Business owner (4)
Car wash owner
Cotton gin marketer
Emergency medical technician/paramedic/firefighter (18)
Flooring company owner
Funeral director (74)
Gas department superintendent
Heating and air conditioning technician
Heavy equipment operator
Information technology specialist
Marine engine repair technician
Nurse/other health care worker (9)
Paving company owner (2)
Shipping clerk (2)
Shooting range owner
Note: One coroner’s office is vacant. Coroner’s offices have been abolished in Fulton, Cobb, DeKalb, Gwinnett and Clayton counties.
Sources: Georgia Government Transparency and Campaign Finance Commission, AJC research.
Reporting suspicious deaths
Georgia law specifies several types of questionable deaths that county coroners are supposed to report to the state medical examiner’s office, where officials decide whether to perform autopsies. Among the deaths covered by the law:
• Violent deaths
• “Suspicious or unusual” deaths, especially of a person 16 or younger
• Unexpected or unexplained deaths of children younger than 7
• Deaths in jails or state hospitals
Source: Georgia Death Investigation Act
Georgia’s constitution first mentioned the office of coroner in 1777, and the position still exists as an elective office in 154 of the state’s 159 counties. These counties abolished the office in the year in parentheses:
Clayton County contracts with the state medical examiner’s office to perform autopsies. The other four counties have appointed their own medical examiners.
Kevin Wallace slumped against a closet door spattered with his blood. His pistol lay just beyond his reach.
A suicide, the local coroner said.
Tom Sublett’s body floated up at a marina, his hands bound in front by black plastic zip ties. A bullet hole gaped from the back of his head.
Also a suicide, another coroner said.
These shootings, 10 months and half a state apart, illustrate many of the gaps in how Georgia examines even the most suspicious deaths, an investigation by The Atlanta Journal-Constitution has found. A centuries-old reliance on elected county coroners puts death cases in the hands of officials who have little or no expertise in criminal investigation or forensic science – and may even help killers get away with murder.
The Journal-Constitution reviewed dozens of cases and analyzed thousands of death certificates issued statewide since 2011, particularly those involving violent acts or unusual circumstances. Almost three dozen times, the newspaper found, coroners ruled that shooting victims died of “natural” causes. In nearly four of every 10 cases ruled suicide, no autopsy was performed to confirm the cause and manner of death.
Georgia was the first state to mention the office of coroner in its constitution, in 1777. Now, 238 years later, it is among the 27 that still elect at least some local death investigators. Four of the other 26 require coroners to be physicians, and one other says they must be licensed medical professionals.
Georgia’s prerequisites: A coroner must be at least 25 years old, registered to vote, and in possession of a high school diploma.
So Georgia’s coroners are grocers, nurses and morticians; farmers, pastors and hairdressers; plumbers, teachers and handymen. In one county, the coroner is a boat-motor mechanic. In another, it’s the owner of a shooting range.
Of Georgia’s 154 coroners, one is a physician.
At least one-third of coroners have experienced significant financial problems, court records show: bankruptcies, citations for failing to pay taxes, court orders to make good on bad debts. Four have criminal records.
Coroners earn as little as $1,200 a year for a part-time job that requires around-the-clock service, often at gruesome, nightmare-inducing scenes: bloody car crashes and shootings; babies shaken or choked to death; bloated, decomposed bodies – all reminders of humanity’s boundless capacity for inhumanity.
“When you’ve got coroners who don’t make but a hundred dollars a month or something – well, you pay for what you get,” said Edgar Perry, the coroner of Turner County and the chairman of the Georgia Coroners Training Council. “It’s hard to get somebody to perform a job with very, very minimal salaries or benefits.”
Georgia coroners do not conduct autopsies or other scientific procedures. But they oversee evidence collection at death scenes, and they make one of the most critical investigative decisions: whether to request autopsies by the state medical examiner.
Often, they decide their own visual post-mortem examinations are good enough.
In 2010 and 2013, state auditors expressed concern that coroners often fail to notify the medical examiner of unexplained or unexpected deaths, as the law requires. Auditors found in 2010 that one-fourth of suicides were never reported to the medical examiner.
After Sublett’s body surfaced at St. Simons Island, the Glynn County coroner asked the medical examiner’s office to perform an autopsy.
But in Wallace’s case, no autopsy was even considered. Wallace was cremated one day after authorities found his body – possibly with a second bullet wound that the coroner never noticed.
Ten thousand bodies
Leon Jones first won election as Bibb County’s coroner in 2004, after 14 years as a deputy coroner. For 30 years, he was an emergency medical technician, and over the years worked at six nursing homes.
“Obviously, I know what I’m doing,” he said recently. “I’ve seen over ten thousand dead bodies – ten thousand.”
On Feb. 21, 2012, the county dispatcher notified Jones that another body had been discovered, in a house on Macon’s west side. Neighbors hadn’t seen the resident, 42-year-old Kevin Wallace, for days. Suspicious, they called the police. An officer found Wallace’s body inside a back bedroom.
Wallace had a bullet wound on the left side of his head, just above the ear, according to a police report. Crime-scene photographs show an exit wound near the right temple. The bullet that seemed to have killed Wallace struck the closet door behind him. Another bullet hole can be seen in a wall.
Wallace’s gun, a .45-caliber semiautomatic pistol, lay on a rug, a few feet from his right knee. The gun had a 14-shot capacity; 11 unfired shells remained.
When he arrived, Jones said in an interview, a police officer told him Wallace had killed himself. Jones said he saw no reason to think otherwise.
“The house was secure from the inside,” Jones said. “Everything pointed to a suicide.”
