by Audrey Dutton ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week. Since last year, ProPublica has been reporting on the troubled system for death investigations in Idaho, where a persons cause of death is determined by elected coroners with no oversight or state support and, often, little training or education.The failures documented by ProPublica left parents without answers in their babys sudden death and let clues vanish in the death of a woman whose family suspected foul play by her husband, a man later charged with killing his next wife.The Idaho Office of Performance Evaluations in January sent the states coroners a formal survey about their work, drawing responses from just over half. The office told coroners that it wouldnt attach names to their responses when it made the survey results public, and some gave unvarnished critiques.The coroner system in Idaho is broken and a joke, one wrote.They also took the opportunity to plead for help, for changes they believe could transform Idaho into a place where death investigations consistently meet national standards.Idaho coroners are elected to an office under county government control and funded by county budgets. Idaho politics have traditionally held the independence of local government as sacrosanct. This years state survey and subsequent interviews by ProPublica revealed a twist: Many coroners believe the states hands-off approach is outdated and harmful, making the quality of a persons death investigation vary based on the county.These local officials want the state to get involved, and they want it badly.Jimmy Roberts of Bingham County, an agricultural area in eastern Idaho, is one such coroner. He worked with two interns in his office to draft a 118-page white paper that highlighted failure points in Idahos coroner system and described how states like Indiana and Arkansas addressed the same problems. In Indiana, as in Idaho, the county coroner is a constitutional elected office. But coroners in Indiana are subject to a suite of state laws that spell out what they must do.The policies that Roberts highlighted from those states include creating a state training council for coroners, defining in law which cases must be autopsied, raising money for coroners through fees on death certificates or paying for toxicology costs through alcohol taxes, and giving coroners first responder status so they can access mental health care for themselves and get a supply of naloxone for reviving people who overdose.Still, its unclear whether ideas like these will gain traction in Idaho after nearly 70 years of warnings and inaction on coroners.Gov. Brad Littles criminal justice commission has begun to take a look at the coroner system, via a subcommittee it created this year that includes coroners, the state police forensics lab director, a state legislator and others but no county commissioners have joined yet, leaving the group without input from the people who control coroner budgets. The subcommittee so far has drawn up a list of problems and brainstormed solutions none of which it has endorsed such as a state fund to help pay for autopsies, a forensic center in eastern Idaho to ramp up autopsy capacity or mandating autopsies in some child deaths. Coroners are not united in how to make the system better and what it will take to get there. Roberts, the Bingham County coroner, sent his 118-page report to fellow coroners and state legislators by email in October. But Roberts told ProPublica his offer to help the leaders of the Idaho State Association of County Coroners work on reform was met with silence. Jimmy Roberts, Bingham Countys coroner, in his office. He drafted a 118-page white paper that highlighted failure points in Idahos coroner system. (Natalie Behring for ProPublica) Torey Danner, the associations president and a member of the governors subcommittee studying the issue, told ProPublica that his focus this year is on low-hanging fruit rather than major systemic changes. Asked about approaches that have gotten results in other states, he said he wants to review the root causes of Idahos problems before committing to any specific reform ideas, so that Idaho doesnt unintentionally implement Band-Aid solutions in haste.Danner said he didnt see Roberts 118-page report come through his email inbox in October but plans to read it after being contacted by ProPublica. He has not deeply studied the reforms in other states. I havent taken the time because I havent had the time, said Danner, one of the few coroners in Idaho to hold the job full time. I mean, Im still trying to do this and run my office, too.Here are five concrete steps other Idaho coroners have suggested. 1. More autopsies Idaho has among the lowest autopsy rates in the U.S., with even worse rankings for autopsies in homicides and unexplained child deaths and money is a factor. About 1 in 4 coroners offices answering this years survey said their budgets affect their ability to do autopsies.Madison County Coroner Sam Butikofer told ProPublica that when he took office in 2019, the countys budget for grooming snowmobile trails was larger than the coroners. (County budget records confirm that.)Under Idahos current setup, each county sets an annual budget for its coroners office that estimates how many autopsies the coroner will have to order in the coming year. An autopsy in most parts of Idaho costs at least $2,300. Small counties in Idaho budget for less than a dozen a year, and a backcountry plane crash, a few unwitnessed deaths on the river, a spate of sudden infant deaths or the rare multiple homicide can quickly eat up the money that was set aside.Lacking the kind of funding other states use to help cover the cost of autopsies, Idaho coroners must decide between forgoing autopsies or blowing the budget and having to justify it to a board of county commissioners made up of elected laypeople.We need to be doing more autopsies, thus we need more money to do so, one coroner told the Idaho Office of Performance Evaluations in its survey.