A look behind Colorado’s decentralized system of coroners who investigate death every day

Listen Now
4min 52sec
Kevin J. Beaty/Denverite
Denver’s Office of the Medical Examiner. Feb. 5, 2020.

Editor's Note: Some of the photos in this story show scenes at a coroner's office.

If someone dies north of Colfax Avenue and the death is unattended or suspicious, that body eventually goes to the Adams County Coroner’s Office. There the elected coroner, Monica Broncucia-Jordan, who is not a physician, will likely contract with a forensic pathologist to perform the autopsy.

But if the same body happens to fall on the other side of the street, it will be sent to Dr. Kelly Lear’s office. Lear, the elected coroner for Arapahoe County, has been a forensic pathologist for almost 20 years and performs autopsies directly.

Yet, again, the same body falls in Denver County just a few blocks down the road and it will be sent to a county medical examiner’s office, not a coroner. That medical examiner’s office has a team of forensic pathologists and the medical examiner, himself, is appointed by city leaders, not chosen by voters.

Why would identical deaths be treated so differently based on where a person dies? 

Blame the state’s scattered, decentralized system of mostly elected coroners.

In all but a handful of counties, voters actually pick their coroner, which is usually a non-memorable event because it’s among the lowest elected positions on the ballot. Often, these people run unopposed. 

Colorado has elected coroners for generations and, generally speaking, the coroners who have been around for decades say party affiliations haven’t really mattered. But once in a while, just like last November in Arapahoe County, coroners have competition and then all of the sudden they are politicians, whose not very public jobs are thrust into a bright spotlight. 

CPR News listener Tim Davis was filling out his Arapahoe County ballot last year and asked Colorado Wonders why he was voting for coroner, why they run in political parties — “Do Republicans make deeper cuts?” he mused —  and what, if any, are the minimum requirements to be a coroner in the state?

“I tend to be interested in quirky things, and I noticed the Arapahoe County coroner had three candidates and they were all identified with a political party and so it made me wonder, how or why this came to be an elected position?” he said. “What would a Republican, Democrat or Libertarian have as philosophies that are different if they were going to be coroner? Why does this enter into the job as a coroner?”

Kevin J. Beaty/Denverite
The Denver Office of the Medical Examiner's Tuesday crew suits up for a morning of autopsies. Aug. 25, 2020.

Some coroners are elected, and others are appointed. Not all are forensic pathologists

Dr. Kelly Lear just won her third term in Arapahoe and this last year, 2022, was the first time she had a rival candidate. 

Her two opponents, a Republican biologist and a Libertarian, didn’t have any death investigation experience. Lear, who is a forensic pathologist, has been working at the Arapahoe County Coroner’s Office since 2004, has conducted roughly 5,200 autopsies.

“I had to play the game … in the sense of I had to be a politician. I had to go out and talk to people in the community and go to events and talk about what I do and what my job is,” she said. “It is not a typically political job, so it’s easy to talk to community members because a lot of people have a curiosity of the coroner’s office, and they have the opportunity to speak to someone in the field unless, of course, they’re experiencing a tragedy.” 

Lear added, “Most of the citizens we talk to in the office, we talk to on the worst day of their life because they just lost a loved one.”

Dr. Kelly Lear, a forensic pathologist and the elected coroner for Arapahoe County.

In Colorado, the vast majority of coroners are elected by voters but in a few counties — Weld and Denver included — they are appointed by elected or county officials. And most of them, particularly in rural counties, are not forensic pathologists. Many actually run funeral homes and when a forensic or medical autopsy is needed, they contract out those services with either a roving doctor or a bigger county with forensic pathologists on staff.

The only qualifications for a county coroner, according to the Colorado Constitution, is they must live in the county they represent, they must be a high school graduate and they must not be convicted of any felonies, unless they are pardoned.

As soon as coroners get elected, they are required to do 40 hours of death investigation training, and then they’re required to become certified death investigators, which requires professional development annually, according to the Colorado Coroner’s Standards and Training Board.

Randy Keller is one of the non-physician coroners in rural Fremont County. His office performs between 80 and 90 autopsies a year. They contract autopsies out with nearby El Paso County, which has five forensic pathologists on staff. 

But just because Keller is not a doctor doesn’t mean he, or one of his deputies, doesn’t do investigations into suspicious deaths, unattended deaths or in-custody deaths. That is especially true at the various state prisons in Fremont County. All in-custody deaths, even non-suspicious ones, are investigated, he said.

“A death investigator or a coroner is sent out to a scene and all of the investigation takes place. There are reports written. Once we are done with all the photography work, checking for levels of rigor mortis, morbidity, we’re trying to determine the date and time of death,” Keller said. “We compile all this to report and that is sent to autopsy and that’s used for determining a manner or cause of death.”

