Lack of autopsies leaves uncertainty in many suicides

HOMICIDES

SUICIDES

UNDETERMINED

NATURAL CAUSES

Source: Analysis of death certificates collected by Georgia’s vital records office.

The funeral-home obituary betrayed nothing unusual. It said simply that the 80-year-old widow “passed away suddenly Sunday evening … following a brief illness.”

The local coroner’s office put a sharper point on the news. It also said the woman died suddenly on a Sunday in March 2012 — but from “self-induced hanging.”

That conclusion was reached without using a basic tool of death investigation: an autopsy.

The woman’s death was one of more than 1,000 across Georgia since 2011 that authorities labeled suicides despite the absence of full forensic examinations, a review by The Atlanta Journal-Constitution found. Officials closed the books on nearly two of every five suspected suicides without conducting autopsies or performing other tests, the newspaper determined by analyzing a database of almost 175,000 Georgia death certificates.

The victims were as young as 14, as old as 92. Elected coroners, most of whom lack training in medicine or forensic pathology, attributed the deaths to causes that ranged from banal to exotic: gunshot wounds, hanging, suffocation with plastic bags, helium inhalation, self-mutilation.

In 69 cases, officials presumed that suicides occurred by drug overdoses. Those presumptions, however, were never verified through the laboratory tests that usually supplement autopsies.

Many forensic experts say autopsies should be conducted in any death that raises suspicions. Several states require the procedure in most if not all suicides. Indiana, for example, mandates autopsies for suicides “without clear evidence of intent, such as those without a note.”

“It really depends on the circumstances of the death,” said Dr. Gregory Davis, a professor of pathology at the University of Kentucky and that state’s assistant medical examiner. But he said officials should establish whether deaths occur from infectious disease, which may signal a public health threat, or from foul play, which may indicate a crime.

Georgia law requires autopsies in only a few instances, such as when a child younger than 7 dies under unexpected or unexplained circumstances. Suicides must be reported to a county coroner or the state medical examiner, who has the authority to decide on an autopsy.

Dr. Kris Sperry, Georgia’s chief medical examiner, said the trace of uncertainty in many suicides does not concern him.

In most cases, Sperry said, “everything surrounding the death is very clear. It is vanishingly rare that a suicide turns out to be something other than what it’s portrayed as being.”

But in 1,068 of the 2,742 suicides reported from 2011 through mid-2013, the medical examiner has either not learned of the deaths or has chosen to let them pass without autopsies. Just 46 homicides, or 3 percent of the 1,564 reported statewide during the same period, were closed without autopsies.

Since 2011, 133 of Georgia’s 159 counties reported suicides. In 67 counties, autopsies were conducted in no more than half of those deaths. In 12 of the 67, no suicides were subjected to examination.

‘Pretty obvious’

In Coffee County, deep in South Georgia, where the 80-year-old widow died, authorities have classified 13 deaths as suicides during the past 2 ½ years. An autopsy was performed in just two.

Neil Sims, a funeral director in Douglas, has been the Coffee County coroner since 1984. In an interview, he said he consults with law enforcement agencies and the state medical examiner’s office before deciding whether to seek autopsies for apparent suicides. He said he considers such factors as whether a victim died in a house locked from inside, the distance a bullet was fired from a victim’s body and the position of the body.

“It’s pretty obvious, usually,” Sims said.

Gunshot wounds to the head caused nine of the 11 suicides in which Sims did not seek an autopsy. The 80-year-old woman was one of three who died by hanging.

About 7:30 on a Sunday evening, according to public records, the woman entered her closet and tied pantyhose around her neck. She attached the other end to the top of the closet door and sat on the floor. She died within minutes, her death certificate reported.

The woman suffered from what the death certificate termed “significant conditions”: congestive heart failure, severe dementia, a urinary tract infection and restless leg syndrome. Without an autopsy, the question of whether those conditions contributed to her death, or drove her to suicide, remained unanswered.

Calling a death suicide upsets many victims’ families, Sims said, particularly in a small town where privacy is elusive.

“Nobody wants a suicide (ruling),” he said. “They don’t want the stigma attached to the family. But you have to rule it the way you think it really is.”

Medical training rare

Every four years, voters in 154 Georgia counties elect a coroner to oversee investigations into all manner of deaths: homicides, accidents, suicides and those that occur from natural causes. Appointed medical examiners — physicians trained in pathology — oversee death cases in Fulton, DeKalb, Gwinnett, Cobb and Clayton counties.

State law requires that a coroner be at least 25 years old, registered to vote and a high school graduate. Each newly elected coroner must undergo 40 hours of training at the state’s law enforcement academy, along with 24 hours of additional instruction each year.

As is the case in most of the 28 states that elect coroners, few Georgia coroners have medical training.

Sixty-nine are funeral directors or work in funeral homes. About two dozen work as paramedics, nurses or emergency medical technicians. The rest come from virtually every other imaginable line of work: One is a hairdresser, one is a heating and air conditioning technician, one is a used-car dealer, one is a barber. And one is a physician.

Twice in the past three years, Georgia’s state auditor issued reports questioning whether coroners routinely notify the state medical examiner about suspicious deaths such as suicides, as the law requires. In a 12-month period ending in 2009, the auditor said, the medical examiner never learned about 26 percent of those cases.

The auditor suggested a new law that would force coroners to report every death, no matter the circumstances, to the medical examiner. The auditor quoted a report by the National Association of Medical Examiners that described systems in which trained pathologists do not control death investigations as “fraught with the potential for serious errors and omissions.”

This year, in a follow-up study, the auditor said the Georgia Bureau of Investigation, the agency for which the state medical examiner works, had shown no interest in imposing stricter laws on coroners. The study quoted the GBI as declaring that “more pressing needs … have supplanted the exploration of changes to the Georgia Death Investigation Act.”

The GBI did not itemize those needs.

Sperry, the chief medical examiner, said Georgia coroners perform admirably and seek rigorous investigations of suicides and other deaths in which “anything is strange or does not quite add up.”

“Our relationship with the coroners is quite excellent,” Sperry said. “The vast majority of them take their jobs seriously, as we do.”