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How to Investigate Coroners and Medical Examiners

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(Andres Cediel/Frontline)

Reporters covering the criminal justice system rarely look at coroners or medical examiners -- instead we focus on cops and prosecutors and defense attorneys and defendants.

I began to look more closely at the Tyvek-clad doctors who staff America's morgues when I started finding cases in which they made repeated errors, or failed to document obvious injuries or reached conclusions challenged by their peers.

The coroner or medical examiner in your area may merit the type of examination that could lead to stories.

Here are a few things I'd encourage you to scope out:

1. Look at the type of system in your area.

Death investigation systems falls into two broad categories. There are offices overseen by coroners, typically laypeople, who are often elected.

Coroners who don't have medical training rely on doctors to do autopsies for them. When the autopsy is complete, the coroner makes the final call on how somebody has died and signs the death certificate.

The other type of system is run by medical examiners. They play the same basic role as coroners, but are usually trained forensic pathologists who are appointed to their position by county or state government officials. Typically, chief medical examiners have experience doing autopsies.

If you're dealing with a coroner who doesn't have any medical experience, check if he or she is overruling or ignoring the doctors who do the actual autopsy work.

If you have an elected coroner, who supports the coroner come election time? Who does he or she rely on for endorsements, fundraising and getting out the vote?

It's important to remember that "controlling the determination of the cause and the manner of death gives you political power," as Jeffrey Jentzen, the author of Death Investigation in America: Coroners, Medical Examiners, and the Pursuit of Medical Certainty, told us.

2. Find out if your local morgue is accredited.

The National Association of Medical Examiners, a nonprofit group dedicated to improving the field of death investigation, inspects and accredits coroner and medical examiner facilities.

NAME has a long list of requirements for accreditation -- among them, that the morgue facilities have to be clean and functional and the doctors need to be properly trained.

Check to see if your local coroner or medical examiner operation is accredited. If it isn't accredited, find out why. Did the office fail its inspection? Does it have shortcomings that have kept it from even seeking accreditation?

For more information on accreditation, check NAME's site, at thename.org.

3. See how many cases doctors handle at your coroner or medical examiner offices.

A key concern of NAME is how many autopsies doctors are doing. The worry is that doctors start making errors start when they try to work too fast, or for too many hours in a row. The association recommends that doctors do no more than 250 autopsies per year, and 325 at the absolute maximum.

But there are doctors who do 400 or more autopsies on an annual basis. Find out if doctors in your area are taking on more cases than NAME says is advisable.

Caseload information should be public record in your jurisdiction, but be aware: Some offices can't -- or don't -- track autopsies on a doctor-by-doctor basis. That could be worth exploring, as well.

4. Check if the doctors at your coroner or medical examiner's office are board certified.

Board certification is like accreditation for doctors. To become a certified forensic pathologist, a doctor must complete a three-to-four year residency, do a year-long fellowship in a coroner or medical examiner office, and pass the forensic pathology board exam administered by the American Board of Pathology.

There are competent doctors who aren't certified, but experts in the field say certification helps to ensure that those doing autopsies understand the finer points of forensic pathology, the area of medicine that focuses on the mechanics of death. Some coroner and medical examiner offices won't employ physicians who lack certification.

For our Autopsies in the U.S.A. database, we asked large coroner and medical examiner offices whether the physicians were certified. The results were surprising -- even in these organizations, 1 in 5 doctors were not.

We also asked why doctors weren't certified. Some had just emerged from a training fellowship and hadn't had a chance to take the exam, which is only offered once a year. Others, though, had failed the test repeatedly. Others chose not to sit for the exam.

You can also ask the pathology board if a doctor is certified.

5. Make sure those doing autopsy work have medical licenses.

To perform an autopsy, a person must have a valid medical license, but I found cases in which non-doctors performed autopsies. Run names past the state medical board.

6. Look for errors and disputes.

Cases in which forensic pathologists' findings or diagnosis of cause of death become controversial can be great jumping off points for reporting.

There is no central place to find such cases, but there are plenty of ways to look for them. Talk to people in the legal community: prosecutors and defense attorneys, as well as civil lawyers -- particularly medical malpractice and civil rights attorneys.

Look for cases where defense lawyers hire experts to review autopsies or where civil attorneys bring in their own forensic pathologists to do second autopsies.

Also, check with independent forensic pathologists, those not affiliated with a local agency. Some offer private autopsy services, either examining bodies that have never been autopsied, or doing second autopsies on bodies that have already been dissected once. These doctors also sometimes review autopsy reports, photos, and slides, looking for errors or oversights. Keep in mind that paid experts typically are brought in by those on one side of a lawsuit -- their opinions should be considered in that light.

Another way to find disputes over autopsies is to check case law. If a judge or panel of judges finds fault with an autopsy, it may pop up in a search of court decisions using Nexis or Westlaw.

> You can also ask the pathology board if a doctor is certified.

FYI, this seems to cost $35, but for Calif. at least, the state medical board lookup (in CA,  http://www.medbd.ca.gov/lookup.html - then the “Physician information” tab ) will tell you freely.

And wasn’t there a 2nd organization doing accreditation, besides NAME? (I can’t remember where/if I saw this, & search isn’t turning it up.)

