Montana’s Coroner Inquest Process Is Terrible And This Year’s Legislative Action Only Pretends To Make It More Transparent

by Travis Mateer

Before we get to the terrible process I’m a bit surprised to see the Missoulian reporting on, the image above is from the website of the Montana Coroner’s Association where they allegedly do the following (emphasis mine):

The Montana Coroner’s Association exists to support the Coroners of Montana through education and training, and to render support to each County Coroner to aid in the timely resolution of death investigations.

Well, HAVE their been timely resolutions of death investigations? According to the Missoulian article, no, and one reason is because the coroner must be a CIVILIAN coroner in order to preside over the inquest. I did not previously know this little fact.

Before we get to that fact, the process of a coroner’s inquest is described and I’m already having some difficulty matching what’s being described with what I’ve seen play out in the MULTIPLE inquests I’ve observed. From the first link (emphasis mine):

Two pending Missoula cases involving use of force by police likely won’t see a courtroom until the fall.

The Missoula County Attorney’s Office currently has two inquests awaiting their day in court because of scheduling challenges and a shortage of coroners, according to Missoula Chief Criminal Deputy County Attorney Matt Jennings. Coroner’s inquests are public inquiries held in courtrooms that examine the causes of and circumstances surrounding the death of a person when they’re killed by law enforcement. 

Inquests play an important role in the legal process. They are required by law for people who die in a prison or jail or in the custody of any law enforcement agent.

A coroner (not a judge) presides over an inquest before a coroner’s jury in a public courtroom. Evidence surrounding the person’s death is presented to a jury, which then decides if the use of the force by law enforcement was justified. Deputy county attorneys present evidence and witnesses to the jury, but they aren’t legal representation for the person who died, or their families.

That last point of emphasis is where my experience deviates from this description. The standard I’ve heard explained to the jury by the coroner presiding over the inquests I’ve attended is whether or not law enforcements committed a CRIMINAL act in using force, not a “justified” act. But maybe my understanding of this process isn’t accurate.

Later in the article we get the civilian excuse from Deputy County Attorney, Matt Jennings:

In an email, Jennings said the coroner Missoula County typically enlists for its inquests doesn’t have dates available until the fall, but the county is trying to find another coroner with sooner availability.

“When a person is killed by law enforcement we have to use a civilian coroner and they have to be from another county,” Jennings said. “There are not many choices.”

He explained civilian coroners usually have other jobs, like funeral directors, so presiding over inquests for other counties tend to be voluntary, add-on tasks for them. He said coroner shortages aren’t unique to Missoula, and his office uses the same coroners that most urban counties throughout the state use.

Yes, I consulted the Montana Coroner’s Association directory and most of the coroner’s listed are NOT civilians, but Sheriffs. This certainly does limit one’s options when it comes to pretending a legitimate process of officer-involved death investigation actually exists in the state of Montana, right Matt Jennings?

Republicans at the state level, with their supposed super majority and billion+ surplus to play with, should have been able to bring elements of the criminal justice system into the 21st century, but I don’t think the move made in this area of the criminal justice system will bring the “transparency” we are being told it will.

Here’s more from the article about what the legislature did to help this inquest process not suck so bad (emphasis mine):

Gov. Greg Gianforte signed House Bill 705 in May, brought by Scot Kerns, R-Great Falls, in this year’s legislative session, which revised Montana’s current inquest laws to allow juries to select an option that a person died by suicide through police intervention, if the evidence supports such a claim.

“House Bill 705 is to provide the jury with greater transparency in cases by allowing them the option, only if warranted, of suicide by law enforcement,” Kerns said at a hearing for the bill in February. “By amending the current law, we will bring transparency to police deadly force cases and allow critical evidence to be presented during the inquest.”

How the hell does “allowing” jurors the option of saying someone used cops to kill themselves bring anything close to transparency to this process? Another obvious question: why the hell wasn’t this an “option” in the first place?

I’m glad the Missoulian’s reporter, Zoë Buchli, is TRYING to bring some clarity to this process, but failing to explain to readers that jurors would need to find law enforcement CRIMINALLY liable for a death will leave readers without the proper context to understand why 39 inquests since 2012 have ALL cleared law enforcement of CRIMINAL liability.

