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 issue 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 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 a grand impact on others.

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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. conveyed. 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 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 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 argument addresses three major issues: lack of funding, conducting

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

Background
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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. 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, 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 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, there are very few offices that 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 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
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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, 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

through google searches and the UCF Library Database, I was able to compose 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 remaining 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 who

contributed the effects to 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 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
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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

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

the system. Another case found 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 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 as Jade Peterson 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 highlight the issue with conducting autopsies and cases in a timely manner.
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The second perspective I found is that of medical professionals in the field, who

collectively argued that the lack of funding was the reason for all their other issues, but seldom

addressed families in the matter of funding issues. 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 an even greater possibility of errors and is moving

in the opposite direction of the family perspective of allocating more time to a case. 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

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.7 The law offered a small solution to a much
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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

Families of Victims Lack of time allocated

to autopsies

Mental and
Medical physical
Medical Examiners Lack of funding Examiner effects on
Mistakes families

Lawmakers/ Law Undertraining/ lack of

Enforcement enforcing proper
techniques

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

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. 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
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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).

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).