(Idaho counties and the state coroners association two decades ago opposed a mandate for coroners to do autopsies in sudden infant deaths, citing cost. County commissioners havent weighed in this year because there are no specific reforms to respond to yet, according to the Idaho Association of Counties.)As noted in a previous report by the state office and in ProPublicas reporting, other states including Idahos neighbors Washington and Wyoming help their local coroners pay for autopsies or the travel required to get them done.Without a state medical examiners office, Idaho has no centralized setup for forensic pathologists to do autopsies. So most county coroners have contracts with the states largest county, Ada, where Boise is located. For the counties in Idahos eastern and northern reaches, the coroner has to plan for an all-day or overnight trip to the Boise area and the gas and hotel to go with it. Autopsy tools in the Ada County coroners office, first image, and the morgue. The office performs most autopsies for counties in south and central Idaho. (First image: Katherine Jones/Idaho Statesman. Second image: Darin Oswald/Idaho Statesman.) Ada County is fully booked with its current workload of autopsies for dozens of Idaho counties. It has just a few forensic pathologists on staff. Its national accreditations limit how many autopsies each of those pathologists can do a rule thats designed to help keep the doctors from being overworked and error-prone but causes backlogs when theres too much demand.Coroners undertook a campaign last year to open a forensic center in eastern Idaho, as a kind of co-op with several remote, rural counties. The plan fell apart when local commissioners got spooked by the cost. Forensic pathologists, the only people who can perform the autopsies, are in high demand; it takes a salary of about $350,000 to lure one to Idaho.The state of Idaho needs to build an eastern Idaho forensic center and stop wasting time and money by attempting to have a county build this required facility, one person wrote in response to the states coroner survey. 2. Higher pay At least seven coroners in Idahos 44 counties have an annual salary below $10,000, according to an annual survey by the Idaho Association of Counties and ProPublicas review of county budgets. Another 12 coroners salaries are between $10,000 and $20,000 a year.Thats not enough to live on, so nearly all Idaho coroners either are retired from a previous career or have another job. Their ranks include medics, nurses and nurse practitioners, a physician, a library director, an attorney, 11 funeral home owners or employees, and at least three with more than two jobs.Idaho County Coroner Cody Funke told ProPublica in July that offices like his need full-time staff. Right now, he has to respond to deaths while hes in the middle of a workday at his main job, which is with the state prison system.The county associations annual survey shows that at least eight county coroners have no deputy on staff to take over when the elected coroner cant answer a call or go to a death scene.Any help would be greatly appreciated but my greatest problem is low wages making it impossible to recruit deputies and any replacement for the elected officials, one coroner told the states survey takers.Another coroner who did have a deputy wrote, My Deputy Coroner works one (1) day a month! I cannot take time off with only one day a month coverage. 3. Office space Cody Funke, the part-time coroner for Idaho County, uses a pickup truck to do his coroner work because the county doesnt provide a dedicated office. (Liesbeth Powers for ProPublica) Half of the coroners who responded to this years survey said they didnt do their coroner work in a county-owned office. Some did it in funeral homes or mortuaries. Some did it in other types of full-time private workplaces. Six coroners, though, said they did most of their work in their own homes. Although the survey didnt break down types of venues coroners used for paperwork versus examining bodies, the lack of dedicated and secure workspace poses a problem for both tasks.Few Idaho counties have a county morgue with coolers and storage for bodies awaiting autopsy, testing or further examination. Coroners in rural areas often turn to a local funeral home or the regional hospital.This practice can imperil a criminal prosecution, coroners told ProPublica, because the body a crucial piece of evidence isnt secured through all stages of an investigation.Without a dedicated exam room or storage for bodies, we are not able to maintain chain of custody and funeral home staff are witness to exam details of cases that must have a high level of confidentiality, wrote Roberts, the Bingham County coroner, in his response to the state coroner survey.In the survey, 59% of respondents said they store dead bodies in a place thats open to people outside the coroners office. Three coroners had postmortem samples, such as blood or fluids waiting