The way the Adams County Coroner is running his office could be dead wrong

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On a quiet Sunday morning last February, Jaime Brown arrived at that dark and unthinkable place every young mother dreads. She walked into the room of her three-year-old daughter, Abigail Holland Brown, and found her face-down on her bed. Her skin was cold and blue.

There was no breath, no heartbeat. Abby was gone.

Aurora paramedics and police responded within minutes, but there was nothing that could be done. Abby had a rare genetic disorder that made her prone to grand mal seizures. She'd been hospitalized several times in her short life and put on various medications. In the fall of 2008, Jaime had moved from Durango to Aurora so that Abby could be closely monitored at Children's Hospital. The doctors told Jaime there were fewer than two dozen known cases of girls with her daughter's condition, in which certain chromosomes were either missing or mutated, resulting in developmental delay. At three, Abby's motor skills and vocabulary were those of an eighteen-month-old child.


Adams County Coroner's Office

Yet none of this made the death any less shocking or bewildering to her 25-year-old mother. Abby hadn't had a seizure for four months, and lately she seemed to be making a lot more progress. The day before, on Valentine's Day, she'd visited with friends and had a wonderful time. "When I put her to bed, she was fine," Jaime says. "I went and checked on her, and she was sleeping away just fine."

A bite mark on Abby's lip suggested that there had been a final, massive seizure during the night. But Jaime wanted to be sure. She pressed the police and an investigator from the Adams County Coroner's Office who arrived on the scene that morning. "I asked them if they were going to do an autopsy, because it made no sense to me why she died," she recalls. "They told me that they were."

Jaime had a particularly urgent reason for seeking an autopsy: Abby has a younger sister, Annabelle, now almost two, who shares the same genetic abnormality. Jaime and the doctors at Children's wanted to know more about how Abby died — was it a seizure? heart trouble? a problem with her medication? — because they might learn something that could help in her sister's treatment.

Several days after Abby's death, Jaime received a distressing call from her daughter's neurologist, Carter Wray. Someone from the coroner's office had asked him to sign the death certificate, Wray said. He'd refused, insisting that he couldn't know if she'd suffered a fatal seizure without an autopsy to rule out other causes. But Adams County wasn't planning to do an autopsy after all. The official review of medical records and witness statements had provided no evidence that Abby's demise was anything but a natural death — no signs of abuse, an accident or other factors. The coroner wasn't inclined to probe further in such circumstances, Wray learned.

Adams County Coroner James Hibbard defends his decision in the Brown case. "The county isn't in the business of paying for private autopsies," he says. "I told the doctor we were satisfied with our scene investigation and what we saw in the records. Why would Children's Hospital want my office to conduct a $2,500 autopsy on a child they'd been seeing and tracking on a regular basis? They wanted a free autopsy."

Jaime Brown disputes this. She says the hospital offered to pay for the autopsy and that she authorized the release of her daughter's body to the hospital when it became clear that Adams County wasn't going to investigate further. But instead, for reasons that remain unclear, the body was released to a funeral home. By the time Children's was able to retrieve it and schedule an autopsy, the body had already been embalmed — making efforts to gauge Abby's medication levels and certain other tests useless. The death certificate, signed by a pathologist at the University of Colorado Health Sciences Center, lists her immediate cause of death as brain swelling as a result of a seizure disorder.

Coroners frequently make tough calls about how far to carry a death investigation. Other budget-minded coroners, confronted with similar evidence of an unexpected but natural death, might well have taken the same position that Hibbard did, while still others might consider the medical mystery involved a greater priority. Brown says she understands the county's refusal to autopsy, but she believes the miscommunication and delays surrounding that decision cost an opportunity to help her other daughter.

"That's fine if they don't want to pay for it," she says. "But they just sat there. If they had done their job in a timely way, I think there would have been a different outcome."

In the forensic cop shows on television, including CSI and its many spinoffs, a cadre of highly trained professionals demonstrates on a weekly basis how easy it is to catch crooks and solve fatal mysteries, usually by subjecting a stray hair, carpet fiber, a blood drop or fingernail crud to some elaborate lab analysis. In the real world, the mechanisms of mortality aren't always so obliging. While forensic science has made impressive strides in recent years, it can't provide definitive answers in every death — and in most cases, its resources aren't even utilized. The vast majority of deaths are natural and require little or no investigation. More than 5,000 deaths are reported in Denver every year; on average, autopsies are performed in only 10 to 12 percent of those cases.

