What Is A Coroner And What Does Their Work Entail?

An interview with Ken Holmes, former Coroner for Marin County, California, Part One

Today SevenPonds speaks with Ken Holmes. Originally from Fresno, CA, Ken began working with the Marin County Coroner’s Office as a death investigator in 1975. He worked there for 36 years, eventually serving as the elected coroner for 12 years. A book about his career and the multitude of cases he worked on, “The Education Of A Coroner,” by John Bateson was published this past August.

Editor’s Note: This interview has been edited for length and clarity.

Lucas Morgan: Hello Ken! Thank you so much for taking the time to speak with me. When did you know you wanted to be involved with this kind of work?

Ken Holmes: Pretty much by the time I was in high school I knew I wanted to be in some form of medicine. When I was young, the human body was fascinating to me. How the brain worked, why we could hear, see, smell and all those things.

As I got closer to college, I realized that twelve years of schooling after high school was not fitting into my life plan. My granddad eventually told me that the coroner’s office did all their autopsies at local mortuaries. And the best way to get to know the human body is at an autopsy or in surgery. So I began looking into the funeral industry, and went that route. I got my first job at a mortuary, and then wanted to transition directly into death investigation.

Portrait of Ken Holmes, former coroner of Marin County

Ken Holmes
Credit: Ken Holmes

Lucas: When was the first time you saw a dead person?

Ken: I saw a dead human for the first time when I was 15. I was with my granddad at a lake in the Sierra Nevada Mountains, and a man who had died sometime earlier was floating on the edges of the lake. We were in a little row boat, and rowed close enough to confirm that it was a human. We then went to find a phone and call the police. Though I wasn’t allowed to get closer than 10 or 15 feet away, I was able to watch the entire process of them bringing him out of the lake.

Lucas: Wow that is quite the story! For those who don’t know, what exactly is a coroner?

Ken: I’m glad you asked that because a lot of people don’t understand it. In the life of a person, there is a birth certificate and a death certificate. The death certificate needs to be certified as to the actual cause of death. If someone is being treated by a physician for something that might end their life and then dies, the physician is required by law to sign the death certificate saying the person died due to the illness they had.

But, there are an awful lot of people who die because of something their physician could never certify. For instance, falling out of a tree, falling off a roof, etc. The law provides that a coroner will look into any sudden or unexpected death. So the coroner’s job serves as an offset to a family physician, if someone should die outside of the presence of a physician. My role was to establish both the cause of death and the manner of death.

Lucas: How long did you work at the Marin County Coroner’s Office?

Ken: Thirty-six-and-a-half years. Nine of those as a death investigator, 14 years in a sort of mid-management role, and the last 12 years as the elected coroner. Coroners were elected to four-year terms. When I retired, however, the board of supervisors combined the coroner’s office with the sheriff’s office. Most counties in California operate this way, where the sheriff also acts as the coroner.

Lucas: How would you learn of a death when you were working? Who would notify you?

Ken: There were two typical routes. First, either a hospital or some sort of institution would call us to say that someone had passed away. And there are criteria for the different agencies to report deaths to the coroner. It doesn’t necessarily mean that there will be an autopsy, but they are required to report the death.

The other most likely way was if a fire department or paramedics were called to the scene of a death. Once they determined there was a death, they would notify our office directly through their dispatch. So, for example, we would hear from the San Rafael Fire Department dispatch or the Novato Police dispatch.

Woman working a police department dispatch system

Holmes and his team would sometimes learn of a death from a police dispatch system. Credit: nwherald.com

Lucas: What is the difference, if any, between a coroner and a medical examiner?

Ken: It’s only a political difference. Generally, a medical examiner is a political appointment, whereas a coroner will be elected by the populace. Medical examiners may be required to have some kind of medical training, such as in forensic pathology. Typically there is no such requirement for coroners. The function, however, is the same: to establish the cause and manner of death. And if it’s an unidentified person, they must establish identification and locate and notify next of kin.

Lucas: What was the first case you worked on?

Ken: Well the first case I worked on, I was on duty but was working under my trainer, who was the Assistant Coroner at the time. It was a suicide, but I honestly don’t remember anything about it. The first night on duty by myself, however, I got a call only 12 minutes into my first hour about a rape/murder victim in Novato.

There was a young girl who had been kidnapped a couple of weeks before. Long story short, the perpetrator hid her body in an aluminum storage shed next to his house and covered her with blankets and carpet. He eventually fled to Washington state where he was caught.

Lucas: How many people were on your investigative team at any given time?

Ken: We had seven permanent staff members: The Coroner, the Assistant Coroner, two office staff and three death investigators. In Marin, we had three death investigators from the time I was hired until the day I retired. We never increased our staff, and I was very proud of that.

It would then vary throughout the course of the work we did. For instance, we sometimes  hired forensic pathologists, forensic dentists, forensic anthropologists, entomologists, forensic X-ray people, etc. But we would only pay them when we used them.

Lucas: I’m sure it varied greatly, but on average how many cases would come to your office in one day? Throughout one year?

Ken: In Marin County, in the course of a single year, there are about 1,800 total deaths. Of those, around 900 or so would be reported to our office. So that comes out to about three a day, if they are reported to us. Out of that 900, we typically did autopsies, which to us is a full investigation, on about 350 a year. Those full investigations involved all of the background, the medical records, interviewing people, etc. and the autopsy itself.

For a long time, I actually held the record for most cases initiated in one day. We worked 24-hour shifts, by the way. One day during my second or third year, I had 10 separate cases that came in. That record was broken years later, but at the time it was by far the highest number. You know, sometimes you’d have a car accident with like five people, but we would consider that one case. To have ten separate reports in one day was really out of the ordinary.

Check back next week for part two of our interview with Ken Holmes, when we continue to discuss the work of a coroner.

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