The following is the fourth chapter in an NPR/ProPublica/Frontline report on death investigation in the United States.
Massachusetts became the first state to replace coroners with medical examiners back in 1877, but making that switch hasn't ensured that death investigations are carried out properly.
Hobbled by mismanagement and chronic underfunding, the state's Office of the Chief Medical Examiner has spent much of the last decade mired in disarray, its woes detailed in a succession of audits and reports.
At times, Massachusetts' forensic pathologists have toiled in disturbingly decrepit conditions. The National Association of Medical Examiners, a nonprofit body that inspects and accredits morgues, issued a blistering inspection report in 2000 identifying more than 50 significant problems at the agency's facilities. At one morgue, since shuttered, doctors were collecting blood, bile and other bodily fluids in 5-gallon buckets and pumping them back into corpses because a septic system had collapsed, making it impossible to wash the fluids down the drain.
"It was a terrible facility—the worst I've ever seen," remembered the inspector, Dr. John E. Pless, an Indiana forensic pathologist, who said the practice posed "an obvious health risk."
Pless also concluded the office would need $10 million annually in additional funds to do its job properly.
The budget has nearly tripled in the past decade, but even today, it is $3 million below the threshold set by Pless 10 years ago. The agency has never regained its NAME accreditation.
The office has struggled with the most basic of tasks. In 2003, it mixed up the bodies of two women severely burned in a Gloucester house fire. The blaze killed Ann Goyette and injured her friend, Susan Anderson. But when Goyette's body was delivered to the morgue, a doctor mistakenly wrote the name Susan Anderson on the death certificate. In fact, Anderson, comatose, swathed in bandages and surrounded by an oxygen tent, was lying in a bed in Massachusetts General Hospital.
By the time the mistake was uncovered, the agency had cremated Goyette's body, further upsetting her already distraught family. "How could the ball be dropped so many times?" asked Goyette's brother, Scott Arnold, who unsuccessfully sued the state over the snafu.
A comparison of data from the nation's 17 statewide medical examiner systems — including Washington, D.C. — shows that Massachusetts' autopsy rate has fluctuated wildly in recent years. In 2004, it had the second-lowest autopsy rate among statewide systems, doing just three autopsies for every 100 deaths. Washington, D.C., the system with the highest rate, performed about 20 autopsies for every 100 deaths that year.
By 2006, under the direction of an ambitious new chief, the medical examiner's office was taking on far more cases and had brought its autopsy rate up to the average level for statewide systems—to about six per 100. But the agency didn't have the personnel or facilities to handle the increase. Unrefrigerated bodies began piling up in the hallways, and blunders mounted.
John Grossman, who oversees the medical examiner's operations as the state's Undersecretary for Forensic Science and Technology, said the agency has made improvements since then. It has hired new medical staffers and developed safeguards against errors.
"I know we've made great strides in the last three years, putting systems in place so that the office is not on the verge of collapse, creating a culture where the doctors feel supported," Grossman said.
But the state also has scaled back its operations since 2007, slashing the number of autopsies its physicians perform by almost 25 percent to about 2,700 per year.
"In a world of unlimited resources, we'd like to do more autopsies, but we don't live in a world of unlimited resources," Grossman said.
Continue reading this NPR News investigation in partnership with ProPublica and PBS Frontline:
Chapter 5: Shortage of Death Detectives To Perform Autopsies
Chapter 6: Oklahoma's Lack of Resources Means Few Autopsies