The Education of a Coroner

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The Education of a Coroner Page 3

by John Bateson


  “It was a mesmerizing experience,” he says, “and I couldn’t get enough of it. Throughout my apprenticeship, whenever there was an autopsy I went and watched, even if I didn’t have to be there. I continued to ask questions and listen to the doctor as he recorded his findings into a Dictaphone. The result was that I began to develop a good grasp of medical terminology when I was still in my teens.”

  The other thing Holmes learned about himself was that he had a lot of compassion. “I didn’t know it,” he says, “but I did. From the beginning, I enjoyed working with families. I felt comfortable around them, and they, in turn, were grateful for my help in making funeral arrangements.”

  San Francisco College of Mortuary Science emphasized the physical sciences—anatomy, pathology, bacteriology, and chemistry. One of the skills that was taught was embalming. It involves withdrawing blood and waste matter from human organs, reshaping or reconstructing disfigured or maimed bodies using clay, cotton, plaster of Paris, and wax, injecting embalming fluid with a pump into arms and legs, closing incisions using needles and sutures, joining lips with a needle and thread, and applying cosmetics to give a dead body a lifelike appearance. Holmes didn’t know it at the time, but the fact that he became a licensed embalmer proved to be a critical stepping-stone to his future career.

  After he graduated, he applied to coroners’ offices around the Bay Area, but there weren’t any openings. Needing to work, he took a job at a mortuary in Sonoma County, just north of Marin. At that time, Sonoma County had only one coroner’s investigator. He was retired from the California Highway Patrol and responded to homicides and accidental deaths, but not to traffic accidents because the police could take care of those. Even so, there were more cases than he could handle so he commissioned every licensed embalmer in the county to be a deputy coroner. This meant that Holmes and other embalmers were responsible for writing a brief report—only a few lines—following suicides and other types of deaths that weren’t being investigated, leaving the investigator to focus on trauma cases.

  One day the investigator was at the mortuary where Holmes worked. He wasn’t there to see Holmes, but he couldn’t help but pull him aside.

  “Damn, Holmes,” he said. “You wrote a report the other day; I wouldn’t write one that long. You went into all sorts of detail you didn’t need to. I certainly got a great picture of what you saw, though.”

  FORTUNE INTERVENES

  Holmes was married and had a son and daughter by this time. In coaching his son’s Little League team, he became friends with another coach, named Henry. One Friday morning Holmes was at the mortuary and it was quiet. No one else was around and there wasn’t anything in particular that he needed to do. Although it was a hot day, Holmes decided it would be a good time to see if he could get the big fountain in front to work properly. He had always liked to tinker, and the fact that it sprayed water sporadically bothered him. Still wearing his standard uniform—black slacks and a white shirt—he rolled up his sleeves and was working on the fountain when Henry drove by. Henry honked and waved, and Holmes waved in return. Because he wasn’t in a hurry, Henry turned around, came back, and the two of them moved to the shade and got to talking. At first they talked about Little League, then Holmes asked Henry what he was doing there. Henry said he had stopped to see a man named Tom who worked at another mortuary nearby. After that Henry mentioned, offhand, something that would change Holmes’s life. He said that Tom told him the Marin County Coroner’s Office was adding a new position, a third death investigator, and Tom had applied for it.

  Holmes was floored. He knew the two current investigators in Marin and the assistant coroner. Despite making repeated inquiries, however, Holmes had never been told that a job was opening up.

  As soon as Henry left, Holmes called the coroner’s office. It was one o’clock. He said he had just heard that another investigator was going to be hired, and asked what the process was for applying. A secretary told him that interested candidates had to fill out an application from the Human Resources Office, and the filing deadline was five o’clock that afternoon.

