Editor’s note: What follows is the second piece in a series of articles that the Fort Worth Star Telegraph is running on the junk science of Autopsies in the State of Texas and how bad medical examiners and wrong autopsies are skewing the legal system. The article is by reporter Yamil Berard. It is excellent.
By YAMIL BERARD
An unlicensed physician determined that toddler Lacey Lynn Nichols died in 2006 from blunt-force injuries to the head and brain. Lesli Tull, a fellow in training at the Tarrant County medical examiner’s office, said the child’s death was a homicide, and a foster parent was charged with capital murder.
Tull also gave cause-of-death opinions in dozens of other cases, including accidental deaths and suicides, without a Texas medical license or a training permit from the Texas Medical Board.
Around the state, some medical examiner offices have relied on the work of medical school interns and unlicensed doctors, as well as physicians who have repeatedly failed certification exams or been disciplined for poor work — even for complex capital murder cases.
Relaxing qualification requirements is one way the offices have tried to keep up with overwhelming caseloads and a shortage of forensic pathologists.
Some pathologists also operate what critics deride as “path mills.” That can lead to significant errors, undermining the criminal justice system, some medical examiners themselves worry.
“Justice becomes secondary when too many bodies come into the morgue every day and when too few people are doing the autopsy,” Galveston County Chief Medical Examiner Stephen Pustilnik said.
Professionals say medical examiners should have specific certification in anatomic and forensic pathology, even though the state requires only a doctor’s license. Without the certification, says Bexar County Chief Medical Examiner Randall Frost, “that’s like graduating from medical school and immediately going in and doing a heart transplant.”
Dallas County Chief Medical Examiner Jeffrey Barnard agrees, adding, “The fact that someone is not alive doesn’t change the quality of the expectations of the medical practice.”
Texas doesn’t keep track of how many certified forensic pathologists work in the dozen county medical examiner offices; some put the number at 50. That’s not enough to serve large counties, let alone the 200-plus smaller ones that turn to them for autopsies.
Dallas County Chief Medical Examiner Jeffrey Barnard agrees, adding, “The fact that someone is not alive doesn’t change the quality of the expectations of the medical practice.”
“There’s only a certain number of doctors out there,” Lubbock County Medical Examiner Sridhar Natarajan said.
Because of the shortage, even some larger medical examiner offices use noncertified pathologists. Records that the Star-Telegram obtained from the American Board of Pathology show that the head medical examiner in Laredo for Webb County is not board-certified. Neither is the one in El Paso.
Webb County Chief Medical Examiner Corinne Stern did not respond to requests for comment. In El Paso, Dr. Paul Shrode has told county officials that he plans to gain certification. He did not respond to repeated requests for comment.
A forensic pathologist employed by Harris County also lacks board certification, even though the medical examiner’s office says it requires such credentials. The physician “has amply demonstrated his expertise during his tenure, and the requirement for certification has been waived for him,” a county official said.
Next page This month, the Harris County office reassigned its assistant deputy chief medical examiner to administrative duties after the Star-Telegram pointed out that his medical license had lapsed last year and had not been renewed. An official said Dr. Roger A. Mitchell was expected to return to regular duties, including autopsies, within about a week once he had renewed his license.
For years, Lubbock County relied on forensic pathology professors at Texas Tech’s School of Medicine to perform autopsies, even though the Texas Medical Board said they lacked proper state medical licenses. The professors had temporary permits that were automatically renewed by the university each year, a board spokeswoman said.
After questions about their licenses were raised last year, the Lubbock County Commissioners Court appointed Natarajan. Texas Tech medical school officials did not respond to repeated requests for comment.
The El Paso County medical examiner’s office uses a pathologist with a troubled history. Dr. Juan U. Contin, who is under contract with the office, had been fired as the county’s chief medical examiner in 2000 for unsatisfactory performance. He was also disciplined by the state medical board in 1991 in connection with his work for a private pain management clinic after the board found that he engaged in “unprofessional conduct that is likely to deceive or defraud the public or injure the public.”
Contin did not return repeated messages.
Lacking permits
In other stopgap measures, some medical examiner offices use interns to do autopsies. Those new physicians are sometimes brought on as fellows with the understanding that they will later take exams to become certified. Meanwhile, they are required to have special permits and be supervised when conducting autopsies.
