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ROBERT SIEGEL, host:

From NPR News, this is ALL THINGS CONSIDERED. I'm Robert Siegel.

MICHELE NORRIS, host:

And I'm Michele Norris.

Two years ago, a blue ribbon panel created by the National Academy of Sciences raised a red flag about a lack of mandatory standards for autopsies. It also expressed concern over a lack of oversight for coroners and medical examiners. The panel recommended that the goal of every state should be to move away from a coroner system which is not based in medicine.

SIEGEL: States, it said, should also hire board-certified forensic pathologists and put them to work as medical examiners.

NPR, "Frontline" and ProPublica have been working together for a year examining the extent of the problems. The result is our series Post Mortem: Death Investigation in America.

Yesterday, NPR's Sandra Bartlett focused on the country's coroner problem. Today, the other half of the equation: Medical examiners.

Dr. ROSS ZUMWALT (Medical Examiner, Albuquerque, New Mexico): Well, let me show you our CT scanner.

SANDRA BARTLETT: I'm standing with Dr. Ross Zumwalt, as he shows off his state-of-the-art medical examiner's office in Albuquerque.

Dr. ZUMWALT: In fact, we're doing the baby now.

BARTLETT: It serves all of New Mexico.

Dr. ZUMWALT: This is such a pleasure to work in this spacious operating room type atmosphere.

BARTLETT: Pleasurable for him, maybe. But to an outsider, looking at a year-old baby about to be autopsied - this office is a grim reminder of where our last medical exam takes place.

Zumwalt is a medical doctor with a specialty in forensic pathology. He examines and autopsies a body to find out why and how someone died. Like other medical specialties, it takes about a dozen years of education and training.

Zumwalt says his new CT scanner will ensure he doesn't miss anything in that last examination. This high-tech X-ray machine takes pictures from several angles at a time.

Dr. ZUMWALT: We would like to put everybody through the CT scanner.

BARTLETT: The lab has nine bodies to be examined and autopsied this day. At the morning meeting, cases are described and then assigned to the forensic pathologists.

Unidentified Woman: Four-eight-seven-five is a 19-year-old female who was the restrained driver of a Ford Taurus, was traveling southbound on Coors(ph). She went to make a U-turn and apparently she was T-boned by a Hummer.

BARTLETT: Zumwalt's Albuquerque facility is one of the best in the country, not just because of the new building and its modern equipment, but also because he has enough staff to investigate and autopsy all sudden or violent deaths.

Dr. ZUMWALT: My assistant is drawing blood from the femoral vein for toxicology.

BARTLETT: His investigators go to the location of a death, to the home or the car accident, and they take the time to talk to family members and witnesses to gather information, to help them determine how and why someone died.

Around the country Zumwalt's colleagues see New Mexico as the gold standard all medical examiner offices should meet, but only a small number actually reach a bar that high.

Our investigation uncovered dozens of autopsies with serious mistakes. We read thousands of pages of records documenting how pathologists missed crucial evidence, like signs of electrocution, strangulation marks, or a bullet hole in the neck.

Zumwalt says where you die makes a difference, especially when your death is unexpected or suspect.

Dr. ZUMWALT: It's certainly incredible to think that just the space of a few yards may mean the difference between competent death investigation and incompetent death investigation. But there may be areas where on side of the border, you have a statewide medical examiner and competent death investigation, the other side of the border may be a small county coroner with few resources and little training.

BARTLETT: As we investigated across the country, we found it's not necessarily the poorer states or those states with smaller populations that fail to provide adequate death investigations.

(Soundbite of machinery)

BARTLETT: We're at the medical examiner's office in Boston, Massachusetts, where bodies are being moved in and out of the stainless steel coolers for the day's autopsies.

Boston is home to some of the best medical facilities in the country. Like New Mexico, it's a state-run system. It was the first in the country to appoint a doctor to act as the medical examiner back in 1877. You'd expect to find another gold standard medical examiner's office, but you'd be wrong.

Today, the Massachusetts medical examiner office is a long way from being first. It has a history of problems. In 2000, an audit found the agency was $10 million short of what it needed to do the job. The average salary for a forensic pathologist back then was $200,000 a year - salaries in Boston were 95,000. Those lower salaries did not attract the best qualified people, doctors who are board-certified forensic pathologists.

And the mistakes piled up over the years, all over the state.

Mr. SCOTT ARNOLD: They're just some baby pictures. These, the ones later on, that kind of bring back some nice memories of...

