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MICHELE NORRIS, host:

From NPR News, this is ALL THINGS CONSIDERED. I'm Michele Norris.

ROBERT SIEGEL, host:

And I'm Robert Siegel.

When there's a sudden or suspicious death, the job of determining the cause of that death falls to one of two people - a coroner or a medical examiner. They decide if the death was natural or accidental, suicide or homicide. Without their final word we can't settle estates, insurance claims, or bring murderers to justice.

NORRIS: But the death investigation system in the U.S. is nothing like TV's "CSI." It's in trouble. A yearlong investigation by NPR, "Frontline" and ProPublica found a dysfunctional system, one short of qualified people, squeezed for resources and lacking any national standards or oversight.

Today, we're going to focus on one-half of the problem: Coroners. In nearly 1,600 counties across the country, coroners are elected or appointed, many with no medical or scientific background.

NPR's Sandra Bartlett brings us the first story in our series, Postmortem.

Unidentified Woman #1: Hello.

Dr. MICHAEL DOBERSEN (Democrat, Coroner, Arapahoe County, Colorado): We're one of - we're your neighbors.

Unidentified Man: Oh, yeah?

Dr. DOBERSEN: And we just wanted to stop by for a minute. I'm running for re-election.

SANDRA BARTLETT: Mike Dobersen is looking for votes in a Denver suburb during the recent midterm elections.

Dr. DOBERSEN: The first thing they usually say is, what do you mean I have to vote for the coroner? The second thing is, you mean you don't have to be a doctor to be a coroner?

BARTLETT: Dobersen has been the coroner in Arapahoe County, Colorado for 17 years. He's a rarity among coroners, not only because he's a medical doctor but also because he's a board certified forensic pathologist.

Dr. DOBERSEN: Again, I'm Michael Dobersen. I'm your coroner.

BARTLETT: Each election, he fights to keep his job or it could be taken by someone with no medical training.

(Soundbite of applause)

BARTLETT: Often, the only requirement to get the coroner's job is to be of legal age and have no felony convictions.

Mr. JAY LEDBETTER (Republican, Coroner Candidate): My name is Jay Ledbetter and I'm running to be the coroner.

BARTLETT: At this candidates meeting, businessman Jay Ledbetter attacks Dobersen for wasting taxpayers' money by doing too many autopsies.

Mr. LEDBETTER: Dr. Dobersen is very good at one thing - autopsies. And he does lots and lots and lots of autopsies.

BARTLETT: Candidate Ledbetter tells the small crowd the Arapahoe County office is too fat and he'll return some of its $1.3 million budget to taxpayers.

Critics have long complained that each election cycle, the job of death investigation becomes a political football, and Dr. Dobersen agrees.

Dr. DOBERSEN: A lot of people really don't understand what the coroner does and tend to vote their political affiliation.

BARTLETT: Once Election Day came, Dobersen - who ran as a Democrat - barely managed to keep his job, winning 51 percent of the vote.

Each election cycle after the votes are counted, it can happen that a businessman, a building contractor or a funeral home director can suddenly be running the coroner's office.

Dr. MARCELLA FIERRO (Former Chief Medical Examiner, Virginia): Most errors are buried. If the death isn't recognized as being suspicious and it's released as a natural death, it's buried or cremated - whatever the family wishes - never to rise again.

BARTLETT: Dr. Marcella Fierro retired as Virginia's chief medical examiner in 2008. Fierro says the autopsy is the cornerstone of death investigation and deciding which cases to autopsy should not be done by elected officials.

Dr. FIERRO: On their best day, if they do not have the training, the skills, the infrastructure, the facility, the access to forensic science, they can't do a good job. It's a question of competency. How can you train someone who is not a physician?

BARTLETT: Fierro sat on the blue ribbon panel when the National Academy of Sciences took a look at the death investigation system. The panel described coroners as the weak link. Our team investigated across the country and found a coroner in Mississippi sent a man to death row after a shoddy autopsy. In Nebraska, coroners often declare death a cardiac arrest without performing autopsies. And in South Carolina, a body was cremated before it was identified because the coroner's office had no refrigeration.

Louisiana has a coroner system and Frank Minyard has been New Orleans' coroner for 36 years. Minyard had medical training as a gynecologist before he won his first election as coroner, but no training in death investigation. Although he has pathologists on staff to perform autopsies, he's in charge and he signs the death certificates.

Over the years, Minyard has been criticized for tailoring his autopsy results toward police theories, or away from police responsibility when there's an in-custody death.

The National Academy of Sciences' report said elected coroners may find it hard to remain impartial and not take sides.

