Mary Sanchez

Medical examiner’s work shows that clinging to rules can lead to mistakes

Updated: 2013-11-13T00:45:23Z


The Kansas City Star

Look to the Jackson County medical examiner for some uncomfortable examples of how adhering too strongly to the rules can lead to mistakes.

The Star’s longtime police reporter, Christine Vendel, produced an exhaustive look into the examiner’s office on Sunday. The lengthy piece is worth a deep read. It raises important questions about how decisions are made in death investigations.

In two cases profiled, one death was ruled a suicide and the other an overdose. In each case, someone later confessed to killing the deceased. Yet the examiner’s office is holding firm on the initial causes of death, seemingly regardless of new information. Go to the article for nuances, as there are many.

But self-justification, an unwillingness to be wrong or at the very least admit being unsure, appears to be at play.

Chief Medical Examiner Mary Dudley says she limits usage of the finding “undetermined” to cases where bodies are charred, badley decomposed or skeletal remains. Most people can understand that those conditions would make a firm determination of cause and manner of death difficult.

No problem there.

But this can also paint the office into a box when findings are inconclusive or at the very least more difficult.

Among the many standout quotes in the story Sunday was this one from the director of an Ohio county coroner’s office: “If you treat a case as a suicide, and believe it’s a suicide, that’s the way its going to turn out.”

That’s self-justification at work. It’s the human penchant to prove one’s own suppositions, to form a theory and run with it, often by either negating or ignoring anything that contradicts it.

But miscategorizing a death can also delay an already elusive sense of closure for families.

So it wasn’t shocking that the first comment posted online about the investigation came from a grieving mother. Cheryl Cooper says paperwork still rules her son’s death an accident. She wants it amended to homicide, an understandable request given that a man is already serving a second-degree murder sentence for the death of Christopher Cooper, 17, who was riding a bike when he was hit during a 2007 police chase.

In fairness to Dudley, it will be important to understand the genesis, the rationales, for many of the rules she has instituted for her office. It’s doubtful that anyone is trying to deceive. But the attitudes that are driving outcomes are not serving the people of this area well.

To reach Mary Sanchez, call 816-234-4752 or send email to

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