[thisisit]

I'm wondering if I can sue the coroner or if there is any action I can take against her... my son died suddenly and unexpectedly while at home alone in his bathtub. His body was held by the coroner's office for autopsy for 10 days. This happened in Lucas County, Ohio. I was told that one reason for the length of time it took for his body to be released was that the coroner was backed up and had a lot of bodies to autopsy because she had been out of town.

When his body was released, I was told the autopsy was completed, and that he died from Sudden Unexplained Death Syndrome, but the report would not be ready for weeks, because they had to wait for toxicology. Believing what I was told, I had his body cremated after viewing at the funeral home. It was a very difficult decision for me to make, but I knew I had to keep moving forward. I had fears and suspicions because I noticed that there were no marks on his head, indicating to me that his brain had not been examined, even though he had a brain tumor. I pushed that fear away, telling myself that they probably did X-rays or MRI on his head for the autopsy instead of cutting it open. Almost 2 months later I went to the coroner's office to pick up his autopsy report only to find out that no autopsy was done and his death was ruled "natural". At that time I asked if I could make an appointment to ask the coroner questions about his death. I was told yes, I could ask for an appointment for any day after noon.

His partner wanted to come with me so I wanted to wait till she could come to make the appointment, because now that we both know that no autopsy was done, we both have questions. I called on Tues. to make an appointment on any day this week and was told I didn't need to talk to the coroner because no autopsy was done. I told the person on the phone that I was aware of that and was very upset about it and THAT is why I have a lot of questions for the coroner. I was put on hold, then was given an appointment for June 29th. I'm so upset.

My oldest son died in an accident at work on my birthday in 2001, and though the cause of his death was obvious, a complete autopsy was done anyway. In 1982 my husband committed suicide and the cause of his death was obvious, but a full autopsy was done on his body too. Now my second son died mysteriously and no autopsy was done. I'm so disturbed about this. Of course, if I would have known no autopsy was actually done on my second son, I would not have had his body cremated. Because I did, though, now I will never know what actually killed him. How can I know that he didn't slip and fall, hitting his head and died because of that, or if he had a heart attack, or drowned, or if his brain tumor had pressed on a part of his brain that regulates vital functions, or some other cause of death??

Is there a way to file a complaint against the coroner? Was it legal to skip an autopsy? Why was an autopsy done on my husband and oldest son when the causes of their deaths were obvious if an autopsy is optional? I know that no matter what an autopsy would have showed, it would not change the fact that my son is dead. However, at least I wouldn't feel so lost about what actually killed him. How can the coroner come to a conclusion that the death was "natural" when she did not do an autopsy? Do I have a case against her? Who would I complain to and can I or should I file a law suit against her?

[DrBill100]

You have noted several unacceptable irregularities in the handling of your son's case. You mention that the coroner advised on the cause of death. Step one in sorting through this is the Death Certificate. Cause of death (as listed thereon)? Who signed it?

I assume (please confirm) that a police report was filed. If not by a relative, perhaps by EMT unit. There is some reason that the coroners office took possession of your sons remains as death occurred in private residence. You will need to get a copy of the police report and/or record from any agency that responded to the scene and determine who pronounced. On scene or hospital.

You certainly have every reason to be upset and this matter should be fully investigated. Exactly where and to whom it is reported is dependent on the chain of custody, sequence of events. Whether the circumstances are actionable in a civil suit are dependent on circumstances not yet determined. However the fact that details of the postmortem examination (or lack thereof) were misrepresented to you point to professional negligence and indifference.

At the very least you deserve answers and I believe I can provide direction to that end.

NOTE: You mention "she" in relation to coroner. I'm showing JP as coroner in Lucas. Old records?

[JudyKayTee]

I appreciate and understand your pain. You can only sue for monetary damages - and I don't see any.

Can you write a letter and complain? Certainly. Can you ask for an explanation of the various stories you were given? Certainly.

If you feel his death was suspicious you can also notify the Police Department and ask that further invesigating be done.

It was "legal" to skip the autopsy if it was the opinion of the coroner that it was an accidental death or that the cause of death was apparent.

Who signed the permission slip for the autopsy? You? The girlfriend?

I had the opposite problem - my husband died after 3-1/2 weeks in the hospital, mostly in a coma. I saw no need for an autopsy and I refused to sign (which was his wish).

