The Real CSI: Death Detective Dysfunction10:37

A morphology technician at   The New Mexico Office of the Medical Investigator stores one of the bodies that is autopsied there. The office was created by the state legislature in 1972 replacing the county coroner system. (John W. Poole/NPR)
A morphology technician at The New Mexico Office of the Medical Investigator stores one of the bodies that is autopsied there. The office was created by the state legislature in 1972 replacing the county coroner system. (John W. Poole/NPR)

In detective novels and television crime dramas like CSI the nation's morgues are staffed by highly trained medical professionals equipped with the most sophisticated tools of 21st-century science. Operating at the nexus of medicine and criminal justice, these death detectives thoroughly investigate each and every suspicious fatality.

The reality, though, is far different. In a joint reporting effort, ProPublica, PBS Frontline and NPR spent a year looking at the nation's 2,300 coroner and medical examiner offices and found a deeply dysfunctional system that quite literally buries its mistakes.

Blunders by doctors in America's morgues have put innocent people in prison cells, allowed the guilty to go free, and left some cases so muddled that prosecutors could do nothing.

In Mississippi, a physician's errors in two autopsies helped convict a pair of innocent men, sending them to prison for more than a decade.

The Massachusetts medical examiner's office has cremated a corpse before police could determine if the person had been murdered; misplaced bones; and lost track of at least five bodies.

Late last year, a doctor in a suburb of Detroit autopsied the body of a bank executive pulled from a lake—and managed to miss the bullet hole in his neck and the bullet lodged in his jaw.

"I thought it was a superficial autopsy," said David Balash, a forensic science consultant and former Michigan state trooper hired by the Macomb County Sheriff's Department to evaluate the case. "You see a lot of these kinds of things, unfortunately."

More than 1 in 5 physicians working in the country's busiest morgues—including the chief medical examiner of Washington, D.C.—are not board certified in forensic pathology, the branch of medicine focused on the mechanics of death, our investigation found. Experts say such certification ensures that doctors have at least a basic understanding of the science, and it should be required for practitioners employed by coroner and medical examiner offices.

Yet, because of an extreme shortage of forensic pathologists—the country has fewer than half the specialists it needs, a 2009 report by the National Academy of Sciences concluded—even physicians who flunk their board exams find jobs in the field. Uncertified doctors who have failed the exam are employed by county offices in Florida, Michigan, Pennsylvania and California, officials in those states acknowledged. Two of the six doctors in Arkansas' state medical examiner's office have failed the test, according to the agency's top doctor.

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.

For 26 years, Tim Brown, a construction manager, has served as the coroner of rural Marlboro County in South Carolina, a $14,000-per-year part-time post. "It's been kind of on-the-job training, assisted by the sheriffs," he said.

Long before the current economic crisis began shrinking state and county government budgets, many coroner and medical examiner offices suffered from underfunding and neglect. Because of financial constraints, Massachusetts has slashed the number of autopsies it performs by almost one quarter since 2006. Oklahoma has gone further still, declining to autopsy apparent suicides and most people age 40 and over who die without an obvious cause.

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.

Dr. Marcella Fierro, the former chief medical examiner in Virginia, is a member of the National Academies of Science panel that issued a report recommending an overhaul the country's death investigation systems. (John W. Poole/NPR)

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."

Continue reading this NPR News investigation in partnership with ProPublica and PBS Frontline:

Chapter 2: In New Orleans, Uncovering Errors and Oversights

Chapter 3: Academy Recommends Phasing Out Coroners

Chapter 4: A State Office Struggles With Mismanagement

Chapter 5: Shortage of Death Detectives To Perform Autopsies

Chapter 6: Oklahoma's Lack of Resources Means Few Autopsies

Copyright NPR 2022.





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