Nurse Coroners Slowly Gain Ground
By Kelly M. Pyrek

As forensic nurses continue to surface on the clinical and medico-legal radar, they are gaining ground in elected positions, namely the coroner's office. While there are no statistics that document the number of nurse coroners in the United States, a number of counties in South Carolina and Indiana are leading the country in putting the skills of these forensic practitioners to work.

Some of the most visible nurse coroners are in Charleston County, S.C., the jurisdiction belonging to coroner Susan Chewning, RN and deputy coroner Bobbi Jo O'Neal, RN, BSN, members of the International Association of Forensic Nurses (IAFN). Their office was featured in a special series of articles examining elder abuse published Oct. 13-20, in The St. Louis Post-Dispatch. The Charleston office is the only office that conducts elder-death reviews similar to child-death reviews, an initiative spearheaded by forensic nurses.

O'Neal, an emergency room nurse by training, says she reached her goal of becoming a coroner through a calculated career path--aided by a little luck.

"I wanted to work in the ER because I knew that would be a good entry into forensics," O'Neal explains. "I went through sexual assault nurse examiner (SANE) training and coordinated the sexual assault response team, and worked on some projects with Susan Chewning, the coroner who offered me the deputy coroner position in . The coroner who ran for election was a nurse; had she not been a nurse I'm not sure others would have seen the value of having a nurse in office."

O'Neal believes the elective process is a good system and that nurses can use it to their advantage.

"The public can choose who they want in office but the problem is the public can only choose between the people who want to run for the job," she says. "If there isn't anyone who has any better skills than the plumber who runs for coroner, that's who voters will get."

O'Neal thinks it's incumbent upon nurses to go after the job if that's what they truly want, instead of expecting someone to hand it to them.

"One of the problems nurses have is that they are used to taking that extra class, putting it on their resume and thinking someone will want them just because of the coursework they have taken. In this world, that's not the case. It's all about networking. You have to get in the game and run for the position. The public will make the right choice. A forensic nurse in Washington state who ran for coroner was the only female and a nurse running against five male police officers. The public voted for her. It shows you the public recognizes the value in choosing a medical person."

That Washington nurse is Patti Hancock, RN, BSN, MSN, a forensic nurse specialist who captured the Stevens County coroner's seat in the Nov. 5, election. Hancock was running against five police officers in the Sept. 17, primary election; in the November election, she beat opponent Tony Harbolt with 51.16 percent of the vote to his 48.84 percent, the difference of 268 votes. She takes office on Jan. 20, .

Hancock knew Washington state law dictated that when a county reaches a population of 40,000, a coroner must be elected. She says she was finishing her master's program when the population was about to hit the magical number, and was convinced she could make a successful bid for the office. Having politics in her family's bloodline didn't hurt, either.

"My father was a state representative, and I have been active in politics during my youth as well as during most of my adult life. I knew this was a way in which I could use my master's-level education and also benefit my county."

Her unwavering sense of professional direction and rise to public office is in contrast to an earlier time when Hancock says she wasn't sure what she wanted for her life. "Twenty-eight years after I first became a nurse I went back to school for my BSN, and followed that with my MSN," Hancock explains. "When I went into the MSN program at Gonzaga University in Spokane, Wash., I wasn't sure exactly what I wanted to do. I knew for certain that I did not want to become a nurse practitioner, yet I didn't know what it was that I wanted. I took a class called 'Foray Into Forensics' and I knew that this was something that I would like and I could use to help benefit the county in which I live."

Hancock says running her campaign wasn't easy, due to the strong presence of her law enforcement opponents, a sort of "home court" advantage she knew she had to overcome in order to win.

"Running against five male police officers was no picnic," Hancock says. "Our county is extremely large in area, about 70 miles wide and 150 miles long. Law enforcement is in every segment of the county, yet there are only two hospitals and three medical clinics in the entire county. So it was much easier for law enforcement to campaign for their fellow officers than for one nurse to campaign for herself. I was extremely lucky in the fact that because my father was a state representative in this county and I was quite well known. My name recognition as well as my family's name recognition went a long way in helping me. I don't know how vindicated I feel but I do know that I have no intention of using law enforcement as my deputy coroners. My campaign was that it is a medical job and I plan on standing by that belief."

