IMPACT OF A FAILING MEDICAL EXAMINER SYSTEM 1

Impact of a Failing Medical Examiner System on the Families of Victims

Skyler Prozor

College of Sciences, University of Central Florida

November 26, 2018

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Abstract

The following research, The Impact of a Failing Medical Examiner System, addresses the

impact on the families of homicide or suicide victims caused by faults in the U.S. medical

examiner system. The paper addresses three major issues that include lack of funding,

conducting autopsies in a timely manner, and incorporating proper training guidelines. The

research includes information from online sources as well as library database sources; because of

time and access limitations, the research does not include information from first-person sources

or research that is unreleased to the public. The research addresses the views of victims’ families,

medical professionals, and professionals involved with different outreaches of law. The results of

the research revealed that current solutions to the issues are few and temporary. Medical

professionals do not prioritize families as a fundamental issue to actively fix, but instead stress

the lack of funding to the system. Professionals involved with law were found to be rather

uneducated on the issue and much of the research from this perspective revealed the

incorporation of proper training guidelines. Potential future solutions include improving

facilities, funding training for medical examiners just starting in the field, revising and enforcing

autopsy rules, and placing more accountability into the hands of medical examiners for mistakes.
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Impact of a Failing Medical Examiner System on the Families of Victims

As a child, watching the television show NCIS would occupy much of my day to day

schedule. I was interested specifically in the television character, Ducky, who played the role of

a medical examiner. As I progressed through high school and began preparing for college, I

realized that the field of forensics and the medical examiner system was much different than the

shows on T.V. portrayed. The medical examiner system has been plagued from its start in 1918

with issues due to heavy caseloads and a limited number of professionals in the field. In the past

decade, the caseload for most medical examiners has spiked exponentially, mostly because of the

increased opiate overdose cases. Along with the issue of cases, the system experienced budget

cuts and, as an effect, an increase in the errors per case. According to a 2007 N.A.M.E. (National

Association of Medical Examiners) study, the state of North Carolina spent an average of $1.76

per person annually on death investigations, nearly half the amount that should ideally be spent.1

As I am currently pursuing a bachelor’s in forensic science with the goal of one day

becoming a medical examiner, I was drawn to researching a topic that could ultimately help

advance the field. Within forensic discourse communities that address issues with the medical

examiner system, there is a gap in which the families of victims are not addressed. Current

forensic discourse communities identify similar issues that are centered around lack of funds and

in turn backlogs of cases, seen in multiple offices across the country. The lack of address in

conversation of victims’ families prompted me to research more on the relationship between the

issues the medical examiner system faces and the effects of these issues on the families of

victims. Specifically, the research study addresses three major issues: lack of funding,

conducting autopsies in a timely manner, and lack of implicating proper training techniques.
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Background

The term Medical Examiner was first used in the U.S in Massachusetts in 1877, replacing

coroners in a few districts. The title of Coroner translated to an elected official who, most of the

time, was not a certified physician. The Medical Examiner system in the U.S. was created in the

year 1918, a century ago to date. It was not until the 1950’s, however, that Medical Examiners

were required to hold the degree of PhD.2 Due to the demanding nature of becoming a medical

examiner, the number of certified medical examiners at the time was extremely low. Only 1300

people since 1959 have been certified as medical examiners.2 With such an underfilled position

and over 150,000 cases of homicide, suicide, and unknown deaths annually; autopsies were

poorly conducted and underfunded. In an attempt, in the early 2000’s, to fix the start-up

problems that medical examiner offices faced, the National Association of Medical Examiners

created Forensic Autopsy Performance Standards. To date, very few offices are accredited

according to the Forensic Autopsy Performance Standards because of the issues offices still face.

With the issue of understaffing and case overloading came the connection of the cause and effect

relationship between the medical examiner system issues and the mental and physical effects of

those issues on the families of victims.

Theoretical Analysis (Methodology)

At the start of my research process, I had sought out to conduct my research through

three different mediums, personal interview, internet sources, and books and other published

scholarly research that were not otherwise easily accessible on the open web. The original UCF

faculty member that I had planned on interviewing, understandably, had a very busy schedule

and was ultimately unable to find time amongst our time schedules to do so. I began my internet

and UCF library database research with keywords that included ‘issues with the medical
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examiner system’, ‘questionable autopsy’ (uncertainties concluded in the examinations of

corpses), ‘family challenges to medical examiner conclusions’, and ‘fixing medical examiner

system’. All of which offered valuable information that would contribute to the background

information on the two topics; however, it did little to connect the two cause and effect ideas. I

shifted my focus towards searching for news articles and case examples of family’s suffering

because of incorrect death rulings, death certificate mistakes, and autopsy mistakes in general.

