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Coroners' inconsistent reports muddle efforts to understand shooting deaths


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By Katharina Buchholz and April Nowicki
CU News Corps

Note: A version of this story ran in the Colorado Springs Gazette on Aug. 23, 2014.

In 2013, at least 547 people were killed from gunshot wounds in Colorado.

Last year, a 1-year-old toddler was shot and killed by her 22-year-old father after he had an argument with the girl’s mother in Westminster. A 12-year-old boy got his hands on a gun and used it to take his own life during a family vacation. A 67-year-old man killed his 81-year-old wife and then shot himself with a rifle in Delta county on the Western Slope.

CU News Corps reporters found these details among hundreds of public records kept by county coroners. The records provided valuable context to the total number of gun deaths, and could help shape a better understanding of why so many people die every year from gunshot wounds.

In January 2013, a group of University of Colorado journalism students began collecting records for every gun death in Colorado for the years 2012 and 2013. The idea was to collect and publish more data than what the state makes available to inform the discussion on gun policy in Colorado. During the project, inspired by Homicide Watch D.C., CU News Corps reporters learned the following:

  • A non-standardized process for requesting public coroners’ records makes accessing complete public information about the state’s gun deaths extraordinarily time-consuming.
  • Custodians of the information sometimes do not understand their obligations.
  • Data provided by county coroners often contain information that is not made available by the state — information that provides important context to the hundreds of gun deaths that occur each year.

The state keeps annual numbers on every death, including age, race, gender and cause of death, provided by the state’s 63 county coroners. State data goes back more than 30 years, and shows that the majority of gun deaths are suicides. But the state provides only numbers with few details and no history.

Getting hold of coroner’s records for 2012 and 2013 — the only public records that would contain the extra context — took nearly 18 months. When CU News Corps reporters analyzed all the reports, they noted that coroners’ reports look different in almost every county and they do not all contain the same information.

The Archuleta and Larimer County coroners did not provide ethnicity in any reports. Park, Logan and Conejos Counties sent some reports indicating ethnicity of the deceased, and some reports without. Eagle County does not record ethnicity in their reports.

Some coroners questioned the standard practice of autopsy reports being public record in Colorado. However, none sought out proper legal channels to be exempt from providing their records to CU News Corps.

Other coroners gave reporters information that the reporters legally were not supposed to have, such as death certificates, which are not public record.

Getting the information

Many larger counties were familiar with providing the records as public information. El Paso County recorded consistent data about each death, and provided them promptly.  Jefferson County sent bi-monthly reports without being reminded. Denver County was especially cooperative and sent lists in chronological order. Douglas County also sent reports unasked after the initial request.

But not all county coroners were willing to hand over their records. After about six months of trying to obtain the records needed to compile the CU News Corps database, more than a third of the counties were identified as deficient in responding. Nine counties took more than three months to reply to requests despite being contacted repeatedly.

One county coroner, Charles Downing of Mineral County, failed to reply because he moved to Arizona temporarily. CU News Corps was informed by the county’s sheriff’s office.

Another coroner, Carlette Brocious of Fremont County, did not provide data for 2013. Brocious agreed twice to send information, but she never followed through. CU News Corps members called her 12 times, but still have not received 2013 information for Fremont County.

CU News Corps reporters called the coroner in Conejos County eight times, and sent two paper mailed requests citing the Colorado Open Records Act. After three and a half months, two reports of deaths in Conejos County were received — one additional gun death was a homicide that was not provided to us because of an ongoing police investigation.

Four emails, three phone calls and two snail-mail CORA requests went to Eagle County, where the office phone does not have voicemail capability. It took almost six months to obtain the reports for six gun deaths that occurred in Eagle County.

Some coroners did not answer phone calls or emails. Others provided some information but were hesitant to send details such as names, which are public record, and locations, which are not public record but were necessary to avoid duplicating the deceased, in the cases of missing names.

Because there is no standard way of requesting coroner records in Colorado, CU News Corps had to comply with multiple different policies imposed by the coroners’ offices themselves. Reporters requested copies of autopsy reports by mail, fax, email and over the phone.

Some coroners said reports had to be requested by the name of the deceased, which was nearly impossible to comply with for many deaths that were not reported in the news or in any other identifiable way. Some coroners were combative over the phone — Montrose County coroner Thomas Canfield told one CU News Corps reporter to “figure it out” when asked how to obtain this public information.

State records on gun deaths are compiled from non-public death certificates in an internal process. The state records therefore don’t encounter many of these problems, but also provide less detailed information.

“Statistics are based on death certificate data, which are completed and reported to the state independent of completion of coroners’ reports,” said Kirk Bol from the Vital Statistics Unit of the Colorado Department of Public Health and Environment in an email. “There are instances where a death certificate is filed with a ‘pending’ cause of death or intent; however, these are typically followed (eventually) by an amended death certificate in which the cause and/or intent is specified.”

If a coroner’s death record is not released to the public in the case of a legal investigation or another circumstance, basic information is still provided to compile state statistics. CU News Corps reporters estimate that at least 20 records were not provided during their research because of circumstances such as these.

Pieces missing

One of the goals of the project was to remember and memorialize each person and the circumstances surrounding their deaths, many of which were horrible, tragic events.

At least 28 men killed themselves after experiencing marital and relationship problems. One man shot himself in the head after he had an argument with his girlfriend. He approached her and said, “Watch this,” before taking his life, according to the coroner report. Not all coroners record circumstances of deaths in the same detailed manner.

Seventy-five percent of the deaths were suicides, with white males being the largest group among the deceased.

CU News Corps reporters found that about 130 reports included toxicology test results, showing that many of the deceased were under the influences of alcohol, marijuana, ecstasy, meth and other drugs.

The reporters combed through each record individually, searching for trends and learning more about the effects depression can have — dozens of records stated that the individual was depressed or had recently expressed suicidal ideations after events such as being out of work. One man killed himself the same day his dog was euthanized.

Some records contained information provided by family and friends of the deceased, which the coroner could sometimes use to provide context around each event, but many did not. One 26-year-old died from an intraoral gunshot wound, but no gun was found at the scene. The coroner ruled the case an “undetermined” cause of death, but Colorado Springs police closed the case, calling a suicide. The firearm was never found, but the case was reopened in July 2014 with new evidence.

Consistency is key

Statistics are only numbers, but each gun death comes with dozens of details that could help citizens understand how guns affect society. Obtaining that context is impossible without a standardized process.

Colorado coroners do not all consider journalistic research a valuable use of their records. Some even seemed misinformed about their duties as record-keepers of the state.

Ouray County coroner Colleen Hollenbeck said in an email that it is the “statute” for coroners to provide reports only if they are requested by the deceased name. But the Colorado Open Records Act does not state anything to this effect — only that coroners’ autopsy reports are “public records open to inspection.”

Another coroner, Frank Vader from Gunnison County, refused to provide the names of the deceased.

“I cannot reveal names for 50 years per state law,” Vader wrote in an email to a CU News Corps reporter.

It was unclear where this timeframe came from, and since coroner’s records include names of victims, Vader’s statement is wholly inaccurate.

Unless coroners improve transparency and consistency in record keeping, important insights in the dynamics of gun deaths in the state will remain hidden. According to the American Foundation for Suicide Prevention, Colorado’s suicide rate was the eighth highest in the nation in 2010, with gun suicide being the most common form of suicide. Understanding gun deaths better could save lives in Colorado.

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Explanatory Multimedia Reporting from CU Boulder Journalism Students
Coroners' inconsistent reports muddle efforts to understand shooting deaths