Twenty-three states have either statewide or county medical-examiner systems, in which doctors are in charge of death investigations. But many other states rely on elected coroners, who may have no medical background or special qualifications for the job — other than the ability to hire forensic pathologists to conduct autopsies as the coroner sees fit. In most Colorado counties, any local resident with citizenship, a high school diploma and no felony convictions can run for coroner.

Jim Hibbard has been the coroner of Adams County since 2003. Although he doesn't have a bachelor's degree, he does have almost thirty years in law enforcement, rising through the ranks of the Adams County Sheriff's Office before running for coroner — experience he considers more than sufficient for the job at hand.

"I had over 3,000 deaths last year," he says. "I look at the reports, and when it seems suspicious to me, that's when it gets autopsied. Everybody in this office takes required training every year. We're not just a bunch of bumpkins."

But unlike most coroners, Hibbard has been a magnet for controversy. His office has been plagued by massive turnover since his arrival — more than fifty firings or resignations in six years, in a department with barely a dozen employees — resulting in a drain of seasoned death investigators and a rash of embarrassing blunders by inexperienced staff and interns. He's had strained relationships with other agencies in the sprawling county, which includes nine police departments and, since the redevelopment of the Fitzsimons campus in Aurora, several of the region's busiest hospitals. A long-running feud with the county's contract pathologist led to Hibbard's prohibiting investigators from speaking directly to the man before finally terminating his contract earlier this year. Although the county boasts a state-of-the-art autopsy facility in Brighton, many of its autopsies are now performed sixty miles away, in Loveland, by other contractors.

Defense attorneys have complained that Hibbard's office has been less than diligent about turning over evidence required to be disclosed in criminal cases. Last June, Adams County District Attorney Don Quick told Hibbard to change the way he did business or face a possible recall election. But since then, the coroner's office has been the target of several Equal Employment Opportunity Commission investigations. Three former female employees claim they were sexually harassed by a deputy coroner (who's since resigned), while others claim they were subjected to retaliation by Hibbard himself for testifying in support of the complaints.

Then, in April, a CBS4 report took a closer look at Hibbard's hiring practices, in the wake of two goofs involving bodies released to the wrong mortuaries. Among the young women with little relevant prior experience taken on as death investigators last year were a nanny, a waitress and a former VIP-room hostess at the Diamond Cabaret, the popular downtown Denver strip club.

Hibbard is still seething about that broadcast, which he claims was a smear job. He declined to meet with Westword in person and refused to comment on any personnel matters or the ongoing EEOC actions. All of the so-called problems in his office, he says, are being conjured up by disgruntled former employees: "You can ask me anything about this office, but don't put me in front of a camera and blindside me. Don't put me in front of a reporter and throw me a curve question."

The coroner maintains that he has a "very stable crew" now and no complaints from hospital staff or law enforcement. But some people who deal with his office regularly tell a different story. "He's gotten more difficult to work with throughout his tenure," says one homicide investigator who works for one of the local police agencies —and, like several sources contacted for this story, asked to remain anonymous. "We get inaccurate information and tirades from him. Many agencies are reluctant to contact him until they have to."

Emma Hall, one of the former investigators who filed a harassment complaint, says Hibbard's approach to death investigation procedures changed regularly — and capriciously. "You had to weigh what was the most ethical or humane thing to do against what Jim had decided was the right thing to do this week," she says. "There were times an investigator would assume that a body was going to get an autopsy, due to the circumstances, and then it wouldn't happen. Other times he'd get upset when we did an external exam because we 'disturbed evidence' for an autopsy.

"One morning I got an e-mail saying the body examination procedure had changed. I went to a scene, did an external, came back to the office — and was told I didn't have to do that anymore. They changed the policy again, that same day, but didn't send out a second e-mail."

To critics of Colorado's elected-coroner system, the complaints swirling around Hibbard's office may seem like an excellent argument for a standardized medical-examiner system. But Hibbard doesn't see it that way.

