Last Responders: The Role of Deathcare Systems during COVID-19

By Staci Zavattaro

Deathcare in the United States is a complex mix of organizational systems. According to the Centers for Disease Control and Prevention (CDC), some states have county-based systems with medical examiners and coroners, some states have district-based medical examiner systems, and still others have state-based agencies. Each jurisdiction has its own rules and regulations regarding who can hold the office, who can handle decedents, and who reports where within an organizational hierarchy. For example, in Ohio, the elected coroner must also be a medical doctor, whereas in New York, an elected coroner does not need a medical degree but then a coroner physician will be appointed to assist as deputy coroner.

While the healthcare infrastructure across the country received significant attention as a result of the COVID-19 pandemic—and rightly so—much less focus has been given to the deathcare infrastructure. This blog post focuses on the role medical examiners and coroners played during the ongoing COVID-19 pandemic: frontline public servants who were called in to handle a massive number of excess deaths while also dealing with regular office operations.

The pandemic not only created new challenges for already strained healthcare systems but exposed and exacerbated new ones; the same is true for the country’s deathcare systems. According to CDC data, more than 1,131,521 deaths in the US have been attributed to the virus, and data compiled by Johns Hopkins University shows that New York State experienced more than 77,000 pandemic-related deaths over the three-year duration of the pandemic (March 2020 to March 2023).1 In New York City, one study found mortality rates seven times the baseline norm.

Along with powerful positive images of resilience—New York City residents seen banging pots and pans on balconies supporting healthcare workers, for example—horrifying images also surfaced, such as mass grave digging and burials on the city’s Hart Island, a potter’s field where unclaimed individuals are sent for burial. An estimate from 2021 shows more than 2,330 decedents sent to Hart Island from COVID-19-related deaths, approximately 75 percent more than the number of decedents sent there who died during the AIDS crisis. Death is always difficult, yet the COVID-19 pandemic brought loss to the forefront of people’s lives. Social distancing restrictions made visiting loved ones impossible, and funerals had to be curtailed given the ban on large gatherings. Sometimes it feels as if these deaths were dehumanized, though the lives lost and those still suffering should not be forgotten.

Deaths from other causes—such as overdoses, traffic accidents, homicide, and suicide—did not stop during the pandemic. In fact, many of these causes saw increases driven by the pandemic. A recent study by the Rockefeller Institute, for example, showed that in 2020, overdose deaths increased by 30 percent over the previous year, reaching an all-time high. The CDC identified specific COVID-19-related links to the increase in opioid deaths—physical and mental challenges associated with the pandemic, along with inability to intervene to provide care.

The COVID-19 pandemic quickly turned into a mass fatality management situation that overwhelmed existing capacities and capabilities.

I interviewed 18 medical examiners and coroners across the United States.2 States represented include Florida, Ohio, New York, Washington, Connecticut, Arizona, Louisiana, Nevada, Illinois, Indiana, Wyoming, and Michigan. Jurisdictions included a regional office serving nine counties, statewide medical examiners, and coroners serving large and small counties. I focus here on the public sector rather than private (funeral homes, private hospitals, private nursing facilities, etc.) because policymakers can directly influence how these professionals are treated and resourced and can enact policies designed to mitigate many of the challenges that exist. The responses given in these interviews reflected three key categories of challenges that cut across states and jurisdictional scopes: capacity, technology, and support.

Capacity Challenges

A key capacity challenge facing the deathcare sector is a shortage of forensic pathologists. Each state has its own rules and regulations regarding who can be a medical examiner or coroner (ME/C), and while in many instances a coroner is elected to their position and need not have medical training (sometimes even a justice of the peace can serve as a coroner), a medical examiner typically is appointed and is trained as a forensic pathologist, a medical doctor trained to intersect that expertise with the law.

According to data from the Bureau of Justice Statistics, ME/C offices throughout the US employ about 10,930 full-time equivalent personnel, with more than half of those belonging to coroners’ offices. Death investigators are the most common employee type, making up 38 percent of the workforce in these offices. There are 890 forensic pathologists working in ME/C offices, but there are 2,210 nonphysician coroners serving much of the US population. Personnel in these offices vary widely based on available resources.

A core problem is lack of forensic pathology training in medical schools, meaning medical students do not get exposure to this field and thus few see it as a viable professional path after school. Autopsies can be vital to the medicolegal death investigation process, though their popularity might be waning given some of the capacity challenges facing these professionals. Autopsy decisions are dictated by law in each jurisdiction, and though sometimes the procedure is difficult, studies have found digital or technology-driven advances do not often yield the same result as a traditional autopsy. Additional capacity challenges include: forensic pathology fellowships are becoming rarer, medical students are not always exposed to an autopsy, hospital autopsies are declining, and funding for autopsies is decreasing. A report from the National Institute of Justice identified further pipeline challenges, including availability of pathology internships/fellowships, lower pay compared to other medical professions, and an increased caseload without resource and personnel allocation. During the ongoing COVID-19 pandemic, this forensic pathologist shortage was keenly felt, as ME/C offices were taking in more decedents without proper staffing resources, often causing significant backlogs.

