We trust experts who take the stand to make the right call -- to provide insight into a situation so that justice can be served. But when it comes to America's coroners and medical examiners, even the most basic standards and qualifications are lost in a lack of oversight and funding.
ProPublica's A.C. Thompson along with our partners at NPR and Frontline have been investigating this growing problem for the past year and found startling results: Several coroners and medical examiners have made suspicious calls on cause of death that have allowed guilty parties to walk free. Autopsy staff have mislabeled or lost bodies. In 1,300 counties, coroners are elected by local voters -- and in many of those counties the candidates don't need to have any medical training.
"We need to require that doctors have their basic certification in the field of forensic pathology -- because right now they don't."
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Mike: Hi, I'm Mike Webb, and welcome to the ProPublica Podcast. Today, we pose the question, "What happens when you die?" We're not asking in a spiritual sense, or when you die of natural causes, or old age. We're talking about mysterious deaths, the kind where you need a coroner or a medical examiner to come in and help determine exactly what happened to you.
During the course of his post Katrina violence investigation, reporter A.C. Thompson found himself looking at one too many autopsy reports. In fact, his dealings with the New Orleans coroner, lead him to start looking into the ways counties and cities investigate death.
Over the course of a year, Thompson, former ProPublican Mosi Secret, and our partners at NPR and Frontline, pulled together information and data that revealed a vary disparate and dysfunctional system for handling death investigations.
Thompson, whose previous work led to the December 2010 convictions of three officers who worked for the New Orleans Police Department, joins us to talk about the Post Mortem investigation. Welcome to the podcast, A.C.
A.C. Thompson: Thanks for having me in the closet.
Mike: All right. I see CSI every week. And I see these deaths, and I see them solve them in an hour. Is there any semblance of that? Is that reality at all?
A.C.: What you should understand is how dramatically different CSI is from reality. And one thing is that the doctors who do this work, they hang out in the morgue. They don't go out into the field, generally. That's the first thing. They have staff that goes out there, but the doctors don't go out there. Two, they don't have all this amazing holographic technology that's like straight out of sci fi. They don't have any of that.
There are some very, very intelligent and very well trained doctors, but there are also a lot of doctors who, frankly, aren't that well trained, and haven't even passed their board exams in forensic pathology.
In a lot of places, they don't even really have facilities. They're operating out of basically makeshift facilities. So, like in New Orleans, they have so little room to work there that they have the bodies stored in tractor trailers behind the facility, which is a converted funeral home. The next thing to understand is most of these people are not attractive and super well attired.
Mike: OK. All right. What exactly does a coroner or medical examiner do, and what's the difference between the two?
A.C.: That's a great question, because there's a lot of confusion about this. They're very similar roles, and they're fulfilled by very different people. So, a coroner is typically a county position, and in many places it's elected. In 1300 counties across the country, the coroner is elected.
It varies from state to state, and county to county, but in a lot of places the coroner doesn't actually have to be a doctor, or have any medical training. So, in California, for example, 48 sheriffs are also the coroners. And they get elected every four years, and they also serve as the coroner.
Mike: And they only have police training I assume?
A.C.: Exactly, exactly. In Nebraska, county prosecutors across the state are also the coroner. So, their training is in law, not medicine. So, it varies widely. In some places, coroners actually are doctors, but for the most part they tend not to be forensic pathologists. And those are the doctors who specifically deal with death.
Mike: OK, medical examiners.
A.C.: Medical examiners do the same thing. They oversee death investigations. They tend to be responsible for supervising autopsies, and at the end of the day, finalizing the death certificate, and saying, "Hey, this is how this person died." But, medical examiners are usually doctors and they're usually forensic pathologists, and they're usually appointed by county or state government.
So, on the one hand, you have coroners. And the coroners, they're overseeing, supervising the autopsies. They're running the coroner's office. They're doing the death certificate. They're saying, "This person died this way" based on the autopsies that doctors are doing for them.
In a medical examiner system, the chief medical examiner is doing all that stuff, but he or her will have the expertise to actually do an autopsy if they need to, to double check an autopsy, or to review the work of their doctors and say, "Hey, I don't know about this. Why don't you run one more test?" And so, they're experts in the field. That's the basic distinction.
Mike: OK. And I thought it was interesting that a lot of people in your story had to go out and hire their own person to do the investigation. They had to spend their own money.
A.C.: Yeah. That is a phenomenon that you see in certain jurisdictions, where people do not have any faith in the coroner or medical examiner. So, those are pretty rare. But, in New Orleans, they become very, very common.
And so, anytime somebody dies at the hands of police or at the hands of the sheriff's department, their families’ going to consider, "Hey, perhaps we should get a second autopsy" because in case after case in New Orleans, the first autopsies have proven to have errors, oversights, or questionable judgments.