for a toxicology lab test, stored in a private residence, and one coroner was storing unidentified or unclaimed human remains there.Butikofer, the coroner in Madison County, had no office when he started the job. Hes asked his county commissioners for at least the past five years to give him a workspace with refrigerated and secured storage and a place to meet with families, according to public meeting minutes. The countys master plan would fulfill that request with construction being complete six to 10 years from now. Meanwhile, Butikofer has worked out of a truck, a card table in his family home, the local hospitals morgue and a temporary space in the county courthouse. I hear rumors that the state has money, Butikofer said in reference to Idahos long-running string of budget surpluses and cash reserves. Im just one little minnow in the pond going, Hey, how bout some of that, you know, for the coroner system?The governor early this year said he supported more resources to help coroners do their jobs. But in mid-August, with major tax cuts hitting and state revenues dropping, the governor responded by ordering spending cuts and other austerity measures a sign that Idaho will be even tighter with money than usual in the coming year. Roberts, the Bingham County coroner, at a budget meeting in Blackfoot, Idaho, last July. County commissioners were reluctant to increase the coroners budget but ultimately did so. (Natalie Behring for ProPublica) 4. Consistency statewide One of the state survey respondents pitched an idea for holding all Idaho coroners to one standard.There needs to be a state run and state funded coroner system with a head coroner elected by the citizens. The top coroner would create a standardized investigation system with protocols for coroners to follow, the anonymous respondent wrote.Coroners interviewed by ProPublica have pointed to the system used by neighboring Montana: a hybrid coroner-and-medical examiner setup, coordinated through a coroner liaison. Montana and its counties didnt have to bootstrap that position financially; it got funding through a federal grant from the National Institute of Justice.Idahos disjointed system leaves it up to each coroner to decide how they do their job. The Legislature this year clarified which kinds of deaths coroners must investigate, but it didnt clarify what investigate means. Can coroners examine the room where the person died? Get medical records to find a diagnosis that might explain the death? Order a blood test to look for fentanyl? Order an autopsy? Other states make it clearer. Arkansas state code expressly gives coroners subpoena power and guaranteed access to a death scene. Laws in states including Kansas, Louisiana, Ohio and Pennsylvania direct coroners to order an autopsy in certain kinds of deaths. Wyomings coroner standards board spells out what a death investigation should include: photographs, a scene investigation, an exam of the outside of the persons body, blood or tissue samples to test for toxic substances, an inventory of any evidence or property or medications the coroner found, and, finally, a DNA sample. 5. More training After living in an Idaho county for a year, any U.S. citizen 21 or older can become the county coroner. Theres no license or certification needed.When coroners take office, they have one year to attend coroners school, followed by 24 hours of coroner education every two years. But theres no enforcement mechanism for that law. At least three other Mountain West states that have coroners Colorado, Montana and Wyoming have penalties for not getting trained: suspended pay, forfeiture of the office or a misdemeanor charge.ProPublica found last year that 1 in 4 Idaho coroners repeatedly fell short of training requirements. Funke, the Idaho County coroner, exceeded the requirements and sought training on his own before taking office, but he told ProPublica he still felt underprepared. Funke, in his second year on the job, signed off on cremation of a woman based on her husbands word she died of Parkinsons, only to learn five years later the man was indicted in the murder of his next wife in Texas. With a decade more experience, Funke said he would do things differently now. National experts told ProPublica that Funke should have gone to the death scene and confirmed a Parkinsons diagnosis before he ruled the Idaho County death natural. Funke said more should be done to prepare coroners for the job.Idaho law doesnt define what a coroner must prove they know before taking charge of death investigations in their county. At least two other states have a higher bar when it comes to deputy coroners, who often do the main work. Indiana requires deputy coroners to pass a written test and complete an externship. Arkansas requires deputy coroners to complete a training curriculum and turn in a certificate that proves they did it. Arkansas law also established a separate salary tier for coroners who complete the training.When Idaho lawmakers made minor revisions to the states coroner law this year, they required training to be approved by a nationally recognized certifying body. But lawmakers did nothing to address the lack of consequences for coroners who skip those classes.The Idaho performance evaluation office said two coroners it surveyed this year urged the Idaho Legislature to step in with stronger leadership, enforceable training standards, and a sustainable funding model to ensure coroners across the state can effectively perform their duties.