The Education of a Coroner

by John Bateson

  In some instances a person’s body temperature was near the ambient temperature but Holmes knew that the person had been dead only a couple of hours based on witness testimony, lividity, and lack of rigor mortis. This meant the body might have been moved, in which case he started recording actual temperatures—of the body, of the room where the body was found, and also outside.

  On CSI and other popular TV detective shows, investigators use liver sticks to determine the exact temperature of a dead person. With a liver stick, the investigator pokes a tiny hole in the liver with a scalpel and inserts a thermometer. Some real-life coroners still use liver sticks, but most have gotten away from them because it doesn’t make much difference. The liver is the densest organ in the body and takes the longest to cool down—that’s the theory.

  “You’re just as well off taking someone’s rectal temperature, though,” Holmes says, “because the rectum is protected.” He adds with a wry smile, “It’s not as good for television viewing, though.”

  Household temperatures vary depending on the room. Attics are warmer than the rest of the house, while basements are cooler. Most garages aren’t insolated so they are warmer on hot days and cooler on cold days than the main house. Anytime Holmes investigated a case, he asked police officers whether windows in the room where the person was found were open or closed when the officers arrived, because that can affect a body’s temperature. If the decedent was found on a floor, Holmes noted whether it was a tile floor, which tends to be cool, or a carpeted surface, which tends to be warm. If a body was found in a bathtub, pool, or spa, he took the temperature of the water and bottled a sample for testing purposes.

  Determining the time of death as well as the circumstances surrounding it can be meaningful for a family. Oftentimes loved ones need to know for their own benefit that nothing could have been done, that Walter died while his wife was out of town, visiting her mother, not while she was running errands.

  “At some level the information helps absolve feelings of guilt and enables people to manage their grief,” Holmes says.

  AUTOPSIES

  The word “autopsy” means “see for yourself.” It is the examination of a human body externally and internally following death using surgical techniques, laboratory analysis, and medical records. Ideally, autopsies would be performed following every death because each one furthers our understanding of diseases and contributes to our body of medical knowledge. Autopsies also reveal undiagnosed or misdiagnosed illnesses that may be hereditary and important for family members to be aware of, as well as provide peace of mind to loved ones by eliminating some of the uncertainty surrounding a death. In addition, autopsies can validate whether environmental hazards were a factor in someone’s demise, or call into question the competency of medical care that a person received, in both instances opening the door for potential litigation. In practice, however, autopsies tend to be performed only when the cause of death isn’t clear, and sometimes not even then. As local governments grapple with budgetary constraints that impact services, funding for death investigations is often restricted, and limitations are set on the number of autopsies that can be conducted in a given year. Whenever this happens, medical science, the needs of families, and the community suffer. Infectious diseases go undetected, rightful compensation is lost, and people literally get away with murder.

  Typically, the autopsy room in a mortuary is small, about the size of a modest living room. It’s not sterile because the risk of disease exists only for the living people in the room. At one time the only special clothing pathologists wore was gloves, an apron, and a mask if the smell was bad. Today, personal protection equipment—a Tyvek jumpsuit with eye guards—is common, especially if the decedent is known to have a contagious disease.

  The floors are linoleum or tile, and there are one or more stainless steel tables with locking wheels. The tables are angled slightly with the head on the left and the feet on the right. There is a lip all the way around the table, and at the bottom is a drain hole that sits over an open sump. A tub that is lined with a plastic bag is placed between the calves of the deceased. When the pathologist has finished removing, examining, and weighing an organ, he or she places it in the bag. At the end of the autopsy, a mortician takes the bag, which contains the person’s heart, lungs, stomach, liver, and brain, and adds embalming powder. The powder absorbs any leftover liquids, controls any odors, and preserves organs. Then the whole bag is put back inside the chest cavity. The chest is stitched up and so is the head, although there’s nothing in it since the brain has been removed; it’s just the skull. After that the body is washed with a hose—not before, because the pathologist doesn’t want to wash off anything that might be evidentiary—dried, placed in a clean body bag, and put in a cooler until instructions are received from next of kin regarding disposition.

  In the early days the pathologist had a Dictaphone, and as soon as the autopsy was finished he or she recorded the findings. Later, pathologists began using voice-activated tapes, dictating the results as they went along. This was easier for doctors, although it created problems for transcribers since the clanking of surgical tools against stainless steel tables can make it difficult to hear. Moreover, sounds tend to echo in an autopsy room. Today, digital recorders are common.

  The average autopsy takes one to two hours, with homicides typically lasting three to four hours. Microscope slides are made and analyzed a day or two later, adding another hour or more to the process. When the toxicology report comes back with the results of blood, urine, and gastric juices testing, time is spent scrutinizing this, too.

  Autopsy results often provide another element in determining the time of death. Food is digested at a fairly predictable rate, usually breaking down in about twenty minutes. If the autopsy is done shortly after death, a pathologist often can tell exactly what foods a person ate last. As with lividity and rigor mortis, there are variables, however. Food doesn’t break down as fast if the person was dehydrated, super-active, or had some sort of chemical imbalance.

