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

Research Questions:
-What major issues lead to Medical examination mistakes of victims?
(Introduction)
- What effects do families of victims experience due to a dysfunctional
medical examiner system? ( Major question of research)
Keywords:
-​​problems with medical examinations
-medical examination mistakes effects on victims families
-improving forensic autopsies
-questionable autopsy
- family challenges to medical examiner conclusions

October 8, 2018
Digital Paper Trail (DPT)

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
-Introduction information about medical examiner system in general and issues
with current system

Pearsall, B. March 3, 2011. Improving Forensic Death Investigation. Retrieved

September 18, 2018, from ​https://www.nij.gov/journals/267/pages/investigation.aspx
- Solutions to decreasing mistakes in medical examiner system that lead to
questionable autopsies

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/article90
92573.html
- Specific issue of medical examiner shortage leading to raised risk of medical
examiner mistakes

Humphrey, S. November 2, 2011. New Okla. law allows families to challenge medical
examiner. Retrieved September 24, 2018 from
https://www.kxii.com/home/headlines/New_Oklahoma_law_allows_families_to_challen
ge_medical_examiner_133118778.html
- Example of family suffering due to questionable autopsies
Sterling, S and Sullivan, P, S. December 14, 2017. Death & Dysfunction. Retrieved
September 24, 2018 from ​http://death.nj.com/10/
- New jersey medical examiner mistakes in multiple cases, family perspective,
charts/graphics of comparative state statistics of ME mistakes

Duluth News-Tribune. July 12, 2015. Medical examiner Uncini: 'I didn't do anything
wrong. Retrieved October 4, 2018 from
http://link.galegroup.com/apps/doc/A421414082/ITBC?u=orla57816&sid=ITBC&xid=8
dfff91d​.
(Permalink:
https://login.ezproxy.net.ucf.edu/login?auth=shibb&url=https://search.ebscohost.com/log
in.aspx?direct=true&db=edsgbe&AN=edsgcl.421414082&site=eds-live&scope=site

Burns, M. May 1, 2013. NJ family suing NC over Medical Examiner’s Mistake.

Retrieved October 4, 2018 from
https://login.ezproxy.net.ucf.edu/login?auth=shibb&url=https://search.ebscohost.com/log
in.aspx?direct=true&db=edsgbe&AN=edsgcl.421414082&site=eds-live&scope=site
- Specific example of Medical examiner autopsy mistake effects on victims family

Thompson, A.C. February 2, 2011. Medical Examiners in America: A Dysfunctional

System. Retrieved October 4, 2018 from
https://www.huffingtonpost.com/2011/02/02/the-real-csi-how-americas_n_816842.html
-Describing major issues of the medical examiner system

Wyatt, D. May 22, 2018. Medical Examiner: Volusia Morgue “potentially dangerous”.
Retrieved October 4, 2018 from
http://www.news-journalonline.com/news/20180522/medical-examiner-volusia-morgue-
potentially-dangerous
- Mistakes of medical examiner could lead to heavy consequences

Haben, R. September 30 2014. Lawmakers Address Need for Improvement in Medical

Examiner System. Retrieved October 7, 2018 from
https://www.northcarolinahealthnews.org/2014/09/30/lawmakers-address-need-for-impro
vement-in-medical-examiner-system/
-Conclusion/ways to improve medical examiner systems

Small, J. February 8, 2018. How families pay for San Joaquin Coroner mistakes.
Retrieved October 7, 2018 from
https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coron
er-mistakes
-​Effects of San Joaquin autopsy mistake on victim’s family

Chipman, J. (2017). ​Death in the family​. [Toronto, Ontario] : Doubleday Canada, [2017].
Retrieved from
https://login.ezproxy.net.ucf.edu/login?auth=shibb&url=https://search.ebscohost.com/log
in.aspx?direct=true&db=cat00846a&AN=ucfl.035945430&site=eds-live&scope=site
(Permalink:
https://login.ezproxy.net.ucf.edu/login?auth=shibb&url=https://search.ebscohost.com/log
in.aspx?direct=true&db=cat00846a&AN=ucfl.035945430&site=eds-live&scope=site​ )
- Specific example of autopsy mistake effects

Vendel, C. November 10, 2013. A Question of Homicide: Rulings by Medical Examiners

raises doubts about protocols. Retrieved October 7, 2018 from
https://www.kansascity.com/news/local/article331394/A-question-of-homicide-Rulings-b
y-medical-examiners-raise-doubts-about-protocols.html
-Shortage/ lack of funding lead to rushed autopsy conclusions

ABC Action News Report. November 21, 2002. Medical Examiner’s apparent mistake
put man in jail. Retrieved October 7, 2018 from ​http://truthinjustice.org/david-long.htm
-specific case of ME mistake effects on family of man accused and family of
victim

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-m
istake/
-​ME mistakes effects family of victim who was originally told dead victim was
not daughter, two days later admitted false identification

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-givi
ng-6679974.php
-Families unsure of victims death due to backlog of autopsies finally informed

Clasen-Kelly, F. May 1, 2013. Butts: Body Swap ‘regrettable, but not violation of N.C
policy. Retrieved October 7, 2018 from
https://www.sfchronicle.com/bayarea/article/S-F-medical-examiner-tackles-backlog-givi
ng-6679974.php
-DEFINITELY using, major ME mistake!!