"I'm a realist," he says. "I haven't made everybody happy. I know that. For everybody I help, I'm sure there's somebody who feels I should have done something more. But I've done no different business than other coroner offices, and I do a good job. I deal with the money in this office like it's mine, and I want to make sure it doesn't get wasted."

The job of coroner dates back to the time of the Norman conquest of England, when local officials were charged with looking after the financial interests of the crown — a responsibility that soon evolved into death investigation. As John Howard sees it, the primary reason the office has survived the passing of the Middle Ages and the advent of specialized medicine has to do with inertia.

"All biological systems resist change," says Howard, president of the National Association of Medical Examiners. "The elected coroners are first and foremost politicians, and they want to protect their jobs."

NAME has long advocated higher standards and more extensive training for coroners — or, better yet, abolition of the elected office in favor of the medical-examiner system. It's a position bolstered by a recent National Academy of Sciences study, which found little coherence in the nation's patchwork of more than 2,300 separate death investigation jurisdictions. "The hodgepodge and multiplicity of systems and controlling statutes makes standardization of performance difficult, if not impossible," NAS concluded.

Howard is one of about 500 board-certified forensic pathologists currently operating in the United States. He's also the chief medical examiner in Spokane, one of three populous counties in Washington that have established NAME-accredited medical-examiner systems instead of coroner's offices. But in several rural counties in the state, prosecutors also serve as coroners. In some states, more than half the coroner positions are filled by local funeral directors, a situation fraught with even greater potential conflicts of interest.

Coroners can and do hire forensic pathologists to assist them, of course, but Howard contends that lay officials shouldn't be in charge of critical decisions about which deaths to investigate. The case literature is rife with accounts of homicides mistakenly pronounced as suicides and vice versa. In Wyoming a few years ago, a man was convicted of killing his wife based on a non-forensic doctor's confusion about entrance and exit wounds; the man was freed from prison only after a forensic pathologist examined the evidence and determined that the death was a suicide. Then there was the case of Charles Cullen, the serial-killer nurse whose murderous overdoses of patients at local hospitals failed to attract the attention of a Pennsylvania coroner; Cullen was caught only after he moved his practice to New Jersey.

"The question is whether quality death investigation is a priority or not," says Howard. "Most people don't want to spend money on death investigations until it's their parent or child or friend. Then they want answers right now, just like on television."

In Colorado, several counties have found workarounds for the coroner dilemma. Denver has long opted out of the elected-coroner system in favor of an appointed medical examiner who also carries the title of coroner. In some other counties, the coroners are still elected but are exempted from term limits if they're also forensic pathologists. That's why Michael Dobersen has been Arapahoe County's coroner since 1993 and Patrick Allen has held the same position in Larimer County since 1979.

Still, that doesn't mean politics has been removed from the process. The nationally renowned Dobersen was narrowly re-elected last year; his challenger had no medical background but happened to be a Democrat at a time when even Arapahoe County was turning blue. "When I first got here, they told me if I wanted the job I had to be a Republican," Dobersen says. "I'm a registered Democrat now."

Lawmakers have occasionally considered setting up a statewide medical-examiner system but have balked at the price tag; forensic pathologists can earn three or four times a coroner's salary. Howard insists that cost is a "lame excuse," since county coroner offices could be replaced by fewer regional medical examiners. But for now most of Colorado remains committed to the status quo, which puts county officials of widely varying education and background in charge of medical experts who make a lot more money than they do. It's a situation with built-in tensions that Dobersen, for one, is glad he doesn't have to face.

"It's good to have one person speaking for all the aspects of the office," he says. "There are some bad medical examiners out there, too, but I think it's best to have someone with a strong medical background in charge every step of the way."

Coroners who aren't pathologists tend to find the NAME advocacy of medical-examiner systems to be highly self-serving. "They have to say that," says Hibbard. "It's job security for them."

As a former cop, Hibbard highly prizes scene investigation. The doctors who perform autopsies for him are just contractors, he says: He's the policymaker, and that's the way it should be.

"Do you actually believe an autopsy is going tell you exactly how a person died?" he asks. "How can a medical examiner, from the comfort of his autopsy suite, decide whether or not a person should be autopsied? I think we've all been influenced way too much by CSI."