For MY reporting on coroner inquests in Missoula, here are some relevant posts:

Missing In Montana And My Cynicism On The Narrative Framing (November 17th, 2021)

If I Wanted To Kill Johnny Lee Perry, Here Is How I Would Set Up His State-Sanctioned Execution (April 29th, 2022)

WTF Is Going On Between The Jurisdictional Sheets Of The Missoula And Mineral County Sheriff Offices? (June 16th, 2022)

The real benefit of the Missoulian article is the official reminder of TWO officer-involved deaths that local authorities have been VERY mum about. I’ll quote the Missoulian article again first, then provide links to how I’ve tracked these cases after that. First, the quote (emphasis mine):

Vance Ledeau, 34, was shot and killed by law enforcement at the Smokejumper Center last August. He was reportedly a robbery suspect, though very minimal details were provided in the aftermath of the shooting about Ledeau’s death and the circumstances leading up to it. Nearly a year later, an inquest for Ledeau isn’t on the county’s calendar.

Gary T. Duncan, a 45-year-old Missoula resident, died from a gunshot wound at the Clinton Market in February, a news release from the Ravalli County Sheriff’s Office stated.

“Sheriff Holton said the coroner’s investigation concluded that the armed suspect/decedent displayed suicidal tendency and was ultimately killed by law enforcement at the scene,” the news release stated.

Ah, now the legislation is making more sense. By “allowing” the suicide-by-cop option, a new rationale for justifying officer-involved shootings has been codified. And this makes for better transparency how?

Instead of reading about pretend efforts by state legislators to improve transparency for the coroner’s inquest process, I suggest checking out MY posts about recent officer-involved shootings and the response by local authorities to local media. Here they are:

Is There A Rural/Urban Divide When It Comes To Local Law Enforcement In Missoula? (August 29th, 2022)

SPECIAL REPORT: You Know Something Stinks When The Missoulian Calls Out ALL Jurisdictions For Killing…Someone? (September 2nd, 2022)

Name Of Man Shot Near Airport Finally Released…But Not Much Else (September 14th, 2022)

On The Glacial Movement Of Information From The Missoula County Sheriff’s Office (November 3rd, 2022)

Does The Missoula County Sheriff’s Office Know What The Word “Deescalate” Means? (February 20th, 2023)

If you appreciate my local reporting, Travis’ Impact Fund (TIF) is one way to support my work, and the donation button at my about page is another.

I’ll note here, at the end, that I’m writing about officer-involved deaths on the day I’m celebrating the THIRD year of leaving the alcohol-involved death-path I was walking when the psychopath class showed their hand three years ago. I may be nowhere close to having my shit together, but at least I’m not still guzzling box wine!

Thanks for reading!

About Travis Mateer

I'm an artist and citizen journalist living and writing in Montana. You can contact me here: willskink at yahoo dot com
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4 Responses to Montana’s Coroner Inquest Process Is Terrible And This Year’s Legislative Action Only Pretends To Make It More Transparent

  1. This is a long-time concern of mine, though we might approach it differently. Seven or eight years ago I researched the death of John Denver, my conclusion was that it was faked. I wrote a long piece but won’t link, as I am not advertising. An ex-military guy, Norman G. Hicks, served as both sheriff and coroner of Monterey County. That is both staff and line, that is, the coroner should be keeping tabs on the sheriff (staff), making sure that every death is as reported. When one guy serves both functions, it can get messy.

    I suspect Monterey County was selected for the staging of Denver’s death because it was understood that Hicks would go along and no one would check up on him.

  2. Travis,

    Congratulations on your three year anniversary of gaining a victory over the “red, red, wine”. You may not have your shit together (yet), but this is a good step toward that goal.

    Carry on, my friend. You’re doing fine.

  3. Coroners inquests are a joke. The county attorney presents what evidence he wants and what witnesses he wants. In my brother,Cole Stump’s inquest they did have either witness who was there giving my brother a boost for a dead battery on a car he was working on. Nor did they show the complete video (not sure if they cropped it out or enlarged it) to not show a person changing next to a police unit while officers are walking around. Officers got called for suspicious activity but Cole working under a hood of aa car was more suspicious than a person changing next to a police unit? A person who was never mentioned that walks up to the scene of where Cole was killed right before it happens. nor was that part of the video shown to the jury only on the back tv’s that the public could see. The county attorney also never mentioned that they had shell casings from different locations (hospital and alley) were marked using the same evidence markers. As for the coroner as far as I know all wounds are to be documented but a major one they didn’t mark was a bullet graze on his top right shoulder. Also how are 4 officers not able to control one person but yet have his head between one officers knees before he fires two contact shots into Cole’s head. County attorney acts more like a defense attorneys then a presenter of all facts.

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