One medical examiner in a large Florida county explained in their interview that once the governor of the state declared a state of emergency related to the pandemic, it triggered a provision that the state’s medical examiners had to certify all emergency-related deaths:

When the governor declared a state of emergency with COVID, we didn’t realize how exponentially it would grow. We had to bring in cases, bring in records and confirm everything when the clinician already knew all the answers.

This meant they had to wait for records, go over the medical records to certify the death certificate, report the findings to the Department of Health, and then return the records. For this office, that amounted to about 600 cases between March and August 2020 where they needed to review records. (For context, in January 2020, the ME’s office handled 171 deaths.) “I did them all because I figured it was just paper review, and I can save the doctors the hassle of having to do this until I realized it wasn’t just reviewing them.”

The problem pattern repeated throughout the country in strained ME/C offices. Backlogs during the pandemic meant families could not carry out burial or cremation arrangements for decedents, and funeral homes remained overwhelmed with increasing workloads. In the pandemic’s early months, testing kits were in short supply, and without those kits, cadavers would pile up while awaiting either kits or private testing facilities. The CDC issued changing recommendations about what decedents to test and how to test them as more became known about the virus in its early days. Eventually, in Florida, the medical examiners banded together and the state’s Medical Examiners Commission changed the aforementioned rule related to emergency declarations requiring medical examiner certification of pandemic-related deaths related to the declared state of emergency.

This foreshadowed a second capacity challenge: human and testing resources to properly count COVID-19 deaths. As the pandemic continued to ravage communities, counting virus-related deaths became challenging. According to one study, global COVID-19 mortality estimates are not accurate because some countries had better access to testing than others; healthcare systems vary widely among countries and even within countries; and comorbidities either changed or were not collected on death certificates. Hospital physicians were overwhelmed, so some death certificates were improperly completed, thus affecting public health data and tracking.

Many ME/Cs are public health agents, and it is critical for them to be able to gather complete relevant data from decedents and use that information to then improve conditions for the living.

One challenge became knowing if someone died from COVID-19 or with COVID-19. As the same Florida medical examiner explained: “Are we trying to figure out if people are dying with COVID or of COVID? So, if someone was shot, I don’t really care if they have COVID. In the beginning, tests were in short supply, so you don’t want to waste tests on people you don’t have to. If [there were] no COVID symptoms before death, we didn’t waste a test on them.”

A coroner in Louisiana explained their office used the following criteria when determining if a person would be counted as a COVID-19 death: the person had to have a reported respiratory illness before passing, confirmed via testing, and had to have died from the respiratory illness. “So, for example, if you have one and two but die in a car wreck, it’s not a COVID death,” they explained.

A third capacity challenge highlighted by the excess deaths was regarded as basic physical infrastructure: morgue storage capacity. New York City was the pandemic’s epicenter during the early outbreak in 2020, and many patients received treatment in the state’s public hospitals. As hospitals and medical facilities became overwhelmed, additional storage capacity was needed to house decedents safely. Temporary refrigeration units were set up throughout the state to meet increased demand—a pattern that repeated throughout the United States.

A coroner in Nevada said their office learned from watching New York City respond to the pandemic, especially concerning morgue storage capacity. They said: “We’ve done training with them for 15 years because I think they’re probably the best agency in the country when it comes to mass fatality response and preparedness.” Once New York City officials began obtaining additional cold storage, they said their office in Nevada followed suit, trying to find places to rent refrigeration trucks, which were in short supply. “Although it may not be your statutory responsibility to manage the surge of decedents, if bodies start piling up, whoever governs your agency is going to start calling on you to help. I mean, who else is going to handle it?”

The Greater New York Hospital Association (GNYHA) released its top lessons learned regarding fatality management in its public hospitals after the pandemic’s worst had ebbed. According to the report, New York City hospitals have fixed morgue space for about 15 decedents each for a total of approximately 800 fixed spaces throughout the city’s public hospitals. Body Collection Points—portable morgue storage space—increased that capacity, with most trailers able to hold 40 to 45 decedents without shelving or 80 to 100 with shelving units. However, the number of decedents proved to be about 800 per day, easily overwhelming even these supplemental portable units.

