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The Real CSI: How America's Patchwork System of Death Investigations Puts the Living At Risk

An examination of the nation’s 2,300 coroner and medical examiner offices reveals a troubled system that literally buries its mistakes.
 
 
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This story was reported by A.C. Thompson and Mosi Secret of ProPublica, Lowell Bergman of PBS “Frontline” and the Investigative Reporting Program at UC Berkeley, and Sandra Bartlett of NPR. It was written by Thompson.

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 Dr. 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.

 
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