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FC Home GA Death Investigation History

Georgia Death Investigation History | Print |

-Randy Hanzlick, MD

February 2002

NOTE: The history presented here is derived in part from documents but much of it is based on memory, personal experience, and the memories and words of others. Some opinions are also expressed which are those of the author. If there are inaccuracies, omissions, or other offenses committed, please accept the author’s apologies in advance.


Introduction and Pre-Georgia History
In reading Georgia’s first Constitution of 1777, it seems clear that the term “coroner” was already quite familiar and in general use in Georgia. Article XI states “In case of absence of the chief-justice, the senior justice on the bench shall act as chief-justice, with the clerk of the county, attorney for the State, sheriff, coroner, constable, and the jurors.” This is the only mention of the coroner in that Constitution. “Coroner”is not defined, nor are the job duties associated with that position. Thus, one would surmise that everyone already knew what a coroner was and what the coroner did. Indeed-- that is the case—and here’s why.

Remember that James Oglethorpe was English and arrived in 1733 in what is now known as Georgia. Already, when Oglethorpe arrived in what became Savannah, “coroners” had existed in England for more than 600 years. They were “old hat” in England and part of English common law. In 1194, the Articles of Eyre required that 3 knights and a clerk in each district attend each death in the district. These elected agents were referred to as “custos placitorum coronae,” or “keepers of the pleas of the crown.” They were called “crowners,” and the term “coroner” obviously grew from the Latin word “coronae.” The crowners had several missions. One was to determine how the death occurred. A second had to do with investigating possible suicides, which were prohibited and resulted in forfeiture of assets to the Crown. A third task was to serve in a fiduciary capacity to appropriately dispose of assets of the estate. They could hear and try pleas of the Crown.

 

21 years later in 1215, however, the Magna Carta restricted coroners and other individuals from holding pleas of the Crown. In 1276, the Parliament’s Statute de Officio Coronatoris described coroner’s duties to “enquire when anyone dies in prison, or comes to a violent or sudden end, and by what manner he came to his end.” These provisions continued to be regarded as common law. By the 1400s, justices of the peace had assumed the fiduciary duties formerly conducted by coroners. So, 332 years before Oglethorpe left England to head toward North America, coroners were defined, their duties were known, and their efforts were concentrated on death investigation. The colonists brought these concepts to New England in the early 1600s, and Oglethorpe followed suit in his trek to Georgia in 1732-33. By the time Oglethorpe arrived, autopsies had already been performed in New England, such as an autopsy in Hartford, Connecticut in 1632 to determine whether a young child may have died from witchcraft.

 

Early Georgia
From the time Oglethorpe founded Savannah in 1733 under the Charter granted by King George II, through the time Oglethorpe had his final departure back to England in 1743, and further still while Georgia was a Crown Colony and the British withdrew in 1782, Georgia followed English Common law. Thus, coroners probably existed during all these times, and almost assuredly after 1755 when the Royal Government was established in the Crown Colony. An Act of April 11, 1768 describes the fees allowed for the coroner for holding inquests. In 1784, it was reaffirmed that the common laws of England that were in force in Georgia in 1776 were still in full force and that coroners were governed by the common law of England. However, good documentation of the English common law and statutes was hard to come by, and in 1823, the Georgia General Assembly enacted legislation which set forth the duties and functions of the coroner. Such provisions carried forth in all revisions of Georgia Code into the 20th Century.

The only time the word “coroner” appears in any of the 10 Constitutions of Georgia that have been in effect since 1777 is in the original Constitution as discussed above. Coroners in Georgia have not been considered constitutional officers. Rather, they have been regarded as public officers. Coroners did have judicial-like authority. They could hold inquests, impanel a jury, compel the presence of witnesses, examine witnesses under oath, issue warrants for arrests of alleged perpetrators of homicides, and require witness to appear at criminal trials.

Of course, as the English settlers came to Georgia and other parts of America, they didn’t all just stay here. Some went back and forth, and emerging concepts in England came back with them. In England, for example, changes to coroner laws in 1836 and 1887 improved coroner death investigations by providing for a physician’s presence at inquests and allowing for the coroner to order an autopsy. Such concepts were brought to New England and other colonies. These were important events because it was recognized that death and dying involve medical issues, and medical professionals were brought into the death investigation processes of coroners. It is important to realize that there was no requirement for coroners to have medical training. This is still true today in Georgia and in some other parts of the United States. In Georgia, specifically, it was not until the mid-1900s that medical doctors began to be more involved in death investigation, and it was not until the late 1980s the medical doctors trained in death investigation began to play a significant role in state-wide death investigation in Georgia.

When the original Georgia Constitution went into effect in 1777, there were 8 counties. Through the 10 different Georgia Constitutions, 159 counties have emerged. The Constitution of 1877 allowed for no new counties. An amendment of 1904 limited the number of counties to 145. Additional amendments in 1906 and 1912 added 3 more. The current Constitution defines a ceiling of 159 counties which is how many there are today. Georgia has more counties than any other state except Texas. That means Georgia also has more coroners than any other state except Texas. At virtually every county courthouse in Georgia stands a historical marker which explains for whom the county was named, other famous locals, and important public officers including the name of the coroner when the county was established. This tells us that coroners have been ingrained in Georgia county government for a long time and are important. It makes sense. After all, dying is one of the only things that all people do, and somebody needs to address the issues when a death occurs.

Preparing a complete report of all coroners in all counties since each county was formed would be an almost insurmountable, if not impossible task. The State of Georgia has not kept state records on these positions and necessary records may not even exist in many of the counties, especially back to the beginning of county history. An account of each coroner, their background, main occupation, and interesting death investigations would probably be enjoyable reading, but collecting the necessary information would probably fall upon county historical societies which may have other interests, different priorities, and insufficient resources to find and report this information. Just think about it. There are 159 counties. Many have existed for more than 100 years and some for more than 200 years, and a coroner’s term has typically been 2 to 4 years. Its conceivable that there have been 2000 to 4000 coroners or more in Georgia’s history. What a biography and historical account that could be!