The COVID-19 pandemic quickly turned into a mass fatality management situation that overwhelmed existing capacities and capabilities. Recognizing the compounding capacity challenges to the deathcare sector exposed by the pandemic, the GNYHA recommended updating morgue staffing plans and capacity, creating or expanding an interdepartmental fatality management team, maintaining long-term storage capacity, and codifying abridged paperwork process to allow for quicker processing.

Technology Challenges

The pandemic also exposed and exacerbated already-struggling technological systems that were not integrated and are not easy to integrate among healthcare and deathcare providers. Having accurate clinical data and health information is vital to a robust public health program, and tracking the spread of disease is a key component of that effort. Many ME/Cs are public health agents, and it is critical for them to be able to gather complete relevant data from decedents and use that information to then improve conditions for the living.

A core problem is that jurisdictions use different computer systems to keep track of vital records and statistics, and oftentimes those systems do not speak to each other, causing a gap in our understanding of vital health information. In Florida, for example, three different agencies were responsible for collecting and aggregating COVID-19-related data, and much of that data came from other entities handling the pandemic, such as counties and hospitals. According to an Auditor General report, data from March 1–October 8, 2020, were not accurate across platforms, and people in charge had to manually match cases across systems. Because of mismatches across the systems and challenges regarding how COVID-19 deaths were classified on a national level, this meant data shared on public dashboards related to COVID-19 was not accurate.

A challenge in accurately tracking and counting COVID-19-related deaths was the scope of the spread. While some patients died in hospitals or under the care of physicians, many did not die under a physician’s care, so records reporting often was not complete, consistent, or accurate. According to one study, people without insurance or access to reliable medical care sometimes did not seek treatment and died. Because they did not have access to healthcare and treatment, they may have not received a COVID-19 diagnosis and, as a result, cause of death may not have been accurately identified. If someone did not have access to healthcare, it often also meant they did not have access to COVID-19 testing and treatment early in the pandemic. If someone died while not under a doctor’s care, the death certificate might not indicate the virus as an underlying cause of death, leaving public health statistics lacking.

Without clear national guidance on what decedents to swab or any underlying cause of death, the person might have died from virus-related complications but may not have been tested, reducing the chances of a valid cause of death finding and reporting. In New York, for instance, former Governor Andrew Cuomo came under pressure for inaccurately reporting death-related data to the public, only disclosing lab-confirmed cases and excluding people who might have died while not under a doctor’s care. Reporting to the CDC, then, was also incorrect, giving at best a fuzzy picture of the virus’s impact.

Indeed, a report from the New York State comptroller found that information technology challenges plagued New York City and the state. The report indicated that poor funding pre-pandemic for information technology was a factor in inaccurate data collection, tracking, and sharing—even before a decision was made to report inaccurate nursing home death counts. Moreover, the report reflected that there were three different systems for collecting data and poor analysis of the data when it comes to public health tracking. New York’s lack of investment in the development of proper systems, staffing, and training to collect, analyze, and share health data was mirrored elsewhere in the country, too.

A medical examiner facility manager in Minnesota explained they were thrust into the role of collecting and sharing pandemic-related data with other agencies. They told a story of the pandemic’s early days when there was little guidance on how, if, and when to test decedents. The office created a form pathologists and investigators could use so COVID-19 could be an option on the checklist of causes being reported—it did not exist as an option before, of course. The form was also then used to track swab samples, which were then sent to a county health facility before being driven to a state testing lab. The entire process was newly created in response to the demands of the virus outbreak.

The manager explained: “I had to report every negative and every positive to every funeral home, every family, and all the positives I had to also report them to the county health department. I had to input every single case into the Minnesota disease surveillance system whether positive or negative. I never used it and had to learn it.” They also had to train their team on how to use the form to maintain proper chain of custody over the samples related to COVID-19 swabs done on decedents, and made training videos given that the investigative team is more than 70 people. “We didn’t have any other option than of teaching every single one of them, given that the form did not exist before COVID-19. The manager had to create a whole new process from scratch to handle the pandemic’s effects on the office.”

This interviewee’s experience highlights the ways information technology is vital in death investigations and public health spaces. The manager for the medical examiner’s office had to create a form, ensure it was used properly (subject to human error), create videos for widespread training, gather and report accurate information, and interface with state and county agencies to share data. Every piece of this system and process had to be newly created.

The pandemic also exposed and exacerbated already-struggling technological systems that were not integrated and are not easy to integrate among healthcare and deathcare providers.

Mental Health and Other Support Challenges

Often called “last responders,” ME/C public servants deal with among the most traumatic situations, yet they are often left out of the discourse about the need for mental health support services in dealing with the human costs of the pandemic.

