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

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.

Some death investigation units do a commendable job. While many coroners and medical examiners don't even have X-ray machines, New Mexico has a new facility equipped with a full-body CT scanner to help detect hidden injuries. Virginia has an efficient, thorough system, staffed by more than a dozen highly trained doctors. The autopsy suite in its Richmond headquarters is as sophisticated and sanitary as a top hospital.

Still, the National Academy of Sciences' study found far-reaching and acute problems. Across the country, the academy said, coroners and medical examiner offices are struggling with inadequate resources, poor scientific training and substandard facilities and technology.

Their limitations can have devastating consequences.

"You call a death an accident or miss a homicide altogether, a murderer goes free," said Dr. Marcella Fierro, Virginia's former chief medical examiner and one of the report's authors. "Lots of very bad things happen if death investigation isn't carried out competently."

A Series of Errors and Oversights

After Cayne Miceli died in January 2009, her body was brought to the New Orleans morgue, a dingy, makeshift facility in a converted funeral home, for Dr. Paul McGarry to autopsy.

An autopsy, the dissection and evaluation of a corpse, generally begins with a physician scrutinizing the body, noting visible injuries. With a scalpel, a doctor then slices a long, Y-shaped incision in the torso and studies the innards, removing and weighing each organ, and using a small rotary saw to remove the top the skull. An autopsy can trace the path of a bullet through a body, or reveal microscopic damage to blood vessels in the brain, or identify a lethal clog in an artery.

By the time Miceli's body was laid on the stainless-steel examination table, McGarry had performed such work for three decades in Louisiana and Mississippi. In New Orleans, he was one of several forensic pathologists overseen by the parish coroner, Frank Minyard, a trumpet-playing local legend who has held his elected office for more than 35 years.

Miceli, 43, had died after being held in a cell in the parish jail, bound to a metal bed by five-point leather restraints. During the autopsy, McGarry observed "multiple fresh and recent injection sites" on Miceli's forearms. He determined that drugs -- he didn't specify the variety -- had killed her, according to his report.

But doctors who had treated Miceli the day she died encouraged her father, Mike Miceli, to look more closely into his daughter's death. He had her body flown to Montgomery, Ala., for a second autopsy by Dr. James Lauridson, the retired chief medical examiner for the Alabama Department of Forensic Sciences.

Lauridson concluded that McGarry had misconstrued the needle marks on Miceli's arms. "In fact, all of the needle puncture marks were therapeutic -- drawing blood, IV's, that sort of thing," Lauridson said.

McGarry's finding also was contradicted by a central piece of evidence: a screen for drugs and alcohol didn't turn up either in Miceli's blood. McGarry had reached his conclusion days before he got the test results, records show.

Lauridson soon pinpointed the real reason for Miceli's demise. On the day of her death, Miceli had gone to the hospital to be treated for an asthma attack. She was arrested after an altercation with hospital staffers; Miceli thought they were trying to discharge her too soon, court records show. Peering at Miceli's lung tissue under a microscope, Lauridson was certain that severe asthma, combined with the way she was restrained at the jail, had caused her death.

"As I examined her lungs, it was very clear right away that her lungs and all of the airways were completely filled with mucous," he said. "To put an asthmatic flat and then tie them down during an acute asthma attack is nearly the same as giving them a death sentence."

McGarry had been wrong, and not for the first time. In fact, a review of medical records, court documents and legal transcripts shows McGarry has made errors and oversights in autopsy after autopsy.

In three instances since 2005, his findings in cases in which people died in the custody of police officers have been challenged by doctors brought in to perform second autopsies. In each case, McGarry's findings cleared officers of wrongdoing. The other specialists concluded the deaths were homicides.

Contacted by phone, mail and in person, McGarry repeatedly declined to comment for this article or related radio and television stories.

Some in the field champion McGarry, praising his track record. "I have the utmost respect for Dr. McGarry and he taught me much when I was in a forensic fellowship program," said Dr. James Traylor in an e-mail. Traylor was trained by McGarry and worked alongside him in the New Orleans morgue. "I am unaware of any ‘mistakes' that he may have made."

Second autopsies are a rarity in most jurisdictions, but New Orleans civil rights attorney Mary Howell said she often taps forensic pathologists to perform follow-ups when she knows McGarry has handled a case. The degree to which their findings have differed from McGarry's is "shocking," Howell said. In some cases, they discovered, McGarry's work was so incomplete that bodies were "half-autopsied."

Gerald Arthur, a 45-year-old construction worker with a history of drug arrests, died after a struggle with police on a New Orleans street in 2006. Based on McGarry's findings, coroner Minyard ruled the death an accident, but a forensic pathologist with the Georgia Bureau of Investigation brought in by Arthur's family to perform a second autopsy found four broken ribs that McGarry had not noted. In his report, the GBI pathologist also stated that McGarry "failed to dissect" key neck muscles, causing him to miss hemorrhages that, in his view, suggested Arthur had been strangled.

In a deposition, McGarry disputed that assertion, saying he had dissected the neck muscles but had come to a different conclusion. "I don't have any evidence that this man had a death due to neck strangulation," he said.

No criminal charges have been brought in connection to Arthur's death. His family settled a lawsuit against the police department last year for $50,000.

Also in 2006, McGarry autopsied Lee Demond Smith, a 21-year-old man who died in jail in Gulfport, Miss. McGarry decided that Smith had been killed by a pulmonary embolism, a blood clot in the lungs, based on evidence of internal bleeding. Again, another specialist brought in to do a second autopsy found injuries that McGarry had not: abrasions on Smith's forehead and chest, as well as a half-dozen bruises on his legs and hands. The doctor concluded that Smith, like Arthur, had been strangled.