Through the sources I found through google searches and the UCF Library Database, I was able

to create three clusters representing major perspectives on the issue that either contributed to the

argument or a counter to the argument. After reading and evaluating the 30+ sources that I had

gathered, I began to eliminate sources based on relativity to the argument and the argument’s

counter. I had eliminated almost half of the potential sources I had gathered, and I was able to

read each remaining source more thoroughly, write down notes relevant to my research paper,

and decide in what area of my research the information would best fit into.

Results

After researching and analyzing each individual source, I was able to categorize the

sources into three major perspectives in addition to a few sources that offered background on the

underlying aspects.

Victims Families and Timely Autopsies

One of the three perspectives that emerged was that of families of victims who expressed

the mistakes medical examiners as a result of the untimely fashion of autopsies. This perspective

offered claims and facts that contributed to the issue of untimely autopsies and the large role it

plays in the effects on families of victims. In the case of Lorraine Young, North Carolina medical
IMPACT OF A FAILING MEDICAL EXAMINER SYSTEM 6

examiner Ronald Key failed to verify the identification of the corpse and sent the body to the

family of the assumed identity. Lorraine Young along with two other women had died in a car

crash, and the bodies were misidentified on the scene. Key based the identification of the body

off the responding police officer’s judgement. The family of Lorraine Young sued the medical

examiner’s office for the emotional stress the office had caused them, the family spent 5 years

worried if they had buried the correct corpse.3 The case of Loraine Young was one of the very

first cases in which a medical examiner’s office was held accountable for pain caused to a

victim’s family. The case was poorly rushed, and an autopsy was not conducted. Within the

medical examiner community, this case occurred shortly before offices began to address the

issues within the system.

Another case, located in Oklahoma City, highlighted again the issue of not conducting

autopsies in a timely manner. In the case of Joe and Donna Turner, daughter Shandra Turner had

been found with a bullet in her chest. The case was immediately ruled a suicide, and therefore

was not put through an autopsy and thorough investigation. The death certificate sent to the

Turner’s denoted the manner of death as suicide, however, without autopsy the Turner’s refused

to believe that. The couple fought long and hard for eleven years for an autopsy as they knew

that their daughter would not have committed suicide. Eleven years later, the new medical

director autopsied the corpse and found it to be a homicide framed to have looked like a suicide.4

In a more recent case, a young woman was hit and killed by a truck in Spanaway, Washington.

The staff at Pierce County Medical Examiner office identified Jade Peterson as Samantha

Kennedy. The family of Jade Peterson heard about the incident and called the examiner’s office

to make sure that the victim was not their daughter as they had not heard from her in several

days. The body a couple days later was correctly identified as Jade Peterson after being sent to
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the family of Samantha Kennedy, and the news was shared with the Peterson family. Both

families after the incident did not receive apologies and the situation was left unexplained.

Aubrey Peterson commented that “she deserves more”.5 All three cases exemplify the stress that

victims' families endured because the autopsies were either conducted late upon a court ruling or

not completed at all.

Medical Examiners and Underfunding

Medical examiners currently in the field collectively argued that the lack of funding was

the reason for most of their mistakes, but seldom addressed families in the matter of funding

issues. Current medical examiners in the field focus on speeding up autopsy times in order to

diminish the caseload and increasing funding for updated equipment and technology. In 2015,

Chief Medical Examiner Michael Hunter for San Francisco, California’s office drastically

decreased the time it took to conduct an autopsy and tackled many cases that had become

backlogged. Hunter steered away from doing extensive body searches on every body that came

through the office and instead focused on being selective with autopsy procedures. Hunter

claimed that by doing this, many families were given closure.6 However, this ‘fix’ is a rather

temporary one, and by speeding up the process of conducting autopsies, there is an even greater

possibility of errors. Hunter’s solutions had critics, who believed that his methods could be

moving in the opposite direction of fixing the mistakes. In the state of New Jersey, in the past

few years two of the state’s top medical examiners have quit simply because of the lack of funds

and little power to fix that issue. According to medical examiner standards, the state of New

Jersey should be spending 31.5 million dollars a year in order to effectively run all the offices in

the state. Currently the state is only allocated 26 million dollars in funds.7

Lawmakers/ Law Enforcement and System Guidelines

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Lawmakers and law enforcement ultimately decide how the medical examiner system

changes and the budget that they receive. Lawmakers sympathize with families in the cause and

effect relationship surrounding my research. A retired law enforcement officer out of New York,

who worked closely with medical examiners, recognized the suffering that families went through

and had a hand in passing a law in their favor. The law that got passed made NAMUS (National