Hibbard points out that there are far fewer trained pathologists than there are coroner positions. "They've pretty well cornered the market," he says. "They've created a niche nobody else can fill, and they know that. But their information is no better or worse than what the investigators are willing to give them. Sometimes you're just doing the autopsy to verify what was found at the scene."

Hibbard believes he brings a perspective to the job that a typical medical examiner might lack. After retiring from the sheriff's office, he worked part-time at a mortuary, an experience that showed him the importance of getting bodies released to families "as soon as possible so they can start their grieving process." For the past three years, his office has been recognized by Donor Alliance for making the most referrals of any coroner in the state that resulted in organ and tissue donations — a total of 72 donors over that period. (There are more than 1,800 Colorado residents currently awaiting transplants.) He's also been an avid supporter of suicide prevention programs and Mothers Against Drunk Driving.

At the same time, several former employees describe Hibbard as an authoritarian and bullying boss, given to lengthy, castigating meetings, explosions of threats and demeaning accusations — more like Captain Queeg than Quincy. "Jim is very much a control freak," says Sherronda Appleberry, who left the coroner's office a few weeks ago after three years as a pathology assistant — one of the longer stays in Hibbard's office among all his employees. "One day he spent two hours yelling at me about a curt e-mail. It turned into 'You're sabotaging the office, you're a cancerous employee.'"

Over the past few years, Hibbard's relationship with his pathology team has been particularly fractious. The high-tech autopsy facility in Brighton, which opened in 2006, leaves no doubt about who's in charge there. While the pathologist works in the autopsy suite, Hibbard can monitor the procedure from a conference room, using seven overhead, remote-controlled cameras to zoom in on the action. He can also relay orders or questions from observers through a Bluetooth receiver clipped to the pathologist's ear.

Until recently, the ear in question was usually that of Michael Arnall, who became the county's go-to forensic pathologist in 2005. Working as an independent contractor, paid a flat rate of $800 per autopsy, Arnall performed 370 out of the 386 autopsies done by Hibbard's office last year. That's double the number of autopsies done in 2006, largely because of the addition of Children's Hospital and University Hospital to the county's service area. (Broomfield, which has no coroner of its own, also sends its cases to Adams County under a contractual agreement.) Yet Arnall and Hibbard clashed frequently, over issues such as what cases merited special attention, Arnall's outside consultations, the deference other staffers showed to the doctor and his opinions — even allegations of pilferage and insubordination.

Arnall declined to comment on his dispute with Hibbard, but a trail of memos and witness statements traces an almost surreal downward spiral. Hibbard once upbraided Arnall for taking four and a half hours to complete an autopsy — not necessarily an unreasonable period of analysis, given that the case involved a murder-suicide, but Hibbard regarded it as "abuse of the paid time to you via the contract and abuse of the personnel that I supply to you for assisting in the autopsy."

The coroner also took his pathologist to task for not starting autopsies on time if the attendees — usually police officers investigating the death — weren't present. But police officers complain that Hibbard sometimes failed to give them enough prior notice to make it to Brighton on time. "He'll notify us of an autopsy ten minutes before it starts or five minutes after," says one. "He's told us, 'I'll make the decision when you need to be there and when you don't.'"

Late in 2007, Hibbard forbade his death investigators from consulting directly with Arnall, insisting that their inquiries be fielded by him or Mark Chavez, then the chief deputy coroner. Hibbard says he was merely trying to limit wasteful chitchat: "What they were told was, 'If you have questions for the doctor that pertain to a case, by all means ask him. If you want to talk about fishing and hunting and his rock collection, you do that on your own time.'"

But that isn't what the memo says: "Effective immediately, any communication sought by an investigator to Dr. Arnall will first go through myself or Mark. Likewise, any communication sought by Dr. Arnall to an investigator will first go through myself or Mark."

A few weeks later, Arnall was banned from staff meetings. Hibbard says Arnall was "disruptive and boisterous" at the meetings and "didn't provide anything." Other sources claim that Arnall was prevented from discussing cases with police investigators, too — "at one point we had to ask the deputy coroner questions, and she'd relay them to the doctor," says one. Hibbard denies this.