No criminal charges have been filed in Smith's death either.

Raymond Robair, a 48-year-old handyman who died shortly after an encounter with police, was autopsied by McGarry in 2005. Based on McGarry's examination, coroner Minyard declared Robair's death an accident.

But McGarry had not noted the wounds covering Robair's legs and arms. A second forensic pathologist hired by Robair's family documented 23 separate bruises, including a thigh contusion more than a foot long. The fatal injury was a severe laceration of Robair's spleen that caused extensive internal bleeding, according to the second autopsy, which was performed by another GBI doctor, Kris Sperry. Robair "was the victim of a beating," his autopsy report states.

Robair's sister, Pearl LeFlore, said her sibling's battered body was communicating a message: "This is what happened to me. ... I died brutally. I was beaten." McGarry's autopsy was "a lie altogether," she said.

Based on McGarry's autopsy, records show, the district attorney's office decided not to prosecute any police officers in connection with Robair's death. "The officers were effectively exonerated by the initial autopsy performed by the Orleans Parish Coroner's Office," wrote an assistant district attorney in a 2008 letter sent to the police department.

Ultimately, in 2010, after conducting an extensive investigation, the U.S. Department of Justice indicted New Orleans Police officer Melvin Williams for allegedly beating Robair to death and charged another officer with allegedly helping to cover it up. The officers have pleaded not guilty.

Cayne Miceli's father is still seeking justice. Mike Miceli has sued McGarry in Orleans Parish court, saying his actions were "extreme and outrageous," and has filed a separate suit against the Orleans Parish Sheriff's Department for wrongful death. Both cases are pending.

"There's no reason for a family to have to go through this," Mike Miceli said. After the lawsuits were filed, Minyard amended the autopsy report, changing Miceli's cause of death from a drug overdose to asthma and labeling it a natural death.

Minyard declined to discuss the Miceli autopsy or other cases in which McGarry's findings have been challenged. He defended McGarry's work more generally. "I'm not aware of any impropriety," the coroner said. "I'm not aware of any mistakes."

Last year, McGarry stopped doing autopsies for Orleans Parish, but he is still working for three Mississippi counties. "He lives in Mississippi, and he's helping them over there," Minyard said. "The travel back and forth was too much."

The Debate Over Coroners

Some experts see coroners like Minyard as throwbacks to an earlier, less scientific era.

The qualifications of those who oversee death investigations vary widely from state to state -- and, in some areas, from county to county. But the main divide is between medical examiner systems, run by doctors specially trained in forensic pathology, and coroner systems, run by elected or appointed officials who often do not have to be doctors.

While Minyard happens to be a physician -- he worked as an obstetrician-gynecologist before becoming coroner -- he isn't a forensic pathologist and never actually puts scalpel to flesh. In the end, though, it is Minyard who decides what words will be typed on the death certificate.

The 2009 report by the National Academy of Sciences, a comprehensive overview of defects in the nation's death investigation system authored by more than 50 luminaries in the field, recommended phasing out coroners and replacing them with medical examiners. (For a detailed, state-by-state breakdown, see our app.)

For Fierro, the Virginia forensic pathologist, the coroner-versus-medical-examiner debate is fundamentally about competence. In her view, only trained specialists should oversee death investigations. "I'm not anti-coroner," said Fierro, one of the authors of the academy's report. "I'm pro-competency."

But another concern raised by the academy is that coroners often are closely aligned with law enforcement agencies. In 48 California counties, the local sheriff serves as coroner. In Nebraska, county prosecutors perform the coroner's duties. "Sensitive cases, such as police shootings and police encounter deaths ... require an unbiased death investigation that is clearly independent of law enforcement," the NAS report stated.

Minyard's close ties to law enforcement have provoked controversy throughout his long career, and his decisions in certain cases, particularly that of Adolph Archie, illustrate just how much power a coroner can wield.

Archie died in 1990, soon after grabbing a revolver from a Superdome security guard and shooting a police officer to death.

When officers captured Archie, the chatter on the police radio turned sinister. "Somebody kill him," demanded one cop, according to a transcript of the radio traffic. "Hang the bitch by his balls," urged another.

By the time Archie reached Charity Hospital, he'd suffered a host of injuries, including broken facial bones and skull fractures, leading hospital staffers to conclude he had been kicked repeatedly, medical records show.

McGarry did the autopsy, noting many of Archie's injuries. Minyard initially told the media he was baffled and didn't know whether to rule the death a homicide. He speculated that Archie might have fallen backward and hit his head on the floor when he struggled with officers, or that officers might have struck him in self-defense.

"When a perpetrator grabs a gun, a policeman has a right to defend himself," Minyard told the local newspaper.

Media reports later revealed that one of the officers who arrested Archie was a friend of Minyard's who rented an apartment from the coroner.

A second autopsy conducted by Sperry, the Georgia doctor, uncovered additional injuries overlooked by McGarry, including more skull fractures, crushing damage to Archie's larynx and bruising of his testicle. After public protests calling for the coroner's resignation, Minyard changed his determination, calling Archie's death a homicide.

Then he shifted his stance again, deciding that Archie had died of an allergic reaction to medication he received in the hospital. To this day, Minyard insists Archie wasn't killed by a police beating. "His trauma never caused his death," said the coroner, adding that "my position was that Adolph Archie died from an allergic reaction to iodine that he was given on the X-ray table."

Prosecutors never indicted anyone in connection with Archie's death.


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