It appears you'll have your answers at the end of June. If you want to cover all bases, go with an Attorney.

[thisisit]

Thanks JudyKT and DrBill. The coroner who signed the death certificate is a woman named Diane Barnett. She did the autopsy on my other son, and I was told she did the autopsy on my second son. No one signed for an autopsy because in certain circumstances an autopsy is mandatory and I was at my son's house after the police summonsed me there. When I got there, there were 2 squad cars and 2 police officers. They called the coroner's office and someone from there came to pick up his body because I was told, under the circumstances, he had to have an autopsy. I waited there with my son's body for about an hour before someone from the coroner's office showed up, at which time they loaded his body into a body bag, laid him out on the floor for me to say goodbye, then loaded him into the coroner's vehicle and left with him. I don't know if the police made a police report, as with my first son they refused to make a police report even though his death was suspicious. He fell off the roof at work, his coworkers removed his ID, fled the scene and called 911 from a remote location reporting an unidentified injured person in the driveway of the address he was at. I repeatedly went to the police asking them to make a police report and investigate, but they refused and nothing was done about it. I'll call the police and ask if a police report was made for this son's death. The death certificate is signed by Diane Barnett MD, Deputy Coroner with the manner of death: Natural.

[J_9]

With the knowledge of his brain tumor it is possible that she ruled the death as natural and didn't feel it necessary to increase the expenses for an autopsy. Many times deaths are ruled natural after medical records are received.

Again, I am so sorry for your loss.

[thisisit]

Thanks J-9, that's probably it... though his doctor didn't think he was at risk of death from the tumor (from what I was told at one of his doctor appointments). I'll find out when I go to the appointment. We were confused about his brain tumor anyway, first we were told it was slow growing, then fast growing, then one doctor said he didn't have a brain tumor at all. I know his symptoms were getting worse, so maybe his medical records showed it was probably the tumor?

[excon]

Hello this:

My condolences on your loss. No mother should have to bury her children...

Being the cynic that I am, I think you were SCREWED. In the very first instance, your son waited until she got done shopping on Rodeo Drive. That, all by itself, is outrageous. Then I find out that your county has an actual coroner, whose whereabouts are unexplained, while your son waited... I'd be curious about where he was.

Then to be flat out LIED to - it's unconscionable!

Given that I believe you have been greatly wronged, I believe you have the basis for a lawsuit. Even if the lawyer you hire doesn't think you do, he can for SURE, get you an appointment with these good for nothing bureaucrats, who are treating you like dirt putting you off that way.

I'd also call your local media. I'd make a stink so bad that these people are run out of town on a rail.

excon

[DrBill100]

There will be a record of some type. Police logs etc. units that responded. The contact sheet from the coroner's office will also contain the name of the contacting party.

Prior to contacting the coroner's office someone had to pronounce him dead.

Usually in the case of a sudden death the individual is taken to the nearest hospital and only then is a decision made to contact the coroner or release to a funeral home.

In determining the cause of death the coroner must have had access to reports from on-scene describing the surrounding circumstances. So reports exist. Only after he was pronounced and at the request of someone on scene did it become a coroners case. Police have that authority. The other alternative was to allow you to contact the funeral home. I understand, given the circumstances, why it was made a coroners case. Once so committed it's difficult to explain any ruling absent a PME including toxicology.

The brain tumor you mention, in relation to the finding, fails to clarify the issue and enhances the need for PME rather than negating it. The condition was not observable by external examination (step 1 in cause of death). Therefore there was no apparent cause. Depending on the location of the brain tumor it could have caused death, it could have caused unconsciouness, or it could have been non-contributory. There is no reason to assume that medical confirmation (via Hx) of such condition was the basis of the coroner's determination. Quite the contrary, if known, it should have led to not away from PME.

You're correct that the coroner does not require authorization for autopsy. Once they obtain jurisdiction they have independent authority, to act or, in all likelihood, not to act to that end. Failure to perform PME is very unusual given the circumstances. The delay raises more questions. PME should occur with 24 hours for the Tox to be relevant. The coroner has a concurrent professional and statutory duty to determine cause of death which doesn't allow for arbitrary (or best guess) decisions. They are obliged to document their findings and to provide that information to the immediate family upon request.

[excon]

They are obliged to document their findings and to provide that information to the immediate family upon request.