Hancock adds that her election to coroner will allow her to hire more nurses, an opportunity O'Neal believes is critical to the future success of nurse coroners everywhere.

"(Success like Patti's) will absolutely elevate the profile of nurses as coroners," O'Neal says, adding that it gives nurses new opportunities to explain their role. "People ask us all the time, 'What exactly do you do?' When you explain it, and teach others that we really are doing nursing, just in a different setting. We can not only investigate the deaths and represent the deceased, we can educate the community. In my jurisdiction, our community is so used to the way we run this office, they would demand that it continue to run this way. I don't think they would accept less. They are used to us as nurses doing educational programs, us taking it a step beyond, 'Yeah, they're dead from a car accident.' Nurse coroners are showing the community how we look out for the living and the dead."

Hancock feels strongly about the need for more nurses working as coroners due to their ability to approach death from a different perspective than law enforcement.

"Nurses have the educational background to understand exactly what causes death and what happens to a body after death occurs," she says. "Death may be a criminal event, but it is always a medical event. Unlike law enforcement who look at the deceased and want to know, 'Who killed you?' nurses look a at a dead body and ask, 'Why are you dead?' If it is determined that the death was due to a criminal cause then it is law enforcement's job to determine who. Who better to determine the manner of death than medical personnel?"

Hancock says the foundation of her campaign for office was education. "I started out by trying to educate the public on exactly what a forensic nurse specialist is and then I went on to explain why nurses make great coroners."

Education will be an ongoing theme for Hancock, both in her efforts to educate her constituents about medico-legal issues as well as in her own self-edification as she builds the coroner's office for Stevens County from scratch.

"My initial agenda is to simply set up an office," Hancock says. "I'm not sure how that will work since the job is only supposed to be a part-time position with a very small budget. I think that I will need at least a fax machine and an answering machine, since my office (if I have one) will most likely not be staffed. I am trying to make contact with all the physicians in the area as well as the medical examiner from Spokane County, where I will send my autopsies. I would meet the law enforcement personnel also, but I figure I pretty well did that during my campaign."

Although she is still buoyant from her hard-won victory, Hancock doesn't kid herself about the work that lies ahead. As she solidifies her new role, Hancock also acknowledges that there are many nurses who will struggle to get where she is now. The most challenging aspect of paving the way for more nurse coroners is spreading the word about forensic nursing, period.

"If more nurses knew they could do the job, then I think more of them would become coroners," she says. "I am not sure that many nurses know about forensic nursing. Every talk I give since I became a forensic nurse specialist I start by educating nurses, doctors and lay people as to what a forensic nurse is."

O'Neal enumerates what she believes to be some of the obstacles in the path of becoming a coroner.

"In addition to putting themselves out there to be seen and heard, nurses face financial issues in their quest to become coroners," O'Neal says. "In most areas of the country, coroners aren't very well paid. A nurse working three days a week in an ICU won't make as much being a coroner as she does in a hospital. These nurses really want to become coroners, but many of them can't take the cut in pay to serve in elected office."

It sounds simple enough, but O'Neal says one of the most important things aspiring nurse coroners must keep in mind is determining what system their state follows: coroner or medical examiner (ME) model. Currently, 22 states follow the ME system; 18 states have a mixed ME and coroner system, and 11 states have coroner's offices, according to the Centers for Disease Control and Prevention (CDC)'s Division of Public Health Surveillance and Informatics.¹

"Part of the problem nurses are having is that some states are under the ME system, an appointed position," O'Neal explains. "In those states, nurses can't be the boss, based on state statutes. I can issue the death certificate but it's not because I am a nurse, it's because I am a coroner. In my state the only ones who can sign a death certificate are physicians or the coroner."

With many advocating a conversion to an all-ME model across the United States, what then, is the future of nurse coroners?

