characteristics and practices of distinct jurisdictions. The source of variation is not only state law but also local authority. Responsibility for death investigations rests at the county level for over 2,000 counties.

Remarkably, for well over a century, there has been continuous concern about the lack of standardization in death investigations and about high rates of errors, whether real or perceived. Concern began to be expressed by progressive reformers over the last decades of the 19th century. Even the National Academy of Sciences weighed in—75 years ago. In 1928, the National Research Council’s Committee on Medical Legal Problems issued its report, The Coroner and the Medical Examiner (1928). The committee was made up of titans of the American legal and medical establishment of that era, including Roscoe Pound, dean of Harvard Law School, and John Henry Wigmore, dean of Northwestern Law School.

The committee stated forcefully, in blunter terms than used today, that the coroner’s office is an anachronistic institution, predating the Magna Carta. The office "has conclusively demonstrated its incapacity to perform the functions customarily required of it.” The committee recommended that the office of coroner be abolished and be replaced by a well-staffed office of a medical examiner, headed by a pathologist. A key goal of the committee's recommendations was the professionalization of death investigation, with medicine as its center. That vision relied heavily on the training and credentialing capacities of what was becoming modern medicine.

That effort has continues over the ensuing decades. The subspecialty of forensic pathology was recognized in 1959. The National Association of Medical Examiners (NAME) was established in 1966, and the country saw a gradual conversion of offices, from coroners to medical examiners, encompassing half the population.

The goal of this workshop is to obtain a progress report on the transformation to a more professional systemnamely, whether the system exploits the full range of tools from medicine and other scientific disciplines, including the development of standardized protocols and access to high specialty technical services and laboratories, to reduce errors. The workshop also addresses this



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