by Audrey Dutton

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Idaho has known for at least 73 years that its frontier-era coroner system does not work. For just as long, the state has failed to make meaningful changes to it.

In a review of legislative records and news archives going back to 1951, ProPublica found a pattern — repeating almost every decade — of reform-minded legislators, trade groups, members of the public, doctors, lawyers and even some coroners pushing to change how Idaho handles death investigations.

ProPublica reported last month how a coroner in eastern Idaho didn’t follow national standards to figure out why 2-month-old Onyxx Cooley died in his sleep last winter. As the coroner would later tell ProPublica, Idaho law says nothing about following any standards. The law provides no oversight, no state medical examiner and no other resources to ensure each county has adequate access to autopsies.

Almost unchanged since the late 1800s, the law does little more than say Idaho’s coroners are responsible for explaining the state’s most inexplicable deaths.

But for decades, it’s been well known that Idaho’s patchwork of 44 coroner’s offices leaves grief-stricken parents without answers in their children’s deaths; creates disparities in coroners’ investigations based on where a person dies; and may even allow murderers to escape prosecution.

“The system needs a complete reform, as a whole,” Dotti Owens, former Ada County coroner, told ProPublica this year.

In the death of Onyxx, the coroner decided not to order an autopsy for the infant, go to the scene or talk with the family. Instead, he deferred to an emergency room doctor’s diagnosis of sudden infant death syndrome, or SIDS. Frustrated detectives called a neighboring county’s coroner to see if he could intervene.

In an interview with ProPublica last month, the coroner, Rick Taylor, defended how he handled the death, saying he talked with doctors and police on the scene and looked at Onyxx’s medical records. “We did basically what I call a ‘paperwork autopsy,’” he said.

Onyxx died weeks before a state agency issued a report to........

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