  Holmes closed the mortuary, told the answering service that he had an emergency, and raced ten miles to the Marin County Civic Center, where all county offices were based. The Human Resources Office was on the top floor of the four-story building, tucked so far in back that it seemed like Siberia. Holmes tried to remain calm as he asked for an application. It turned out to be six pages long, and a woman told him that he needed to attach copies of his high school and college transcripts. Holmes filled out the application as neatly as he could by hand, and said that he could provide the attachments but couldn’t get them that day. The woman said that since it was Friday, it probably would take a couple of days for applications to be processed, so if he could get them to her by the first part of the following week she would add them to his application. She didn’t need to be so accommodating, but she was.

  On Monday, Holmes called his high school and college to get the transcripts. Faxes didn’t exist in those days so he paid to have them mailed overnight. Tuesday afternoon he delivered the documents to Human Resources, and the woman included them.

  It turned out that there were sixty-eight applicants for the one position. As with most government jobs, people in the HR office did the initial screening. One of the requirements listed by the coroner, Dr. Ervin Jindrich, was that the person have a California embalmer’s license. Jindrich himself was a certified forensic pathologist, but he knew the value of an embalmer’s license.

  “It meant you’re not afraid of death,” Holmes says, “and you’re used to people crying.”

  Being unafraid of death is an obvious requisite for a coroner. Doctors, soldiers, cops, and firefighters become habituated to death the more they witness it, but coroners have to start out undaunted by dead people in all their forms. As for being used to people who are crying, this might sound cold or insensitive, but in fact it was practical and relevant. Coroners’ investigators have to be able to function in an environment where people are feeling enormous pain and grieving a significant loss.

  “It’s easy to get sucked into someone’s grief and want to comfort them,” Holmes says, “but you also have to be able to step back and focus on other aspects of the job.”

  As it turned out, half the candidates lacked an embalmer’s license and were eliminated from further consideration. Tom, the man who had told Holmes’s friend Henry about the opening, was still in the running, however. Moreover, he knew everyone in the Marin coroner’s office even better than Holmes. Tom had worked with them longer and more closely. In a moment of ill-advised and inappropriate candor, Keith Craig, the assistant coroner, told Holmes that Tom had the inside track and almost certainly would be hired. Hearing this, Holmes was despondent. His dream job was going to someone else.

  Tom was so confident of his standing, however, that he hadn’t submitted all the information that HR required. As a result, his application was thrown out. Craig, among others, was flabbergasted to learn that Tom hadn’t made it past the first step. He had seemed like a sure thing.

  That was the opening Holmes needed. He went through the interview process, which culminated in oral boards before a panel of five coroners from neighboring counties, and ended up being ranked the top candidate.

  Looking back to that period of time, Holmes still marvels at the confluence of events that ended with his hiring. The fact that it was a quiet day, that he was outside the mortuary fiddling with the fountain, that Henry not only waved but stopped and came back because he wasn’t pressed for time, that Henry mentioned the position not knowing that Holmes would be interested in it, that Holmes had enough time to get to the civic center and fill out an application, that HR allowed him to add grade transcripts after the filing deadline, and that Tom’s application was thrown out because it was incomplete, seemed nothing short of miraculous.

  After he started, Holmes asked Jindrich why he hired him. After all, Holmes had no investigative exper
ience.

  Jindrich was thirty-five at the time—only three years older than Holmes—and had been elected coroner a year earlier after working as an autopsy specialist for the coroner’s office in San Francisco. In appearance he resembled a young Abraham Lincoln with a narrow face, full beard, sharp eyes, and a sweep of dark hair.

  Jindrich said, “Your understanding of medical terminology and medical situations was much higher than anybody else’s. You can learn fairly quickly to be a good death investigator if you have a natural tendency to ask questions. I can teach you what you need to know. It takes years and years to learn medicine, however, and I don’t have time to teach you that because in two weeks you’re going to need to hit the street.”

  Clearly, all of the time that Holmes had spent standing next to doctors during autopsies and asking questions had paid off. When he succeeded Jindrich as coroner, Holmes emphasized the same qualities in hiring investigators as Jindrich had—that is, familiarity and comfort with death, extensive knowledge of medicine, an innate inquisitiveness and willingness to ask questions, plus compassion for grieving families.

