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

In fulfillment for ENC 1102 credit under the supervision of Professor Steffen Guenzel
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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 research includes research 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 issue are few and

temporary. Medical professionals do not prioritize families as a fundamental issue to actively fix.

Professionals involved with law were found to be rather uneducated on the issue and focused on

the monetary aspects of mediating the system’s issues. Potential more permanent 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 that have such a large impact.

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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 the heavy caseloads for a severely understaffed field. In the past decade the

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

opiate overdose cases. The system has experienced an overload in case load, budget cuts and an

increase in the errors per case. According to a 2007 NAME (National Association of Medical

Examiners) study, the state of North Carolina spent an average of $1.76 per person annually on

death investigations.1 As I am currently pursuing a bachelor’s in forensic science with the goal of

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

help advance the field. Within forensic discourse communities that define and address issues

with the medical examiner system, there is a gap in which the families of homicide, suicide, and

unknown death victims are not addressed. Current forensic discourse communities identify

similar issues that are centered around lack of funds and 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.

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, majority of
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the time, was not a certified physician. As addressed in the introduction, 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, otherwise known as a forensic pathologist,

the number of certified medical examiners at the time was, in proportion to the number of cases,

extremely low. Only 1300 people since 1959 had become certified as medical examiners.2 With

such an underfilled position and over 150,000 cases of homicide, suicide and unknown deaths,

autopsies were quickly 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, there are very few offices

that are accredited according to the Forensic Autopsy Performance Standards because the issues

offices still face. With the issue of understaffing and case overloading, came the connection of

the cause and effect relationship seen between medical examiner system issues and the mental

and physical effects of those issues on the families of victims. Case overload causes a back-up in

death certificate issuing and thorough autopsies.

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 written texts

that were not otherwise easily accessible on the open web. The original 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 examiner

system’, ‘questionable autopsy’ (uncertainties concluded in the examinations of corpses), ‘family

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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, did little to connect the two cause and effect ideas. I shifted my focus

towards searching for news stories and case examples of family’s suffering because of incorrect

death rulings, death certificate mistakes, and mistakes of autopsies. Through the sources I found

both through google searches and the UCF Library Database, I was able to distinguish three

major perspectives on the issue that either contributed to the argument or a counter to the

argument. After overlooking and reading 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 source

thoroughly, write down notes relevant to my research paper, and decide in what area of my

research the information would fit best into.

Results

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

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

underlying aspects. One of the three perspectives I found was that of families of victims whose

deaths were due to homicide, suicide, or the manner of death being unknown. This perspective

offered claims and facts that supported my argument in favor of prioritizing solutions that effect

victims’ families. In the case of Lorraine Young, North Carolina medical 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. 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
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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.

Within the discourse community, this case occurred shortly before offices began to address the

issues, mentioned before, within the system. A case found in Oklahoma City highlights another

issue of the medical examiner system that directly effects the emotional and physical health of

families. 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

case 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 after being sent to the family of Samantha Kennedy, and the news

was shared with the Peterson family. Both families after the incident were not apologized too and

the situation left unexplained, Aubrey Peterson commented that “she deserves more”.5 All three

case examples from the perspective of families of victims indirectly highlight the issues with the

medical examiner system of under staffing, a limited budget, and thorough autopsy procedures

not being concretely followed and ultimately just how much these issues affect families.
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The second perspective I found is that of medical professionals in the field, who did not

support fixing issues that had to do with families of victims effected by medical examiner

mistakes. Instead, focus was mostly on increasing funding for equipment and speeding up the

autopsy times. Contrary to the argument of my research, 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 drastically

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

backlogged. 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

more room for errors like those of the cases mentioned before.

A third perspective on the topic, is that of lawmakers and individuals involved with law

enforcement; who 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 M.E. offices within a 60-day period. 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.

Discussion

The argument of the research is found to be similar through the eyes of an individual

personally effected by an M.E mistake as well as common people and other professionals not in
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the field of forensic science who sympathize with victim’s families. The stance on the idea,

however, differs greatly in the eyes of current medical examiners and professionals in the field.

Issues with the medical examiner system in the U.S are agreed upon across the board, the system

is underfunded, understaffed, and autopsies are under analyzed. 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

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).

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