While Arnall was on vacation, a former intern says, Hibbard declared that the doctor's office was a fire hazard — and ordered the intern and a staff member to dispose of stacks of paperwork. "We spent a good part of the day shredding his files," she recalls. "I recognized a lot of them as autopsy reports. I was one scared intern."

Last December, Hibbard informed Arnall that his contract was being terminated. "He was dismissed for a number of reasons," Hibbard says now. "It was a time when it was beneficial for both of us to part ways."

Yet the timing of the announcement suggests one particular reason loomed larger than the rest. It came just moments after a confrontation between the doctor and the coroner concerning the cameras in the autopsy suite and where they were focused — a bizarre piece of a much larger rumpus involving allegations of sexual harassment and retaliation that now appears to be headed for a courtroom.

Burnout and turnover are occupational hazards among death investigators. Young people drawn to the sleek, neon-tinged, fast-paced world of CSI soon discover that the job is filled with horrors and pitfalls that TV never mentions or glosses over, from grisly traffic fatalities and decomps to angry, uncooperative next of kin and low pay.

The logistics of the work can be especially daunting in a place such as Adams County, which spans 1,200 square miles, from Denver's teeming northern suburbs to a scattering of small towns on the plains; its eastern border is more than seventy miles from the office in Brighton. Frequently there's only one investigator available per shift to cover the death calls, heading out in all kinds of weather to conduct scene investigations and transport bodies.

But several ex-employees who left the coroner's office over the past two years say that the investigative demands weren't the most stressful part of the job. Dealing with Hibbard and his longtime ally, Chief Deputy Coroner Mark Chavez, was far more exhausting, they say — and demoralizing. "I think I'm a hard worker, and I was being treated as if I was a piece of garbage," says one investigator, who handed in her badge last year.

New investigators received six to eight weeks of in-house training. But the training didn't prepare them for the constant shifts in policy and procedure, the ex-employees say, or for Hibbard's wrath at bi-weekly meetings, served up in generous portions to those who failed to meet his expectations. "The meetings got worse and worse," says Emma Hall, who worked for Hibbard for eighteen months. "It became a two-hour ass-chewing every time. If somebody did something he didn't like, it became a punishment for the rest of the staff. It got to the point where I didn't want to take any cases because I didn't know what was going to be perceived as right or wrong."

The situation worsened as veteran investigators departed and were replaced by rookies — predominantly female. "I've trained with several agencies, and at one point Adams had several investigators who had been there a long time," says one of those who joined the exodus. "They all left. I trained someone who had worked in a mine previously. We had someone who had worked at Village Inn. They were very difficult to train. We had an on-call investigator who distributed nude pictures of herself around the office.

"All of a sudden, we had all these women who had no experience, no knowledge. Usually they were single — and they were all relatively attractive."

In some ways, Chavez served as a buffer between the investigators and Hibbard. But several women say they felt uncomfortable around Chavez, a former Brighton police officer. They claim he asked inappropriate questions about their personal lives and engaged in unsolicited massages and other touching — claims that would eventually mushroom into sex-harassment allegations.

One woman who left the office in 2007 recalls telling Chavez that the pants on the uniform issued to her were too tight. Chavez insisted that she model the pants for him so he could see for himself. "I didn't know what else to do but put them on," she says. "He looked at them and said he'd get me a larger size."

Two other women say they received cringe-inducing neck and shoulder rubs from Chavez but were reluctant to report the matter because of possible reprisals; the chief deputy had considerable input on their evaluations and whether they would survive their probationary term. "I never felt comfortable asking him to stop it," says one. "There was a lot of fear in the office. You just wanted to be a happy employee, a very compliant employee, or you were going to have hell rain down on you."

Chavez's employment had been an issue in Hibbard's 2006 re-election campaign because he owned a Brighton crematory. Hibbard's opponent, also an Adams County police officer, regarded the business as a clear conflict of interest. Hibbard had brushed off that controversy — there's no law against deputy coroners doing business with local mortuaries on the side — but he apparently didn't become aware of the harassment allegations until last spring.

According to documents prepared in the harassment probe, Adams County DA Quick paid a visit to Hibbard on April 15, 2008, to express concern about problems in the office. Quick won't comment on the conversation, but Hibbard reportedly told members of his staff that his job was in jeopardy. "According to Coroner Hibbard, Mr. Quick had threatened him with a recall election due to his inability to work with outside agencies and the way in which he manages his staff," one employee later wrote.