Mike: Well, that was one of the things that really got me about your story, because justice really hangs in the balance based on the work that these guys do. So, for instance, you wrote about a woman in Oklahoma whose death was ruled a suicide. Why don't you tell us about that case?
A.C.: So, in Oklahoma... Oklahoma, as a general rule, the state medical examiner's office, which deals with all suspicious deaths in the state, they do not autopsy suspected suicides, or people killed in suspected murder-suicides situations.
Mike: How can that be?
A.C.: Well, you know. What it is, a lot of states, it says explicitly in the law, "Hey, if there's a suicide, we need an autopsy. If there's a violent death, we need an autopsy." Oklahoma's law has wiggle room, and it says, "You need to investigate these kinds of deaths." But, that can be construed to mean, you can send somebody to the scene, but you don't need to do an autopsy.
Now, they don't do autopsies, frankly, because they don't have money. They don't have enough money to do them.
But for now, the state ME's office is saying, "Hey, look, we're short three forensic pathologists. All of our doctors are overloaded. We have a fair amount of suicides, a fair amount of drug overdoses. We can't autopsy all these people."
The other kinds of cases they don't do in Oklahoma are cases where if you're 40 or over, and you die without an obvious cause, they will not autopsy you. Typically, they'll take your blood, and they may check it for drugs, but they don't autopsy you. And so, what that means is, it's possible that people are dying of diseases that would be good to know about, because it could be an emerging disease trend.
They're dying of things that would be really good for their family to know about, because it could be a congenital factor. Or they could be dying of foul play, and it's not getting picked up. Now, you know, people who have obvious bruising, and they got a hammer mark in their heads; they're going to get autopsied, hopefully, in Oklahoma. But people, you know, more borderline cases won't.
In other jurisdictions, suicides definitely get autopsied, because there's the fear that a suicide could actually be a murder.
Mike: A murder in disguise.
A.C.: And that has happened before. It happened in Texas in 1979, where a murder suicide got written off as a murder suicide, and in fact it wasn't. It was a double murder. So, these things happen. And with the 40 year old and up people not getting autopsied; other places put that cut off line more at around 60. Hey, if you drop dead. There's no obvious cause, and you're 60 or over, we're going to figure that it's just some old people stuff.
If you're younger than that, we want to know, because it could be any number of things we need to know about. Oklahoma—no money, so they just don't do it.
Mike: I'm thinking about insurance companies. It's got to impact the payouts that they make.
A.C.: This is the thing that's really important, and it's hard for people to understand sometimes. Jeffery Jentzen, who's an expert in his field, and he wrote a book called "Death Investigation in America." He told us, he said, look, you need to understand. Controlling the cause and the manner of death in America gives you political power. And that is an important thing to understand.
So, it has ramifications in a criminal case. If you say something is a homicide, someone is going to get prosecuted. If you say it's not a homicide, they won't be.
Mike: No one looks into it.
A.C.: And in the same way, there's all kinds of other issues. If you say something's an accident, there may be an entirely different response from the insurance company if there's life insurance, then you would get if it is some other class of death, like suicide. So, yeah, these are very important things to determine accurately how people die.
Mike: OK. I want to talk about another case. What happened with Ann Goyette and Susan Anderson in Massachusetts?
A.C.: So, this goes back a few years in Massachusetts. And Massachusetts is another state medical examiner system. They deal with all the suspicious deaths in that state. It's been a very troubled system for a long time. For the last 10 years, there's been one audit and one investigation after another finding problems there.
It's starting to turn around at this point, but it's definitely still under funded below what it should be. So, go back with us a few years. Ann Goyette and Susan Anderson are friends, and they live in Gloucester, and a house fire breaks out right around Christmas.
The medical examiner gets one of these women at its facility, because she's dead, and the other woman winds up in the hospital – Massachusetts General Hospital – covered in bandages, with all kinds of medical apparatus around her, and they make a mistake. The medical examiner thinks that Ann Goyette is the woman who lived, and Susan Anderson is the woman who died.
But, in fact, the woman who was in the cooler at the medical examiner's office was Ann Goyette. So, Ann's family is at the hospital. And they can't really see her because she's wrapped up in bandages, and she's in a coma, and she's surrounded by an oxygen tent. And they think, wow, this is terrible. But at least she might come out of this.
Mike: She's alive. Right.
A.C.: But when the woman woke up from the coma, it was Susan. And Ann Goyette's family said, “Oh my goodness. What has happened here?” And by the time they found out, the medical examiner's office had already cremated Ann's remains. And so her family said, “Look, we never wanted to cremate her. We wanted to bury her whole body. And she had died by fire. And we felt like that's a horrible, violent way to die. And to be cremated is a horrible, violent way to pass on, as well.” So, they were very distraught.
And those kinds of problems are things that have cropped up over and over in Massachusetts. So, we got documents, for example, that showed in 2009, the Worchester office of the ME operation, that they had lost track of every blood and tissue sample in their facility. They didn't know whose sample belonged to whom. And they had a corpse in the cooler with no tag or ID on it. This is the kind of problem that they continue to have there.