The 2nd organization providing professional accreditation is the International Association of Coroners and Medical Examiners.

Thanks E.
A good starting resource in Calif. is the “Coroners Personnel Resources” page, under oes.ca.gov at preview.tinyurl.com/4frur7q

And here’s the IACME (International Association of Coroners and Medical Examiners) accreditation page:
http://theiacme.com/iacme/accreditation.aspx

A caveat re my above “for Calif. at least, the state medical board lookup will tell you freely [of pathology board certification]” - this info’s self-reported, so I guess it’s the verification that’ll cost you.

Forensic Medical Group appears to have taken its website down, and when I called, neither man nor machine picked up.

Comment got eaten; apologies for the terseness of this replacement.

Gill - middle initial?  (presumably H, but…)

FMG-inc website listed him on staff as of last week; though PP story says FMG said he left in Dec.

Calif Med board website not helpful, reports no problems with Dr. Gill.

I very well know of a case wherein the coroner made a big mistake in a pre-maturely determination 0n the manner of death and questionable autopsy report,but got no help anywhere,no money,sothe cover-up from detectives and medical examiner office.No justice for 5 years now,exactly when Frontline report came out on Feb.1,2011.We need help from people who are just,who would not ask for up-front fee,but who would help us establish the truth and justice!

My sister died on June 5th, 2010 in Massachusetts. We requested an autopsy report and still have no results - eight months later. Whenever we aks the Medical Examiner’s Office for the report, they say it is not ready or not completed. I am out of patience and want to take the next step to get some answers but I have no idea what that step should be. Any suggestions?

For the statistics provided in this investigation on # autopsies, does this distinguish between internal and external?  (Is it still termed an autopsy if it’s an external examination only? this news story - http://placerherald.com/detail/152773.html - referred to them both as autopsies)

anyone have any info on lake co ohio coroner info?

DeathInstitute

Feb. 7, 2011, 4:41 p.m.

There are gross deficiencies in the current death investigation process within every state. We’ve been involved in the monitoring of the death investigation system in this country nationwide for 20 years; aggressively working with our clients to obtain information and outcomes they’re not only entitled to, but cannot obtain or are outright denied by those charged with the public trust. http://www.wrongfuldeathinstitute.com
This recent investigative report while needed, has merely touched the surface regarding the root issues involved with the coroner/medical examiner system and the far reaching consequences of incorrect death reporting& faulty death certification via the death certificate.  We specialize in the policies/procedures/rules and regulations in place within each death system as they square up with state statutes and effect outcomes for those in society & within the jail/prison system nationwide. 
There are numerous issues and information that were not brought up or reported on in these articles. 
For example: The comment made that “Coroners who don’t have medical training rely on doctors to do autopsies for them. When the autopsy is complete, the coroner makes the final call on how somebody has died and signs the death certificate.” 
Isn’t accurate. Whether he does/doesn’t is a net result of a relationship. Some coroners do not order autopsies at all.

Anna -
  In my jurisdiction ANY examination done by the pathologist (MD/ME) is considered an autopsy (full, partial, and external exams).

The Sheriff is an appointed Coroner in my county, so presumably the Sheriff’s Dept. helps him get elected!

If there were questions about a death in police custody, would it be up to private investigators, investigative journalists, or civil rights attorneys to provide objective analysis?

Kevin B. Weiss, MD

Feb. 10, 2011, 10:36 a.m.

I’m pleased to see this article notes the importance of having a forensic pathologist who is Board Certified by the American Board of Pathology (ABP).

ABP is a Member Board of the American Board of Medical Specialties (ABMS), the organization that has set the standards in physician certification for more than 75 years.  Board Certification by one of the 24 ABMS Member Boards is voluntary and demonstrates to the public that a physician has made a commitment to lifelong learning.  The physician’s knowledge and skills are then assessed to ensure high quality health care.

To find out if a forensic pathologist or other physician specialist is ABMS Member Board Certified, visit CertificationMatters.org.


Kevin B. Weiss, MD
President and CEO
American Board of Medical Specialties

After having seen the Frontline broadcast and read the articles in ProPublica I was struck by the fact that our local coroner (Rock Island County in Illinois) opted for a toxicology screen rather than an autopsy in the case of a man who was found dead in his car in the parking lot of a local mall.
It seems to me that this death would have been textbook for the latter.

FOIA process (& wording) for getting billing records?

It would be awfully nice if someone were still available for a Q&A…

If I order a Coroner’s report for a particular case#, will that include any autopsy, toxicology etc reports?  (or in ordering it have I asked for the wrong thing?)

A forensic path. company’s billing records for a county aren’t public documents?

(correction, it seems they are public)

This article is part of an ongoing investigation:
Post Mortem

Post Mortem: Death Investigation in America

A year-long investigation into the nation’s 2,300 coroner and medical examiner offices uncovered a deeply dysfunctional system that quite literally buries its mistakes.

The Story So Far

In TV crime dramas and detective novels, every suspicious death is investigated by a highly trained medical professional, equipped with sophisticated 21st century technology.

The reality in America’s morgues is quite different. ProPublica, in collaboration with PBS “Frontline”  and NPR, took an in-depth look at the nation’s 2,300 coroner and medical examiner offices and found a deeply dysfunctional system that quite literally buries its mistakes.

More »

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