Suspicious death: The thankless role of the medical examiner

Tess Crawley, University of Tasmania

Stefan Timmermans Postmortem: How Medical Examiners Explain Suspicious Deaths, Chicago, University of Chicago Press, 2007 (384 pp). ISBN 9-78022680-399-9 (paperback) RRP $29.95.

The first opportunity I had to read Postmortem: How Medical Examiners Explain Suspicious Deaths by Stefan Timmermans was on a plane. I was travelling to a funeral. A month later the coroner was still deliberating over the circumstances surrounding the death of our friend. It may have been suicide or it may have been an accident. This is what qualifies her death as suspicious.

Medical examiners and coroners do not investigate all deaths. Suspicious (or equivocal) deaths, deaths in institutions, and deaths of infants are reportable and in these cases an autopsy is typically required. Postmortem is a book for those interested in what makes certain deaths ‘suspicious’ and how decisions are made about the circumstances leading to those deaths. Through judicious use of case examples, procedural detail, and sociological analysis, Timmermans educates the reader without resorting to the macabre. Postmortem also explores the often competing social, moral, legal, and medical contexts and dilemmas faced by medical examiners.

Timmermans’ treatise is the result of three years of research in an undisclosed medical examiner’s office in the United States. Names are changed to shield the identities of the workers and their cases. In a world where macabre fascination with death and death investigation drives the success of television shows such as CSI and Silent Witness, and books such as those by Patricia Cornwell and Kathy Reichs, Postmortem is a refreshing departure from the ghoulish. This is not a step-by-step description of the autopsy process, although there are some references to this. (Readers interested in the finer forensic details of death investigation are encouraged to dive into the comprehensive work by Australians Ian Freckleton and David Ranson (2006).) Rather, Timmermans takes us through an insightful exploration of the murky waters of expert decision-making.


Medical examiners (or forensic pathologists) are tasked with identifying cause of death, the mechanisms by which death occurred. In America medical examiners carry the added responsibility for determining manner of death, or the circumstances that lead the deceased on the path to their demise. In Australia this responsibility rests with the coroner, typically a magistrate (American coroners tend to be elected officials, not always with medical or legal training). If cause of death was drowning, did the deceased enter the water willingly with stones in their pockets (suicide), were they held underwater (homicide), or did they slip and fall in, unable to swim (accidental death)? In some cases such as heroin overdose, manner of death is often unclear. In the late 1950s Edwin Shneidman, a psychologist with the Los Angeles Centre for Suicide Prevention, was approached by the then Los Angeles County Coroner to provide expert advice on how to distinguish accidental overdose from suicide, based on what could be deduced about the pre-death mental state of deceased individuals. Shneidman’s work has been credited as the genesis of the development of the psychological autopsy, an investigative technique conducted by mental health professionals in cases of equivocal death. It is most commonly used to assist coroners and medical examiners to determine whether death meets the criteria for suicide: self-inflicted fatal injury with the intent to die.

An unknown number of suicides are ultimately classified as accidental deaths.

Intent is a thorny issue. As Timmermans points out, even suicidal people die accidentally. Suicides are often the result of ambivalence towards life rather than a singular pursuit of death. This is perhaps why so many bereaved families are left grappling with feelings of guilt and helplessness: ‘If only I’d known …’. In many cases even the suicidal person doesn’t have foreknowledge of their actions; instead a convergence of elements presents suicide as an opportunity to end what is perceived as inescapable pain or despair.

As intent can be so unquantifiable, Timmermans tells us that medical examiners err on the side of caution. Unless the ‘51 per cent rule’ is supportable; that is, unless the evidence leans heavily in that direction, suicide can’t be a justifiable determination. This speaks to the long-held belief that suicide statistics are misguiding, so prone are they to under-reporting. An unknown number of suicides are ultimately classified as accidental deaths or given undetermined or open findings because they fail the 51 per cent rule. Timmermans’ medical examiner explains that in America there is a very real risk of litigation by aggrieved and bereaved family members when an incorrect manner of death determination is made. Litigation can be driven by the stigma of a determination of suicide, or the withdrawal of access to life insurance payouts. Aside from litigation, the medical examiner explains, the added distress caused to an already grieving family by reaching an incorrect suicide determination is unconscionable. The tendency towards caution in manner of death determinations is therefore understandable, if statistically frustrating.


The authority of medical examiners to make decisions on such sensitive issues as cause of death is a theme peppered throughout Postmortem. Medical examiners possess forensic authority, or medico-legal expertise bestowed upon their role by virtue of training and experience. They also possess cultural authority, or the power we invest in them by virtue of our faith that they remain unbiased and rely on evidence to come to their determinations.

