The following is the last chapter in an NPR/ProPublica/Frontline report on death investigation in the United States.
Lack of resources has forced Oklahoma to engage in a risky brand of triage.
The state's Office of the Chief Medical Examiner has been without its top doctor for nearly a year. Three of its nine slots for forensic pathologists are empty.
Its remaining six doctors handle overwhelming caseloads. Most did between 300 and 400 autopsies last year, said Timothy Dwyer, the state's chief investigator. One did more than 500—double the maximum number recommended by the National Association of Medical Examiners.
Because of the grueling pace, the state has had to impose limits on the types of cases it investigates: Oklahoma typically does not autopsy possible suicides or alleged murder-suicides. In most instances, it does not autopsy people age 40 or older who die of unexplained causes.
"If we did an autopsy on every suicide, it would be all consuming, as with drug overdoses," said Cherokee Ballard, the office's chief administrator. "With suicides, we don't autopsy most them because it's an obvious cause of death."
But experts called Oklahoma's practices alarming. A savvy criminal can make a murder look like a suicide, said Dr. Robert Bux, a forensic pathologist who serves as coroner for El Paso County, Colo.
"The only way you're going to be able to sort it out, from my standpoint, is to do a complete autopsy," Bux said.
"I've had a lot of suicide cases they didn't autopsy," added Kyle Eastridge, a former homicide detective with the Oklahoma City Police Department and the Oklahoma State Police. "I don't think that every suicide is a murder, but I think we miss murders."
In the absence of forensic findings, families sometimes are left to forage obsessively for clues about what became of their loved ones.
When a bullet shattered the face of 17-year-old Carissa Holliday and left her dead in a trailer outside of Tulsa, no doctor ever autopsied her body.
Instead, a forensic pathologist looked at her wound and filled vials with blood and fluid from her eyeballs, screening them for drugs and alcohol. Two days after her death, before the lab tests had even come back, the doctor ruled her death a suicide, records show.
Holliday's mother, Andrea, didn't believe the ruling—Carissa left no suicide note, and the pathologist's report did not address potential clues such as whether there was gunshot residue on her hands.
"For a year and a half, I dug and investigated and got clues and witnesses to prove that she didn't kill herself," said Andrea Holliday, who wrote a self-published account of her daughter's final hours titled Never Forgotten.
The medical examiner has not reopened Carissa Holliday's case, and the official ruling on her death remains unchanged.
In 2009, NAME yanked Oklahoma's accreditation, in part because of its failure to autopsy suspected suicide and homicide cases.
Fierro, the Virginia forensic pathologist, called Oklahoma's decision not to look carefully into unexplained deaths of residents over 40 a mistake. Forensic pathologists have been critical in a range of investigations stretching beyond criminal justice, from identifying defective cribs to tracking the spread of infectious diseases. They play a crucial role in mapping public health trends, she said.
"If you want to improve the quality of people's lives, then we need to know what it is that causes them to be ill, sick or injured so that they can prolong their life," Fierro said.
Even at some of the nation's more robust death investigation units, staffers worry that they do too few autopsies to fulfill their watchdog role.
The Los Angeles County Department of Coroner looks into a comparatively large portion of deaths, roughly one in three each year, said Craig Harvey, the chief death investigator. Yet he would like to do more.
"I would love to have the staff to respond to every nursing home death. They're fraught with potential misses," Harvey said. "But if anything was to go wrong in those facilities, unless somebody says something, there's a good chance the case will pass through the system without ever being seen by the coroner."
The Price of Reform
The National Academy of Sciences has mapped out a plan to improve troubled coroner and medical examiner operations.
In its 2009 report, the academy called for the creation of uniform federal standards for death investigation and recommended making certification mandatory for doctors working in the field of forensic pathology.
So far, however, those suggestions have made little headway in Washington.
Sen. Patrick Leahy (D-Vt.) recently introduced legislation aimed at upgrading the quality of forensic evidence, but his bill would impose no new requirements on the doctors at the center of death investigations. Instead, it would establish a committee to examine how to ensure that qualified practitioners are doing autopsy work.
Many of the academy's proposals would take money—money to educate doctors, to hire more of them and to construct up-to-date facilities.
It's not an overwhelming amount. DiMaio, the former Bexar County medical examiner, estimated that the price of a good medical examiner's office is about $2.50 per person per year, "which is probably less than what you pay for a Coca-Cola in a movie theater."
So far, however, even that is a price many communities have been unwilling to pay. Oklahoma, for example, spends about one-third less each year on its medical examiner than DiMaio's formula suggests it should.
Dr. Victor Weedn, the Maryland assistant medical examiner, said basic misunderstandings about the significance of death investigation have made it a hard sell.
"It's difficult for people to spend money on medical examiner systems," Weedn said. "They see it often as wasting money on the dead, without realizing that everything that is done in a medical examiner office, or a coroner office, is truly done for the living. We try to protect society. We look for deaths that are premature, or that should not have happened, so that we can go forth and correct those errors in society."
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.
ProPublica Deputy Editor of News Applications Krista Kjellman-Schmidt and Director of Computer-Assisted Reporting Jennifer LaFleur and reporter Ryan Gabrielson of the Investigative Reporting Program at UC Berkeley contributed to this report.