director of the state Crime Laboratory. The Crime Lab works closely with coroners.

The Democrat-Gazette examined about 2,000 documents obtained through state Freedom of Information Act requests to all 75 of the state's coroners for their reports on children who died over a six-year period.

Forty-four coroners had provided documents as of Dec. 19. The Desha County coroner originally denied the request until a prosecutor issued a subpoena for them.

Coroners in White and Carroll counties hadn't returned calls or emails as of Dec. 19.

Six county coroners supplied reports with the names of the decedents and other details blacked out, a violation of the public records law.

Other coroners responding to the newspaper's request said they hadn't had any minors die in their counties since 2012.

The newspaper began filing the information requests in September. The state's Freedom of Information Act requires public records to be made available for inspection or copying immediately. If the requested records are "in active use" or in storage, officials responsible for maintaining records must certify that fact in writing and set a date and time within three days for the records to be inspected.

Act 1288, passed in 2009, requires coroners to investigate deaths and create a preliminary report within five days for deaths caused by injury, drugs, poison, not being attended by a physician within 36 hours, or if the death occurs in a state-run facility. The reports must include 14 details about the decedent and the way in which the body was found.

The law requires that photographs or information about where photographs can be accessed be included in the report, but no references to photographs have been included on any death certificates the newspaper has examined.

Kevin Cleghorn, the Saline County coroner and the president of the Arkansas Coroner's Association, said death certificates include all the information required by law, but not writing a coroner's report isn't a recommended practice.

"I wouldn't do that, personally," he said. "In case I have to go to court on a case."


In at least nine counties -- Hot Spring, Calhoun, Yell, Marion, Johnson, Sharp, Sebastian, Dallas and Baxter -- coroners told the newspaper that their predecessors took the records with them when they left office.

Attempts to obtain records from former coroners in those counties were successful only in Sebastian County.

Coroners in nine other counties -- Johnson, Greene, Drew, Clay, Arkansas, Poinsett, Mississippi, Desha and Bradley -- did not have coroner's reports but supplied the newspaper with Crime Lab reports, Health Department records or death certificates. Two of those sent only lists of the names, ages, causes of death, dates of death and sexes of the deceased.

In one case, a death certificate was the only record provided in the case of a baby born prematurely and taken to the hospital in a plastic bag.

Eight more coroners -- in Lonoke, Marion, Jefferson, Randolph, Jackson, Grant, Sharp and Hempstead counties -- provided a mixture of death certificates, Crime Lab reports, coroner's reports and news reports for deaths. Some deaths had only a death certificate or Crime Lab report while others had more documentation.

Coroner's reports that were completed were often handwritten and one page long. In Baxter County, the report provided included no narrative of the scene, which involved a gunshot.

Handwritten reports leave room for errors in gathering death data, said Austin Porter, the deputy chief science officer at the Arkansas Department of Health.

"Anything handwritten, of course, can have mistakes," Porter said. "Electronic does make it easier for all of us."

The department uses the information to label the cause of death using the International Classification of Diseases and then to allocate money based on data in each region and build programs to prevent the most common causes of death.

"Money is allocated based on the data," said Nathaniel Noble, the chief of vital records at the Health Department. "Some federal, some state. ... There are other grants that we have been awarded to address other causes of death that are disproportionately higher here in Arkansas."

Channell said the Crime Lab relies heavily on coroner's reports when determining the manner of death. The cause of death is the specific injury or disease that leads to a death, and the manner of death is the portion of an investigation that can spark a criminal case.

The general categories for manner of death are natural, accident, suicide, homicide and undetermined.

"It's the manner of death that's important," Channell said.


The state Crime Lab, the Health Department and the coroner's association are working together to train coroners in conducting death investigations. Arkansas does not have training requirements for its coroners.

At one session at the start of December, a couple of deputy coroners traveled to Batesville for training in conducting death investigations on infants and filling out Sudden Unexplained Infant Death Investigation forms.

Dr. Pamela Tabor, who taught the class along with Cleghorn, said that since she started doing training for coroners, she's seen an improvement in the quality of investigations and how well they fill out reports. Tabor is the former director of the Arkansas Infant and Child Death Review Panel, which re-examines investigations into the deaths of children.

"Where could this have been prevented? What was missed?" Tabor said of the review panel's work.

Tabor walked the December class participants through a few sample cases to show them circumstances that commonly cause deaths of babies, such as toys in the crib, co-sleeping and letting pets sleep with infants.

Cleghorn said it is difficult for coroners to find time to go to training sessions because many work more than one job.

Coroners are elected for two-year terms in all counties except Pulaski and Faulkner, where they are appointed. Coroner salaries range from $4,114 per year in Howard County to $103,388 in Washington County.

All except 12 make less than $30,000 per year, according to information from the Association of Arkansas Counties.

That means most take on other jobs, usually in funeral homes. Many have the funeral home number listed online as their coroner contact number, and several asked that records requests be sent to the general funeral home email.

"They don't get paid enough to do what they do," Cleghorn said.

Cleghorn said he's also training coroners in a new electronic system that he hopes will be used statewide soon. Arkansas has had the system for about a year, and nearly 20 coroners are using it, he said.

"Ultimately it makes what we do in the state of Arkansas better," Channell said of the system.

The new system has a mobile app, allows photos from the scene to be uploaded into the file and will create data in real time, Cleghorn said. The Crime Lab, Health Department and other coroners will be able to view investigations.

"They can see the information that they need to do the autopsy," he added.

Channell said officials are working to add a feature that would automatically fill in the death certificate to streamline the work coroners do.

Before the association discovered the computerized system, the group was looking into creating its own system for coroners. A "silent partner" is paying for the software for the next five years, Cleghorn said.

"Whereas all the others were the little Prius of reporting systems, MDI Log is the Cadillac," he said.

Ryan Pate, the Pike County coroner, said some previous coroners kept their records, while others turned them over to police for investigations and didn't keep a copy. He's implementing MDI Log in his county. Pate said he was appointed in 2018 to finish the term of a coroner who moved out of state.

"It was handwritten, paper reports," he said. "Most of the coroners, they'd get a file cabinet at their house, and they would keep their own files."

In Sebastian County, a Democrat-Gazette reporter reviewed the previous coroner's files, which he keeps in storage. Former coroner Terry Campbell said his predecessor kept the records too, so he was just following status quo.

That won't be an issue with the new log system, Cleghorn said. The software will belong to the county, so all records entered into the system will stay there regardless of who wins elections.

Nineteen new coroners won elections in November and will take office in January. Cleghorn said they're already reaching out about how to get training.

"They want to do the job and do right and take care of their constituents in their county," Cleghorn said. "What we do is for the families left behind, getting them answers."

Information for this article was contributed by Lisa Hammersly of the Arkansas Democrat-Gazette.

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