As previously mentioned, the Georgia Constitutions have not specifically defined coroners or their duties. However, the Constitutions, such as the 1877 version, do define certain criteria for county governments, including provisions that there be certain county officers, and that there be uniformity in the types of county officers from one county to another. The nature of these county officers is, according to the Constitution, determined by the Georgia General Assembly (Legislature). The legislature has enacted laws that require certain county officers in each county such as sheriff, tax collector, coroner, and others.

Today, in Georgia, 154 of the 159 counties still have the elected office of coroner. Coroners serve 4 year terms and may be re-elected without term limitations. Requirements are minimal. One must be a registered voter and live in the county where the office is being sought, be at least 25 years of age, possess a high school diploma or equivalent, have no felony convictions, complete a basic training course, file an affidavit attesting that qualifications have been met, and attend yearly update training courses. In Georgia, deaths occurring in counties having a coroner are first reported to the coroner. The coroner then notifies the medical examiner system operated through the Division of Forensic Sciences (DOFS) within the Georgia Bureau of Investigation (GBI; see below), and arrangements are made for transport and postmortem examination, if needed. In the past, a high portion of coroners in Georgia have been funeral directors. With time, however, the percentage of funeral directors has decreased and the office of coroner is held by more and more people in other disciplines such as paramedical ones. Coroners are required to complete a 40 hour training course upon election and then attend additional 32 hours courses each year while in office.

 

The 20th Century

For the first 53 years of the 20th century, coroners continued to operate under the principals of English common law as clarified and set forth by the General Assembly’s act of 1823, and as codified several times after that date including Georgia Code 21-2 as established in 1933. When coroners needed a physician to perform a postmortem examination, they would have to rely upon whomever was willing and available to perform such examinations. Often, perhaps, medical examinations just didn’t take place. The laws did not provide specifically for physicians to assist in death investigations. It occurred mainly by happenstance.

It was not until 1953 that the first major change in death investigation occurred in 20th century Georgia. In that year, Code Section 21-2 was repealed. In its place, a new Code 21-205 was enacted and titled “The Georgia Postmortem Examinations Act.” It was substantially similar in many respects to the 1954 “Model Postmortem Examinations Act” put forth by the National Commissioners on Uniform State Laws. Obviously, Georgia had gotten early wind of the Model Act and was timely in including some its provisions, which concentrated on a move toward so-called “medical examiner systems” which could be developed in place of the time-honored coroner systems. By 1954, some regions of the country had already abolished the office of coroner and established a system in which physicians were appointed as “medical examiners,” New York City being one example and having done so in 1918. Such systems spread in the mid-20th century, especially in the northeastern United States.

The 1953 Georgia Postmortem Examinations Act did not dramatically alter the law related to coroners. What it did do, however, was establish law for a system that would improve death investigation services state wide by providing for more organized availability of postmortem examinations. It also provided, in conjunction with other state laws, that a county could abolish the office of coroner and establish in its place a county medical examiner system. County medical examiner systems are discussed in more detail below. Presently, the improvements having state-wide implications will be discussed.

Many things were happening in the 1950s in Georgia as far as death investigation is concerned. We need to take a step back for a moment to lay a foundation for discussion.

In the late 1940s, Dr. Herman D. Jones was asked by the Fulton County Police Chief to establish and direct a Crime Lab for Fulton County, which he agreed to do. The lab opened in June 1947. Dr. Jones had the same viewpoint that many have today, and that is that a crime laboratory should be independent of politics. He had declined a former invitation from Governor Arnall in the 1940s for fear of political interference. Dr. Jones was not a medical doctor. He went to college at Auburn University and Vanderbilt University and had received a doctorate in physical sciences from Columbia University. He had worked in Alabama’s toxicology laboratory until 1942 when he moved to Atlanta as Professor of Biochemistry at Oglethorpe University. He left that position to start up the Fulton County Crime Lab in 1947. There was a Fulton County Coroner at that time.

In 1951, Governor Tallmadge asked Dr. Jones to set up a State Crime Laboratory and promised him that such a crime lab would be free of political influence. In 1952, the Georgia General Assembly worked with the City of Atlanta and Fulton County and they agreed to transfer the Crime Lab to the Department of Public Safety and make it a State Lab. This was accomplished in 1952. At first, the state lab was a three-man operation, but it grew in subsequent years. Operations were housed at the Old Confederate Soldiers Home on Confederate Avenue.

Around and prior to 1953, concern had arisen about the quality of death investigation and in 1953, the General Assembly enacted the Georgia Postmortem Examinations Act. The Act, among other things, established the Director of the State Crime Lab (Dr. Jones) as Georgia’s Chief Medical Examiner and authorized the State Crime Lab to provide and conduct postmortem examination services. It is important to remember that Dr. Jones was not a medical doctor. He did, however, learn how to perform autopsies and did them as Chief Medical Examiner. Dr. Jones retired in 1969. He had been the mainstay of medical examiner services for the State for nearly two decades. During his watch, a new GBI Crime Lab was built in 1957 on Confederate Avenue on the site where the Confederate Soldiers Home had stood. . This facility housed the Crime Lab until the current State Crime Lab was opened on Panthersville Road in Decatur in the Fall of 1984.

By 1969, Dr. Larry Howard had worked at the Crime Lab for 13 years. He held a PhD degree and had worked as a toxicologist but had also learned how to perform autopsies while working at the lab and had taken some course in pathology. He was named Director of the State Crime Lab in 1969 and became Georgia’s second Chief Medical Examiner as provided for in State statute.

