Coroners Who Miss All the Clues

By Anastasia Toufexis

The headless, handless body of a woman covered with green algae was fished out of a lake in upstate New York. The hospital pathologist who performed the autopsy judged the slim, athletically built victim to be in her 20s and said she had been dead three weeks. A few days later, medical examiner Michael Baden autopsied the body and came to a startlingly different conclusion. Bone spurs on the woman's spine and her atrophied ovaries revealed that she was about 55 years old, and microscopic study of the algae indicated that the body had been in the water at least 1 1/2 years.

Far from being an isolated outrage, such a botch-up is shockingly common, claims Baden, co-director of the forensic sciences unit of the New York state police. In a new book, Unnatural Death (Random House; $17.95), he and co- author Judith Adler Hennessee present a fascinating and disturbing picture of a shamefully inadequate U.S. coroner system. About 7% of the 2 million Americans who die annually meet an untimely end, by murder, suicide or accident. By law, such deaths must be investigated. Though the public may believe that every coroner is a skilled sleuth like television's Quincy, fewer than 400 forensic pathologists -- medical doctors with advanced training in anatomy, laboratory testing and legal-medical investigation -- are on public payrolls; twelve states do not employ any medical examiners at all.

Often the coroner is a funeral-home director and sometimes even a tow-truck operator, whose primary ability is transporting bodies. The coroner frequently hires hospital pathologists to do the autopsy. Those unfamiliar with signs of violence may confuse gunshot entrance and exit wounds or may be unable to tell whether a fractured skull was caused by a fall or a blow. Or they may ignore important evidence, such as the contents of a victim's stomach or hairs and fibers left on clothing or skin.

As a result, the guilty often go free. People get away with murder in about a third of the 20,000 deaths identified as homicides each year; other murders go undetected. Misinterpreted evidence can also lead to the innocent being punished. Even worse, people are sometimes jailed for crimes that never occurred. The classic example: when an alcoholic dies after a fight, the police often assume that the assault killed him, but a careful autopsy may show a lethal level of alcohol in the blood. Bungled investigations can also create lasting controversies. Mistakes in the autopsy of John F. Kennedy fueled charges of a conspiracy and cover-up.

Moreover, public health is damaged by the lack of trained medical detectives. M.E.s are usually the first to sound the alarm about faulty product design, new diseases or social problems like child abuse. Says Dr. Donald Reay, Seattle's chief medical examiner: "Look how much the public knows about cocaine and firearms. That's because people are dying from drugs and gunshots."

Still, much valuable knowledge is being lost, according to the Centers for Disease Control in Atlanta, because there is no uniform method for collecting information on unnatural deaths. Increasing numbers of M.E.s believe their expertise can also serve the living victims of assaults. Dr. Charles Petty, chief medical examiner of Dallas, regularly checks bruised children brought to a county hospital to see if they are being battered.

Another major deficiency in the current coroner system is that it leaves medical examiners open to political pressure. Virtually all are appointed by elected officials. And politicians and district attorneys often want team players. M.E.s who are too independent may eventually be ousted from their posts, charges Baden, citing his own experience as chief medical examiner of New York City. Former M.E.s in Detroit, Pittsburgh and Los Angeles put forward the same claim. "No one says lie," observes Baden, "but they want to push you further than the science permits."

To make the prosecution's case stronger, a medical examiner may be pressured to say a woman was raped before she was murdered, though the evidence is equivocal. Or the M.E. may be pushed to attribute the death of a person in police custody to the victim's use of cocaine rather than a choke hold applied by officers. M.E.s may deny being subjected to such nudging, but they agree that their independence must be guarded.

Some forensic pathologists suggest giving medical examiners civil service status or allying them more closely with medical schools, where independence is a tradition. Many advocate setting up regional forensic centers to provide expert consultants to local communities. Almost all emphasize that higher salaries are needed to lure bright young doctors into the field. Most M.E.s make less than $100,000 a year, while a pathologist who runs a hospital's laboratory services can pull in more than double that amount.

A strong system for investigating unnatural deaths is becoming increasingly necessary. Capital punishment has returned. Defense attorneys are more aggressive in challenging the accuracy of evidence. Citizens groups are more vocal in their charges of police brutality. Warns Baden: "It's more important than ever that we don't make mistakes." A lax system will erode public faith in the credibility of the medical examiner, and that would be a crime.

With reporting by Kathleen Brady/New York and Dennis Wyss/San Francisco