Soon after the body was found, Jones spoke to a private detective hired by Wallace’s family. According to the detective’s transcript, Jones said he didn’t check the time or day of outgoing calls on Wallace’s phone; didn’t know that Wallace’s safe was open and empty; didn’t look at Wallace’s car, which was packed with clothes as if he were planning a trip; and didn’t look around the house for signs of a struggle.
“I only went to the one room,” Jones told the detective. “Being coroner, our job is the body. We don’t go rambling, looking through people’s houses. We go to the body, do our thing and get the hell out of the house.”
In the interview with the Journal-Constitution, Jones said he did not report the Wallace case to the medical examiner’s office because the cause and manner of death were so obvious.
“There was no reason to do an autopsy,” he said.
Wallace was cremated the day after he was found, before a second investigator hired by the family reviewed the death-scene photos.
Philip Tricolla, a retired homicide detective with the New York Police Department, spotted suspicious details: among them, the absence of burned gunpowder near the wound on Wallace’s head, a lack of blood on Wallace’s hands and on the gun, and, most notably, what appeared to be a second bullet wound in Wallace’s right chest.
“No way an investigator walks in and right away says, ‘Suicide,’” Tricolla said in an interview. “How could there not be an autopsy?”
“More than likely,” Tricolla said, “that guy did not kill himself.”
Lack of aptitude
Twice each year, newly elected coroners and newly appointed deputy coroners gather at a state law-enforcement training center to learn the art of death investigation.
The coroners and deputies emerge five days later, empowered to declare whether a baby died from natural causes or from subtle abuse, whether a drug overdose was accidental or intentional, whether an apparent drowning victim was already dead before entering the water. They officially possess the authority to determine the innumerable ways people die or are killed.
Beyond the initial 40 hours in the classroom, coroners and deputies must attend a three-day refresher course each year. Classes focus on such subjects as blood spatter and ballistics evidence, as well as administrative duties.
“There is a lot of material there,” said Perry, the head of the coroners training council. “I don’t think anybody can have too much training.”
In an interview, Perry took care to avoid offending his peers. Still, he acknowledged some coroners lack the aptitude to learn investigative techniques.
“We’ve had some people who ran a wrecker service, that sort of thing,” he said. “There are some occupations that have never had anything to do with death.”
About one in five coroners now in office works in medical fields, but that includes firefighters certified as paramedics or emergency medical technicians. Few have diagnostic or forensic experience. Even the sole physician among the coroners is an orthopedist.
The largest group of coroners run or work in funeral homes – a job that Perry described as well-suited to the duties of the office. Morticians, he said, have studied anatomy, pathology and other disciplines relevant to death investigations.
Perry is a funeral director.
Jimmy Durden was a funeral director for more than 50 years. He was Glynn County’s coroner or deputy coroner almost as long.
On Dec. 11, 2012, Durden arrived on the scene shortly after Tom Sublett's body surfaced at a St. Simons Island marina. Durden saw the zip ties binding Sublett’s hands in front of the body. He noted the gunshot wound in the back of Sublett’s head, just behind the right ear and pointing downward. He learned from police officers that they had not found a suicide note or a weapon.
“The first thing he said was, ‘It’s suicide,’” said Mark Johnson, a lawyer for Sublett’s family. “Immediately. Then it all just went from there. It shut down the investigation.”
Sublett, 52, was a real estate salesman who was completing a four-year term as a Glynn County commissioner. On Dec. 10, he attended a poker game with several other men. The last time anyone saw him was 10:30 p.m., when he dropped off a friend on the way home.
About 2:30 a.m., Sublett’s wife, Carol, started calling friends to ask if they knew where her husband was. Then she called the police.
“He’s not an alcoholic, he doesn’t run around,” Carol Sublett told the 911 operator. “He’s a county commissioner, and he’s not home, and I don’t know what to do.”
Friends searched for Sublett, and one found his car, a Toyota Avalon, at a waterside park shortly before 4 a.m. The body was discovered two hours later, less than half a mile away.
Sublett’s car keys, cell phone and money clip were missing. So was the 9 mm Smith & Wesson handgun he normally kept in his car. A police report suggested no motive either for suicide or homicide. Sublett had “no known domestic or relationship issues,” the report said, “no known enemies.”
Why Durden decided on suicide isn’t known; he died in November 2013 at age 76 without publicly discussing the case in detail.
After an autopsy, the state medical examiner’s office also classified the death as suicide. But a pathologist’s report offers no explanation of how Sublett could have bound his own hands, twisted his arms over his head and fired a bullet that traveled from the skull down to his right shoulder blade, all before dropping the gun and falling into the water.
Johnson, the family’s lawyer, said that because of recent surgery, Sublett couldn’t raise his right arm above his shoulder. “Yet, somehow, he’s able to contort himself? I don’t know how you could ignore that.”
The coroners’ rulings left both Sublett’s and Wallace’s families unsettled.
But Abram Brown, a former Glynn County coroner who returned to the job after Durden died, said families often struggle to accept the truth that a coroner reveals. He described Durden, who had once been his deputy, as an experienced, capable coroner.
“He did a good job,” Brown said. “If he didn’t, I wouldn’t have asked him to run.”
Wallace’s family is convinced he was murdered – maybe over a drug deal, maybe because of a dispute with a man who worked on his house.
But because Wallace was cremated without an autopsy, “there are a lot of questions that are unanswered,” said Stuart James, the family’s lawyer.
Jones, the coroner, said he followed standard procedures in the Wallace case.
He said he thoroughly examined the body and saw no gunshot wound except the one in Wallace’s head. Other bullets fired from Wallace’s gun, he said, may have been “test shots.”
He is confident in his findings.
“We know what we’re doing,” Jones said. “We don’t do a half-assed investigation.”