In 1980, the “State Crime Lab” was renamed the “Division of Forensic Sciences (DOFS).” It remained a division within the Georgia Bureau of Investigation (GBI). Although the Director of the GBI was typically appointed by the Governor and had changed numerous times since the GBI began in 1938 (Joseph Bray 1938; Arthur Hutchins 1940; WS Roper 1941; William Spence 1943; Joseph Bray 1946; George Bagby 1947; William McLemore 1947; Delmar Jones 1948; Barney Ragsdale 1963; Hugh Smith 1971; William Beardsley 1972; Beverly Ponder 1975; E.P. “Phil” Peters 1980; J. Robert Hamrick 1985; Milton “Buddy” Nix 1992), and 8 times since Dr. Jones became Crime Lab Director in 1952, there had been only two Directors of the Crime Lab (Division of Forensic Sciences) between 1952 and 1989 when Dr. Howard retired as DOFS Director. Governor Tallmadge’s promise of no political interference appears to have held up, at least in terms of stability and tenure regarding the Crime Lab directorship.

While Larry Howard was DOFS Director, by the early1980s, two additional forensic scientists at DOFS learned how to perform autopsies while working at the lab. One was Dr. Byron Dawson and the other was Warren Tilman. The former had a PhD in science and the latter a Masters degree, and both had worked as forensic scientists at the Crime Laboratory. Thus, until the mid 1980’s there were three individuals performing postmortem examinations for the DOFS system, and none of the three were physician pathologists. All had learned their autopsy skills primarily while working at the GBI Crime Lab (DOFS).

Requests for postmortem examinations continually grew as coroners realized that such services were available and valuable. Further, there was no billing back to the counties so these postmortem examinations were free to the counties. Demand exceeded the staff resources that were available. Further, Dr. Howard recognized that postmortem examinations involved medical issues and that it would be preferable to have postmortem examinations performed by physician pathologists. Thus, in the mid 1980s, Kenneth Alonso, MD, was hired to provide postmortem examination services. Dr. Alonso was a pathologist in hospital-based practice but had some experience in forensic pathology and became a board certified forensic pathologist. His hiring marked the first time that a medical doctor (and certified pathologist) had been hired to perform postmortem examinations in the DOFS system. In 1988, Dr. Alonso returned to private practice and the DOFS hired Janet Pillow, MD, who had just completed her forensic pathology training at the Fulton County Medical Examiner’s Officer in Atlanta. She worked with DOFS for about a year and then accepted an offer to work in northern Florida.

It was July 1989 and DOFS needed help to meet demand for postmortem examinations. Dr. Larry Howard had retired, and Dr. Byron Dawson was named as the third DOFS Director and retained the title of Chief State Medical Examiner. The medical examiners who worked at the Fulton County Medical Examiner’s Office had a sincere interest in assisting with the improvement of death investigations throughout Georgia. Thus, the DOFS and Fulton County entered into a contract which provided for the Fulton County Medical Examiners to perform postmortem examinations for the DOFS, at the DOFS, along with the DOFS personnel who were also performing them. The Fulton County medical examiners who provided such services included Saleh Zaki, MD (then Chief Medical Examiner and now retired), Randy Hanzlick, MD (then Associate Medical Examiner and now Chief Medical Examiner for Fulton County), Gerald Gowitt, MD (then Associate Medical Examiner and now Chief Medical Examiner for DeKalb County), Thomas Young, MD (who had just completed forensic pathology training at Fulton County, had become an Associate Medical Examiner, and is now Chief Medical Examiner in Kansas City, Missouri), (and Steven Dunton, MD (then in Forensic Pathology Fellowship Training and now Chief Medical Examiner for Gwinnett County). All of these forensic pathologists, except Dr. Zaki, had trained in the Fulton County Medical Examiner forensic pathology fellowship..

By late 1989, it became apparent that the medical examiner staff at Fulton County would need to enlarge to adequately perform postmortem examinations at both Fulton County and DOFS. In late 1989, Kris Sperry, MD, a forensic pathologist who had trained in New Mexico, was interviewed and hired as an Associate Medical Examiner for Fulton County in December 1989. So, by the end of the 1980s, there were six forensic pathologists performing postmortem examinations for the DOFS system. All of these examinations were performed at the DOFS Crime Lab in Decatur, and were done by them in addition to the examinations they performed at Fulton County. The non-physician medical examiners at DOFS continued to perform some postmortem examinations also. Between the two offices, about 2000 postmortem examinations were being performed per year. These forensic pathologists were very busy.

The DOFS Crime Lab system by 1971 had two branch crime labs—one in Savannah, and one in Columbus. Each of these had a small morgue where autopsies could be performed, but no pathologists were hired to work there. By 1977, two additional branch labs had been built in Augusta and Moultrie. These also had small morgues but no pathologists to work in them. Cases continued to be sent to the DOFS lab in Decatur if an autopsy was needed. Branch labs were eventually added in Macon and Summerville, making a total of 6 branch labs. In the early 1990s, John Parker, MD, who had trained in forensic pathology in Dallas, Texas, was hired to work in the Macon DOFS branch. He was the first medical examiner to occupy and work in a branch lab full time. He was replaced in 2000 by Melissa Sims, MD, who trained in forensic pathology at the Medical University of South Carolina in Charleston. When Dr. Parker left Macon, he continued to work as a forensic pathologist on a part time basis for Fulton County, DeKalb County, and in the DOFS lab in Decatur. In 1994, Anthony “Tony” Clark, MD, also a graduate of the Fulton County forensic pathology training program, was hired to work in the Moultrie DOFS lab where he still works today. Cameron Snider, MD, another pathologist who trained in forensic pathology at Fulton County in 1997-98, was hired to work in the new branch lab in Summerville. He worked there for about two years and then returned to his home in Pennsylvania. His vacated position in the Summerville (Trion) lab was subsequently filled by Vania Revell, who then left and was replaced by former AFIP forensic pathologist William "Billo" Oliver, MD, in 2003.