Missing and Unidentified System) public and accessible to all and required that all unidentified

corpses be entered by medical examiner offices within a 60-day period.7 The law offered a small

solution to a much bigger problem, but it was one of the very first state laws regarding Medical

Examiners that was in the interest of families rather than the medical examiner. In the article

“Lawmakers Address Need for Improvement in Medical Examiner System,” Senator Tommy

Tucker and Senator Don-Davis comment on the legislation that was passed in 2001, but

ultimately failed. The senators were focused on bringing the North Carolina offices up to

standards, however, addressed the difficulty of finding and training new medical examiners.8

Discussion

According to my research, families of victims, medical examiners and lawmakers/ law

enforcement all agree that medical examiners make mistakes and that these mistakes lead to

mental and physical distress on victims' families. The reasons for the mistakes are found in

different areas: Medical examiners insist that lack of funding is the cause of the mistakes offices

experience, lawmakers / and law enforcement representatives argue poor training and execution

skills along with a lack of following standard protocols is the major cause, and the families of

victims blame the untimely manner of autopsies or the lack thereof.

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Families of Victims Lack of time allocated

to autopsies

Mental and
Medical physical
Medical Examiners Lack of funding Examiner distress on
Mistakes victims’
families

Lawmakers/ Law Undertraining/ lack of

Enforcement enforcing proper
techniques

Bias plays a large role in proposed solutions and importance of issues. Solutions to the individual

issues are rather different, however, in some cases Medical Examiner offices have attempted to

fix some of the issues by attempting to get rid of backlog by speeding up autopsy processes

whereas others have petitioned for greater funds to update equipment, technology, lab space, etc.

Currently solutions to this issue are only short-term, however, examples of suggested future

solutions include finding ways to attract more students to the field of forensic pathology through

increased wages, improving facilities, funding training for medical examiners just starting in the

field, revising and enforcing autopsy rules, and placing more accountability into the hands of

medical examiners for mistakes that have such a large impact. One of the greatest issues I found

with the lack of improvement with the issues the system faced was due to the countless laws and

regulations that safe guarded medical examiners from nearly all mistakes made. Potentially, by

making the work of medical examiners more transparent and passing laws and regulations that

place accountability into the hands of medical examiners, along with allotting more funding for

facilities and drawing individuals into the career, the likelihood of mistakes by medical
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examiners will greatly diminish and in turn the cases of family suffering due to mistakes by M.

E’s will as well. Research into the regulations governing medical examiner offices, as well as

training and qualifications for M. E’s by state can greatly contribute to targeting current

weaknesses in specific laws or practices that could be altered in hopes of moving towards

solutions contributing to the argument of my research.

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References

1 Charlotte Observer. In NC medical examiner system, heavy autopsy

caseloads raise risk of mistakes. https://www.charlotteobserver.com/news/special-

reports/nc-medical-examiners/article9092573.html (accessed Sept 18, 2018).

2 National Academies. An Overview of Medical Examiner/Coroner Systems in the United

States.

http://sites.nationalacademies.org/cs/groups/pgasite/documents/webpage/pga_049924.pdf

(accessed Sept 18, 2018).

3Charlotte Observer. Butts: Body Swap ‘regrettable, but not violation of N.C policy.

https://www.charlotteobserver.com/news/special-reports/nc-medical-

examiners/article9088730.html (accessed Oct 7, 2018).

4News 9. Former employees speak out on problems at Oklahoma’s ME’s office.

http://www.news9.com/story/14736879/former-employees-speak-out-on-problems-at-

oklahomas-mes-office (accessed Oct 8, 2018).

5 Q13 Fox. Mixed-up morgue mistakenly tells family that dead woman ‘not your

daughter’. https://q13fox.com/2014/03/20/family-of-accident-victim-angry-at-medical-

examiners-mistake/ (accessed Oct 7, 2018).

6 San Francisco Chronicle. S.F Medical Examiner tackles backlog, giving families closure.

https://www.sfchronicle.com/bayarea/article/S-F-medical-examiner-tackles-backlog-

giving-6679974.php (accessed Oct 7, 2018).

7 The Washington Post. State lawmakers won't adequately fund medical examiners' offices.
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https://www.washingtonpost.com/news/the-watch/wp/2017/12/14/state-lawmakers-wont-

adequately-fund-medical-examiners-offices-this-is-a-huge-

problem/?noredirect=on&utm_term=.c80271a717c4 (accessed Nov 28, 2018)

8North Carolina Health News. Lawmakers Address Need for Improvement in Medical Examiner

System. https://www.northcarolinahealthnews.org/2014/09/30/lawmakers-address-need-

for-improvement-in-medical-examiner-system/ (accessed Oct 7, 2018).