Mysterious Circumstances Surrounding a Death: A Coroner’s Duties When a Cause of Death Is Never Known

Mysterious deaths are not just the stuff of movies and television. Rather, every day in Southern California and elsewhere around the world, deaths occur (or are discovered) in which the cause is not readily available. Like many people, you may wonder what happens if no cause of death is found.

Situations in Which a Cause of Death Might Never Be Confirmed With Certainty

There exist a set of different types of scenarios in which the cause of death might never be confirmed by authorities with certainty. The two primary authorities involved in undertaking investigations to reach a cause of death are the county coroner or medical examiner and law enforcement agencies.

The primary situations in which the cause of death may never be found or confirmed with certainty include:

Understanding the Difference Between Cause of Death and the Manner of Death

Many people believe that the cause of death and manner of death are the same thing. They are not.

Cause of death is defined as:

The underlying cause of death refers to the disease or injury that initiated the train of morbid events leading directly to death or the circumstances of the accident or violence that produced the injury.

Manner of death is defined as:

The fashion or circumstances that result in death, which are designated either natural or unnatural

Coroner’s Investigatory Process

When a death occurs for which the underlying causes cannot immediately be discovered, the police or sheriff together with the county coroner or medical examiner is called to undertake investigations. Law enforcement and the medical examiner work in tandem but have different tasks and objectives to undertake in order to attempt to ascertain the underlying cause of death.

The coroner’s investigatory process begins at the scene of the death itself. Thoroughly investigating the scene of death can provide useful evidence as to how the death occurred. For example, if an overturned ladder is at the death scene and the deceased individual is sprawled near that ladder, this evidence will be helpful in working to reach an ultimate determination as to the cause of death.

The next phase of the coroner’s investigatory process is an autopsy. An autopsy is a comprehensive dissection of the body of the deceased individual. Here again, the objective is to identify the cause of death through an autopsy.

If a definitive cause of death cannot be ascertained via an autopsy, the third stage of a coroner’s investigation becomes necessary. This stage typically involves additional forensic investigation in the form of laboratory testing. This usually requires the submission of samples of blood, other bodily fluids, and tissue to a designated laboratory for testing.

The Final Coroner’s Report and Death Certificate

When all three phases of the coroner’s investigation come to a conclusion, the medical examiner prepares a final report. The coroner’s report thoroughly summarizes all aspects of the investigation undertaken by the medical examiner. If a cause of death could not be ascertained, the coroner’s report will state that conclusion.

In addition, a coroner’s report will delineate the reason or reasons why making a formal determination of the cause of death proved impossible. In many cases, the coroner provides significant detail as to why the cause of death could not be determined because others desire or even need this information.

For example, the family of a deceased person is likely to sincerely desire to understand why a specific cause of death couldn’t be determined. Lacking a cause of death oftentimes is stressful for the family and hinders the bereavement process and finding closure. However, if a family is provided a clear recitation of why a cause of death was impossible to determine, this information can prove helpful to a grieving family, at least to some degree.

Law enforcement investigators may also be keenly interested in the determination of the cause and manner of death. If a coroner is unable to provide a cause of death, but nonetheless delineates why this proved impossible, law enforcement investigators at least have some data which might be helpful in fleshing out evidence in some other way that might be useful in building a homicide case.

In addition to preparing a comprehensive coroner’s report, the medical examiner also signs off on a final death certificate. When the cause of death is not ascertained, the medical examiner prepares a final death certificate that lists the cause of death as undetermined.

In the final analysis, California law does not mandate a cause of death be found in every case. A good faith effort by a county coroner or medical examiner must be undertaken in an attempt to ascertain a cause of death.

Nearly always, when a coroner issues a determination that death is undetermined, a particular case is closed. Two rare exceptions exist, which are:

  • Evidence suggests the manner of death of a homicide
  • Concern exists regarding a public health threat associated with a death

In such instances, because of the involvement of law enforcement or health agency officials, a coroner may forgo closing a case as an investigation by one or another of these agencies continues.