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The way we were

Pima County ahead of its time in shift from coroner to medical examiner

Police dramas, long a staple on television, have made the public take for granted the presence of professional experts like medical examiners. We easily forget that this is a relatively recent phenomenon, and that this function was once entrusted to laymen. The shift from an elected coroner to a medical examiner is another example of Pima County's increasing sophistication as we moved from frontier outpost to modern metropolis.

The First Territorial Legislature established an elected office of coroner in 1864 as a part of the law that organized the counties. In keeping with the medieval roots of the office, the duties of the coroner included filling in for the sheriff in the event of his absence or a conflict of interest. This happened rarely if ever in the history of Pima County or anywhere else in Arizona and this responsibility was eventually written out of the statutes.

The bulk of the coroner's duties revolved around what would be more familiar to the modern reader, namely the investigation of suspicious deaths. The coroner was empowered to hold an inquest to inspect the body and scene and to empanel a jury of nine to 15 citizens to render a finding as to "who the person killed is, and when, where and by what means he came to his death, and if he was killed or his death occasioned by the act of another, by criminal means, who is guilty thereof." To this end, the coroner could issue warrants, subpoena witnesses, and solicit the expertise of medical professionals. No salary was specified, so the coroner's work was compensated through fees and mileage charges. Significantly, the law allowed justices of the peace to act as "ex officio" coroners in the case of absence or a vacancy.

Like a grand jury, a coroner's inquest was a precursor to a criminal trial, and was a means to determine if a crime was committed rather than determining legal guilt or passing sentence. A typical finding of a Pima County coroner's jury read like this one from 1880:

"That deceased was named Jose Martenez [sic], that he came to his death by a wound inflicted on the left side of the breast, near the heart, by a large bowie knife, by a person to the jury unknown."

In Pima County, the office was one of low profile and election contests were low-key affairs. At times, one political party or another would not even bother to field a candidate. As a practical matter, the duties of the office frequently fell to the justices of the peace, making the coroner seem redundant. In 1887, the "Measly Fourteenth" Territorial Legislature eliminated the coroner as a separate elected office and directed that justices of the peace continue to serve as "ex officio" coroners. This system continued until well into the 20th century.

A search through the existing records of coroner's inquests in Pima County in this era shows that their investigations went beyond deaths by violence, and included industrial accidents, illnesses, and eventually, automobile crashes. Some of these, needless to say, were more complicated than others. A finding in a death by a lightning strike in Greaterville in 1901 included only testimony from two witnesses and ran for a page and a half. However, the proceedings concerning a Tucson man who died in jail in 1914 after a beating at the hands of a drunk and jealous husband went on for nearly 30 pages and included testimony from witnesses and law enforcement as well as a physician.

As early as 1890, the Arizona Daily Star criticized the coroner system as lacking in expertise. Progressives, however, largely saw the placing of this duty in the hands of an elected official as a means of enforcing accountability in cases where findings favored mine owners and railroads in workplace accidents. Elsewhere, the State of New York abolished the office of coroner in 1915 and created the nation's first medical examiner's office as a part of a nationwide movement to professionalize government. The Arizona State Legislature made a small step in that direction in 1929, authorizing county attorneys to appoint "qualified physicians" as medical examiners. Instead of holding an inquest, the coroner could merely sign off on the findings of an autopsy performed by a medical examiner, though the jury process remained in the law and was still used.

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For the next few decades, Pima County's practice was to hire physicians as medical examiners on a case-by-case basis. Often, in those days, they were called in simply because a justice of the peace was unavailable. One physician recalled that the justices of the peace were loath to work at night, so medical examiners were summoned for cases that occurred after sundown. Likewise, the county had no morgue, so instead contracted with local mortuaries on a rotating basis.

The county made its first steps toward professionalizing the system in 1954 when three physicians: Drs. A.F. Fuller, G.O. Hartman and Louis Hirsch were appointed as on-call contract medical examiners for $15 per on-scene call and $25 per post-mortem examination plus mileage and per diem. Meanwhile, all three of Pima County's justices of the peace called for ending the coroner system altogether, a reform that met with resistance at the legislature from their counterparts in Maricopa County, who were eager to maintain the prerogatives of the office.

By 1960, Dr. Hirsch was under contract as Pima County's chief pathologist and a company he had organized, Southern Arizona Pathologists, held a contract to provide medical examiner services. This brought stability to the system, though the lack of a central morgue was still a source of frustration until 1968 when this was built as a part of the County Government Center project.

Coroner's juries were being used with less frequency, though inquests were still called in high-profile, politically charged cases such as the 1970 Pioneer Hotel Fire. The last coroner's inquest in Pima County was for the death of a local television personality in 1973. By the time the Legislature finally did away with the coroner's system in 1975, Pima County had already long relied on professional medical examiners, and was more than ready for the modern era.

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