This 2001 report by the North Carolina Medical Examiner Study Group was requested by the legislature in part in response to a series of news articles that raised concerns about the quality of death investigation in North Carolina. The report provides information about the structure and responsiblities of the Medical Examiner system and makes a number of recommendations for improving the system including improved training, utilization of trained death investigators, and assuring adequate resources for the performance of death investigation and autopsies throughout the state.