What Is a Coroner’s Inquest?

Many questions have been raised in the drowning death of Iowa's Brandon Ellingson, while he was in the custody of the Missouri Highway Patrol on Lake of the Ozarks.  Most recently, news agencies across the state reported on the "verdict" of the recent coroner's inquest.  Some agencies reported it correctly, while others were less responsible, reporting the story in ways that made it appear that law enforcement was somehow absolved of any liability as a result of the coroner's inquest.  One example can be found in Des Moines television station KCCI's headline: "Jury makes decision on charges in handcuffed Iowan's drowning."  The manner with which the coroner's inquest was reported across our state lead us at GRL Law to ask: What exactly is a coroner's inquest and what if anything is significant about the "verdict" that was handed down in Brandon's case?

The "verdict" that was handed down on September 4th at the Morgan County Justice Center was NOT that of a grand jury (determines whether charges are filed), criminal jury (determines whether charged individual is guilty or not guilty), or even civil jury (determines whether party to law suit is legally responsible for money damages).  Rather, it was simply one of a coroner's inquest.  Missouri has a peculiar law whereby in certain circumstances, the county coroner may impanel a jury to make a determination of manner of death for him.  Under Missouri law, a coroner way issue a warrant to summon what is referred to as a "coroner's jury" in situations where the coroner has been notified of a dead body of "any person, supposed to have come to his or her death by violence or casualty."  Vernon's Annotated Missouri Statutes, 58.260.  In these situations, a jury of "six good and lawful citizens of the county" are required to appear before the coroner, to inquire how and by whom the person came to his or her death.  Once the jurors are sworn, the coroner then gives them the charge to ultimately determine the manner of death.  Evidence is presented and the jury makes the determination of the manner of death which is ultimately certified on the decedent's death certificate for statistical purposes.

There are only four possible "manners of death" to be assigned by a coroner or medical examiner.  They are: Natural, Homicide, Accidental, Suicide.  "Natural" is generally described as when the body ceases to function of its own accord or when there are medical factors such as terminal illness, heart disease or similar conditions in one's body which bring about the death.  "Homicide" is generally described as the intentional taking of one human life by another human by way of a purposeful and planned action meant to end the deceased's life.  "Suicide" is generally the deliberate taking of one's own life.  "Accident" is generally when a death occurs other than natural, murder or suicide.

The result of the coroner's inquest into Brandon's death was the conclusion that his death should be categorized on his death certificate as "accidental."  That is ALL the "verdict" means.  Nothing more, nothing less. He did not die of natural causes; nobody intentionally killed him; and he did not kill himself.  The result of the coroner's inquest does not mean that law enforcement was not to blame or that they did not do anything wrong.  In fact, it appears from reports of the Trooper's testimony that they admitted they were not properly trained and did not take appropriate measures to ensure his safety while being transported in the boat.  This may very well still give rise to legal liability but it is important to understand that the results of the coroner's inquest should not be read as determining anything other than legal manner of death.