Hibbard subsequently met with Arnall, who informed him of the investigators' complaints about Chavez and urged him to put a stop to it. Hibbard took the matter to the county's human-resources division, which hired the Mountain States Employers Council (MSEC) to conduct an investigation. Six weeks later, Chavez resigned.

Chavez declined to comment to Westword on specific allegations about his conduct but denies that he harassed anyone. His accusers were pursuing "probably four different agendas," he says, and used his efforts to mediate problems in the office against him. He attributes the high turnover in Hibbard's office to low pay and the unrealistic expectations of rookie investigators. "Mr. Hibbard has his quirks," Chavez says. "But he's probably made more progress in that office in the past six years than there was in a hundred years previously."

In any case, the departure of the deputy coroner didn't resolve the turmoil. Adams County refused to release the MSEC's findings to the complainants, two of whom are now represented by civil-rights attorney David Lane and are pursuing EEOC actions of their own. And several former employees — including investigators Dustin Bueno and Emma Hall and pathology assistants Monica Jordan and Sherronda Appleberry — maintain that Hibbard retaliated against them for assisting in the investigation of Chavez.

 Hall resigned last July, after weeks of what she describes as a kind of endurance test involving heaped-on assignments, unfair write-ups and unfounded accusations. The final insult, she says, was being accused of stealing a cross from a necklace worn by a decedent that she'd processed.

"Apparently Jim thought I stole it," she explains. "He said nobody could leave until the cross was found. They went through my cubicle, every place they thought I could have hid it. I don't have anybody to vouch for me because they send us alone to a scene, and now I'm getting accused of stealing from a dead person."

After Chavez left, Jordan and Appleberry found their workload increasing, too — including a time-consuming new procedure to prepare bodies for mortuaries that the pathology assistants regarded as punitive and unnecessary. Both would later complain of long sessions in Hibbard's office, during which they were reprimanded for everything from poor attitude to poor comportment during their required participation in the annual county parade.

"He told me that I can fly his flag or go work somewhere else," Jordan wrote in a report to human resources. "He told me to take a pad of paper and pen into the conference room. He told me to have a report to him in thirty minutes that addressed why I wasn't doing my job, why I didn't wear a hat at the parade, why I left my fellow co-workers, and why I didn't require 'my people' to do their job.... [An investigator] stated that he could hear Coroner Hibbard yelling at me all the way at his desk."

The two women also claimed that Hibbard was using the cameras in the autopsy suite for more than observing autopsies. Last fall, Appleberry informed human resources that she appeared to be under surveillance while working in the suite. "Each time I moved, the camera followed until it found me," she wrote. "The autopsy had been over several hours before, and yet my every move was being followed."

Hibbard has offered varying explanations about what he was doing with the autopsy cameras. At one point he claimed to be studying condensation on the lens and ordered the camera covers to be cleaned; months later, in response to the retaliation claim, he contended that the cameras are "currently used to monitor job performance and to ensure employee safety."

The assistants, though, believed they were being electronically stalked. They began to take pictures of the monitor in the suite that showed what the cameras were looking at, alerting Hibbard that they were watching him watching them watching him.... One day last December, Arnall took a picture of the monitor himself. According to a statement by Jordan, Hibbard then "came storming into the room" and demanded the camera. "Dr. Arnall came back a few minutes later," she wrote, "and told me that he'd been fired."

Hibbard ordered the monitor in the suite to be turned off except during autopsies. Personal cameras, cell phones and recording devices were abruptly banned from the office, too. But Appleberry and Jordan maintained that they could still see the overhead cameras move to follow them around the room. In e-mails to DA Quick and County Attorney Hal Warren last February, they expressed outrage that Hibbard was using the cameras to "zoom in and out on our bodies" and possibly peek down their scrub shirts. This time the response was a memo from the office's administrative coordinator, announcing yet another new policy: Pathology assistants were now required to wear crew-neck T-shirts under their scrubs in order to maintain a "clean, neatly groomed, professional appearance."