Mark Koponen, MD, had done his basic pathology training in New Mexico and came to Atlanta in 1990 to do his forensic pathology training with the Fulton County Medical Examiner. After completing training, he stayed on as a Medical Examiner there assisting in both Fulton County and DOFS cases. Anthony Clark, MD, came from Connecticut in 1991 to do his forensic pathology training and likewise stayed on after completing it to work with the DOFS and assume duties in Moultrie in 1994. Geoffrey Smith, MD, had trained in pathology at Emory University and did a forensic pathology training year at the Fulton County Medical Examiner’s office. For a period of time, Fredric (Rick) Hellman, MD, who had come to Atlanta from North Carolina, served as a Medical Examiner for both Fulton County and the DOFS lab, but moved to Pennsylvania in 2000 to become the Medical Examiner in Delaware County. Dr. Hanzlick left the Fulton Office as an Associate Medical Examiner in 1991, but continued to work on a part time basis doing postmortem examinations for the DOFS and later, for Fulton County.

In 1997, the DOFS decided to end the contract with Fulton County and hire its own medical examiners as employees. Doctors Sperry, Koponen, Hellman, and Smith became medical examiners solely for the DOFS in Decatur. Law changes in 1990 (see below), had created a State Medical Examiner Position, and Dr. Sperry became the DOFS’ Chief Medical Examiner in July 1997 and was in charge of Doctors Koponen, Smith, and Hellman. The Chief Medical Examiner position was established within the GBI DOFS with the Chief Medical Examiner reporting to the DOFS and GBI Directors. The DOFS medical examiner system is described in further detail below.

As additional funding became available, positions were added for forensic pathologist medical examiners at the DOFS. In 1999, Keith Lehman, MD, from North Carolina and another graduate of the Fulton County forensic training program, was hired. Similarly, Kris Podjaski, MD, who came from Connecticut, also trained in the Fulton County program and was hired by DOFS in 2000 when he completed his training.

In 2000, another board certified forensic pathologist, Andrew Falzon, was hired by DOFS to work in the main DOFS lab in Decatur, just outside of Atlanta. He subsequently moved to New Jersey and was replaced in 2001 by Jacqueline Martin who moved to Atlanta from Syracuse, New York. This completed the group of DOFS medical examiners who were working as of year 2001. The group at that time consisted of Doctors Sperry, Martin, Lehman, Smith, Podjaski, and Koponen at the Decatur DOFS, Clark in Moultrie, Sims in Macon, and Revell in Summerville. All but Sims, Martin, and Revell had either worked at the Fulton County Medical Examiner’s Office or had trained there, as had Cameron Snider who was the first medical examiner to work in the Summerville DOFS lab. Thus, the Fulton County office has made a major contribution to improvement and expansion of medical examiner services in the State.

Around the state in other locations, the 1953 Postmortem Act also allowed for the appointment of medical examiners throughout the state to assist coroners locally in their death investigations. Many times these were physicians but not necessarily pathologists, and almost always, they had other jobs as physicians and did only occasional work for the coroners. A typical scenario might be the pathologist at a local hospital who could examine bodies for the coroner or perhaps do an autopsy in selected cases. Through the history of the DOFS system, however, it has been fairly routine for autopsies in homicide and other difficult cases to be done in Atlanta by the DOFS medical examiners, and now, more recently in the branch labs that are staffed with pathologists (Macon, Moultrie, and Summerville). The main lab in Decatur serves as the “back up” for the branch labs to provide medical examiner services when the branch lab forensic pathologists are on vacation, off on weekends, or are otherwise unavailable. The main lab continues to serve a large portion of northeast, middle, and southeast Georgia.

Other board certified forensic pathologists who have served the state in some capacity include James Metcalfe, MD; David Rydzewski, MD; Jerome Tift, MD; and James Whitaker, MD. The first two trained at Fulton County. Doctor Metcalfe then moved to the Dalton, Georgia area and did some forensic cases for coroners, but then went back into hospital-based pathology practice in Tennessee. Doctor Rydzewski moved to Carrollton, Georgia and does some autopsies for the coroner in the area but most does hospital-based pathology. Lawrence Alligood, MD, has also served the same area and has assisted the coroner through his hospital-based pathology practice in Carrollton. He also assisted in the Atlanta area in the late 1970s. Doctors Tift and Whitaker came from out-of-state and have provided some forensic pathology services for coroners, but for the most part, practice general pathology in the Macon and Warner-Robbins areas, respectively.

At the time of this writing in December 2001, the DOFS in Decatur was constructing a new autopsy facility adjacent to GBI headquarters, which is scheduled to open in the Spring of 2002. It was also in the process of rebuilding or renovating several of the older branch laboratories. The long term plan is to place forensic pathologist medical examiners in each of the branch labs.

Important developments have occurred in the DOFS medical examiner system as far as academics are concerned. One was the establishment of a forensic pathology residency program which accepted its first resident, Laura Darrisaw, in July 2001. Another is affiliation with the Medical College of Georgia, from where general pathology residents periodically come to gain exposure to forensic pathology. There has been a long standing relationship between the GBI DOS and the Fulton County forensic pathology residency program and the FCME residents spend part of their year performing autopsies at the Crime Lab and rotating through the Crime Lab sections such as toxicology and firearms examination.

Review of the “Modern” Death Investigation Era in Georgia
For the purpose of discussion, let’s define the beginning of the modern era of death investigation in Georgia as 1953 when the Postmortem Examinations Act was passed, a mechanism for the state to perform postmortem examinations was contained in the law, and Dr. Herman Jones became the state’s first Chief Medical Examiner. Let’s also assume that, as the American Medical Association has resolved , the autopsy is a medical procedure and constitutes the practice of medicine, and that autopsies should, therefore, be performed by licensed physicians, preferably ones with formal training in pathology and autopsy procedure and interpretation, and better still by forensic pathologists with training in forensic pathology and death investigation. Using these criteria, the DOFS death investigation services did not really begin to “modernize” until the mid 1980s.