  The timing of the autopsy can have an effect, too, because digestion continues after death for as long as food enzymes are working in the stomach and small intestine—generally four to eight hours. Almost coincidentally, but not predictably, decomposition starts then, so food begins to decompose at the same time that the interior lining of the stomach begins to decompose. This is why bodies are refrigerated prior to autopsy, to stop the digestive system and retard decomposition.

  Oftentimes, especially in cases that go to trial, a defense attorney or prosecuting attorney asks the coroner how long the person had been dead before his or her body was found. This is common on TV shows. There are so many variables, though, that Holmes learned not to rely on any of them until he knew everything he could about somebody, which might take several weeks depending on how many people he needed to talk to, how quickly he was able to contact them, and when the autopsy and toxicology reports would be back. After that he would give the broadest range he could, within reason. If it looked like the person had been dead two days, for example, he gave a range of one to three days. This way if someone came forward later and said that he talked with the decedent the day before he was found, Holmes didn’t look foolish by having said that the person had been dead exactly two days.

  “Lividity, rigor, body temperature, and digestion help determine time of death,” Holmes says, “but it’s not a science. That’s one of the first things I learned. Depending on the circumstances, there may be pressure from multiple entities to be as precise as possible, as quickly as possible. It’s folly to do that, though. Better to be slow, deliberate, and get as much information as you can first, then provide a reasonable estimate, not an exact one.”

  LOOKING FOR BOOGEYMEN

  Another thing Holmes learned—although it took time—was to trust his instincts. When he was being trained, first at the police academy and then on the job, he was told to take nothing for granted.

  “Question everything
people tell you,” his trainers said, “family members, friends, doctors, nurses—everyone. Don’t be too trusting.”

  Most of the instructors at the academy were police officers, and Holmes’s supervisor, Keith Craig, was a retired cop as well. Since their focus was on wrongdoing, they expected people to lie to them and were suspicious of anything they were told. The same level of skepticism didn’t play out well in the coroner’s office, though. It was important for coroners’ investigators to question, but not to assume that everything they heard was less than the truth. That kind of attitude distances coroners from families and is why the relationship between coroners’ offices and families tends to be better in counties where the operation of the coroner is separate from law enforcement.

  Because of the way he was trained, Holmes started out suspecting people of equivocating or withholding information. “I found myself looking for boogeymen where none were to be found,” he says.

  An example of this was the death of a twenty-seven-year-old woman named Brie. “She was beautiful,” Holmes says. “Brown hair, green eyes—every man’s idea of a knockout.”

  She also was the consummate party girl, going so hard and so long that few people could keep up with her. Whether it was alcohol, drugs, or sex, she embraced it eagerly and hungrily. Her lifestyle caught up with her, however, after a wild night in a motel room.

  Brie invited two men her age who barely knew her to the room. Then she unloaded a duffel bag full of sex toys, condoms, lubrication, hard rock CDs, a portable player, and an assortment of drugs.

  The three of them went at it, starting with marijuana and beer, then moving on to hard liquor and heroin. Brie showed them how to inject themselves, and she drank lots of Gatorade so that she would urinate often and flush the drugs through her system. Eventually the two men had to turn down her demands for more sex because they were exhausted. They fell asleep in the room, only to wake up the next morning and find her lying dead next to them. She was still holding a cigarette that had burned down to the filter, there were empty liquor bottles and used condoms in a trash can, and on a nightstand next to the bed were drug paraphernalia and heroin.

  Police officers questioned the two men one time, and decided that they didn’t have enough information to charge them with a crime that would stick. Holmes wanted to continue investigating, however. He spent nearly three full days interviewing both of them because he thought they were partially responsible for Brie’s death.

  “They claimed that she rented the room, provided the drugs and booze, and masterminded or scripted the marathon sex between all three of them,” Holmes says. “It sounded too concocted, though, a story better suited to the pages of Penthouse magazine than a coroner’s report.”

  He adds, “They were alone in the room for a long enough period of time to have built their story,” which enhanced his suspicions.

  During his investigation, Holmes talked with other people who knew Brie. They confirmed that she was a needle user and on a crash course for an early demise. He also talked to acquaintances of the two men and was told that they weren’t sophisticated enough to have scored the drugs and come up with a plan to use Brie, then kill her. Except for minor marijuana use, both were clean.

  Just to cover all the bases, Holmes went to the hotel and checked the heater in the room. It wasn’t likely, but he wanted to rule out any chance that there had been a carbon monoxide leak. The heater functioned perfectly.

  By now a different picture of the event had taken shape in his mind. It was helped by the fact that both men were visibly shaken when Holmes talked to them, and their stories never wavered. One man was in tears through most of Holmes’s first two interviews with him.

  Among other items found in Brie’s duffel bag were Alcoholics Anonymous books and a journal. Another investigator in the coroner’s office contacted Brie’s AA sponsor, who said that the two of them talked almost every day, and Brie had been sober more than seventy days. The sponsor hadn’t heard from her in the past four days, however.

  Holmes says, “I could have saved myself a lot of time if I had been more open-minded at the outset. Not that I resented the time I put into the case, but if I had been less suspicious in the beginning, I could have reached the same conclusion faster.”

