Real CSI: Patchy U.S. Death Investigations Put the Living at Risk

Only about 20 percent of coroners have forensics certification, and most face limited resources and large workloads, according to a new investigation















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In his view, laypeople are entirely capable of running a medical operation, noting that many hospitals are helmed by chief administrators who are more knowledgeable about finance than anatomy. "That model works well in hospitals all over the United States," he said.

Massachusetts: An Office In Turmoil
Hobbled by mismanagement and chronic underfunding, the state's Office of the Chief Medical Examiner has spent much of the last decade mired in disarray, its woes detailed in a succession of audits and reports.

At times, Massachusetts' forensic pathologists have toiled in disturbingly decrepit conditions. The National Association of Medical Examiners, a nonprofit body that inspects and accredits morgues, issued a blistering inspection report in 2000 identifying more than 50 significant problems at the agency's facilities. At one morgue, since shuttered, doctors were collecting blood, bile and other bodily fluids in 5-gallon buckets and pumping them back into corpses because a septic system had collapsed, making it impossible to wash the fluids down the drain.

"It was a terrible facility -- the worst I've ever seen," remembered the inspector, Dr. John E. Pless, an Indiana forensic pathologist, who said the practice posed "an obvious health risk."

Pless also concluded the office would need $10 million annually in additional funds to do its job properly.

The budget has nearly tripled in the past decade, but even today, it is $3 million below the threshold set by Pless 10 years ago. The agency has never regained its NAME accreditation.

The office has struggled with the most basic of tasks. In 2003, it mixed up the bodies of two women severely burned in a Gloucester house fire. The blaze killed Ann Goyette and injured her friend, Susan Anderson. But when Goyette's body was delivered to the morgue, a doctor mistakenly wrote the name Susan Anderson on the death certificate. In fact, Anderson, comatose, swathed in bandages and surrounded by an oxygen tent, was lying in a bed in Massachusetts General Hospital.

By the time the mistake was uncovered, the agency had cremated Goyette's body, further upsetting her already distraught family. "How could the ball be dropped so many times?" asked Goyette's brother, Scott Arnold, who unsuccessfully sued the state over the snafu.

A comparison of data from the nation's 17 statewide medical examiner systems shows that Massachusetts' autopsy rate has fluctuated wildly in recent years. In 2004, it had the second-lowest autopsy rate among statewide systems, doing just three autopsies for every 100 deaths. Utah, the state with the highest rate, performed 15 autopsies for every 100 deaths that year.

By 2006, under the direction of an ambitious new chief, the medical examiner's office was taking on far more cases and had brought its autopsy rate up to the average level for statewide systems -- to about six per 100. But the agency didn't have the personnel or facilities to handle the increase. Unrefrigerated bodies began piling up in the hallways, and blunders mounted.

John Grossman, who oversees the medical examiner's operations as the state's Undersecretary for Forensic Science and Technology, said the agency has made improvements since then. It has hired new medical staffers and developed safeguards against errors.

"I know we've made great strides in the last three years, putting systems in place so that the office is not on the verge of collapse, creating a culture where the doctors feel supported," Grossman said.



4 Comments

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  1. 1. JamesDavis 07:55 AM 2/2/11

    The old saying, "The dead don't lie", except in America. Sad, very sad.

    Reply | Report Abuse | Link to this
  2. 2. Didonai 06:31 PM 2/4/11

    Well, the coroner HERE in SowKlina is forensics certified. My luck. I guess I'll take my wife and visit
    another state with shoreline cliffs?

    Reply | Report Abuse | Link to this
  3. 3. Didonai in reply to stew6302 06:32 PM 2/4/11

    He spoke fluent FRENCH. So, what's YOUR PROBLEM?

    Reply | Report Abuse | Link to this
  4. 4. bucketofsquid 05:21 PM 2/7/11

    It is pretty sad when the only intelligent comment is from JamesDavis. On the positive side, it is nice to know that we can engage in wholesale slaughter and get away with it. If either left or right wing extremists gain significant power in congress, their supporters can be eliminated easily. An overwhelmed forensics system would be unlikely to find any real evidence.

    Reply | Report Abuse | Link to this
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