Many underfunded and understaffed medical examiner and coroner offices have stopped doing autopsies in some categories of deaths. In some states suicides are not autopsied, in others people who die in car accidents, and many jurisdictions have stopped performing autopsies on people over the age of 60 unless it is an obvious violent death. In Oklahoma, for example, they lower the age limit to 40.
An investigation by NPR, PBS Frontline and ProPublica found concerns among law enforcement and health care professionals over the trend to assume the elderly always die of natural causes. They fear there's a quiet epidemic of what they call "gray homicides" going undetected and unpunished.
When 80-year-old Elmore Kittower died while living at Silverado it was assumed he died of natural causes and no one asked for an autopsy. Silverado is one of the nation's most high-end homes for dementia patients, located 90 minutes outside Los Angeles. Patients pay $7,000 per month for a semi-private room there.
But the day after Kittower was buried, his widow received an anonymous call from someone who worked at Silverado, saying her husband's death was likely caused by a staff member who beat him.
The police were called, and according to Los Angeles Deputy District Attorney Robin Allen, the anonymous caller provided enough information to warrant exhuming the body and performing an autopsy.
"When I read the coroner's report, I knew we had a serious case here," Allen says. "I knew that I had somebody, Mr. Kittower, who had suffered horrific abuse. He had multiple rib fractures at different stages of healing. He had a sternal fracture. He had a fracture to his larynx, to his toes."
Yet when the sheriff's office and paramedics first arrived at Silverado, they didn't consider any foul play.
"There are just assumptions, I think, that people sometimes wrongfully make about the elderly — that they're always going to have bruising, they're always going to fall," Allen says.
But Kittower was bedridden from a stroke, so it's unlikely his injuries were caused by bumping into things or falling.
Craig Harvey, the chief death investigator for the Los Angeles County Coroner's Office, says they can't investigate deaths if they aren't alerted to them. In the case of a home like Silverado, it would be up to a doctor or ambulance staff to call the coroner.
"There's no way that we can look at every case we should probably be looking at," Harvey says. "When you only see 1 in every 3 cases, the possibility that a homicide's going to be missed are pretty great."
Review Team Finds More Suspicious Deaths
Harvey says the suspicion that homicides of the elderly were being missed prompted the county to put together a team to review deaths. The team includes the coroner's office, law enforcement, social services and a geriatrician.
Allen says once the team started looking they found a lot of elderly people dying under suspicious circumstances.
"I normally have at least 15 active cases on my caseload at any time," she says. "It is amazing how many more cases we had than when I entered this unit five years ago. ... The level of seriousness and complexity of the cases has taken on an additional dimension as well."
Allen says it is hard to prove murder or neglect in the elderly because they have many medical problems. But she says that doesn't mean coroners and medical examiners should simply stop doing autopsies on older people.
In the investigation into Kittower's death, Allen says she had a lot of evidence showing caregiver Cesar Ulloa had beaten and abused him.
"Because [Kittower] had a blood clot dislodge and that wound up killing him, we couldn't say to a medical certainty ... that the physical violence that he had suffered shortly before his death caused the clot to dislodge," she said. "I realized that we really weren't going to be able to charge a homicide."
But the more she thought about Kittower and what he had suffered, she decided to charge Ulloa with torture. A jury agreed that's what happened to Kittower and four other residents. Ulloa was sentenced to life in prison.
Kittower's Autopsy Unveils Additional Trauma
After Richard McDonough, a former Hollywood TV director, retired, he began to develop dementia. His night wanderings became too frequent and dangerous, so his wife, Mary, along with their three children made the difficult decision to move him into a home where he could be safer.
"We had promised each other we would never put the other one in a nursing home. I would say, 'I will always take care of you,' and Richard would say, 'I will always take care of you,' " Mary McDonough says.
The first couple of nursing homes were a bad fit for his needs, but then in December of 2006, McDonough says, they found Silverado.
"It was perfect," she says. "He could walk out any of the doors, except the front door ... and walk all around. They had a little pitch-and-putt course, a swimming pool that was well-guarded and fenced. It was a lovely place. It was like a home."
She says Richard seemed less agitated at Silverado and she thought his care was very good. But one day, the home called a meeting to tell the families a caregiver had been arrested in connection with the death of one of the residents: Elmore Kittower. Mary McDonough said she was shocked but not worried about her husband.
During the time the caretaker was being investigated, Richard died. That was in 2008. Mary says it wasn't a surprise because he had become very weak.
What did surprise her was when six months later a detective came by to talk with her and her daughter Molly. He told them caregivers at the home had seen the suspect in the Kittower case beat other residents, including Richard.
"What could I have done?" Mary McDonough says. "That always goes through your mind, what could I have done to stop that. But I never saw anything. He had bruises and maybe a little abrasion here but so did a lot of the others."
Without the autopsy, Kittower's abuser would have gotten away with it, says Allen.
"The deaths are complicated," Allen says. "But we can't just say it's complicated and push it aside. We can't just say they're old and they're going to die soon and not look at it as something that is significant."
Allen says if autopsies on the elderly are stopped, the truth about a suspicious death may never be learned.
"In this particular case, the truth did go to the grave; it was buried, it was 6 feet under with Mr. Kittower. And this abuse would have just continued," Allen says. "It was only that death that actually got someone to come forward. And I think [if] these secrets go to the grave ... more and more people will just get abused in the process."