Mike: Can you tell me about another outrageous case?
A.C.: I really think that for me, Louisiana, Mississippi, that's the heart of it. And like you said, that's where it started for me. Here's why. Over a 20-year span, you had cases in New Orleans, and at least one case in Mississippi, where a doctor, Dr. Paul McGarry, was doing autopsies, and he was not documenting key injuries, significant injuries.
And in each of these cases, the people had died after an encounter with the police or with the sheriff's department. And the net effect of Dr. McGarry's autopsies was to let the police and the sheriffs off the hook. And in some of these cases, we're talking about Raymond Robair. Raymond Robair died in 2005. And when Paul McGarry does his autopsy, he says, “Oh, I think it's an accident. He died of internal bleeding from having a badly damaged spleen.”
His family hired a second pathologist to do a second autopsy. And this doctor says, “What was going on here? There are 23 bruises on Raymond's arms and legs. One of them is more than a foot long on his thigh. I don't think that that is the result of an accidental fall, which is what Paul McGarry thought. I think this is what happens when somebody beats the crap out of you. And I think this is a homicide.”
After five years, the federal government picked that up and they said, “We think it's a homicide too. We're charging these cops for killing Raymond Robair. We're charging one for allegedly beating him to death, and one for allegedly helping to cover it up.” But, for five years, there was a big question about whether there would ever be real investigation into Raymond's death because of what went on in the coroner's office.
When you see that, that looks like evidence not of an accidental fall to the concrete randomly that lacerates somebody's spleen, breaks their ribs and kills them. But, it looks like they got, whooped up on, and it looks like they got murdered. And so, when you see a doctor who doesn't note these kinds of injuries, you say, what's going on here?
Mike: Yeah, you have to ask questions.
A.C.: And the problem with Dr. McGarry, is that we saw this over and over again in both Mississippi and Louisiana.
Mike: Was he ever reprimanded or prosecuted for his work?
A.C.: Here's the thing is that this is kind of a vortex in American medicine and law. There is very little oversight. There is very little supervision of these doctors. So, I can only think of a handful of cases in the country where somebody that does autopsies for a living lost their medical license because of malpractice. There's very, very, very, very few of these cases. Very few.
And for Dr. McGarry, he's never faced any serious sanction that we're aware of. And this pattern, like I said, it's been cropping up for at least 20 years.
Mike: OK, so we've established that doctors, that they all have very different training. And you've talked about some of the problems that have existed or that you reported on. How do we make it better?
A.C.: People keep asking me that, and they seem to think that this is like going to the moon or something, that this is like a space mission.
Mike: The great American challenge.
A.C.: And really, it's not that hard. The government is never going to spend this kind of money in a terrible economic climate to do this. And I actually think that's ridiculous. We need to require that doctors have their basic certification in the field of forensic pathology because right now they don't.
We looked at the 69 largest coroner and medical examiner offices. And we found that, one out of five doctors didn't have their certification. They couldn't prove that they actually had been trained in the field of death investigation, of death mechanics, and could pass their board tests to prove that.
Now, the National Academy of Sciences, they did a big report on forensics. And one thing they said is, "Hey, look, we've got to get rid of these coroners. We can't have elected officials who are at the whims of the voters, and powerful blocs, making these decisions. You need to be a doctor to do this. And specifically, you need to be a doctor who knows what he or she's talking about." That's a bigger challenge. That will take some money and take some time.
That means we need to have somewhere around 13 to 1600 new doctors doing this work in those locations. But, that eventually is what we're going to have to do.
Mike: OK. And then you also mentioned oversight.
A.C.: So, there are no federal standards. There are no national standards for how to do this. Senator Leahy, Patrick Leahy, has a bill now that would put together a panel to consider standards in this field. Another thing that's been proposed, the National Academy, said, "Hey, look, we need to create a National Forensic Science Center that will create standards for, and guidelines, for all the forensic sciences for DNA, for fingerprints, for bullets, for cutting up dead people." And that's probably not a bad idea.
Mike: Alright. Well, A.C., thank you so much for joining us.
You can read the Coroner's Investigation at ProPublica.org/postmortem, that's one word. And you can find links to the Frontline documentary, the NPR stories, and the reports from the investigative reporting program at UC Berkeley Graduate School of Journalism there as well.
This week, our favorite quote from our "Officials Say the Darndest Things" Tumblr is, "Millions of people in Cairo are in an uproar. Rumor is they heard our new spring collection is now available online."
Who said it? Kenneth Cole, via Twitter, to direct attention to his new spring collection. He has since removed and apologized for the tweet.
You can see other choice quotes at officialssay.tumblr.com.
That wraps it up for the podcast this week. It was produced by Minhee Cho. Thanks for listening. For ProPublica, I'm Mike Webb. We'll catch you next week.