  It wasn’t clear whether Brie’s death was an accident or suicide, so Holmes ruled that the manner of death was undetermined. In the end, he was confident that it wasn’t a homicide, though.

  “I believe she overdosed by cumulative effect,” he says, “but not intentionally. She built a high early in their night and tried to keep it with beer, hard liquor, and heroin. I think she lost track of the quantity, and died after they all passed out.”

  CHAPTER 06

  THE OVERDOSE THAT WASN’T

  When Carol Filipelli died under mysterious circumstances, and Ken Holmes investigated her death, he discovered facets of her life that were eye-opening. It was the stuff of bestselling novels and popular movies—in fact, a well-known writer heard pieces of it from a doctor who treated Carol, and wanted Holmes to discuss it. Holmes refused. In his mind, the public didn’t need to know the story. Even Carol’s parents and brother didn’t need to know more than the basics of what happened to the twenty-six-year-old onetime model, Holmes believed. What good could come from describing secrets that Carol kept hidden from everyone? It is only with the passage of nearly forty years and his retirement as the coroner of Marin County that Holmes discusses the case now.

  On Tuesday, January 24, 1978, police officers were called to a two-story luxury apartment in Sausalito by a neighbor who requested a welfare check on the person who resided there. Carol Filipelli hadn’t answered when the neighbor knocked on her door and phoned her. That wasn’t unusual since Carol traveled frequently, but what concerned the neighbor was that Carol’s dog had been outside, loose, for several days. Carol never let the dog out on its own.

  Sausalito is one of the most affluent communities in Marin. It was that way in 1978, and it’s that way today. Multimillion-dollar homes are perched on hillsides with panoramic views of San Francisco Bay. The waterfront resembles a chic seaside village with fancy boutiques, expensive restaurants, and high-end art galleries. The Sausalito Yacht Club is home to impressive sailing and racing vessels. Located just north of San Francisco, at one end of the most famous bridge in the world, the Golden Gate Bridge, Sausalito also serves as the gateway to California’s fabled wine country, redwoods, and northern coast.

  Carol Filipelli’s apartment had the same breathtaking views as the most expensive homes in Sausalito. The furniture was tasteful and expensive. A late-model Mercedes was parked in the garage.

  At 2:40 P.M. that Tuesday, police arrived to find Carol’s front door locked. They went around the side and gained access through an unlocked sliding glass door in the rear of the apartment. Carol’s body was upstairs, in the master bedroom. Dressed in a maroon robe and black socks, she was lying at an odd angle on the floor, as if she had fallen from her king-sized bed. The receiver of her phone was off the hook, and an alcoholic drink was on a nightstand nearby. The closet doors in the bedroom were closed, and the sliding glass door leading to an outside balcony was locked.

  Bill Thomas was the coroner’s investigator who was on duty at the time. He checked in with the responding officers, then examined Carol’s body. There was no evidence of trauma and no unusual markings. Lividity, the process by which blood settles after it ceases to circulate, was pronounced and fixed. Rigor mortis—the stiffening of muscles—had passed, and her body was room temperature. These signs indicated that Carol had been dead at least twenty-four hours, and probably longer. Upon moving her body, Thomas noted a clear fluid coming out of her mouth. He took nasal, vaginal, and vitreous humor swabs (the latter is the fluid behind the cornea), which is standard practice in cases like this. He also preserved the drink on the nightstand.

  Searching the apartment, Thomas found miscellaneous papers and checks, assorted jewelry, designer clothes in the mast
er bedroom closet, and $889 in cash. It was in the master bathroom that he discovered the apparent cause of Carol Filipelli’s death. The wastebasket had five empty pill bottles. All were for prescriptions in Carol’s name that had been filled recently. One was for 500-milligram capsules of Doriden, a sedative for insomnia. The prescription, thirty-six pills, was only four days old, yet the bottle was empty. Two other empty bottles had contained Valium. The fourth bottle once held Quaalude, an antidepressant, while the last bottle was for Minocin, an antibiotic used to treat bacterial infections, including those caused by sexually transmitted diseases. Three different physicians had prescribed the medications, and the bottles, collectively, had contained 260 pills at one time.

  Thomas knew from experience that unless additional information surfaced during the autopsy or in conversations with Carol’s family and acquaintances, it was unlikely that the reason for her death could be determined. The cause—a drug overdose—seemed obvious, but the manner—whether it was accidental or intentional—wasn’t clear. Without compelling evidence such as a suicide note, there was no way for the coroner to rule one way or the other.

  After Thomas completed his examination, Carol’s body was delivered to a funeral home in Mill Valley where the autopsy would be performed. Carol’s dog, as well as a caged bird, were turned over to the Marin County Humane Society.

  The autopsy confirmed Thomas’s initial assessment. There was no indication of trauma—no bruises, lacerations, or punctures. There was nothing unusual about Carol’s heart, lungs, liver, kidneys, brain, bile, or body cavities, either. Samples of Carol’s blood, urine, and gastric fluids were sent to a lab in Oakland. The results wouldn’t be known for several weeks, although that wasn’t a concern. Given the empty pill bottles in the bathroom, no one doubted what the toxicology report would show.