Kevin J. Beaty/Denverite
Dr. Sterling McLaren, a pathology fellow with the city's Office of the Medical Examiner, examines an organ during an autopsy on Aug. 25, 2020.

What do coroners do?

Coroners sign death certificates and conduct death investigations. They will either directly perform autopsies or send bodies away to someone else for an autopsy if the death is unnatural, is due to violence or injury or intoxication, is the result of an accident, is unexplained or when no physician is in attendance and is unable to certify the cause of death.

They also will investigate in-custody deaths during police actions or sudden deaths, when the person was, otherwise, healthy, according to the state constitution.

After what can be a lengthy probe, coroners will determine both the cause and the manner of death. The cause of death can vary widely: falling down the stairs, a heart attack, strangulation, a car accident, a drug overdose. The manner of death is one of five things: an accident, a homicide, a suicide, natural causes or undetermined. 

The vast majority of cases are fairly straightforward, according to coroners interviewed for this story, but once in a while, a decision stirs controversy or is revisited. 

In extremely rare instances, coroners can change a cause or manner of death with new investigation information. 

That happened with the high-profile police death of Elijah McClain, a 23-year-old Aurora resident who died in the hospital a few days after Aurora police officers forcibly arrested and detained him in 2019.

Initially, Adams County Coroner Broncucia-Jordan signed off on a contractor forensic pathologist’s decision to report that McClain’s cause and manner of death was “undetermined.” CPR News reported at the time she met with police officers ahead of her decision. 

Coroners work with law enforcement and public health officials all the time, but they are supposed to remain independent and uninfluenced by what other people say in the course of their cause and manner of death investigations.

Broncucia-Jordan’s decision to not call McClain’s death a homicide threw the initial investigation into whether law enforcement should be held accountable for his death into a tailspin, and no one was ultimately charged with any crimes because the district attorney at the time said he couldn’t do anything with the “undetermined” cause and manner of death.

That changed when Gov. Jared Polis appointed Attorney General Phil Weiser as a special prosecutor to the case, though, and Weiser sent the case to the statewide grand jury in 2021. 

During the course of that closed-door investigation, Broncucia-Jordan and her contracted forensic pathologist said they received new information that sparked them to change his cause of death to ketamine —   the manner of death is still undetermined. 

Ultimately, three former police officers and two paramedics were criminally charged in McClain’s death. They have arraignments later this month.

Denver's Office of the Medical Examiner. Aug. 25, 2020.
Kevin J. Beaty/Denverite
Denver's Office of the Medical Examiner. Aug. 25, 2020.

In the pandemic and an era of vaccine backlash, political affiliation plays a role 

In recent years, coroners say they navigated another unexpected political earthquake: the COVID-19 pandemic and the vaccines against COVID-19.

“It was the first time I’d ever really seen anything become political with this office,” Keller said.

Lear agreed. She said she particularly felt the polarization on the campaign trail with one opponent who was outspoken in questioning whether the COVID-19 vaccine caused adult deaths.

“I don't do a Republican autopsy or a Democrat autopsy, it's a medical field. I'm a medical doctor. But this really brought medicine into more of a political realm and not in a good way,” she said. “People would challenge me about it, do you do autopsies on COVID deaths? Do you do autopsies on vaccine-related deaths? Do you believe that the vaccine kills people? I definitely came across all that.”

Does the decentralized approach to death investigations work?

Most western states share Colorado’s decentralized approach to death investigations. Sixteen states plus the District of Columbia instead have statewide medical examiner systems, according to a 2018 report from the Bureau of Justice Statistics.

Lear sees advantages to that from a public health perspective.

As it is, she and other big county coroners are often on the front lines of death trends and public health crises. They see directly the spike in homicides caused by gun violence. They see growth in overdose deaths caused by fentanyl and now, most recently, laced with Xylazine, an animal tranquilizer, that has been cited in an increasing number of drug-related deaths across the country.

The problem with the decentralized system, Lear said, is that it’s much harder to share data and information. 

Have a burning question about Colorado? Ask Colorado Wonders, and we'll get on it

She tries to talk to other big county coroners with forensic pathologists at the top of the office, Denver and El Paso County, notably, but she said it’s anecdotal and patchy. A network of communications about what coroners are seeing and how that could be spread out as a public message would be helpful, she said. 

“I might see five deaths, Denver might see eight deaths and El Paso has, you know 10 and when you put them together, it’s significant,” she said. “But because the coroner system silos everybody so much, we wouldn’t know everything about what everybody else is seeing. I’m sure Adams is seeing things that I don’t know about. It puts us in our own little area without encouraging information sharing.”

But Keller, in Fremont County, thinks Colorado’s coroner system is working as it should.

“The system seems to work very well here, we've got some very responsible people in these positions,” he said. “They all work very hard. They work long hours. I would hope that everybody keeps them in their thoughts and prayers because they see a lot of bad things.”