The Education of a Coroner

by John Bateson

  “Someone who’s been managing a $1 million budget, I don’t think he can have any comprehension of what a $50 million budget is like,” Doyle said.

  Holmes countered by saying that he had always managed a balanced budget, whereas the sheriff’s department frequently had overruns. In addition, Holmes had advanced certificates from the state’s Commission on Peace Officer Standards and Training, making him qualified, he felt, to assume the sheriff’s duties, while Doyle wasn’t qualified to be the coroner because he had no training in medicine or forensics.

  Doyle garnered more endorsements than Holmes and raised a lot more money—$100,000, a large amount given Marin’s small size and the fact that little funding had been spent on sheriff’s elections in the past. The results were predictable. Doyle received 63 percent of the 39,500 votes that were cast, while Holmes received 37 percent. In the same election, the supervisor who wanted Holmes to issue a public apology to Tabitha received 52 percent of the votes in her district to earn another term as supervisor.

  Holmes began making plans to retire on December 31, 2010, the last day that the coroner’s office would operate independently. One thing he did was send all of the coroner’s case files from earlier than 2000 to the Marin County library to be archived. It was the policy of the sheriff’s office to destroy most records that were ten years old or older, and Holmes didn’t want that to happen with his records.

  “Coroners’ records are different than arrest records,” he says. “To destroy them isn’t just about the legal implications of a homicide, accidental death, or car wreck. Coroners have information about families that goes back generations. Every week we had people coming to us with questions about genealogy because there was no place else for them to get the information. Mortuaries don’t have it all; cemeteries don’t have it all; families seldom have it all. Many of the things that come to bear on a person’s life are in the coroner’s records.”

  At one time Holmes and his staff tried to microfiche inquest records from the 1800s and early 1900s. The records were on onionskin paper, however, which started to dissolve in the process. After they put the first ten pages in a scanner, they stopped. The heat was taking the ink out of the onionskin. Some of the inquests were fifteen pages long, recorded in calligraphy—“Difficult to read, but absolutely beautiful,” Holmes says. “We had hundreds of them because every single one since 1853 was kept, and I was afraid that the sheriff’s office would either try to find a way to minimize them or get rid of them.”

  In the olden days, an inquest was held whenever someone died. The coroner had the power, by law, to go into the hallway of whatever building he was in and pick six people for the jury. He didn’t need a subpoena, and the people had to come immediately, unless they had a compelling reason why they couldn’t. That is still true today, incidentally, although no one does it that way. When Holmes held an inquest, he would go to the regular court jury pool, take forty people off the roll, and sort through them just like any other jury trial. The only difference was that the process would be completed in one day whereas jury selections in courtroom trials can take several days or longer.

  Holmes was told that the only records older than ten years that the Marin County Sheriff’s Office kept now were the original report pertaining to a criminal case and the case’s disposition. The handwritten notes taken by deputies during interviews weren’t retained, which alarmed him since they contained many details. He thought that if similar information in coroners’ records was discarded, it would constitute an enormous loss. In addition to a one-page summary, each coroner’s file included an investigative report, supplemental findings, pathology and toxicology reports, police reports, and suicide notes if found. Some files had fifty pages or more. In addition, there were photographs taken at the scene and during autopsies, as well as all of the negatives. The latter were kept so that if copies were requested by the district attorney, defense attorneys, or insurance companies, the coroner could provide them. Holmes believed that if he ever supplied an original print or negative, there was a risk that it wouldn’t be returned.

  The Marin County Library was two floors above the coroner’s office in the Frank Lloyd Wright–designed Civic Center building; nevertheless, moving all of the files there was a chore. Dozens of large, four-drawer file cabinets, each one filled with paper records of cases that collectively went back nearly 150 years, were loaded onto dollies and taken upstairs by elevator. Library staff weren’t quite sure what to do with them but recognized their historical value and made plans to house the collection.