  This last is as important for investigative reasons as it is a requisite of human kindness. Investigators who relate poorly to families can’t always obtain the information needed to make an accurate determination regarding someone’s death. When they ask a question, they often get yes-or-no answers because most individuals are cautious. If an investigator can convince people that he or she is on their side, however, family members and friends answer at greater length, sometimes providing important details with little or no prompting.

  This was the part of the job that Holmes found particularly rewarding, and some of the people he came to know after notifying them of a death continue to send him emails periodically and greeting cards during the holidays. Either they want him to know that they are well, or they just want to stay in touch.

  At the time Holmes was hired, however, the day when he would be responsible for hiring other investigators was far off in the future. He was thirty-two years old, fresh-faced, with keen eyes and a receding hairline that he compensated for by growing long sideburns, and there was much that he needed to learn first. He was about to enter a different world than the one he knew.

  CHAPTER 02

  BAPTISM BY FIRE

  During his first two weeks, Holmes shadowed the assistant coroner, Keith Craig. Craig was the person responsible for training and managing the three investigators. His widow’s peak of steel-gray hair was slicked back, his mustache was groomed, and he wore aviator-style glasses. For the most part humor was wasted on him, and he was happiest when there was little to do. Five years earlier he had retired from the California Highway Patrol, collecting a good pension, but he wasn’t ready to retire altogether yet.

  “He was a holdover from the previous coroner,” Holmes says, “because Dr. Jindrich thought he needed to keep someone who was familiar with administrative details.”

  The two death investigators were holdovers, too, and Jindrich had no hesitation when it came to retaining them. Both men were experienced, having started four years before Holmes, competent, and dedicated. Like Holmes they were former morticians and embalmers.

  Bill Thomas was twenty-seven, single, five foot nine, and originally from the Midwest. He had a full head of dark hair, a handsome face, and a captivating personality.

  “In addition to being funny and engaging,” Holmes says, “Bill told the most outrageous stories without ever cracking a smile. His charisma and humor made him a hit with everyone, especially women. Most of the nurses in most of the emergency rooms in Marin dated Bill at some point, and many of them, I think, would have jumped at the chance to marry him if he had proposed. He was somebody who everyone gravitated to.”

  Don Cornish was the opposite. Tall and somewhat portly, with just a fringe of hair, he was forty years old and reserved. He also was devout in his Christian faith, although he never preached it. For many years, Holmes didn’t know he had any faith at all. Cornish was happily married and had four daughters, none of whom he ever referred to—at least in Holmes’s presence—by name. Instead, he called them Daughter #1, #2, #3, and #4. He and his family owned twenty acres of land in Calistoga where they raised livestock and harvested fruit trees. Calistoga is in Napa County, more than an hour’s drive north of Marin County. All during his tenure as a death investigator, which lasted twenty-seven years, Cornish maintained a small apartment close to work in order to avoid commuting.

  Bill Thomas and Don Cornish were the ones who ended up primarily training Holmes, but it was Craig whom Holmes followed his first two weeks. The first week, Craig handled each case while Holmes observed. The second week, Holmes handled cases with Craig looking over his shoulder. Starting his third day, Holmes wrote the case report even though Craig did the work. Afterward, Craig reviewed it.

  Holmes’s first report concerned a suicide from the Golden Gate Bridge. A California Highway Patrol officer called the coroner’s office after the body of a fifty-five-year-old woman was found on Lime Point, a pinprick of land below the north tower of the bridge. Craig and Holmes responded, and Holmes noted their findings with terse objectivity, as instructed.

