Journalism in the Public Interest

California County Opens Review Into Autopsies by Doctor With Checkered Past

Our investigation describing the troubled career of forensic pathologist Thomas Gill prompts officials in Northern California to re-examine his work in more than two dozen homicide cases.


Dr. Thomas Gill at the Jackson County Medical Examiner’s Office in Kansas City, Mo., in 2004. Solano County, Calif., where Dr. Gill performed autopsies while working for Forensic Medical Group, is now reviewing more than two dozen homicide cases in which Dr. Gill performed the autopsies. (Michael McClure)

March 3: This post has been corrected.

Officials in Solano County, Calif., are reviewing more than two dozen homicide cases in which Dr. Thomas Gill, a forensic pathologist with a 20-year history of errors and misdiagnosed causes of death, performed autopsies.

The review was prompted by stories published earlier this month by ProPublica, PBS "Frontline" and NPR, in partnership with California Watch and the Investigative Reporting Program at UC Berkeley, that described Gill's troubled career.

Solano County Sheriff Gary Stanton said today that his staff is checking Gill's written autopsy reports for inconsistencies and possible inaccuracies. Gill conducted more than 300 death investigations in Solano County from 2007 to 2009, financial records show.

"We just want to make sure that what we presented was accurate," Stanton said. "We want to make sure that we didn't withhold any information that should have gone to any defense attorney."

The Solano County review was first reported this morning by The Reporter newspaper in Vacaville. (And here is coverage by California Watch.) 

Solano is the second California county to initiate a formal inquiry into Gill's work. Yolo County, whose sheriff barred Gill from performing autopsies for his agency in December after learning from reporters about his past, is checking Gill's findings in five homicide cases.

In our investigation, we described how Gill repeatedly resurrected his career despite the trail of problems that followed him from Indianapolis to Northern California to Kansas City, Mo. In 2006, the California State Bar called the doctor "incompetent" in a report on a bungled homicide investigation in Sonoma County.

Most recently, Gill worked for Forensic Medical Group Inc., a private autopsy firm that holds contracts with more than a dozen jurisdictions across Northern California. The firm cut its ties with Gill at the end of last year, saying that it no longer had enough cases to justify employing him. Doctors with the firm did not return calls for comment on the Solano county review. Previously, in a written statement, the firm said it was "not aware of any significant errors in Dr. Gill's work performance or reports" for them.

Gill, 67, also did not immediately respond to calls for comment today. In a written statement for our earlier report, he acknowledged he had made mistakes early in his career, when he lacked formal training, but he defended his more recent work, saying his findings had not been contested or reversed since 2007.

Stanton said he alerted Forensic Medical Group to an inaccuracy in one of Gill's reports in 2008.

An autopsy assistant discovered a spleen left behind in a morgue sink after Gill finished autopsying the body of an inmate who died in the California Medical Facility, a prison hospital. The organ was intact and had not been cut, Stanton said. When Gill submitted his report on the death, however, he wrote that he had dissected the spleen as part of his examination.

"I have a report that says he did," Stanton said. "I have a spleen that says he didn't."

The sheriff notified Forensic Medical Group of the discrepancy and asked that the firm no longer send Gill to perform its autopsies.

In 2009, Stanton said he hired Dr. Susan Hogan as Solano County's chief forensic pathologist, replacing the private company.

Hogan, who previously worked with Gill at Forensic Medical Group, will lead the review of Gill's autopsies, Stanton said.

Correction: This post mistakenly said that in 2009 the Solano County Sheriff hired Dr. Susan Comfort to be the county’s chief forensic pathologist. The sheriff hired Dr. Susan Hogan for the job.

Ryan Gabrielson is a reporter for California Watch. 

When presumably disinterested 3rd parties like coroners are incompetent, that’s a very scary situation.  The guilty go unpunished; the innocent get prosecuted.

Sad state of affairs. Isn’t it a bit strange to hire contract coroners? I think it would be optimal if we had the right to choose our coroner before we died. Gives me the willies thinking what a coroner could do to your body especially if he is unsupervised.

Having seen the PBS presentation, I’m further alarmed that he was hired time after time, with not apparent investigation of his past. That in itself may indicate a much more fundamental problem with quality of oversight of all state, county, & municipal services. Really scary stuff!

robert von bargen

Feb. 25, 2011, 2:20 p.m.

As a retired medical malpractice defense attorney, I can attest to the extent to which doctors are able to move from state to state or town to town and somehow escape their past.
I had the task of representing a young doctor who thought she was in a valid fellowship program, but the doctor who ran it had been disciplined and/or barred from practice in at least three other states.
The living can now check their doctor’s record at medical society websites.  Autopsy surgeons, however, have compliant victims who are unable to choose their doctor.

roberto glaubach

Feb. 25, 2011, 6:35 p.m.

I will state once more: phisicians records database MUST be federalized.That´s means that any health care practicioner past
(with or without departures from standards of care) must be able to be accesed by patients countrywide.We have to stop wrongdoer´s turism from state to state. Enforcement authorities have the responsibility of the managing of the licensees database updating and cleareance .The non-disciplination of wrongdoers wides dangerously the medical malpractice across the US territory.STOP ! Please,people dies due to the spurious veil of impunity given by many Medical Boards over single or gross departures cases.

robert von bargen

Feb. 25, 2011, 9:06 p.m.

Another example of the idiocy of the concept of States Rights in the 21st Century.  People die from bad doctors; from pollution from neighboring states, from guns bought in states with weak gun laws and from ignorance and poverty because some school systems don’t recognize basic scientific facts and graduates of their schools are ill equipped for modern living.

“Help us and journalists around the country by sharing your stories and experiences.”(link)

Suggestion: make the web form secure.

roberto glaubach

Feb. 28, 2011, 10:49 a.m.

Of course,people die from even many other causes like car crashes,tifoons,fire,aids,epidemics,starvation,ignorance,idiocy and/or stupidity to qualify or to avoid risks,etc etc. What I´m trying to say when I blame enforcement and medical boards about a lack of control and/or wrongdoings disciplinarian actions, is that a more rigorous action to control and suspend licenses of bad doctors can improve health care quality.I completely agree with the concept of “poor,bad or weak education” of many graduates,rather than that,a poor or weak updating of knowledge of some doctors with a big “ego” who believe that they know everything they need to care people,The health care system is polluded with bad docs as well as bad nurses.The true fact is that we are facing a corrupted network of spurious interests : Insurance cartels,medical associations and health care providers and,:corrupted politicians.I don´t mentioned legislators but….

IRoberto Glauback has stolen my thunder.  In an health (and death) care system driven by profit, everything must fall to the lowest possible standard.

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.

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