Although the claims of retaliation resulted in another personnel investigation, no findings have ever been released. Meanwhile, the battle in the autopsy suite continued to escalate. In April, Appleberry fired off an e-mail to Quick that contained several allegations about photos from one case ending up in another case file, a child's bone that was mislabeled as an adult femur and sent astray — and an ominous reference to "an established policy in the Coroner's Office not to disclose certain things to the attorneys."

The e-mail went out on a Friday afternoon. The following Monday morning, Appleberry was called into Hibbard's office and told she was being "released" pending an investigation.

"He told me to empty my pockets," Appleberry says. "I told him no. He told me I needed to take off my lab coat. I told him no. He told me, 'I don't know if you're stealing.' I told him if he thought that, then he should call the cops. Then he asked me why I thought it was okay to contact the district attorney."

Six weeks ago, Jordan and Appleberry received letters from Hibbard informing them that their jobs were being eliminated "due to the outsourcing of the pathology function." Since Arnall's termination, Hibbard had arranged for veteran pathologist Patrick Allen and his pathology partner, James Wilkerson IV, to take over his office's autopsy work. Allen and Wilkerson's Loveland-based practice has more or less coronered the market in the northeastern portion of the state; Allen serves as coroner not only of Larimer County, but Weld County, too, and does contract work for several smaller northern counties as well as much of southern Wyoming.

Shifting the Adams County autopsies to Allen and Wilkerson will put the duo on pace to do around 850 autopsies a year — well in excess of the 250 cases per pathologist recommended by NAME. It also put an end, for now, to the camera wars in Brighton: No autopsies means no pathology assistants. Thirteen months after the sex-harassment complaints triggered two investigations of the coroner's office, everyone involved had been fired, laid off or quit — except for Hibbard himself.

Unless people stop dying, a coroner's work is never done. Hibbard doesn't believe the upheaval in his office has had much effect on the cases his team handles, but many of those purged from his office disagree.

They tell stories about improperly stored or preserved specimens; the wrong bodies — or, as in Appleberry's memo, wrong body parts — sent to mortuaries; an eighteen-year-old apprentice investigator who left a death notification for next-of-kin on an answering machine, a gross breach of accepted procedure (see "Speaking for the Dead," June 16, 2005); the occasional body mistakenly sent for autopsy that didn't need one.

Alarming as these incidents might sound, such mistakes can and do happen in other jurisdictions, too. The more difficult questions concern what kind of deaths merit further investigation. Many coroners don't devote a lot of resources to probable suicides, for example, but the concept of "probable" varies widely. Apparent suicides in Adams County rarely result in an autopsy, and several sources say Hibbard's policy on drawing fluids for toxicology tests can be wildly inconsistent.

Even drug overdoses, it seems, don't automatically warrant a tox screen. Last fall, an eighteen-year-old male collapsed and died at a rave in unincorporated Adams County; he'd reportedly been drinking and taking ecstasy. The body was released to a mortuary and embalmed; it was only after an emergency-room doctor refused to sign the death certificate that the body was retrieved for autopsy. The procedure didn't alter the finding of accidental death by drug overdose, but it did provide additional information about the drugs in the youth's system — through tissue samples, since embalming had made blood work useless.

"I have no issue with what the investigator did in that case," Hibbard says. "The doctor wasn't going to co-sign, but he attributed the death to overdose, too."

In another case earlier this year, Hibbard concluded that the death of a 28-year-old heroin user in Thornton was due to "multiple drug toxicity." Toxicology tests showed the presence of morphine and Xanax in the man's system, and witness interviews indicated that he'd been shooting up with his girlfriend shortly before she found him unresponsive in the bathroom. The morphine level wasn't exceptional, though, and even the Xanax, while outside the therapeutic range, didn't constitute what toxicology manuals list as a fatal dosage. When asked about the case, Hibbard points out that the combination of drugs could still be fatal, even in small amounts. But this is the kind of death that another office might decide to autopsy, just to rule out other causes that can't be excluded by toxicology alone.

Suicides and drug overdoses may pose haunting questions for family members, but they rarely draw the kind of scrutiny that accompanies a homicide investigation — especially if the decedent is a child. Adams County currently has two cases of suspected child abuse in which defense attorneys are mounting extensive challenges to the work done by Hibbard's office.

