In the United States, there is no single system for investigating death. Depending on where you die, your death may be investigated by a coroner, a medical examiner, or some hybrid of the two. The difference is not just bureaucratic. It affects who investigates, how they are qualified, what standards they follow, and how accountable they are to the public.
Los Angeles has operated under both systems and has been at the center of the national debate about which one produces better outcomes.
The Coroner System
The coroner is one of the oldest government offices in the English-speaking world, dating back to medieval England. The office was originally responsible for protecting the financial interests of the crown in cases of death — collecting taxes and fines associated with violent deaths — and only gradually evolved into a death investigation role.
In the American coroner system, the coroner is typically an elected official. In many jurisdictions, there are no medical qualifications required for the position. A coroner may be a funeral director, a farmer, a retired teacher, or anyone else who can win an election. The coroner then hires or contracts with physicians to perform the actual medical examinations.
The advantage of the elected coroner is political accountability. The coroner answers to voters, not to the mayor or county executive who might have political reasons to influence the outcome of a death investigation. A coroner who does poor work or makes controversial determinations can be voted out.
The disadvantage is obvious. An elected official without medical training is responsible for overseeing a fundamentally medical operation. The quality of the work depends entirely on the physicians the coroner hires and the coroner’s willingness to defer to their expertise.
The Medical Examiner System
The medical examiner system developed as a reform alternative. In this model, the death investigation office is led by a physician — typically a board-certified forensic pathologist — who is appointed rather than elected. The medical examiner brings scientific qualifications to the role and is expected to run the office according to professional standards.
Most large cities have adopted the medical examiner model. New York City established its medical examiner’s office in 1918, and other cities followed throughout the twentieth century.
The advantage is expertise. The person leading the office understands the medicine, can evaluate the quality of the forensic work, and can make determinations that withstand scientific scrutiny. The office is less susceptible to political influence in individual cases.
The disadvantage is that an appointed official can be fired by the political authority that appointed them. A medical examiner whose findings embarrass the mayor or the police chief may face pressure — subtle or otherwise — to adjust future determinations. The insulation from political interference depends entirely on the strength of the appointing authority’s commitment to independence.
The Los Angeles Story
Los Angeles County operated under the coroner system for most of its history. The office was led by elected coroners — some competent, some less so — who oversaw what became one of the largest death investigation operations in the country.
The most famous figure in the office’s history was Dr. Thomas Noguchi, who served as chief medical examiner-coroner from 1967 to 1982. Noguchi was a trained forensic pathologist who brought medical credibility to the office while operating within the elected coroner framework. His celebrity case autopsies — Robert Kennedy, Marilyn Monroe, Sharon Tate, Natalie Wood — made him nationally famous and earned him the nickname that he sometimes embraced and sometimes resisted.
Noguchi’s tenure also demonstrated the vulnerabilities of the system. He was fired in 1969 by the county board of supervisors amid allegations of mismanagement, reinstated after a civil service hearing that became a public spectacle, and eventually removed again in 1982 amid renewed controversy. The episodes illustrated how a death investigation office could become entangled in political dynamics that had nothing to do with the quality of the forensic work.
In 2014, Los Angeles County replaced the elected coroner system with an appointed medical examiner system, renaming the office the Department of Medical Examiner-Coroner. The change reflected decades of advocacy by forensic science organizations and reform-minded county officials who argued that death investigation was too important and too technical to be led by whoever won an election.
The National Patchwork
Across the country, the landscape is a patchwork. Some states are entirely medical examiner systems. Some are entirely coroner systems. Many are hybrids, with medical examiners in urban areas and coroners in rural counties.
The disparities in quality are stark. In some rural jurisdictions, the coroner is a part-time position held by someone with no forensic training and no access to a forensic pathologist. Deaths that would be thoroughly investigated in a well-resourced urban medical examiner’s office may receive only a cursory review.
National organizations — the National Association of Medical Examiners, the National Institute of Justice — have advocated for universal adoption of the medical examiner model, with minimum qualification standards for leadership positions and accreditation requirements for offices. Progress has been slow. Coroner systems are entrenched, and the cost of transitioning to a medical examiner model is significant for small jurisdictions.
Why It Matters
The system under which a death is investigated can determine whether a homicide is detected, whether a suicide is correctly classified, whether an outbreak of environmental or occupational deaths is identified, and whether the forensic evidence is sufficient to support a prosecution.
When the system works, the difference between coroner and medical examiner may be invisible. A competent coroner who hires good pathologists and follows best practices can produce work that matches a medical examiner’s office.
When the system fails, the consequences fall on the dead and their families. A missed homicide. A misclassified death. A report that falls apart under cross-examination because the office that produced it lacked the expertise or resources to do the work properly.
Los Angeles, having lived under both systems, understands this better than most. The transition from coroner to medical examiner was not an abstract policy debate. It was a response to decades of experience with the strengths and weaknesses of both approaches, shaped by the city’s unique history of high-profile cases, political drama, and institutional ambition.
The debate continues nationally. How we investigate death is a reflection of how much we value accuracy, independence, and the rights of the dead. The answer varies, quite literally, by zip code.