Minyard dismisses the idea. He says calling a death a homicide, a suicide, an accident or undetermined is his call.

Dr. FRANK MINYARD (Coroner, New Orleans): The police has nothing to do with my classification. And we have had battles with the police and the district attorney, and we always come out on the palace of truth. You got to keep that in the back of your mind - Palace of Truth.

BARTLETT: The Palace of Truth has been a little shaky of late. Over the past year, Minyard has had three deaths certificates challenged. In two of those cases, police officers were charged with murder in deaths Minyard called accidental or undetermined.

In the third case, the family of Cayne Miceli is suing after learning that the first autopsy in her case was botched.

(Soundbite of a conversation)

BARTLETT: Mike Miceli serves a customer in his ice cream parlor in Gulf Shores, Alabama.

Unidentified Woman #2: Thank you very much.

Mr. MIKE MICELI (Plaintiff): Have a nice day.

BARTLETT: There are pictures of his daughter Cayne on the walls and news articles about her death. Cayne died in 2009 at the age of 43. She went to a New Orleans hospital with an asthma attack. She was treated and told to go home. She argued that she was still having trouble breathing and she refused to leave. The hospital called the police and Cayne was taken to jail. By the next day, she was on life support.

Mike Miceli remembers the shock of seeing his daughter.

Mr. MICELI: Cayne was there with tubes, you know, coming out of everywhere, had a neck brace on. And the doctor told us that, you know, there was no hope that...

(Soundbite of weeping)

Mr. MICELI: ...what we saw is the way she would be, and we needed to make a decision.

BARTLETT: The decision was made to take Cayne off the respirator. She died a few minutes later.

Afterwards, the doctors asked to speak Miceli privately. They told him there was something wrong with the way Cayne died. Just how wrong became clear when Miceli received the death certificate.

Mr. MICELI: It didn't say accidental. It said cause of death: drug-related, fresh puncture wounds in arm.

BARTLETT: Miceli decided to get a second independent autopsy. He had his daughter's body flown to Alabama and he called Mary Howell, a lawyer who's taken on many cases in which Minyard's office has done questionable work.

Ms. MARY HOWELL (Attorney): Here's the important thing about Minyard: He is not a forensic pathologist. And so all he can really do is report on what his pathologists are reporting to him. And so, he's really dependent largely upon the objectivity and the truthfulness of his personnel and that's been a problem.

BARTLETT: Dr. James Lauridson performed the second autopsy. He's a former chief medical examiner in Montgomery, Alabama, who now works independently. He says the first pathologist was too quick in his conclusions.

Dr. JAMES LAURIDSON (Former Chief Medical Examiner, Montgomery, Alabama): The medical examiner saw needle puncture marks on her arm and came to the conclusion that this was a drug-related death, never carried the examination further or looked at the medical records.

BARTLETT: The needle marks on Cayne's arms were made in the hospital, as doctors tried to revive her. But the pathologist blamed it on drug abuse. Blood tests showed no illegal drugs in her system.

Dr. LAURIDSON: Well, my reaction was that this was a autopsy that should never have been glorified with a report.

BARTLETT: The real reason for Cayne's death became clear during the second autopsy. Her lungs were full of mucous. Lauridson ruled she died of bronchial asthma, after she was put in a restraint in her jail cell.

Dr. LAURIDSON: To put an asthmatic flat and then tie them down during an acute asthma attack is nearly the same as giving them a death sentence.

BARTLETT: In January 2009, coroner Minyard signed the death certificate calling Cayne's death a drug overdose. There was never an investigation into how the police treated her in jail. Minyard ignored the second autopsy results. He only changed the death certificate in April 2010, after the Micelis filed their lawsuit. Minyard won't comment on the lawsuit but he defends his pathologists.

Dr. MINYARD: I have to believe what my pathologists say. I couldn't do this job if I didn't believe them, point blank, 100 percent, no questions.

BARTLETT: The mistakes made by the coroner's office in New Orleans may seem like an exception, but similar mistakes can be found all over the country. Inadequate budgets mean the offices can't hire enough of the best pathologists to do the job right. And coroners who supervise those pathologists don't always know that mistakes are being made until the second autopsy reveals the truth.

Tomorrow, we look at medical examiners. It's the system the National Academy of Sciences recommends for every state, but our investigation found many shortcomings with that system, too.

Sandra Bartlett, NPR News.

NORRIS: You can watch an hour-long "Post Mortem" documentary tonight on "Frontline" from PBS. And for more on our investigation, visit propublica.org and npr.org.

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