KANSAS CITY, Mo. -- In most of Missouri when there's an unexpected death, a coroner is notified. The coroner determines the cause of death.
It's a lot of power for an elected official who needs almost no qualifications to hold the job.
However, FOX4 Problem Solvers found that some serious mistakes are prompting calls for change.
If a coroner botches a death investigation, those who often pay the biggest price are the family members of the deceased. In fact, it's their outrage that's leading the call for change.
Dustin Chance was 36 years old when he died. Jayke Minor was 27. Both families will never know why they died, because the coroner never ordered an autopsy.
“He was one of those people always on the go. We went to bed and he just didn't wake up,” Joy Chance, Dustin’s wife, said.
“Jayke was a good kid. He didn't deserve this. No family deserves to go through what we have,” dad Jay Minor said.
Saline County Coroner Willie Harlow is an executive board member of the Missouri Coroners and Medical Examiners Association.
He was so alarmed by what happened in these two cases, the sudden and inexplicable deaths of two seemingly healthy young men, that he wants Missouri law changed to hold coroners more accountable.
“A coroner is elected for four years. That's a long time to keep someone in office who is not doing their job. Anybody can be the coroner,” Harlow said.
That’s a disturbing, but little-known fact.
“There was a guy who was running who was a taxicab driver. What qualifications would a taxicab driver have to be coroner? Well, he has the same qualifications as anyone else: Over the age of 21 and lived in that county for six months. So that's a little scary,” Harlow said.
Although large metropolitan areas like Kansas City use medical examiners, who are also doctors, the majority of rural Missouri relies on coroners.
“My son passed away eight-and-a-half years ago, unexpectedly, no known medical conditions,” Jay Minor said.
Even the head of Missouri’s coroner’s association says an autopsy should have been performed, but the Howard County corner never requested one.
It took Jay Minor three years and the help of a different county's coroner to even get the report detailing how his son died.
“I have your report, but it's full of mistakes,” he said.
Where his son's name should have been written is another person's name, scratched out with his son's written above.
The report says the body was found in the living room, but the police report says he's in the bedroom. The body is described as warm, but the police report states the body was cold. And police arrived an hour before the coroner.
But what has the dad most upset: His son’s death is listed as “drug overdose." This is something the coroner couldn't possibly have known because there was no toxicology report.
“I found that hard to believe, so we kept pressing and that's when this all started to snowball,” he said.
Officials at the Missouri Coroners and Medical Examiners Association were so outraged they went to the attorney general to see if the coroner could be disciplined, but there was nothing the attorney general could do.
Howard County Coroner Frank Flaspohler insisted that the error-ridden coroner's report that Jay received three years after his son died wasn't finished and shouldn't have been released.
“I started typing that in because I just type over an old one. And I ended up printing that report before it was finished and giving it to a fellow coroner. When I handed it to him, I said, ‘This isn`t right. Don't give it to the family, it’s got the name misspelled,’” Flaspohler said. “So I had no clue that he would give it to the family, and he did.”
But the coroner he gave it to, the Pettis County coroner, said he was never told that.
Flaspohler, who has been coroner for 30 years, acknowledges he made mistakes. He said since Jayke's death he's changed his policies and tripled the number of autopsies.
Unfortunately, what happened in Howard County isn't unusual.
“I asked him for an autopsy, and he told me no. His exact words: They were a poor county and he couldn’t justify it,” Joy Chance said.
She lives in Odessa and had been camping with her husband Dustin near Lake of the Ozarks. She said he seemed fine when they went to sleep, but he never woke up. The Miller County coroner, who is also an EMT, handled the death.
“He started saying, ‘I believe your husband had undiagnosed sleep apnea.’ I argued with him about it. And then he said that my husband may have had a stroke or a heart attack. And I just got really upset. I said he was 36 years old. There was nothing wrong with him,” Chance recounted.
She kept demanding an autopsy, but he refused.
“The statute says it’s the coroner’s job to determine the manner and cause of death,” Harlow said, who added that guessing isn’t good enough.
“He wasn't somebody that you just hear about. He was an actual person, he was a father, he was a husband, he was a brother, he was a friend. And I feel like he didn't get any respect at all,” Joy Chance said.
A bill before the Missouri legislature will mandate better training for all coroners. If they don't comply, they can be fined and lose some of their powers.
Jay Minor has been fighting to get it passed for three years, it will be called “Jayke's Law.”
After multiple complaints, both coroners eventually corrected their report, but both families are still upset with the final version.