(Permalink :​http://ucf.catalog.fcla.edu/permalink.jsp?29CF020888991​ )

Charlotte Observer. May 16, 2014. Untrained medical examiners fail families, imperil
justice. Retrieved October 7, 2018 from
http://insidestoryobs.blogspot.com/2014/05/coming-sunday-untrained-medical.html
-Lack of proper training and technique of county ME leads to the revelation of
many mistakes of autopsies
Giacalone, J. July, 26, 2016. NY state passes law requiring medical examiners to use
Namus. Retrieved October 7, 2018 from
http://joegiacalone.net/ny-passes-law-requiring-mes-use-namus/
-Step toward decreasing the effects on families due to rushed autopsies and poor
examination practices

Logan, S. July 7, 2018. Province fills vacant medical examiner posts in calgary.
Retrieved October 7, 2018 from
https://calgarysun.com/news/local-news/vacant-calgary-medical-examiner-posts-filled-bu
t-concerns-remain-for-local-mla/wcm/222d317d-4cbf-4150-bb75-2b34b0c98e29
-Steps toward fixing medical examiner system

Cal Coast News. April 23, 2017. SLO medical examiner tied to another questionable
autopsy finding. Retrieved October 8, 2018 from
https://calcoastnews.com/2017/04/slo-medical-examiner-tied-another-questionable-autop
sy-finding/
-Family questions autopsy conclusion

December 7, 2015. Families suffer due to medical examiner shortage. Retrieved October
8, 2018 from
https://www.cbsnews.com/news/families-suffer-due-to-medical-examiner-shortage/
-many families left to wonder true cause of death of deceased victims due to
backlog/ lack of ME’s.

Schaper, D. February 2, 2012. Families suffer through Chicago morgue backlog.

Retrieved October 8, 2018
from​http://news.wbfo.org/post/families-suffer-through-chicago-morgue-backlog
-psychological effects on families of victims
Stern, Susan B., "Immediate Aftercare Program for Survivors and Families of Homicide
Victims: The Case of Cobb County Government" (2010). ​Dissertations, Theses and
Capstone Projects.​ 227.
https://digitalcommons.kennesaw.edu/etd/227
- Help for victims of families of homicide victims
- May not be prevalent but possibly useful in compiling solution ideas

Geberth, V. January 1, 2013. The Seven Major Mistakes in suicide investigations.

Retrieved October 8, 2018 from
http://www.practicalhomicide.com/Research/7mistakes.htm
-ME major mistakes in ruling deaths homicides, families often reject suicide
rulings

Wen, P. November 29, 2016. Haunted by a word, a family battles medical examiner’s
office. Retrieved October 8, 2018 from
https://www.bostonglobe.com/metro/2016/11/28/haunted-word-family-does-battle-with-
medical-examiner-office/tMWFZA2BUQLi04VlQnpr0M/story.html
-Family disagree with conclusion of quick medical examination

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-okl
ahomas-mes-office
-Medical examiner perspective of problems with medical examiner system and
autopsies

Drummond Ayres, B. July 21, 1994. Simpson Case has errors, coroner says. Retrieved
October 8, 2018 from
https://www.nytimes.com/1994/07/21/us/simpson-case-has-errors-coroner-says.html
-Major case, OJ Simpson, mistakes in autopsy lead to tremendous effects on
victim of case family
-prime example for explaining urgency of solutions

Balko, R. December 14, 2017. State lawmakers won’t adequately fund medical
examiner’s offices. This is a huge problem. Retrieved October 8, 2018 from
https://www.nytimes.com/1994/07/21/us/simpson-case-has-errors-coroner-says.html
-Perspective of lawmakers, difficulty with solving the problem of decreasing
medical examiner mistakes.
**(Fix citation when doing annotated bibliography): E-book
Rao, D, Dr. History of Medicolegal System. Retrieved October 8, 2018 from
http://forensicpathologyonline.com/e-book/introduction%20%2526%20history/history-m
edicolegal-system

Altman, L, M.D. August 20, 1996. T.W.A. Pathologist says he did what he could, when
he could. Retrieved October 8, 2018 from
https://www.nytimes.com/1996/08/20/science/twa-pathologist-says-he-did-what-he-could
-when-he-could.html
- Old case that shows the prevailing difficulties with medical examiner and
problems with autopsy that have continued to occur for three decades