For the public, the work of medical examiners is important but necessarily invisible.

Yet developments in medical technologies such as imaging techniques have led some to question the justification for the continued reliance on autopsy and organ removal to identify cause of death. Such questions pose a clear threat to the medical examiners’ continued authority. Indeed, some have even argued the autopsy procedure fails to meet the Daubert standard for admissibility as expert evidence. (In 1993 the case of Daubert v. Merrell Dow Pharmaceuticals before the US Supreme Court set the legal precedent for admissibility of expert testimony. The ‘Daubert standard’ is a benchmark for the assessment of the expert nature of individual witnesses and of the methods by which they came by their evidence—for example medical examiners and their use of the autopsy. Put simply, the expert evidence must be relevant and reliable. The expert witness must have appropriate training and experience, must be offering something unique to the court, and their methods must be recognised as valid and reliable by their professional peers.)

Culturally, the work of medical examiners is viewed by the public as important but necessarily invisible (we want to know they do a good job, but we don’t want to know too much). There also seems to be some distaste within the medical profession for the choice to specialise in death rather than in helping the living. This point is illustrated well in Timmermans’ description of the multi-dimensional ethical quagmire of organ donation. In cases where homicide is suspected, organs are evidence. For organ procurement organisations, organs mean life for numerous individuals. Thus there is a battle to determine who is serving the greater good (serving justice or saving lives). The reality is, of course, rarely so black and white. Medical examiners’ findings and subsequent policy recommendations have the power to save many lives (for example, recommendations impacting on motor vehicle safety, on babies’ sleeping positions in light of sudden infant death syndrome (SIDS), etcetera). Further, Timmermans highlights, organ procurement organisations in the United States are increasingly linked with the cosmetic surgery industry rather than with organ transplants and so their ‘life saving’ drive for organs comes under a cloud. One unfortunate example is the pressure placed on medical examiners to release skin (the body’s largest organ) for the production of collagen, while burns victims remain on waiting lists for skin grafts.

Timmermans describes the ethical quagmire of organ donation.

Timmermans helps us come to understand not only how medical examiners make their often difficult decisions, but also the need for them to have courage in their convictions. This is especially so in homicide cases. Homicide prosecutions exemplify the nature of adversarial legal systems such as those operating in Australia and the United States, where prosecution and defense teams may pit medical experts against one another, hoping to discredit competing evidence in the eyes of the jury. In a fascinating dissection (pardon the pun) of the controversy surrounding the validity of ‘shaken baby syndrome’, Postmortem reveals just how this messy this adversarial system can be. In this dramatic example, the courtroom risked drowning in theoretical arguments about whether or not shaken baby syndrome even exists before one expert ultimately changed his mind before a court, rendering his evidence and testimony useless. Such unscientific practices, as can sometimes be found in the ‘expert for hire industry’, risk the discrediting of not only individual experts, but can threaten the ongoing forensic authority of an entire profession. This is why admissibility guidelines are so important: Is a particular medical examiner deemed an expert by his or her peers? Is the evidence they present relevant and outside of evidence which can be presented by any other witness (or deduced by the court)? And are the methods used by the expert based on solid scientific practice?


In light of such issues, we can understand the conservatism of medical examiners when making decisions about suicide versus accidental death. We can appreciate the need for tightly controlled policy and procedure. We can perhaps see that all of this takes time. Sadly for grieving families this often means delays in the release of loved ones for burial and even longer delays in the release of autopsy results.

Ultimately medical examiners are in a thankless role. We would not choose to come into contact with them. We hope upon hope that the deaths of our loved ones, and indeed ourselves, will come peacefully and naturally at the end of a long and fulfilling life. Beyond the fascinating case studies and the intriguing theoretical issues, a simple question runs through the core of Stefan Timmermans’ study of the work of medical examiners: ‘Why do we die too soon?’ Upon turning the final page of this book one is led to the conclusion that medical examiners can’t answer that question. They can tell us the how, the where and the when, but the ‘why now’ remains part of the Great Mystery.


Daubert v. Merrell Dow Pharmaceuticals (1993) 509 US 579.

Freckleton, I., & Ranson, D. 2006, Death Investigation and the Coroner’s Inquest, Oxford University Press, Melbourne.

Shneidman, E. 1998, The Suicidal Mind, Oxford University Press, New York.

Dr Tess Crawley is a clinical psychologist, psychology lecturer, and founder of the Clinical Forensic Psychology Lab at the University of Tasmania.