  As with other facets of the coroner’s work that people in the sheriff’s office didn’t fully understand or appreciate prior to taking over, the realization was slow in coming that everything would need to be kept. There were too many instances when law enforcement personnel had to access old information because it had bearing on an open case. As a result, over time all files ended up being moved out of the library and into a big storage area used by the sheriff.

  THE AXE FALLS

  Because Sheriff Doyle had promised the board of supervisors that merging the coroner’s office with his department would save money, there had to be funding cuts. The cuts wouldn’t be in the sheriff’s budget but in the coroner’s. The first one was the assistant coroner position. Gary Tindel, the former sheriff-coroner of Yuba County, represented the old regime and also posed a perceived threat to the newly appointed coroner because Tindel had far more knowledge and experience in death investigations than the sergeant did. Abolishing the position reduced costs as well as removed any fears. It didn’t leave anyone to train or supervise the three investigators, but the thinking was that new investigators would come into the job already trained, and the sergeant could do the supervising. As for other responsibilities of the job, they would be spread out or eliminated.

  Another cost-cutting move was to reduce the number of autopsies that were performed in the county. The stated rationale was that they weren’t necessary, but the real reason, Holmes believed, was that autopsies are expensive and, from the sheriff’s point of view, only worth doing in homicide cases. That’s not surprising, although Holmes had cases where police officers were quick to attribute someone’s death to a manner other than homicide so that they didn’t have to investigate.

  “In the 1980s,” Holmes says, “we were called to a house where a man was found dead on the floor of his kitchen. He had been stabbed three times in the heart, once in the lung, and once in the belly. Police found the knife that had been used. It had been washed off in the sink—there were small drops of blood there—then put back on a magnetic knife rack. Three cops were at the scene, and they discussed at length the angle of the knife for each piercing. They dusted the knife for fingerprints, but it had been wiped clean. The blood in the sink proved to be that of the decedent. The police couldn’t develop any other scenarios or a suspect, so they decided that he must have stabbed himself, wiped the knife, returned it to its holder, cleaned the sink, then laid on the floor and died. They concluded in their report that it was a suicide even though we said it was undetermined and a probable homicide.”

  Over the years, one of the police officers involved in the case and Holmes shared a bemused laugh over it. Sometimes it’s not easy to determine what happened, but at least you make an effort to find out. Next of kin deserve it.

  “In today’s world,” Holmes says, “the police would never do that. City chiefs and sheriffs wouldn’t allow it. A man stabs himself five times, then has the wherewithal to rinse the knife, dry it, and hang it back on the rack before he staggers around and dies? It’s not impossible. He could have had a really solid heart, and the knife went in cleanly and came out cleanly so there was only a little blood. Similarly, you can puncture one lung and your other lung will keep functioning, at least for a short period of time. It’s not likely, though.”

  With the merger, the Coroner Division of the Marin County Sheriff’s Office, as it was now known, stopped doing autopsies on most suicides, i
ncluding Golden Gate Bridge jumpers. Autopsies stopped being done on most hospital deaths, too, where a person died during the course of receiving treatment or while undergoing surgery. Instead, the new coroner accepted the explanation of medical staff concerning a patient’s demise. This was problematic, though, since doctors and nurses have a vested interest in deflecting blame. In the vast majority of cases, they are competent, and when there is a poor outcome it’s usually for reasons beyond their control. That was why Holmes referred to deaths in hospitals that ended up in court as “medical misadventures” rather than medical malpractice cases. There were isolated instances, however, where someone made a preventable mistake and a person died as a result.

  “In one case,” Holmes says, “an anesthesiologist didn’t use the right combination of gases, and a patient died. The decedent was an old man, and there probably were a lot of things wrong with him. Moreover, he needed the surgery; it wasn’t elective. Still, he was given the wrong anesthesia, plain and simple. When Dr. Jindrich finished the autopsy and reviewed the surgical notes in hospital records, he saw that there had been an inappropriate mixture of gases. The anesthesiologist’s jaw hit the floor when we told him; he didn’t realize what he had done. It was an accident, in no way intentional. Even so, it was his fault.”