BARTLETT: Scott Arnold is spreading out a collage of photos, showing him with his sister, Ann.

Mr. ARNOLD: That's the two of us. We were in a marching band together.

BARTLETT: Arnold lives in Gloucester, about an hour's drive from Boston. In 2003, his sister, Ann Goyette, was badly burned in a house fire.

Mr. ARNOLD: The police did say to my father that there were two victims, one had died. So we knew it was serious.

BARTLETT: At the hospital, doctors told him they'd put Ann into a coma.

Mr. ARNOLD: She was in a oxygen tent, you know, a full face mask with tubes down her throat.

BARTLETT: After almost a week, Arnold and his father were told Ann was out of the coma and talking.

Mr. ARNOLD: So off we went, walked into the unit and there was the girl who we didn't recognize - I'd never met her before - sitting up in bed. And I looked at her and I don't know why, but I said, Ann? And she says, no, my name is Susan. And my father kind of collapsed.

BARTLETT: Arnold says they went home and waited for someone to call and tell them the real Ann was dead. Finally, the state police came by to ask Arnold to identify his sister's body. But all they had to show him were photographs. Her body had been released to the wrong family and she'd already been cremated. They had to arrange a funeral service without a body.

This is an extreme case but not rare in Massachusetts. Multiple audits and inspections document that mixing up bodies or forgetting about them in the cooler was routine. Autopsy reports and death certificates took months and sometimes years to be completed.

Even when funding began to improve in 2004, the problems continued. The most recent audit in April of 2007 describes the office as being on the verge of collapse.

Dr. HENRY NIELDS (Acting Chief Medical Examiner, Massachusetts): Yes, I think that was an exaggeration. I didn't sense that.

BARTLETT: Dr. Henry Nields is now the acting chief medical examiner. He worked in the office in the late '90s, before leaving for a job in New York. He came back to Boston in 2006.

Dr. NIELDS: I mean, I had only been here less that a year. But it didn't feel like it was on the verge of collapse.

BARTLETT: Nields got his promotion when the then-chief medical examiner was fired for misplacing a body. The body was found but it was buried in the wrong grave. The one that was supposed to be buried there was still in the cooler at the morgue.

John Grossman is Massachusetts' undersecretary of forensic science and technology. He oversees the medical examiner's office. Grossman says the firing show he's serious about ending the mistakes.

Mr. JOHN GROSSMAN (Undersecretary of Forensic Science and Technology, Massachusetts): The real problem at the end of Dr. Nields' predecessor term was that he covered it up. And as often the case, the cover-up is worse than the crime. He was fired for cause.

BARTLETT: Shortly after that firing, another incident brought yet more embarrassment. Dr. William Zane told a grand jury that a dead man's brain had swelling and bleeding, a sign of a severe beating. After another pathologist looked at the same brain, Zane was forced to admit he'd made a mistake. At the trial, he testified that the swelling was actually caused by the fluid in which it was stored. He also identified the victim as Caucasian, when he was actually African-American.

The result was that charges in the case were reduced from murder to manslaughter.

Dr. Henry Nields became Zane's boss after this incident.

Dr. NIELDS: Yeah, I don't - I don't know the specifics of the case. There are, as I'm sure you know, there are African-Americans who are relatively light-skinned. So I can't say that that was the case, in this particular case. I don't know.

BARTLETT: This wasn't the first time Zane found himself embroiled in controversy. In 2003, he was one of several staff members investigated by the state attorney general's office in the death investigation of a three-month-old child. Another doctor did the autopsy, but Zane was blamed for sending the wrong eyeballs out for testing.

He didn't lose his job for these mistakes. For a time, he was not allowed to do autopsies on potential homicide victims. But today, he's doing a full range of autopsies.

We tried to contact Dr. Zane but he didn't respond. His bosses said he could not be made available for an interview with NPR.

Nields says all that is in the past.

Dr. NIELDS: Well, the place has already been fixed to some extent. You know, I hate to come back to the money thing but we certainly need more funding to be at the level where I would like to be, and I think it's a better place today than it was yesterday.

BARTLETT: Nields' budget in 2010 was still more than $3 million short of what the office needed to operate 10 years ago.

So what will it take to change the system? Some say federal money is needed to raise the standard of death investigations. The National Academy of Sciences recommends a national oversight body to establish and enforce best practices.

Sandra Bartlett, NPR News.

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