Scattered death data, missing records in Texas justice of the peace investigation

By Dalton Huey

AUSTIN (KXAN) – "Should the decision to call for an investigation in the cause of an unnatural death be placed in the hands of a public official or in those of a person who is trained in the medical profession?"

The Odessa American published those words more than 60 years ago.

The 1963 covered a "hotly disputed" question in Texas about whether a justice of the peace should have authority to determine the causes of "unnatural" or "questionable" deaths. Most of Texas' 254 counties still use the elected role in death inquests instead of medical examiners – which exist in only 14 counties.

But recent reporting and academic studies related to justices of the peace and unnoticed murders and suicides , flawed COVID-19 death findings , unidentified migrant remains , nursing home foul play and oversights with state death data suggest the newspaper's decades-old question lingers today.

KXAN's reporting into this issue began with a cause of death determination by a Burnet County justice of the peace in 1965 and led to a statewide investigation into a system that has existed in Texas for 200 years.

Over nearly a year of research, our team faced challenges obtaining death records and tracking cause of death data to analyze potentially-concerning trends.

Burnet County records from 1965

In 1965, 13-year-old Daynon Lewis was found dead with her knees on the ground, hanging by a jump rope tied around a rafter in a small shed behind her home in Marble Falls, newspaper archives detailed.

She was buried less than 48 hours after the discovery. A week later, a Burnet County justice of the peace ruled her death an accident without ordering an autopsy, according to her death certificate.

Because that justice of the peace, the sheriff and many others who might have had first-hand knowledge of the investigation into Daynon's death have also since died, KXAN initially hoped to rely on records from the investigation to provide a better understanding of this case.

Texas' record retention laws require justices of the peace to file death investigation case records with the district clerk's office. However, it wasn't until 1987 that those records were made "permanent." Prior to this law change, justices had the option to destroy the records once they were filed with the clerk's office.

Regardless, KXAN submitted record requests to the Burnet County sheriff, district clerk, the justice of the peace, as well as with the Texas Department of Public Safety, which KXAN learned was initially involved in Daynon's death investigation.

Our request required the Burnet chief court clerk to take bolt cutters to an off-site location where archived records were stored.

Records related to Daynon's death, as well as others from the 1960s, were nowhere to be found. The clerk couldn't say exactly what happened to these records but told KXAN they were likely lost or destroyed in a natural disaster.

As a result, KXAN's investigation into Daynon's death and historical death data in Burnet County required extensive newspaper archive research both online and in library archives, as well as combing through thousands of death certificates from 1964 to 1996.

KXAN found 135 deaths in Burnet County during this timeframe that were classified as either homicide, suicide, accidental or unknown. Nearly half were determined without autopsies performed.

Statewide death investigation records

The majority of death investigations in Texas are conducted by justices of the peace , elected officials with little to no background in the medical or forensic field, who are on call 24/7 to respond to a death in their precinct.

If justices determine an autopsy is necessary – a decision they make at their own discretion – they can have the bodies sent to other counties with medical examiners .

With around 900 justices of the peace in Texas, KXAN endeavored to gather comprehensive statewide data to investigate possible trends in cause of death rulings, how often autopsies are performed and potential problems or errors that required death certificates to be amended.

KXAN first sent a mass email to every justice, asking them to provide the number of death investigations they had conducted, the number of deaths referred to a medical examiner for an autopsy and records of death investigations where changes to the original death certificate had to be made since 2019.

Responses from justices across Texas began pouring in.

With the exception of a small handful of justices refusing to fulfill our requests – citing Texas Government Code §552.003(1)(B) , which states the judiciary is not subject to the Texas Public Information Act – the majority of responses KXAN received were helpful and informative.

However, it quickly became apparent the information we requested would be more challenging to obtain than previously anticipated.

KXAN learned Texas law requires death certificates to be submitted within 10 days of a death regardless of whether a determination on cause of death or autopsy is complete. This meant nearly all deaths sent out for an autopsy required the filing of a medical amendment simply because the results of an autopsy or toxicology report are rarely complete within the 10-day timeframe. Since amendments are common, it's hard to use them to track ones related to changing a cause of death or making corrections.

Secondly, a common theme emerged from numerous justices, especially those in smaller, rural counties – fulfilling our requests would be "almost impossible" given their resources, manpower and lack of automated record-keeping.

Processing our request "would substantially and unreasonably impede the routine operation of the court," multiple justices said.

Regardless, some justices mailed paper copies of the records KXAN requested. One justice from a small East Texas border county even sent hand-cut redactions of her inquest records.

After speaking with numerous judges and fielding questions about our requests, KXAN learned of a statewide database where the information sought might be maintained.

State electronic death registry

In 2019, the Texas Department of State Health Services implemented a new electronic death registration platform called the Texas Electronic Vital Events Registrar or "TxEVER ."

KXAN reached out to DSHS and obtained data for the number of deaths certified by a justice of the peace for each Texas county since 2019.

Of the Texas counties operating under this system, justices have medically certified over 140,000 deaths since 2019. Justices of the peace in only 20 counties completed nearly half of all the death certifications in Texas.

Although beneficial, the data KXAN obtained still had its limitations because we didn't have context for the specific precincts within each county. It also didn't provide details about what caused these deaths.

According to the Texas Constitution , every county in the state is required to have at least one and up to eight justice of the peace precincts, depending on the county's population. As such, KXAN faced yet another challenge in tracking trends and analyzing justice-specific cause of death data.

KXAN reached back out to DSHS to see what options were available to obtain more comprehensive data.

Texas' 25-year statute

Knowing the information we needed was maintained within the TxEVER database, KXAN requested data showing a decedent's name, date of death, county and listed cause of death for every person who died in Texas from 1965 to current.

Obtaining some of the requested data was possible, though KXAN was unable to get anything more recent than 1999, due to a Texas law making death records confidential until the 25th anniversary of the date of death.

The challenges didn't stop there because of a limit in data available from the state. DSHS' response to KXAN's data request was: "Our digitized records go back to 1989."

KXAN received 10 years' of Texas death data from 1989 to 1999 containing the identities of over one million people who have died with their associated cause of death.

Although unable to get comprehensive death records or data beyond 1999, the data we obtained was used in conjunction with various online public archive resources to gain insight into Texas' justice of the peace system, beginning with Burnet County, where Daynon died in 1965.

KXAN's David Barer, Richie Bowes, Arezow Doost, Eric Henrikson, Josh Hinkle, Robert Sims and Kate Winkle contributed to this report. Special thanks to Keith Mezger for use of his historic barn outside Marble Falls for this project.