  In time, Holmes’s successor resumed the practice of doing autopsies on people who died in hospitals and clinics, but not for suicides from the Golden Gate Bridge. If families of bridge jumpers wanted an autopsy or toxicology test done, they had to pay for it.

  Related to autopsies, the part-time position of the person who transcribed audio accounts of physicians’ pathology findings into written reports was also cut. He or she was paid only fourteen dollars per hour, so the savings weren’t significant, however, the impact was big. During Holmes’s tenure, dictated autopsy reports were transcribed the following day, making it possible for the coroner to issue death certificates promptly. After the change, the pathologist who did the autopsy was expected to transcribe his or her own notes and provide them to the coroner. It’s an onerous task and at the bottom of every physician’s to-do list. As a result, death certificates stopped being produced in the same timely manner.

  GOING IN DIFFERENT DIRECTIONS

  Following the election, Holmes’s three investigators began receiving calls from coroners in other areas wanting to recruit them. Dave Foehner, the last investigator Holmes hired, left December 31, 2010—the same day as Holmes—to take a job as a coroner’s investigator in the Maryland Office of the Chief Medical Examiner. In short order he was promoted to supervisor, then to assistant coroner. There were so many cases, however, that he became frustrated by the inability of investigators to follow through on many of them and ended up leaving.

  The situation was different for Pam Carter. She wanted to continue but had a bitter history with the sergeant, before he became the new coroner and her boss.

  “He married one of Pam’s best friends,” Holmes says, “and his authoritative and arrogant personality ruined their friendship.”

  Carter ended up leaving and today is the founder, president, and principal owner of a company that developed, manufactures, and markets an aerial fitness program for home use.

  Darrell Harris was the only one of the three investigators who stayed. In 2008, the Marin Independent Journal reported that he had been named investigator of the year by the California State Coroners Association. Since he was the only person left in the office with experience in death investigations, he ended up training the two cops who replaced Foehner and Carter. Five years after Holmes retired, in October 2015, the sergeant who succeeded him was reassigned and Harris was named the new deputy chief coroner under Sheriff-Coroner Robert Doyle.

  As for Holmes, when San Francisco’s chief medical examiner stepped down in 2014, Holmes was asked if he would be interested in the job temporarily. While he wasn’t a physician, Holmes knew how to run a coroner’s office and that was what people in San Francisco needed. There was a six-month backlog of more than eight hundred cases—far more than in most other parts of the country. Holmes said thanks, but no thanks. A job that in essence was sixteen hours a day, seven days per week, held no appeal at this stage in his life. Besides, he had other interests he wanted to pursue.

  One of the things he had dreamed about since adolescence was owning a hunting ranch. In 2002, after a divorce, Holmes sold the house in Fresno that he had inherited from his grandparents and bought a 360-acre hunting ranch in Colusa County, about 120 miles northeast of Marin. There, on days off, he led commercial hunts for deer, wild pigs, turkeys, and doves.

  When he remarried, his new wife liked to hunt, but not at the ranch. It was too hot in the summer and too muddy in the winter. They talked about owning property at Clear Lake, north of Marin, and ended up buying a place there. From that point on the ranch started going to seed. Six years after he bought it, Holmes sold the ranch and decided to scratch another item off his bucket list—he bought a Ferrari. For more than two decades he had built and driven cars in circle track auto racing, and ever since he saw his first Ferrari at a racetrack when he was a teenager he had dreamed of owning one.

  On Sunday mornings, while everyone else in his household was asleep, he drove his new toy to the coast “just to stretch its legs.” Twice he took it to Sears Point–Infineon Raceway.

