In 1991, 22 potential organ donors in Colorado were lost due to coroner refusal. This reflects a 41% loss of organ donors in Colorado based on 53 donors for the same year, which prompted Colorado Organ Recovery Systems to ascertain whether there was a national trend in coroner/medical examiner refusal of potential organ donors. A survey was developed to determine the release rates of investigators for the six most common scenarios that lead to organ donation. These surveys were mailed to each organ procurement organization in the United States and were returned by 55 (82%) of them. Coroners were found to release cases for organ donation approximately one-half as often as medical examiners. Child abuse (nonaccidental trauma) is the category least often released, with coroners releasing only 8% of the time, while suicide is the category most often released (still, only 54% of the time). Different investigators in the same areas are consistent approximately 72% of the time. These figures, when presented to a task force, initiated the development of a protocol for organ and tissue donation for coroners' cases in Colorado. Early results of the protocol include the coroners' release of six organ donor cases since its introduction.