Hello Dr:

Their obligations notwithstanding, THIS bureaucracy FAILED in its duty, and continues to do so. When the OP called to question them, she was put off. I see no reason to believe they'll, all of a sudden, become cooperative should she call them back.

I think she needs the meanest, baddest lawyer in her town.

excon

[DrBill100]

Hello Dr:

Their obligations notwithstanding, THIS bureaucracy FAILED in its duty, and continues to do so. When the OP called to question them, she was put off. I see no reason to believe they'll, all of a sudden, become cooperative should she call them back.

I think she needs the meanest, baddest lawyer in her town.

excon

You are correct and the bureaucratic response, lackadaisy, indifference and incompetence is pervasive in coroners and ME offices across the country. But when you go after a government unit you want your ducks in a row. She can get information quickly, by pushing the right button, that would take months by subpoena. I share your anger.

Also, it is my experience that once placed on notice of suit pertinent records often mysteriously disappear or can't be found.

[thisisit]

Thanks again DrBill. I have a piece of paper that (instead of being an autopsy report) states, as written:
Anatomic Diagnoses: NO AUTOPSY PREFORMED, EXTERNAL EXAMINATION ONLY.

Then below that is the
Summary of toxicology results:
Alcohol level: NONE DETECTED
Carbamazepine: 0.4 mg/L in Blood SUBCLAV
GC-MS SCREEN: None detected in Blood Subclavian

Then down below that it says
Opinion: It is my opinion that N.P. (initials) died of CHRONIC SEIZURE DISORDER. The following significat conditions were present: cLINICAL HISTORY OF REMOTE BRAIN TUMOR. Manner of death: Natural.

Oddly, he was a known pot smoker yet that doesn't seem to have been dectected in his blood tests

He was pronounced dead when the coroner's office got to the house. I was so upset during that time that I don't know what official from the coroner's office was there, just assumed it was a doctor though because that is the person who pronounce him dead, then he was taken to the coroner's office, not the hospital. I don't even think EMT was there because it was obvious that he was dead for hours before he was discovered. Even though, though, his time of death was listed as the time the lady from the coroner's office examined his body while he was still in the bathtub.

My son was in an unusal position in the tub also. His head was at the drain end and he was on his side and the water had all leaked out of the tub, but his hair was wet and there was a little water under him, no blood though. It just looked like he was sleeping, no apparent injury.

[JudyKayTee]

As far as drugs - I've seen drugs not mentioned in order to keep the Death Certificate "clean" for life insurance purposes. If drugs were not a factor that testing is not necessarily mentioned.

Again - I see no lawsuit here because I see no damages. Complaints, yes. As far as how quickly the Coroner gets there, well, that's something to argue about.

I realize you are very upset and grieving this recent, tragic loss; however, this is the legal board and my legal advice is that you NOT post this much info if you have any intention of taking any action in this matter.

You could very well be guilty of slander or defamation or whatever else the people you have named BY NAME care to call it. I'm not saying "they" would win. I'm saying they have legal resources which you, undoubtedly, do not have and if you harm their "professional reputation" - which will be the action - I see you having an uphill climb.

Again - purely legal advice. It is a mistake to try to get closure or specific advice (using names) or fingers pointed at people in charge.

You have a hearing date. I would hope that helps you find some peace. "Trying" this case on a public board is going to hurt you.

I do not mean to further upset you and (again) this is purely legal advice. I'm not saying it's correct or fair. I am saying I don't see your monetary damages and I might see "theirs."

[DrBill100]

Let me acquaint you with the response you are most apt to receive from the coroner:

PME was performed (technically true). We felt internal examination was unnecessary. We did perform toxicology.

The body position and physical circumstances are virtually identical to those in an Illinois case where death was attributed to drowning. That should have been considered in this case.

I'm still having a bit of a problem with how this evolved. Who first discovered the body. Who was called (police or ambulance). Who decided that he was beyond medical intervention. There are clear indications to a trained observer i.e. lividity and even to untrained, rigor mortis, but these decisions are seldom made on scene.

The time of death is procedurally correct. It is the time when a competent medical authority confirms it. That is yet another reason for removal to nearest hospital.