Statewide in the late 1970’s and early 1980s there were only a few physician forensic pathologists in the state. These include Robert Stivers, MD, Saleh Zaki, MD, John Feegel, MD (all at Fulton county), Joseph Burton, MD and William Anderson, MD (mainly working in DeKalb and Cobb Counties), James Metcalfe in North Georgia, and Jerome Tift, MD and James Whitaker, MD in the Macon and Warner Robbins areas. Six of these were board certified in forensic pathology. Feegel and Anderson moved out of state in the early 1980s and Tift, Whitaker, and Metcalfe did only occasional forensic death investigation work Kenneth Alonso, MD became board certified in early 1980s and was subsequently hired by DOFS as its first physician, pathologist medical examiner. Thus, by 1984, there were only two board-certified forensic pathologists practicing full time forensic pathology in the state (Dr. Zaki, in Fulton County and Dr. Alonso at the DOFS). By 1985, Randy Hanzlick, MD, had completed training and had become board certified. The total sum of forensic pathologists working full time in death investigation in Georgia in 1985 was five (Stivers, Zaki, Hanzlick, Burton, Alonso). Of these, three worked almost exclusively in Fulton County, and Burton worked mainly in Cobb and DeKalb.

After the first GBI DOFS “medical examiner” was established in statute in 1953, it took 30 years for the DOFS system to have its own physician forensic pathologist. It was not until 1989, however, that the first real sign of hope for growth in the DOFS forensic pathologist staff occurred, when the medical examiners for Fulton County began to provide medical examiner services for DOFS. In the 1990s, the presence of forensic pathologists grew considerably. The stories of individual counties with their own medical examiner systems (Fulton, Cobb, DeKalb, and Gwinnett) will be detailed below. But overall, the vital statistics for forensic pathologists in the year 2000 in Georgia were:

Total forensic pathologists in the State: 23

Total board certified forensic pathologists in the State: 19

Total forensic pathologists practicing fulltime routine death investigation: 16

Total board certified forensic pathologists practicing fulltime: 14

Total forensic pathologists working in the DOFS system: 9

Total board certified forensic pathologists working full time in county systems: 6

As of the year 2001, of the 16 full time, forensic pathologists practicing in the State of Georgia, 10 trained in Fulton County, 2 more have been staff pathologists for Fulton County, and 5 were recruited from other states (Washington, Minnesota, South Carolina, Texas, New York). Of the 9 working for the DOFS system, 6 trained in Fulton County and 1 had worked for Fulton County before moving to the DOFS.

In the year 2001, the forensic pathologists practicing full time, routine death investigations in Georgia were (MD title is omitted for brevity): Steven Dunton, Gerald Gowitt, Carol Terry, Randy Hanzlick, Michael Heninger, Eric Kiesel, Kris Sperry, Mark Koponen, Geoffrey Smith, Keith Lehman, Kris Podjaski, Melissa Sims, John Parker, Anthony Clark, Jacqueline Martin, and Vania Revell. Retired were Saleh Zaki and Robert Stivers. The remaining forensic pathologists in Georgia were practicing part time, not at all, or had returned to other forms of practice such as consulting. These included Joseph Burton, David Rydzewski, Jerome Tift, James Whitaker, and Kenneth Alonso.

Between 1980 and 2000, the number of autopsies performed by the DOFS medical examiners has increased from about 500 per year to about 2000 per year. Build it and they will come!

Major Changes in Georgia Death Investigation Statutes
The Georgia Postmortem Examinations Act of 1953 was a pretty good one. It described the types of deaths that needed to be investigated by coroners and medical examiners; provided for the Director of the Division to serve as the State’s Chief Medical Examiner; detailed the requirements to run for the office of coroner; described procedures for coroner’s inquests and the other duties coroners could perform; detailed the roles and interactions of the coroner, medical examiner, law enforcement agencies, and DOFS; and included provisions for counties that wished to abolish the office of coroner and establish a medical examiner system. The Act was originally Code Section 21-205, was modified slightly through the years and was renumbered Georgia Code Title 45 where the death investigation laws reside today. Georgia Code 45-16-1 began with the laws related to coroners, and section 45-16-20 began the section formally titled “The Georgia Postmortem Examinations Act” which described all the specific of death investigation procedures in Georgia. Today, the law is called “The Georgia Death Investigation Act.”

A major change occurred in the Act in the 1989. At that time, there was much interest in child abuse and neglect. There was also much interest in clarifying some of the details about the death investigation system, including the need to more clearly define certain words, terms, and phrases that were in general use or mentioned in the Act. There was also interest in formalizing a medically-oriented State Medical Examiner system for DOFS to enable continued improvement in death investigation services throughout the state.

The medical examiners working in the Fulton County Medical Examiners were directly involved in writing proposed law changes to address these issues. Those most directly involved included Saleh Zaki, Randy Hanzlick, and Gerald Gowitt. These three worked closely with Joseph Burton, who was medical examiner in DeKalb and Cobb counties at the time, along with representatives from the Division of Forensic Sciences, GBI, and State Representatives Steve Thompson and Mary Margaret Oliver who were major sponsors of proposed legislation. The work in late 1989 and early 1990 was feverish, and the proposed changes specified in Act Number 1385 (HB 1323) ultimately passed the General Assembly and were signed into law by Governor Harris on April 16, 1990. At this same time, laws were created that provided for county child fatality review committees and a state child fatality review panel, each of which had defined memberships and duties.

The revised 45-16-20 and subsequent sections of Chapter 16 fully defined terms such as “medical examiner, “ “scene investigation,” autopsy,” “inquest,” and many other related terms in common use. It also made more clear the duties of specific individuals, Second, the law called specific attention to the need to investigate deaths of children. Third, and very importantly, Act Number 1385 also included revisions of Chapter 3, Title 35 (which coves the GBI) provided for the creation of a State Medical Examiner which was required to be a board certified forensic pathologist with formal training and experience.