In the pandemic’s early days, there was little known about how the virus was spread and transmitted. For some medical examiner and coroner offices, procedures did not change much because they already treat every decedent as a risk to their own health. Personal protective equipment is a fixture in ME/C offices, yet some autopsy pathologists reported having to change some procedures to reduce the potential spread of airborne particles. For first—and last—responders, the pandemic exacerbated mental health challenges because of the unknowns associated with transmission of the virus and repeated exposure to individuals potentially infected with COVID-19.

New York Health + Hospitals launched a mental health program for its staff in 2020, and there was a marked effort to support paramedics and EMS workers responding to the pandemic’s onslaught. Yet little additional focus was given to providing care for death responders. A path forward for some ME/C offices might be hard to find when there is still a stigma associated with receiving mental health support, yet ME/Cs deal with traumatic events each day, and clearly more so in the wake of a public health crisis.

One coroner in a Washington county described the job this way: “It’s a mentally challenging job. We’re dealing with things here every day that most people may experience once in their lives, maybe twice, and the folks that work here are dealing with it four and five times a day.” They are a certified peer counselor, and their office contracts with a trauma-informed psychologist who specializes in first responder crisis response. “[Staff] have the ability to reach out on their own to contact [the psychologist]. She will do initial counseling and then if they need more follow-up, she has resources to send to specialized help.”

Before the pandemic, medical examiners and coroners reported feeling stress and burnout in their roles. A meta-analysis of studies about medicolegal death investigator workplace hazards found commonly identified challenges: constant exposure to dangerous situations (crime scenes, autopsies, for example); long hours without proper resource support; chemical and biological agent exposure; and continued emotional trauma and secondary trauma reliving experiences. One study with responses from 211 ME/C personnel indicates that while most respondents felt happy and satisfied in their roles, stress resulted mainly from interacting with families, as well as direct and indirect exposure to remains and crime scene information. The study authors indicate the findings are idiosyncratic and depend upon the individual—mental health and coping is often an individual exercise.

More research is needed to examine pandemic-related burnout and stress among this community, but one medical examiner in a large Arizona county said they hope the pandemic is finally going to shift the conversation toward proactive mental health strategies for their deathcare peers. “You think you’re not going to get exposed to trauma in our field is like saying you’re going to go swimming and not get wet. So, do we teach you to swim in a healthy way or do we use the old ‘you can either do it or you can’t’?” As a leader in their office, they have integrated mental health into the unit’s standard operating procedures and made it as important as any other part of safety culture such as preventing slips and falls. New employees sign a values pledge and are onboarded into an overall culture of wellness. “We onboard people who look at [the pledge] and go yea, that’s how I want to operate, and I want to work for an organization that does that.” Their office also has peer support and a quiet room on the premises for staff to use during business hours. “It’s nice that we’re no longer trying to kind of pretend it’s not challenging work.”

Policy Options to Address Challenges

To mitigate, if not overcome, some of the significant challenges highlighted here, policymakers could consider several actions:

  • To stimulate proper levels of capacity, additional funding could be invested to develop a greater number of forensic pathologists on staff, or to create a pool of funds able to be tapped for access to forensic pathologists on a contractual basis. (For example, Maricopa County, Arizona, launched a loan repayment plan to recruit qualified forensic pathologists.)
  • Ensure ME/C offices at all levels are fully staffed, expanding as needed. One report from the National Institute of Justice indicates that specific need is based on a jurisdiction’s size, population, total number of deaths, and statutory requirements surrounding medicolegal death investigation.
  • Invest in records management integration within state and local deathcare agencies, and ensure compatibility and communication with other public health data systems. A process to ensure that such technology is kept current and staff are trained in its use also could be developed. The Forensic Technology Center for Excellence offers guidance on facility design and technology needs.
  • Expand mental health offerings for employees in the public deathcare sector, focusing on trauma-informed care. Experts specializing in such services for first responders could be expanded to provide similar services for ME/Cs. One example is the Nevada Peer Support Network focusing on first and last responders, while another model is First Responder Trauma Services. Additionally, ME/C leadership can integrate access to mental health resources into standard operating procedures as indicated in the examples above.

The resource constraints in ME/C offices need to be better understood at all levels of government. Better interaction between policymakers and public deathcare agents would go a long way to finding out and better knowing what medical examiners and coroners do and need.


Staci Zavattaro is a Richard P. Nathan Public Policy fellow at the Rockefeller Institute of Government and a professor of public administration and a research associate with the Center for Public and Nonprofit Management at the University of Central Florida

[1] In the first year of the pandemic (2020), the New York State Department of Health cites 36,337 as the total number of deaths caused by COVID-19 statewide, the second leading cause of death that year; for New York City alone, the number of COVID-19-caused deaths was 21,948, the city’s leading cause of death that year and more than 60 percent of the statewide annual total.
[2] Some identifying details of interviewees have been changed to protect the privacy of individuals.