IMPACT OF A FAILING MEDICAL EXAMINER SYSTEM 1

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

Skyler Prozor

University of Central Florida

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

Growing up, watching the television show NCIS and shows like that 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. This gap 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

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
IMPACT OF A FAILING MEDICAL EXAMINER SYSTEM 3

1950’s, however, that Medical Examiners were required to hold the degree of PhD. 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. Over the past couple of decades, to

date, there are 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.

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’, ‘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
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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 the argument. 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 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. A case found in Oklahoma City highlights another issue of

the medical examiner system that directly effects the emotional and physical health of families.
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In the case of Joe and Donna Turner, daughter Shandra Turner had been found with a bullet in

the 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.

The second perspective I found was that of Medical Examiners and current related

professionals in the field, whom did not support fixing issues that had to do with families of

victims effected by mistakes but rather focused 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
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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, the budget that

they receive. As lawmakers, they as well sympathize with families in the cause and effect

relationship describing my research. A retired law enforcement officer out of New York, whom

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.

Analysis

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, 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
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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.

Discussion

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.

References

1 Clasen-Kelly, F. November 17, 2013. In NC medical examiner system, heavy autopsy

caseloads raise risk of mistakes. Retrieved September 18, 2018, from

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

examiners/article9092573.html

2 Hanzlick, R., MD. (n.d.). An Overview of Medical Examiner/Coroner Systems in the United

States. Retrieved September 18, 2018, from

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

3 Clasen-Kelly, F. May 1, 2013. Butts: Body Swap ‘regrettable, but not violation of N.C policy.

Retrieved October 7, 2018 from https://www.charlotteobserver.com/news/special-

reports/nc-medical-examiners/article9088730.html

4 Loren, J. May 26, 2011. Former employees speak out on problems at Oklahoma’s ME’s office.

Retrieved October 8, 2018 from http://www.news9.com/story/14736879/former-

employees-speak-out-on-problems-at-oklahomas-mes-office

5 Patel, T. March 20, 2014. Mixed-up morgue mistakenly tells family that dead woman ‘not your

daughter’. Retrieved October 7, 2018 from https://q13fox.com/2014/03/20/family-of-

accident-victim-angry-at-medical-examiners-mistake/

6 Green, E. December 16, 2015. S.F Medical Examiner tackles backlog, giving families closure.

Retrieved October 7, 2018 from https://www.sfchronicle.com/bayarea/article/S-F-

medical-examiner-tackles-backlog-giving-6679974.php