There should be a full toxicology report with the date and time of testing. But due to a process called Postmortem Redistribution (PMR) PM tox reports are always unreliable. When only one sample site is used (as noted above) they are meaningless.
Proper procedure requires three sample sites, usually urine, femoral blood and vitreous humor. Many times hair as well.
I am sure it will be their claim that since the sample was negative there was no need for additional testing. That is true in living subjects but not so in PME analysis. When I say proper procedure, it is no where mandated, rather agreed upon amongst forensic pathologists, and widely published.

The medical Hx is interesting, within the coroner's records it should be noted how obtained and when. You will need that information. I don't see how post facto it influenced the determination. (If I were reviewing this independently my first assumption would have been accidental death by drowning. I can't see how that was ruled out without internal examination of the heart and lungs.)

As Ex-con noted this, on the face of it, this looks like bureaucratic bungling. But courts reject opinion and accusation absent fact. I have been involved in many ME cases and you're confronting a government agency that will retrench, professional organizations that won't speak against their members (forensic pathologists) and their lawyers are free. So any information that you can obtain with a smile and expression of personal concern is to your benefit. Believe me all info ends at the mention of lawsuit.

NOTE: I just noticed that this is a legal board. When I use the term case it is in a medical sense. My background is in physiological psychology, a "fur piece" from the law. My involvement in medico-legal autopsies is with emphasis on the "medico-"

[thisisit]

Thanks again DrBill, I'll try to be as nice as I can. My exhusband told me last night that the coroner in Lubbock TX was sent to prison for not doing his job right. I don't care if it's the government, to me that means they should be held to the highest standard, not the lowest.

My son was as white as the bathtub and as cold as the tub when he was found, and rigor mortis had set in. His girlfriend found him when she got home from work. He was just getting into the tub when she left for work, so we think he died soon after she left. She was at work for 8 hours. Long enough for the water to leak out of the drain, which it did have a slow leak.

She called 911, hysterical, and reported that my son was dead in the bathtub. They asked HER if she wanted the police to come out. Bizarre. Her response was YES, I'm not a doctor! The police called me as soon as they got there and told me to come to my son's house, that he had died. They were very kind but I don't remember them filling out any paperwork. I'll call them tomorrow and ask if they made a police report and if so if I can have a copy of it.

Thank you for all your thoughts on this.

[thisisit]

Also, his brain tumor was on his pituitary gland

[JudyKayTee]

I'm sorry you don't like my advice; I'm sorry you are 100% they "won't get anything" from you.

This is a legal board. Maybe it's time to move it to a discussion or medical thread.

DrBill has provided very valuable advice. I will also add that maybe it was bungling, maybe it wasn't - but what are the damages here?

Again - that is what counts on the legal board. Perhaps this is a discussion for a medical thread.

[thisisit]

Thanks again Judy, it isn't that I don't like your advice, not at all. I appreciate your views on this. It's more that I feel I don't care what they could do to me, I guess, after all, the worst possible thing has already happened. As far as damages goes, you are right, there is no monetary damages... I would have had to pay for a funeral no matter what. The damage is mental anguish. It is difficult to put this matter to rest in my mind when I don't even know what killed my son. Knowing that I will never know is unsettling, to say the least.

[DrBill100]

... Perhaps this is a discussion for a medical thread.

Frankly until your previous post I thought this was a medical board. Somehow I wandered from home and don't know how I got here. If it's agreeable with thisisit I would like to see it moved. Either that or call my parents and have them pick me up.

[thisisit]

:) It doesn't matter to me where the question is put. I wasn't sure where to post it to begin with.

[excon]

Hello again,

No matter WHERE it's posted, the conversation will be the same with the same participants. I'd leave it be. And, your expertise is welcome here, DrBill.

My friend, Judy, as always, makes a good point. She doesn't see actual damages... I don't either.. I'm hoping, however, that the actions of these jerkoff bureaucrats was soooo egregious, and that there are statutes requiring compliance with certain laws and if not complied with, there's a penalty, so that she can get compensated.

I'm not a lawyer. I'm hoping that a lawyer can reveal, that which I cannot. If he can't, and if he's mean enough, he can get the county to move. I can't believe their action here didn't massively violate their own rules and procedures. I'm NOT sure if punitive damages wouldn't be awarded. She might only need $10 in actual damages, yet be awarded hundreds of thousands of $$$'s in punitave damages...

Or, I could be whistling Dixie.

excon