A major interest among Georgia’s medical examiners at the time was to establish a medically-based, professional State Medical Examiner’s Office that was run by forensic pathologists and was independent from the GBI (a law enforcement agency) and its Division of Forensic Sciences (DOFS). Neither the GBI nor DOFS supported the concept of an independent State Medical Examiner’s Office. So, a compromise had to be reached. GBI did support the establishment of a State Medical Examiner Office within the DOFS.

A good aspect of the revised 35-3 was the enabling of a Medical Examiner Commission which was to consist of the Commissioner of Human Resources, a district attorney, a defense attorney, two physicians (one of which had to be serving as a full time medical examiner in Georgia, and the other, it was hoped, would be a Dean or professor affiliated with a medical school), a coroner, a superior court judge, a layperson, a sheriff or local law enforcement officer, and a licensed funeral director. The purpose of this Commission was to make recommendations for improving death investigation services, and to recommend candidates for appointment as the State Medical Examiner. This was an important concept because it included the stakeholders involved in death investigation, it provided for evaluation and recommendations from outside the GBI system, created a quality assurance mechanism to thoroughly evaluate potential candidates to serve as the State Medical Examiner, and could assist the State Medical Examiner, GBI, and DOFS in the establishment of death investigation policy and procedure. In essence, it provided a non-law enforcement oversight to the death investigation system. The Commission was never implemented and the provisions for it were redacted from the law in 1997 (see below).

Another important aspect of 35-3 was that the State Medical Examiner would appoint, after consultation with the local coroner and other officials, local medical examiners who could assist coroners on a local basis. This provision was included to provide a mechanism to evaluate the credentials of physicians who wanted to serve as local medical examiners, to ensure that such local medical examiners met some minimum qualification, and to ensure that the best qualified people locally were considered.

As mentioned, the Commission was never implemented. Further, a State Medical Examiner, consistent with the spirit of the revised statute of 1990, was not actually hired until 1997 (see below). Funding was commonly blamed, but political reasons may have also played a role.

Another important aspect of revised 45-16 was that it had language which effectively prohibit non-physicians to serve as medical examiners. This was a major advancement. The statute contained language which grandfathered the last remaining non-physician medical examiner. That person was permitted to continue until leaving services, after which said time non-physicians could no longer continue to serve as a medical examiner. This paved the way for improving death investigation by requiring medical examiners to be physicians.

In 1997, the entire Code Section of 35-3-15, which had created the State Medical Examiner and Commission in 1990 was struck. In its place, a much shorter 35-3-153 was created. This section, which passed the General Assembly and was signed into law by Governor Zell Miller, created a “Chief Medical Examiner” for the DOFS system to be appointed by the GBI Director. It also allows the DOFS Director (who need not be, and to date, has not been a physician) to serve as State Medical Examiner if there is a vacancy in the position. Related changes in 45-16 loosened the requirement that the Chief Medical Examiner approve the appointment of local medical examiners working for coroners. So, in some respects-- other than the very positive step of confirming/continuing the Chief Medical Examiner position-- one might argue that death investigation statutes took a slight step backward at this time in terms of pursuing an autonomous State Medical Examiner system.

The current laws put the GBI in control of who the Chief Medical Examiner is, and places medical examiner operations within the GBI DOFS. Although having the medical examiner within a law enforcement agency may be construed as inappropriate in theory, practically speaking, the situation has advantages. Major ones are that law enforcement agencies tend to be well funded, and there is a major investigative agency and Crime Lab readily available to the Chief Medical Examiner. A large supportive infrastructure is in place.

The good side of the 1997 statute changes was that a board certified forensic pathologist was hired as DOFS Chief Medical Examiner. Kris Sperry, MD, who had worked in the Fulton County Medical Examiner’s Office, applied for the position and was selected. In July 1997, Dr. Sperry became the State’s first Chief Medical Examiner. At the same time, he took with him several medical examiners who were based at the Fulton County Office through a contract with the GBI, and these included Frederic “Rick” Hellman, MD, Geoffrey Smith, MD, and Mark Koponen, MD. All of these forensic pathologists were then based in the DOFS Crime Lab in Decatur. The medical examiner staff there grew between 1997 and 2001 as described above. The actual appointment of a forensic pathologist Chief Medical Examiner for the state, and funding of professional staff, were major advances in the history of death investigation in Georgia, but didn’t happen until almost the end of the 20th century. A State Medical Examiner System totally independent of law enforcement agencies has not been realized. Perhaps that remains for the 21st Century.

A few details about the DOFS Chief Medical Examiner position may be helpful. Major duties include the oversight of other medical examiners working in the DOFS system both in the main lab in Decatur and in the regional branch labs throughout the state. Routine duties include the performance of postmortem examinations and all that goes with it such as court testimony. The Chief Medical Examiner also has some responsibilities in the planning and execution of training held for coroners via the Georgia Coroners Training Council, which was established more than a decade ago. The Chief Medical Examiner does not have administrative responsibility for the county medical examiners in counties that have abolished the office of coroner—these counties operate as free standing, independent, and autonomous death investigation systems except that they rely upon the DOFS for Crime Lab services and forensic science expertise.

The regionalized death investigation system operated through the GBI DOFS provides a valuable service because coroners in virtually every county have access to trained forensic pathologists for consultation, performance of postmortem examinations, and testimony at the local county level. Problems inherent in the system include limited access of the pathologist to the death scene (because of the distances involved); reliance upon the coroners to appropriately refer deaths to the medical examiner; significant time commitment for travel throughout the state to testify in the various counties; the need to acquire investigative information via phone or fax in many cases rather than in person; and the transport costs involved in picking up and delivering bodies in many locations throughout the State. Finally, the State has transport vehicles and drivers, and there is no bill back to the counties that use the transport or medical examiner services. This helps the counties who may not be able to afford these services, but the “free” services may also provide a disincentive for individual counties to establish their own county death investigation system, where feasible and affordable. Because of demographics, tax-bases, population distribution, and geography in Georgia, it seems that full implementation of a regional death investigation system is the best option, while encouraging counties to established their own medical examiner systems, if possible,

Development of County Medical Examiner Systems
At present, 5 Georgia Counties have abolished the office of Coroner to establish a County Medical Examiner. These are, in order, Fulton (1965), Cobb (1973), DeKalb (1981), Gwinnett (1989), and Clayton (2001). Each of these counties is contiguous with Fulton County. The first three were systems in which forensic pathologists had worked and in which the Coroners were supportive of a change to the medical examiner system. The impetus for change in the fourth county grew out of concern from the District Attorney, Director of Public Safety, and interested local forensic pathologist medical exainers. The most recent followed the indictment and arrest of the incumbent Coroner on charges mainly related to financial improprieties. A brief summary of the events in each county is presented below. In Georgia, the usual procedure to abolish the coroner is to hold a county referendum on the issue and then have the office formally abolished by an act of the state legislature.

