The Education of a Coroner: Lessons in Investigating Death - Softcover

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John Bateson was executive director of a nationally certified crisis intervention and suicide prevention center in the San Francisco Bay Area for sixteen years. He is the author of three previous books—The Last and Greatest Battle, The Final Leap, and Building Hope.

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The Education of a Coroner

CHAPTER 01

FIRST BLUSH

I first met Ken Holmes in 2010 when I interviewed him for my book The Final Leap, about suicides from the Golden Gate Bridge. I was executive director of a nationally certified crisis intervention and suicide prevention center in the San Francisco Bay Area at the time, and Ken’s office was responsible for conducting the autopsies of most Golden Gate Bridge jumpers, as well as for notifying their families of the death. After the book came out, I was recruited to serve on the board of the Bridge Rail Foundation, an all-volunteer, nonprofit organization dedicated to ending suicides on the bridge. Ken was on the board also, and we had numerous opportunities to talk further. It didn’t take long for me to realize that his experiences over nearly forty years in the Marin County Coroner’s Office and the cases he’d handled would make a riveting subject for a book.

I had another reason for writing The Education of a Coroner: I didn’t know much about the workings of a coroner’s office, and wanted to learn more. How do coroners approach a death scene and what do they look for? How are families notified of a death, and what psychological techniques are employed? How has the world of forensic pathology changed with advances in technology?

The first time Ken and I met to discuss it was in a brew pub in Larkspur, in central Marin County. He had been retired three years by that time, although he still had—and continues to have—frequent contact with many of his former colleagues, and also attends annual conferences of the California State Coroners Association, where he once was president. We had communicated by email before then and I had run my general idea by him. I would review eight hundred case files that he had preselected and copied onto electronic disks, then we would schedule a series of days when we would meet and discuss the cases that I thought were the most interesting. Along the way we also would talk about his background, training, responsibilities, lessons learned, and people he worked with. First, though, I said I needed to get a sense of whether the stories he told were compelling and had universal appeal.

“Sure,” he said, and with no further prompting he launched into a thumbnail sketch of one case, then another and another until after only a few minutes my head was spinning. He apologized and said that once he started talking about his work, it was hard for him to stop.

Holmes is a natural storyteller, and his deep, melodic voice is both authoritative and soothing. A barrel-chested man with sharp eyes—even in his seventies—strong hands from having spent years outdoors, and a handsome face framed by a trimmed gray beard, he is someone who makes friends easily and holds on to them because at the end of the day, and especially at this stage in his life, friends and family are what matter most. He is quick to laugh—especially at himself—and has a range of knowledge that is impressive. Whether it is medicine, politics, hunting, guns, home repair, sports, food, wine, or cars, he can hold his own in a conversation with anyone.

“Let’s back up,” I said, “and focus on one case for now. You pick.”

“Okay,” he said, and he proceeded to tell me some of the highlights of the Carol Filipelli case, which is described a little later in this book.

At the end, all I could say was, “How many more stories do you have like that?”

He shrugged and said, “Dozens?”

* * *

Some of the cases cast Holmes in the national spotlight because of who they involved—rock legend Jerry Garcia, rapper Tupac Shakur, porn kings Jim and Artie Mitchell, and the infamous Trailside Killer. It was the deaths of people who weren’t well known, however, that remain the most vivid and noteworthy in his mind.

Several cases took nearly a decade to close, two took twenty years, one took thirty, and one took forty-four years. It might seem like a luxury for a coroner to be able to pursue cases so doggedly—certainly that’s not possible in large cities and statewide coroner’s offices. In some respects it was, but Holmes’s belief—then and now—is that family and friends of the deceased deserve to know what happened no matter how long it takes. Coroners deal with death, but their purpose is to find answers for the living.

If the work of coroners were less dramatic, we wouldn’t have so many TV shows about it. Holmes watches some of them and says that they get most—though not all—of the details right. Even so, inevitably he comes away thinking that real life is more moving than any fictionalized treatment can be. Nothing beats a story that happens to be true.

It helps to have a glamorous setting, which is why the original CSI TV show was set in Las Vegas and there is now CSI: Miami, CSI: New York, and NCIS: Los Angeles. If the emphasis were on gritty, then we would have CSI: Camden, CSI: Detroit, and NCIS: Compton.

The setting where Holmes worked is every bit as enthralling as the biggest cities with the brightest lights. I say that not because I was raised in Marin—as an adolescent it didn’t seem all that exciting—but because the county has a national reputation, despite its small size. Part of that is due to its physical beauty. Situated just north of San Francisco, Marin is surrounded by water. The Pacific Ocean lies to the west, and the eastern and southern borders end at San Francisco Bay. Only the northern portion abuts land—the beginning of California’s legendary wine country. Otherwise, access is across the Golden Gate Bridge to the south or the Richmond–San Rafael Bridge to the east.

There are no large urban centers, processing plants, factories, or notable industries in Marin. Mostly the county consists of coastline, rolling hills, dairy farms, and small towns. Hundreds of thousands of people come every year to visit Point Reyes National Seashore, Golden Gate National Recreation Area, Muir Woods, Mount Tamalpais, Stinson Beach, Tomales Bay, and Samuel P. Taylor State Park.

The other reason why Marin is well known is its affluence. It ranks among the top twenty counties in the United States in terms of household income, and is home to rock stars, movie stars, professional athletes, and wealthy business executives. The median price of homes is just under $1 million, and in many communities it’s considerably more.

This doesn’t mean that all is rosy, however. In 2014, the Robert Wood Johnson Foundation reported that nearly 25 percent of adults in Marin engage in binge drinking during any given month—one of the highest averages in the state. More than thirty residents die per year from drug overdoses, a large number in a small county. In addition, Marin is second to San Francisco when it comes to suicides from the Golden Gate Bridge.

Marin also has pockets of poverty. In the Canal District of San Rafael, people from dozens of cultures, speaking a multitude of languages, live close together in low-income housing. In Marin City, built during World War II to house shipyard workers and immigrants, local residents—predominately African-American—lived for years in crowded tenements until gentrification started pushing them out, creating new sources of tension.

Then there is San Quentin Prison, the oldest prison in California and one of the largest penitentiaries in the United States. Built...