I received this book for free from NetGalley in exchange for an honest review. This does not affect my opinion of the book or the content of my review.The Education of a Coroner by John Bateson
Published by Simon and Schuster on August 15th 2017
Genres: Biography & Autobiography, Personal Memoirs, Law Enforcement, Medical, Forensic Medicine
Format: Electronic ARC
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Coroners deal with death, but their purpose is to find answers for the living.
Ken Holmes’s career at the Marin County coroner’s office spanned nearly forty years. He started out as a licensed embalmer at a funeral home, which led to him becoming a death investigator for the county. During the last twelve years of his career, he was the elected county coroner. In this book he reveals the intricacies of his job, a job that most people would rather not think about: the tell-tale signs our bodies leave behind, the collecting of evidence, the family notification process, differences between TV representations and real life, changes in technology over the years (fingerprint cartooning was a thing!), preparing the county for mass casualty events, running investigations in areas where people are hostile to law enforcement, working with press, and dealing with the politics. As an employee of the coroner’s office, Holmes had to be not only a detective and a doctor, but a “consoler, advocate, educator, mentor, teacher, and bureaucrat.”
One of the most surprising things I learned from this book is that there aren’t any national standards for coroners. In most states, it’s an elected position. Not all coroners are medical examiners and often they aren’t even required to have medical training. The author mentions that one Indiana county elected a high school senior as coroner! I also had to adjust the high-tech image in my head of what I thought a coroner’s office looked like. The Marin County coroner’s office doesn’t even have a lab or morgue on premises. Those services are contracted to outside facilities.
Marin County is an affluent area that’s home to one end of the Golden Gate Bridge, one of the world’s top suicide sites, and San Quentin Prison, location all of California’s 750 male death row inmates. Every year, approximately 300 of the 1,500-1,800 deaths in Marin County require autopsies. During his decades of experience, Holmes saw a wide variety of cases, both personally and through his colleagues’ work. This book highlights the most interesting and memorable cases in his career, as well as the lessons he learned along the way. There are quite a few out-of the-ordinary incidents: a serial killer haunting the trails, a small cult near Holmes’s home, celebrity victims and instigators, and the time Holmes became a witness to an active crime.
Real life truly is stranger than fiction! I would’ve found many of the cases unbelievable if Holmes hadn’t experienced them for himself. A large number of the victims he investigated died by their own hand; more than twice as many Americans die by suicide than by murder. Since these are real-life cases, they don’t all have neat and tidy endings. Some of the cases took decades to solve and many only reached conclusion by a series of unlikely coincidences. Thanks to Holmes’s impeccable record keeping skills and his dedication to following cases even after they left his hands, there’s closure to more cases than I expected.
There are so many fascinating cases in this book, but here are three that were extra memorable for me:
• January 1978: Carol Filipelli died in what appeared to be a drug overdose, but her toxicology screen came back negative for drugs. Nothing was adding up, so Holmes was persistent and kept digging for answers. It turns out that she may have been murdered by a former lover with a highly unusual weapon, but unfortunately any evidence was destroyed when she was cremated.
• June 1997: Death row inmate Sammie Marshall died after being forcibly removed from his cell. Holmes ruled it undetermined, but he believes it was a homicide and regrets succumbing to the pressure of law enforcement: “I’m not an advocate for inmates or anybody who does something bad, but I’m an advocate for doing something the right way, and they did it wrong.” There’s a revelation at the end of the chapter that makes the story all the more tragic.
• Two brothers thought a small town bank would be an easy target, but got more than they bargained for! The bank teller made four calls to handle the situation and only the last one was to the police department.
“The more time you spend around death, the more you appreciate life.”
Not every victim gets justice. Sometimes by the time the details of the case become clearer, there’s no way to prove their theories. Other times there are political concerns and budget constraints. The cops or district attorney may not want to deal with a case for various reasons, so the coroner’s office might receive pressure to rule a certain way. Most California counties have a combined sheriff’s/coroner’s office where the sheriff is the coroner. During Holmes’s tenure, the Marin County coroner’s office operated separately from the sheriff’s office. He outlines the benefits to having an independent coroner’s office. For instance, law enforcement has priorities that may come into conflict with the interests of the victims’ families. The time constraints of a combined office can lead to families never getting answers. In a couple of baffling cases, a person’s death was determined to be a suicide even though there were multiple clues that pointed to foul play.
“Every death has a story, just like every life. Coroners are privy to it in ways that other professions are not. That’s what draws people like me to it, the chance to be present, understand, and help others deal with something that usually is awful, at a time when people tend to feel most alone.”
The body’s process of shutting down may be gruesome, but it’s an inescapable part of our life cycle. This book was a real page-turner! It has a very small-town feel, both because of the time Holmes spends on each case, as well as his and the author’s personal connections to some of the victims. I side-eyed a few of the casual conclusions made based on appearances, but for the most part, this book is a fascinating look at a long and varied career. In the conclusion, Holmes talks about how his views on suicide victims, the good guy/bad guy dichotomy, and the justice system have evolved with his years of experience. I admired Holmes’s dedication to the victims’ families and the time and energy he devoted to their cases. His insistence on getting answers for the families made this book a compelling read.
The author John Bateson also wrote The Final Leap: Suicide on the Golden Gate Bridge.