Fulton County (1965). Some of the history in Fulton County is taken from written records, but much is taken from the personal memory of Wallace Vaughn, who was working as a morgue attendant in Fulton County in the Coroner’s system of the early 1960s, and who remained a morgue attendant for Fulton County until his retirement in 1992. Thanks to Wallace for his excellent memory and willingness to recount it. He was a painter working for the county when the Steiner facility was being constructed, and was hired as the first morgue attendant because of his military experience in the medical/mortuary services.

In the late 1950s, Tom Compton was the elected County Coroner for Fulton County. He was an attorney who worked with the State Court. The Coroner’s Office was on the 9th floor of the County Courthouse. In 1960, Tom Dillon, MD, originally from Georgia, and a medical examiner in the Boston area, was recruited and returned to Georgia to work in the Fulton County Coroner’s Office as a coroner’s pathologist. Tom Compton himself recognized that the needs of the county were outgrowing the abilities of the coroner system and he not only advocated a switch to the medical examiner system as had occurred in other major cities in the United States, it was basically his idea. Thus, the non-physician coroner advocated change to a medical examiner system. Most assuredly, Dr. Dillon’s experience played a facilitating role. Tom Compton had been critically involved in getting the first facility built for coroner’s operations in 1961, in the renovated basement of the Steiner Building near Grady Hospital. It had been an animal research lab prior to that time.

The Office of Coroner was abolished at the end of Tom Compton’s terms and Dr. Dillon became the first Fulton County Medical Examiner in 1965. Two younger physicians, Dr. Snell, and Dr. Robert Stivers, worked with Dr. Dillon. Dr. Snell was drafted, and Dr. Stivers continued to work there while in medical training. Upon Dr. Dillon’s death, Dr. Stivers became the next Medical Examiner for Fulton County (1970). He served until 1988 when his Associate Medical Examiner, Saleh Zaki, MD, was named Chief Medical Examiner following Dr. Stiver’s retirement. Dr. Zaki served until 1998, when Randy Hanzlick, MD, an Associate who had worked with the office since 1982, was appointed as Chief Medical Examiner.

The facility in the Steiner Building was used until 1974, when the Medical Examiner moved to a new 8800 square feet facility constructed at 50 Coca Cola Place, near Grady Hospital. There it remained until the current 33,000 square feet facility opened in April of 1999. For nearly two decades, the Fulton County Medical Examiner has offered an accredited training program in forensic pathology, in conjunction with Emory University School of Medicine, through which about 30 pathologists have matriculated.

Cobb County (1973). Prior to 1973, the Cobb County Coroner relied upon a local hospital pathologist, Dr. Scherer, to perform autopsies for the county. Dr. Stivers, who was Medical Examiner for Fulton County, eventually provided autopsy services for the coroner, replacing Dr. Scherer. There was no serious opposition to the abolition of the office of coroner and the idea had support of the District Attorney and others. In 1973, Cobb County abolished the Office of Coroner and Dr. Stivers became the Medical Examiner on a contract basis. Subsequently, Dr. Stivers made a choice to concentrate his efforts in Fulton County, and he recruited William Anderson, MD, who had trained in North Carolina, to become the Medical Examiner in Cobb County around 1977. Dr. Joe Burton, who had trained in Miami, was also performing some autopsies for Cobb County. About one year later, in 1978, Dr. Burton acquired the contract to serve as Cobb County Medical Examiner. He remained in that role until February of 1999 when his associate, Dr. Brian Frist, assumed the contract as Chief Medical Examiner. Dr. Frist had gained his forensic pathology experience working with Dr. Burton in the DeKalb County Medical Examiner Office (see below). Originally, autopsies were performed in Kennestone Hospital in Cobb County, but in the mid-1980’s, a free standing medical examiner complex was constructed near the police department in Marietta.

DeKalb County (1981). Dr. Stivers als provided pathology services to the Coroner of DeKalb County. About the same time Dr. Stivers ceased providing services to Cobb County, he did so in DeKalb as well and Dr. Anderson also assumed the pathologist duties for DeKalb County. When Brian Cavan (an attorney) was the coroner, he ultimately spearheaded a move toward a medical examiner system in DeKalb. Dr. Burton had also provided autopsy services for DeKalb and eventually acquired the contract as Chief Medical Examiner. Dr. Burton remained Chief Medical Examiner until March of 2000, at which time Gerald Gowitt, MD, who had trained at Fulton County and become an associate of Dr. Burton, acquired the DeKalb contract as Chief Medical Examiner. Through the years, pathology services were provided to Dr. Burton by Randy Hanzlick (early 1980s), Wayne Ross (who trained at Fulton County and eventually returned to the Northeast, Emily Ward (who later moved to Mississippi), Jan Garavaglia (who later moved to Texas), Gerald Gowitt and Steven Dunton (both of who trained at Fulton County-- Dunton later became Chief Medical Examiner for Gwinnett County; see below); and Brian Frist, who worked with Dr. Burton for several years and later became Chief Medical Examiner in Cobb County as described above. More recently, John Parker has provided regular coverage in DeKalb for Dr. Gowitt, and other local forensic pathologists also provide occasional coverage there. Originally, autopsies were done in a small morgue at the police station and offices were maintained in rented commercial office space. In the late 1990s, DeKalb County constructed and opened a stand alone medical examiner facility with autopsy and office areas.

