"If we did an autopsy on every suicide, it would be all consuming, as with drug overdoses," said Cherokee Ballard, the office's chief administrator. "With suicides, we don't autopsy most them because it's an obvious cause of death."
But experts called Oklahoma's practices alarming. A savvy criminal can make a murder look like a suicide, said Dr. Robert Bux, a forensic pathologist who serves as coroner for El Paso County, Colo.
"The only way you're going to be able to sort it out, from my standpoint, is to do a complete autopsy," Bux said.
"I've had a lot of suicide cases they didn't autopsy," added Kyle Eastridge, a former homicide detective with the Oklahoma City Police Department and the Oklahoma State Police. "I don't think that every suicide is a murder, but I think we miss murders."
In the absence of forensic findings, families sometimes are left to forage obsessively for clues about what became of their loved ones.
When a bullet shattered the face of 17-year-old Carissa Holliday and left her dead in a trailer outside of Tulsa, no doctor ever autopsied her body.
Instead, a forensic pathologist looked at her wound and filled vials with blood and fluid from her eyeballs, screening them for drugs and alcohol. Two days after her death, before the lab tests had even come back, the doctor ruled her death a suicide, records show.
Holliday's mother, Andrea, didn't believe the ruling -- Carissa left no suicide note, and the pathologist's report did not address potential clues such as whether there was gunshot residue on her hands.
"For a year and a half, I dug and investigated and got clues and witnesses to prove that she didn't kill herself," said Andrea Holliday, who wrote a self-published account of her daughter's final hours titled Never Forgotten.
The medical examiner has not reopened Carissa Holliday's case, and the official ruling on her death remains unchanged.
In 2009, NAME yanked Oklahoma's accreditation, in part because of its failure to autopsy suspected suicide and homicide cases.
Fierro, the Virginia forensic pathologist, called Oklahoma's decision not to look carefully into unexplained deaths of residents over 40 a mistake. Forensic pathologists have been critical in a range of investigations stretching beyond criminal justice, from identifying defective cribs to tracking the spread of infectious diseases. They play a crucial role in mapping public health trends, she said.
"If you want to improve the quality of people's lives, then we need to know what it is that causes them to be ill, sick or injured so that they can prolong their life," Fierro said.
Even at some of the nation's more robust death investigation units, staffers worry that they do too few autopsies to fulfill their watchdog role.
The Los Angeles County Department of Coroner looks into a comparatively large portion of deaths, roughly one in three each year, said Craig Harvey, the chief death investigator. Yet he would like to do more.
"I would love to have the staff to respond to every nursing home death. They're fraught with potential misses," Harvey said. "But if anything was to go wrong in those facilities, unless somebody says something, there's a good chance the case will pass through the system without ever being seen by the coroner."
The Price of Reform
The National Academy of Sciences has mapped out a plan to improve troubled coroner and medical examiner operations.
In its 2009 report, the academy called for the creation of uniform federal standards for death investigation and recommended making certification mandatory for doctors working in the field of forensic pathology.
So far, however, those suggestions have made little headway in Washington.
Sen. Patrick Leahy, D-Vt., recently introduced legislation aimed at upgrading the quality of forensic evidence, but his bill would impose no new requirements on the doctors at the center of death investigations. Instead, it would establish a committee to examine how to ensure that qualified practitioners are doing autopsy work.