"I think that the (ME model) would be the best of all systems, but there are fewer than 1,000 forensic pathologists in the U.S. to date, the last statistics I have heard," Hancock says. "So I don't see how this would be feasible. Most counties could not afford the expense and would not really have the need. We see about 50 to 60 unattended deaths a year in Stevens County; that would hardly keep an ME busy and justify the expense."

O'Neal and Hancock offer advice for forensic nurses who want to become coroners.

"Nurses need to have either ER or ICU experience, something where they are seeing forensic cases," O'Neal says. "We get calls all the time where a med-surg nurse wants to get into forensics. I tell them you need to go where you will see forensic cases in action. They have to figure out their state's system, either coroner or ME; that's an important step because they must know if it is an elected or appointed position. If it's an elected office, run for office; if it's appointed, get to know the person currently in that position."

"I was very grateful that I had people like Bobbie Jo to talk with when I started," Hancock recalls. "Anyone running for the office of coroner should contact other coroners and pick their brains as to what works. Join groups before you run; join a political party and become an active member. Establish a name for yourself long before you throw your hat into the ring."

O'Neal believe the best preparation for coroner work is hands-on training; hundreds of forensic nurses agree, judging by the popularity of the internship program offered by the Charleston County Coroner's Office.

"I get so many e-mails about the internship I can't keep up with them," O'Neal reports, adding that least year was the first time the program was officially offered to students. "We've always had students in our office, whether it's undergraduate nursing students or the like. We started getting tons of requests from nurses through the IAFN because we were one of the only offices in the country who were predominantly nurses. We hosted some of them and thought we should establish a formal program because nurses are caught in a classic catch-22 scenario; nobody will hire them because they don't have experience; they are not experienced because no one will hire them."

O'Neal adds that many nurses are pursuing their national certification through the American Board of Medico-Legal Death Investigation and were needing their skills checked off by a preceptor.

"A lot of nurses couldn't get checked off so they couldn't take the test; they couldn't take the test because they couldn't get checked off," O'Neal continues. "So we started a hands-on internship where students would be on call with us 24 hours a day and do whatever we are doing. If we are fingerprinting an unknown deceased, they are also fingerprinting. If we are knocking on a door at 3 a.m. to notify a decedent's next of kin, they are going to be right there with us. It's not a classroom experience. We never know what will come in; we've had weeks where we were begging for a case and weeks where we were so busy the interns couldn't believe it. We cover all the things a week-long, didactic course would, but we do it out in the field. Students will feel the rigor, talk about lividity, see interviews of family members; they will be right there with us."

O'Neal says response to the internship has been "overwhelming."

"Last year we filled up in about two weeks. One week each month we host two interns at a time; we take 18 interns per year. Response has been huge because there is nowhere else for them to go to get practical experience. If we are going to encourage nurses and really believe forensic nurses are great in this role, which we do, then somebody has to train them. They have to network, but they can't get into the system for hands-on training because no one will let them in. We're hoping if we can get them in the door and teach them, or encourage them to run for office, and get more nurses out there as coroners, everyone will benefit. Patti Hancock is in a position where maybe she can hire another nurse. Many of them don't even know if this is something they want to do; we can show them the ropes."

O'Neal says the infiltration of nurses into the U.S. coroner's system will be a slow process, but believe it will take off eventually.

"Houston just hired their first nurse," O'Neal reports. "She is not doing the kinds of things we are; she is more of an assistant to review medical records, but the office will get a sense that maybe they are missing the boat somewhere; I hear they are ready to hire a second nurse. Houston is a huge office, with 15 or 20 investigators, so the fact they recognize maybe they need another nurse in the office is encouraging. That ME will talk to a colleague and will say, 'Our nurse is great, you need to have one.' Word will spread and eventually nurses will get in everywhere. But for a while, nurses will have to go in kicking and screaming to get attention. We tell them to do some police or EMS ride-alongs to network and observe. Who goes to crime scenes first? They do. They will know the coroners and MEs. Start to network and figure out who makes decisions. Then get yourself in the door."

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