  “Because of the way the track is configured, I could only get it up to 135 miles per hour,” he says. “There were several other places where I had it up to 150, though, on Highway 280 by Stanford. If you go there late at night or early in the morning on weekends, you can open it up a little.”

  As much as he loved the car, Holmes found that it was sitting in his garage most of the time. He didn’t drive it to work, and he was so busy on his days off that he had relatively few opportunities to take it out then. Reluctantly, in September 2014, six years after he bought the car, he sold it.

  Currently, Holmes and his wife are completing renovations on their place in Clear Lake. Reporters still contact him on occasion, wanting his take on a case, and he stays in touch with many of his former colleagues, retired coroners and investigators in Marin and elsewhere whom he got to know through cases that crossed county lines or through his years with the California State Coroners Association.

  Holmes also continues to hunt, accompanied by his two black Labrador retrievers—Quincy (named after the medical examiner in the TV show of the same name) and Mia. He loves to camp, too, has a motorboat that he takes out frequently, is an enthusiastic dancer, and enjoys rooting for local sports teams, particularly the San Francisco 49ers and Giants. He also operates an estate liquidation service and does some consulting in forensics.

  LESSONS LEARNED

  It’s natural at the end of a long career to look back and reflect on what one has learned. In one of our last conversations prior to submitting the final draft of this book, I ask Holmes what he has learned about life, death, and human nature.

  “Death knows no keeper,” he says. “It’s a great leveler. The rich and famous are touched the same as your average Joe. I have seen members of the Hells Angels—scary dudes—on their knees weeping at a roadside where one of their members was killed and his wife was seriously injured in a motorcycle accident. I have talked with homeless people after another homeless person died and they were beside themselves with grief. I have also met with celebrities—Jane Russell and her husband Bob Waterfield, Norton Buffalo, Elvin Bishop, Klaus Kinski—after a loved one died. All of them had to face it alone because grief is a personal thing. Even in a roomful of people, you are by yourself. There’s lots of advice out there, and some might apply, but in the end we go through it alone.”

  Holmes had retired by the time Robin Williams died in 2014, but thirteen years earlier, in 2001, he was called to the scene following the death of Robin’s mother, Laurie Williams, from natural causes. It was the same house in Marin County where Robin later killed himself—Robin bought the house for his mother, and moved into it after
she died—and Holmes explained the next steps to the actor-comedian. Robin listened silently and dutifully, like any grieving family member. There were no jokes, funny faces, or affected accents—only profound sadness.

  “I have a hard time when I hear someone say that another person isn’t grieving ‘appropriately,’ ” Holmes says. “Just what is appropriate for a young mother whose five-year-old daughter drowned in their pool because Mom went into the house ‘for a moment’? How does an eighty-year-old man grieve for his wife of sixty-one years? How does a doctor grieve when his next-door neighbor, who happens to be his patient, dies because the doctor’s diagnosis was incorrect? How do police and fire personnel grieve when they are bombarded constantly with every imaginable kind of death? How do they grieve for one of their own, whether a family member or another person who wore the badge?”

  The questions are rhetorical; Holmes doesn’t expect answers.

  “I firmly believe that we never have ‘closure’ following a death of someone close to us,” he says. “We may find some peace, we may ‘get through it’ and our lives continue, but true closure is elusive at best and probably nonexistent.”

  “Have there been any instances where your thinking has changed dramatically over the years?” I ask. “Where you felt strongly about something early in your career and over time shifted 180 degrees in the other direction?”

  Holmes says, without hesitation, “I have experienced two prominent changes in my personal attitude. The biggest is my attitude toward suicide. When I first became a death investigator, I had little regard for people who jumped off the Golden Gate Bridge or killed themselves another way. After years of meeting with families of suicide victims, however, and reading the heartbreaking notes left behind, notes that explained the person’s troubles and formidable barriers to a healthy life, my view changed completely. I became aware of the whole mess we have in this country regarding mental health, and of the urgent need as a society to address it.