One possible mechanism for quality assessment is case-type reviews. Similar cases are grouped according to cause of death (such as drug-related deaths or drowning) to determine how consistently they are handled. Another mechanism is an undetermined-cause-of-death review, in which an office takes every case of an undetermined cause of death and assigns it for review.


The overarching barrier to professionalism and quality, according to several participants, is budgetary. Lean budgets leave insufficient funding for training and for programs in quality assurance. An office’s budget is the most important determinant of the number of autopsies that it performs in a given yearnot the scientific evidence from the scene (Steven Clark, Vincent Di Maio, Kris Sperry).

The discussion focused on ways to promote greater commitment to quality assurance, especially for coroner offices that lack NAME accreditation, including

  • Setting up a dedicated fund for training by charging the public $1-2 per death certificate (Steven Clark, Mary Fran Ernst).

  • Promoting professional partnerships across small offices in remote locations with offices that more well-staffed (Ross Zumwalt).

  • Raising awareness by challenging incumbent coroners’ lack of training during county elections (Steven Clark).

  • Encouraging states to require coroners and medical examiners to complete training courses, and to set up a coroners-training board with responsibility for maintaining standards (Steven Clark).

A final discussion item focused on the type of quantitative outcome measures that could be used to evaluate the efficacy of quality-assurance programs. One approach was case-type reviews (such as accidents or electrocutions) that compare each case type with an office's own guidelines for that type. Several participants did not feel that winning or losing a legal case would be a good outcome measure of a quality-assurance program (Kurt Nolte, Garry Peterson).

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