Looking into the high number of deaths classified as “natural deaths” by the coroner or medical examiner prompted me to seek more information on how this process of determining post mortem death causes are determined and what scientific methods are used to conclude such a findings. Needless to say, I was shocked to find out there is a significant difference between a medical examiner and a coroner. First the procedure of an autopsy consists of the dissection and evaluation of a corpse, and begins with the close scrutiny by a physician for visible injuries. A traditional Y shaped incision in the body allows a close study of the internal organs with weight of each organ taken. Looking for cause of death, many things can be revealed during such a process and eventual listing of cause of death is recorded on the death certificate. “The qualifications of those who oversee death investigations vary widely from state to state — and, in some areas, from county to county. But the main divide is between medical examiner systems, run by doctors specially trained in forensic pathology, and coroner systems, run by elected or appointed officials who often do not have to be doctors.”
Following several articles written by ProPublica, PBS Frontline and NPR it became clear that the procedures are not always conducted the way they should be. In fact, it is fair to say that there are many innocent people sent to prison because of serious mistakes made by doctors in some of our nation’s morgues as well as contaminating some cases so badly, a second autopsy would not help prosecutors deliver their cases. Identified as being conducted “superficial” in mannerism, these autopsies are flawed in many ways. As of this day, there is an extreme shortage of pathologist and because of this shortage; there are states that are employing doctors who have flunked their medical board exams to fill these jobs. Uncertified doctors [didn’t know there was such a thing] exist and are employed by county offices in Florida, Michigan, Pennsylvania and California. There are many more counties that employ such persons but the list in too long to list. In many places “the person tasked with making the official ruling on how people die isn’t a doctor at all. In nearly 1,600 counties across the country, elected or appointed coroners who may have no qualifications beyond a high-school degree have the final say on whether fatalities are homicides, suicides, accidents or the result of natural or undetermined causes.” A survey of more than 60 of the nation’s largest medical examiner and coroner offices by ProPublica, PBS “Frontline” and NPR found 105 doctors who have not passed the exam — or more than 1 in 5 doctors on their full-time and part-time staffs. “The qualifications of those who oversee death investigations vary widely from state to state and, in some areas, from county to county. But the main divide is between medical examiner systems, run by doctors specially trained in forensic pathology, and coroner systems, run by elected or appointed officials who often do not have to be doctors”
Case in point was one particular coroner examiner who in at least three instances since 2005, found disputable conclusions related to those cases where people died in the custody of police officers have been challenged by doctors brought in to perform second autopsies. In each case, this particular examiner had findings that cleared officers of wrongdoing. In 2006, this same examiner autopsied a 21-year-old man who died in jail in Gulfport, Miss. He determined that this person had been killed by a pulmonary embolism, a blood clot in the lungs, based on evidence of internal bleeding. Again, another specialist brought in to do and found injuries that the examiner had not: abrasions on the forehead and chest, as well as half-dozen bruises on his legs and hands. The doctor concluded that this person had been strangled. The other specialists concluded the deaths were homicides. In this particular case where the coroner ruled the death an accident, a rare second autopsy revealed four broken ribs that had been missed, internal hemorrhage was not detected and other noted mistakes were recorded.
Some cases revealed “half-autopsies” that were incomplete yet a finding was documented for cause of death on the death certificate. Persons interviewed during this investigation made it clear that these coroner systems come in many different shapes and sizes with minimal budgets to do their jobs. Some are insulated and appointed by county commissioners that makes the position very political and subject to the desires of the county elected officials. Some admit the presence of undue political and law enforcement pressures to resolve cases in manner that closes the matter at hand. “Because of the grueling pace, the state has had to impose limits on the types of cases it investigates: Oklahoma typically does not autopsy possible suicides or alleged murder-suicides. In most instances, it does not autopsy people age 40 or older who die of unexplained causes. “If we did an autopsy on every suicide, it would be all consuming, as with drug overdoses,” said Cherokee Ballard, the office’s chief administrator. “With suicides, we don’t autopsy most them because it’s an obvious cause of death.”
The National Academy of Sciences delivered a plan to Congress to improve troubled coroner and medical examiner operations. In its 2009 report, the academy called for the creation of uniform federal standards for death investigation and recommended making certification mandatory for doctors working in the field of forensic pathology. At this point, little or no headway has been made in the Congress to improve these operations and the creation of national federal standards for death investigations. Thus, in the meantime a “dysfunctional system that quite literally buries its mistakes” will exist to practice unless Congress takes the time to change the way it does business inside these icy cold morgues throughout the country.