Some death investigation units do a commendable job. While many coroners and medical examiners don't even have X-ray machines, New Mexico has a new facility equipped with a full-body CT scanner to help detect hidden injuries. Virginia has an efficient, thorough system, staffed by more than a dozen highly trained doctors. The autopsy suite in its Richmond headquarters is as sophisticated and sanitary as a top hospital.
Still, the National Academy of Sciences' study found far-reaching and acute problems. Across the country, the academy said, coroners and medical examiner offices are struggling with inadequate resources, poor scientific training and substandard facilities and technology.
Their limitations can have devastating consequences.
"You call a death an accident or miss a homicide altogether, a murderer goes free," said Dr. Marcella Fierro, Virginia's former chief medical examiner and one of the report's authors. "Lots of very bad things happen if death investigation isn't carried out competently."
A Series of Errors and Oversights
After Cayne Miceli died in January 2009, her body was brought to the New Orleans morgue, a dingy, makeshift facility in a converted funeral home, for Dr. Paul McGarry to autopsy.
An autopsy, the dissection and evaluation of a corpse, generally begins with a physician scrutinizing the body, noting visible injuries. With a scalpel, a doctor then slices a long, Y-shaped incision in the torso and studies the innards, removing and weighing each organ, and using a small rotary saw to remove the top the skull. An autopsy can trace the path of a bullet through a body, or reveal microscopic damage to blood vessels in the brain, or identify a lethal clog in an artery.
By the time Miceli's body was laid on the stainless-steel examination table, McGarry had performed such work for three decades in Louisiana and Mississippi. In New Orleans, he was one of several forensic pathologists overseen by the parish coroner, Frank Minyard, a trumpet-playing local legend who has held his elected office for more than 35 years.
Miceli, 43, had died after being held in a cell in the parish jail, bound to a metal bed by five-point leather restraints. During the autopsy, McGarry observed "multiple fresh and recent injection sites" on Miceli's forearms. He determined that drugs -- he didn't specify the variety -- had killed her, according to his report.
But doctors who had treated Miceli the day she died encouraged her father, Mike Miceli, to look more closely into his daughter's death. He had her body flown to Montgomery, Ala., for a second autopsy by Dr. James Lauridson, the retired chief medical examiner for the Alabama Department of Forensic Sciences.
Lauridson concluded that McGarry had misconstrued the needle marks on Miceli's arms. "In fact, all of the needle puncture marks were therapeutic -- drawing blood, IV's, that sort of thing," Lauridson said.
McGarry's finding also was contradicted by a central piece of evidence: a screen for drugs and alcohol didn't turn up either in Miceli's blood. McGarry had reached his conclusion days before he got the test results, records show.
Lauridson soon pinpointed the real reason for Miceli's demise. On the day of her death, Miceli had gone to the hospital to be treated for an asthma attack. She was arrested after an altercation with hospital staffers; Miceli thought they were trying to discharge her too soon, court records show. Peering at Miceli's lung tissue under a microscope, Lauridson was certain that severe asthma, combined with the way she was restrained at the jail, had caused her death.
"As I examined her lungs, it was very clear right away that her lungs and all of the airways were completely filled with mucous," he said. "To put an asthmatic flat and then tie them down during an acute asthma attack is nearly the same as giving them a death sentence."