Gwinnett County (1989). Prior to 1989, the Gwinnett County Coroner was Randy Simpson. Gerald Gowitt had a contract with the coroner to provide forensic pathology services. Prior to that, the coroners (Randy Simpson and earlier, Billy Wages) had used the pathology services of Dr. Tom Orourke and Dr. Dove, respectively. In 1989, the Director of Public Safety, the District Attorney, and local forensic pathologists advocated a move to the medical examiner system which occurred in 1989. At that time, Joe Burton acquired the contract with Gwinnett County to serve as Chief Medical Examiner. He held the contract until May of 1999 when Steven Dunton (who trained at Fulton County and had worked as an associate of Dr. Burton) assumed the contract as Chief Medical Examiner. Autopsies are performed in an autopsy facility in the county police department complex, which was constructed with federal grant funds in the 1970s.

Clayton County (2001). The Coroner serving in Clayton County prior to 2001 was indicted for alleged financial improprieties. In 2001, the state legislature approved the abolishment of the Office of Coroner in Clayton County. However, the County is still in the process of making plans for its medical examiner system and, in the meantime, is using the DOFS medical examiner system to perform its autopsies. At present, Clayton County does not have its own autopsy facility.

Hybrid systems
For a good number of years, several county coroners have specifically contracted with forensic pathologists to provide autopsy services instead of using the GBI DOFS medical examiner system. These include Hall, White, Henry, Rockdale, and Paulding counties. Each of these is within an hour’s drive from downtown Atlanta. For the most part, the pathologists providing these services are those who work (or have worked) in the DeKalb County medical examiner system or other local forensic pathologists who provide part time services or coverage in these counties.

Georgia, in General
The State of Georgia includes 159 counties of 58,909 square miles of which 853 square miles is water. The Southeast corner of the state abuts the Atlantic Ocean. Roughly, Georgia is about 300 miles tall and 200 miles wide on average, with longest intrastate distance being about 350 miles from the northwest to southeast extremes. Atlanta is about 100 miles from Tennessee to the North, 50-75 miles from Alabama on the West, 125-150 miles from South Carolina on the East, and 225 miles from the Southern border of the State with Florida. Atlanta is the only major city east of the Mississippi that is not on a major body of water, and is about 1000 feet above sea level. Brasstown Bald, the highest point in Georgia in the North Georgia Mountains, is 4784 feet above sea level. A line drawn from the Northeast to the Southwest corner of the state parallels closely the Appalachian Mountains and most areas to the west of the line are hilly to mountainous. The Middle part of Georgia has rolling hills and the Southeast part of the state is low land.

The year 2000 population was 8,186,453 which is 65% white, 29% black or African American, and about 5% other races. About 5% is of Hispanic or Latino ethnicity. There are, on average, 139 people per square mile.

In 1998, mortality data for Georgia were as follows: Homicides 663; Suicides 823; Motor Vehicle Fatalities 1616; other non-natural deaths 1581; total deaths 60,262; total non-natural deaths 4,683.

Closing Comments
Over the years, the medical examiner services in Georgia have been provided by non-pathologists, hospital-based pathologists, non-boarded forensic pathologists, and board certified forensic pathologists—with a trend evolving toward the latter. The existence of two forensic pathology training programs in Georgia will surely maintain and facilitate that trend. One can reasonably state that, as far as professional death investigation services are concerned, most major advancements from the physician and medical viewpoints in Georgia have occurred in the past 10-15 years.

Coroners in Georgia do have a Georgia Coroners Association. Coroner training is conducted at the Georgia Public Safety Training Center in Forsyth, Georgia, and is organized by the Georgia Coroner’s Training Council. The medical examiners and their affiliated investigators do not have a formal organization or association in Georgia. Development of such an organization (s) may be worthwhile, if not advisable.

The author wishes to thank Terry Mills of the GBI DOFS for providing historical documentation (“History of the GBI”), John Cross, JD of the Fulton County Medical Examiner’s Office for conducting statute and historical research , Joe Burton,MD and Gerry Gowitt,MD for recounting the events concerning County Medical Examiner systems in Cobb, DeKalb, and Gwinnett counties, Wallace Vaughn for his excellent memory of events and people from the 1960s, and Kris Sperry, MD for his continual insights into Georgia death investigation in his role as Chief Medical Examiner. Some information was also derived from a Supplemental Brief for Respondent, Case 35714, in the Supreme Court of Georgia, and regarding the role and functions of the coroner on the basis of common and state law.

Changes since 2002

Since 2002, because of state budget shortfalls, pathologists no longer staffed the Summerville and Moultrie DOS labs with Dr. Oliver moving to Greenville, NC in 2009 and Tony Clark moving to Tallahassee Florida in 2008. In 2002, Daniel Brown, MD, was hired to work at the DOFS lab in Augusta, Lora Darrisaw was hired to work in the Decatur DOFS lab, and Jamie Downs was hired to work in the Savannah DOFS lab. In 2004, Eric Eason (an FCME Forensic Pathology Program graduate) was hired to work in the Decatur lab. Dr. Douglas Posey was hired to work in the DOFS lab in Decatur in 2005 and Jonathan Eisenstat joined the staff there in 2006. Edmund Donoghue, former Chief Medical Examiner in Chicago/Cook County was hired in 2007 to work with Dr. Downs in Savannah. In 2008, FCME forensic pathology program graduate Steve Atkinson was also hired to work in the Decatur DOFS lab, as was FCME graduate Stacey Tate in 2009. Thus, FCME has provided three of nine the forensic pathologists hired by GBI since 2002.

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Fulton County Medical Examiner

430 Pryor Street SW
Atlanta, Georgia 30312
Phone: 404-613-4400
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