In some cases, though, medical examiners have hired them without the required permits.
Tull wasn’t the only unlicensed fellow in Tarrant. Dr. Carl Wigren did dozens of autopsies until his lack of a license and training permit was questioned in 2007.
Chief Medical Examiner Nizam Peerwani said the county now requires the permits. “We now reinforce that,” he said.
Some peers say Tarrant’s failure to ensure that interns have proper credentials is a blemish on the integrity of death investigations.
“It is a way for our own practitioners to denigrate the importance as well as the value of our profession; that’s as if to say it’s OK if she doesn’t have to fill out and have the necessary paperwork that clinical doctors have,” Pustilnik said.
In Dallas County, a fellow’s autopsy on a woman helped convict the woman’s boyfriend of capital murder, according to court records. The case is being reopened in federal court after another pathologist who reviewed the case for the defense found what he said were “15 points of error” in the autopsy.
The medical examiner’s office concluded that Daniel Clate Acker strangled Marquette George while he was driving his manual-shift truck and that she was probably dead or near death when she was dumped from the vehicle.
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Acker’s appeals attorney contends that George jumped from the truck, and Dr. Glenn Larkin, a former medical examiner in Pennsylvania who reviewed the case for the defense, said all her injuries resulted from hitting the truck and the ground. He also said there was no indication that the victim’s clothes were examined. That’s important, he said, because there would likely have been tire impressions if the victim had been run over after being strangled, as prosecutors contended.
Barnard said he could not comment on the case.
Tull’s qualifications may become part of an appeal for Charles Yarbrough, a Coleman County foster parent charged with capital murder last year, his attorney said.
Tull didn’t testify at the trial, although she performed the autopsy. Instead, another Tarrant County medical examiner who witnessed the autopsy testified that the toddler died of blunt-force injuries to the head and brain. Yarbrough was eventually found guilty of reckless injury to a child.
If the state did not disclose information about Tull’s lack of qualifications to the court, it’s an issue, said Yarbrough’s attorney, Robert McCool. “If the state is aware of evidence that helps the defendant and they don’t tell you, they’ve got a problem.”
Prosecutor Heath Hemphill said the use of fellows to conduct autopsies is not an issue because autopsy reports don’t rely on just one individual. “Every autopsy has to be agreed to and signed off by every medical examiner in that office,” he said.
Large caseloads
As staffs are stretched thin, medical examiners often just pick up the pace.
There’s a fierce split on how many autopsies a pathologist can do before quality plummets.
The National Association of Medical Examiners says the quality of work is intrinsically tied to the number performed. A forensic pathologist with no administrative duties should perform no more than 250 autopsies a year, the organization recommended after studying the workload capabilities of offices nationwide. When the workload is greater, no matter how skilled the pathologist, there is a tendency to cut corners or make mistakes, it reported.
When the workload exceeds 350 per pathologist, mistakes are likely to be flagrant and reflect errors in judgment, the association says.
A 2006 survey by the Texas Association of Counties indicated that the number of autopsies was much higher in some counties.
Other records show that the chief medical examiner in Travis County at one point carried the load for deaths in 45 neighboring counties. A 2005 audit indicated that two pathologists each may have handled an average of more than 500 cases, counting both Travis County cases and private autopsies.
Nueces County Chief Medical Examiner Ray Fernandez said that he doesn’t want to do more than 350 a year but that the workload won’t give him a break. He handled 387 autopsies in 2008, even after the county provided a part-time forensic pathologist to help.
“Everybody hears the number 250 and 350, and they magically think it’s one autopsy a day,” Fernandez said. “The problem is that you don’t always have one a day. Some days, it may be five, 10. Some days you may have none.”
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But Peerwani says caps may dissuade medical examiners from doing complete autopsies. They may stay under the limit, for example, by doing more external examinations. He sees the one-autopsy-a-day guide as akin to requiring a surgeon to perform an appendectomy a day and go home.
“We have eternally questioned the wisdom and philosophy of limiting the number of autopsies,” Peerwani said.
It’s reasonable for a pathologist to do about 450 complete autopsies a year, he said, if the office has the staff and resources to support that, as he says Tarrant’s does. In 2008, his office completed 1,029 full autopsies and 305 partial autopsies, as well as 747 inspections/external examinations for the counties in the medical examiner district. In 2008, the office also completed 532 autopsies for nonjurisdictional counties, a medical examiner official said. In 2008, the office had four medical examiners and a fellow.