  Arrived at Lime Point at 1330 [1:30 P.M.]. Deceased was lying face down among the rocks on shoreline on east side of Golden Gate Bridge north of north tower. Clothing consisted of white bra, yellow blouse, and maroon with white polka-dotted slacks and vest. An obvious fracture of the right leg was apparent at the scene. Officer Lee of the CHP gave Assistant Coroner Craig a pair of tan sandals and two pairs of glasses that he stated were found on the bridge above the deceased. An apparently abandoned vehicle was found at Vista Point by Officer Lee, registered to the husband of deceased. Identification was made through this registration. Marin County Sheriff’s Office checked the address, found no one at home, and in conversation with neighbors was given the husband’s telephone number at work. Telephone notification made after physical description given by husband and identification of old scars. Husband stated that his wife had been ill for about five weeks with a cold-like illness. He had made an appointment for her tomorrow to see her physician. Autopsy pending.

  Craig read the report and had one comment. “You forgot to mention that no note was found.”

  The death of a twenty-nine-year-old woman ended up involving Craig and all three investigators in the coroner’s office, mainly because a number of people needed to be interviewed and none of them was particularly cooperative. The woman, a nurse, died at the home of a psychologist in Bolinas following what was described by participants as an encounter group session but more likely was a drug party.

  The night before she died, she and a dozen other people were at the house. According to the psychologist, stated through his attorney, the decedent “acted out,” was angry, and yelled frequently. The next morning, someone noticed that she wasn’t moving. A local physician was called to the residence, and he pronounced her dead.

  Everyone who was present maintained that the get-together was therapeutic in nature and participants paid several hundred dollars to attend. This was contradicted, however, by physical evidence Holmes and other investigators found that a smorgasbord of narcotics had been consumed.

  It appeared likely that the woman died from an overdose of a psychiatric, hallucinogenic drug known as MDA. She had fifty-milligram capsules in her possession, and a substantial quantity was found in her system. The coroner’s office urged the district attorney to file manslaughter charges against the psychologist, but the DA decided that there wasn’t enough evidence. The manner would remain undetermined.

  A week later, Craig and Holmes were called to the scene of a warehouse fire in Novato. Two youths—Alan Pariani, age seventeen, and Robert Lomanson, eighteen—were working at the back of the warehouse when a drum of Scotchgard exploded in the front. The wall of flames prevented their exit, so they tried to escape through metal doors in the rear. These doors were padlocked from the outside, however. When Craig an
d Holmes arrived, they found a heartbreaking scene. The boys’ dead bodies were near the rear doors, victims of burns and smoke inhalation. It turned out that a month earlier the warehouse had been cited by fire marshals for unsafe conditions, including the padlocked doors; however, no corrective action had been taken yet.

  FIRST HOMICIDE

  After two weeks of training, Holmes began his first shift alone. It was a Wednesday night, supposedly the quietest night of the week. At 12:28 A.M., he was notified by the county’s Communications Center that the body of a young woman had been found in a Novato trailer park, the victim of an apparent homicide.

  The Communications Center handled most of the emergency calls in the county. Dispatchers relayed information to the coroner’s office, as well as to local fire departments, paramedics, the Public Works Department, animal control, and police in all but four Marin cities (those four cities had their own police dispatch centers).

  Despite the late hour, there were half a dozen police cars parked in the area, motors off but blue lights flashing, when Holmes arrived. He could see cops in uniforms and shiny badges milling around, talking in small groups and waiting for him. All were at least four trailers from the actual site, a mobile home with a detached metal storage shed in the rear. As soon as Holmes exited his car, he understood why they were keeping their distance. It was an unusually hot night, and the malodorous smell of decomposing flesh was one that Holmes knew well.

  Decomposition begins as soon as someone dies. Internal chemicals and bacteria break down a body’s tissues and initiate the decaying process. In the first stage, flies and ants arrive. After that the body becomes bloated as other insects—maggots and beetles—feed on tissues under the skin and lay larvae. The beginning of active decay is marked by the body deflating as larvae hatch, pierce the skin, and release the body’s gases, which are the source of the putrid odor. Once most of the flesh has been removed, the odor dissipates and many of the insects that were feeding on the body leave. In the last phase of decomposition, other scavengers—centipedes, millipedes, snails, and cockroaches—consume what is left until only bones remain.

 

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