The first case involves the death of 22-month-old Taylor Bach in 2007. Her mother's boyfriend, Steven Burnley, claimed that the girl was eating breakfast when she suddenly started shaking and collapsed. The postmortem examination found bruises on the face and scalp, a subdural hematoma and retinal hemorrhaging — all classic signs of what's popularly known as "shaken baby syndrome," or SBS. The autopsy report, prepared for Hibbard by Patrick Allen, states that the child died of a closed head injury and blunt trauma. Burnley was arrested and charged with first-degree murder.

Burnley has prior domestic-violence charges and admitted slapping the toddler a few days before her death; he seemed made for the part of SBS perpetrator. But SBS isn't the slam-dunk conviction it used to be. Several experts in the field have reversed course in recent years, acknowledging that other brain-swelling factors, such as severe infection, can mimic the symptoms of abuse. In the case of Taylor Bach, the autopsy also turned up evidence of pneumonia. The prosecution suggests the infection could have come from the time the dying child spent on a hospital ventilator; the defense points to a series of other events, including a prior fever and a hospital finding of a sinus infection, as part of an alternative explanation for how the girl died.

Fernando Freyre, Burnley's attorney, declined to comment on the case. But court documents show that the defense is attacking the adequacy of the coroner's investigation. Not enough brain-tissue samples were taken or preserved to rule out infection, Burnley's team contends. The bruising wasn't subjected to the kind of testing that would help determine if it occurred at the time of the fatal injury or earlier, as Burnley claims. The case is shaping up as a test of whether anything less than a truly exhaustive, by-the-book death investigation, five-hour autopsy and all, will suffice in suspected abuse situations.

Similar issues involving the preservation of evidence have surfaced in another case of suspected abuse: the death of a six-month-old boy in Westminster last February. The autopsy examination found head contusions and a subdural hematoma. The suspect, 22-year-old Justin Taylor, pleaded not guilty to child abuse resulting in death. The case against him includes an alleged admission to police that he'd dropped the "pissed off" boy on his head after he tried to kick Taylor "in the balls." But recently, in a letter to Taylor's pubic defenders, a prosecutor acknowledged that the decedent's brain had been stored in an "unconventional" manner, in a heat-sealed pouch, by someone in the Adams County Coroner's Office. The heat altered the shape and consistency of the tissue and made analysis of the injuries more difficult; it's not clear at this point how much damage the heat-sealing did to the prosecution's case, or Taylor's ability to mount a defense.

Scott Evans, head of the Brighton division of the state public defender's office, declines to comment on the Taylor case. But he says his office has had trouble getting documents from Hibbard's office for years. "The autopsy report was the only thing we were getting," he says. "There were a lot of other materials in their files, including reports from other agencies they would consult and interviews with witnesses. They were not passing the copies on to the DA, who has to forward everything to us."

Hibbard says he only recently learned about the disclosure problem, which he blames on the district attorney's office: "We were sending compact discs to the district attorney's office, and we found out they were sitting in someone's drawer. I can tell you this, when it leaves this office now, I make someone from the DA's office sign for it, because I'm not going to be the bad guy anymore. Now that I know what they weren't getting, I make sure they do get it and get it through the proper channels."

The district attorney and the public defender don't agree about much, but they both disagree with Hibbard's explanation. "Sometimes there are issues getting reports from the coroner's office in a timely way, but there isn't a systemic problem," Quick says. "The idea that discs are getting dumped in a desk drawer, that's not true at all."

Evans says the situation only improved recently, after months of court battles and subpoenas dispatched to the coroner's office. "There were just too many cases where we weren't getting the materials for the DA to be the source of the problem," he says. "The prosecutors would stand up in court and say they hadn't received it, either. The last couple of cases, I've been receiving the materials through the DA's office, so the coroner is getting some of it to them. I just don't know whether it's all of it or not. We don't know what's been lost or damaged or screwed up. We just don't know."

Hibbard can be passionate on the subject of his independence. As an elected coroner, he isn't subject to what police, doctors, lawyers or journalists want the case to be about. It is what he decides it is. "I don't speak for anybody but the decedent," he says.

Yet he clearly speaks louder for some decedents than others. Jaime Brown wishes someone in Hibbard's office had spoken up for her daughter Abigail.

"I know I have a different attachment — it's my child," she says. "To them, it was just another body."

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