Donald Lee, executive director of the Texas Conference of Urban Counties, said strict limits on autopsies will cause costs to soar. If forensic pathologists are doing up to 500 autopsies a year, he said, that’s fine. That’s two procedures a day.
“Without these strict limits, we can get it done, and we have gotten it done,” Lee said.
Not so, other experts say.
“Most medical examiners nationwide are in agreement that there has to be a limit,” Frost said. But in Texas, he said, some offices are “doing case after case after case, and doing them very poorly.”
The caps are intended to combat the idea of “one guy standing in the morgue all day long taking bodies and running them through the mill as quickly and as cheaply as possible,” Pustilnik said. At 450 autopsies a year, “that’s gross malpractice,” he said. “The people of the state of Texas are being misserved and malpracticed on.”
Dr. William Rohr, chief medical examiner in Collin County, said he was maxed out at 280 autopsies last year. “To do a case right, anywhere from putting on scrubs all the way to getting all of the typos out of the autopsy report, if you want to do it right, it takes a lot of time,” Rohr said.
Taking shortcuts
Some medical examiners have come up with shortcuts to keep pace.
Peerwani’s office was criticized for ruling on the causes of some babies’ deaths without inspecting the places where they died. That occurred with cases outside the counties his office services. In such cases, the office often classified deaths as natural, attributed to sudden infant death syndrome.
Information from death scenes can be crucial because it stands the greatest chance of being intact and free from manipulation or contamination, said Larkin, the former Pittsburgh medical examiner.
“The death scene and the body is one continuum,” he said. “It is one piece of evidence.”
Another timesaver is doing partial autopsies or external examinations rather than complete autopsies.
Peerwani said his office does full autopsies when homicide is suspected. Otherwise, it may do external examinations or partial autopsies, such as checking the heart of someone thought to have died of a heart attack. Most cases of natural death can be solved in these ways, he said.
He grants that important information could be overlooked.
“Nobody has a clear idea if we are missing a death, the truth,” Peerwani said. “But it is impossible to do a complete autopsy on every case.”
Smaller counties that contract with medical examiners also may limit the scope of an autopsy. The justice of the peace has the authority to decide whether a full autopsy is needed — or whether one is needed at all. In some counties, such requests are rare.
Dr. Randy Hanzlick, who inspects medical examiner offices for the National Association of Medical Examiners, said partial autopsies, particularly in cases of trauma, may miss important elements, leading to significant errors. “If you take at face value everything you’re told, you don’t look beyond what you’re told, you’re not going to find the unexpected,” Hanzlick said.
One oversight is causing Peerwani’s office to re-examine some procedures.
This spring, the office said it would begin to X-ray victims of unwitnessed car crashes, especially those with massive head trauma, in response to an error in the ruling of a 66-year-old found dead inside his overturned pickup.
Daniel Obrine’s death had been ruled the result of the crash until a Houston funeral home found part of a bullet jacket lodged in his cheek. Obrine had been only externally examined after the April 26 wreck, without X-rays or an autopsy.
The case, which is unsolved, is now classified as a homicide.
Online: The National Academy of Sciences report, tinyurl.com/pathologist-shortage
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Misleading clues
Death scenes can hold important clues. But they can also mislead, Tarrant County Medical Examiner Nizam Peerwani said. He recalls a case in which police found a man shot in the head in his home. No gun was found and key valuables had disappeared, leading investigators to believe that the man was murdered. But medical examiners found traces of antidepressants in the man’s blood and learned in discussions with his psychiatrist that he was depressed and had suicidal tendencies. What’s more, blood splatters on his arms indicated that the head wound had been self-inflicted, Peerwani said. Police later apprehended a suspect who confessed to burglarizing the home after the man’s death. The gun was among the items he stole. His death was found to be a suicide.
— Yamil Berard
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Death investigations In 2008, the Tarrant County medical examiner’s office did full or partial autopsies or external examinations of 2,081 deaths in the four counties it serves. Here’s how the deaths were certified:
Homicides: 130 (6%)
Suicides: 258 (12%)
Natural: 998 (48%)
Accidental: 644 (31%)
Undetermined: 51 (3%)
The office also performed 532 autopsies for nonjurisdictional counties.