Second Chances Shows Flaws In Death Investigations The chronic shortage of forensic pathologists has allowed for one doctor to continue performing thousands of autopsies and to serve as an expert witness in criminal cases despite firings for inaccurate findings and alcohol abuse.

Second Chances Shows Flaws In Death Investigations

Chris Reynolds vividly remembers his first encounter with the work of forensic pathologist Dr. Thomas Gill.

It was 2001. Reynolds, a Santa Rosa private investigator, was hired by a Sonoma County man accused of killing his wife. Gill, who conducted the wife's autopsy, was the prosecution's key witness, having determined the death was a "textbook" case of suffocation.

Reynolds' client's prospects looked grim. But when Reynolds dug into Gill's background, he unspooled a history in which Gill landed post after post despite a lengthening trail of errors and, in one instance, drinking on the job.

Dr. Thomas Gill at the Jackson County Medical Examiner's Office in Kansas City, Missouri in 2004. Gill was hired as the No. 2 official in the office before he lost his job and returned to California. Michael McClure hide caption

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Michael McClure

Dr. Thomas Gill at the Jackson County Medical Examiner's Office in Kansas City, Missouri in 2004. Gill was hired as the No. 2 official in the office before he lost his job and returned to California.

Michael McClure

Gill had been fired for inaccurate findings and alcohol abuse by the coroner in Indianapolis, Reynolds discovered. Demoted for poor performance as a fellow for the Los Angeles County Coroner, he resurfaced at a private autopsy company in Northern California.

Reynolds learned that Gill had missed key evidence in the Sonoma County case and that he had been coached by prosecutors to downplay his past, prompting the dismissal of the murder charge.

Yet, in the decade since, Gill has continued to do thousands of autopsies and to serve as an expert witness in criminal cases. In 2006, the California State Bar deemed Gill incompetent. The next year, Gill was rehired by Forensic Medical Group Inc., the Fairfield firm that handled the case investigated by Reynolds.

The private forensics firm has held contracts with 16 Northern California counties to perform autopsies. Besides Sonoma County, Gill has conducted death investigations or testified in court cases in eight counties as a doctor for Forensic Medical Group. He had done more than 800 autopsies during a three-year period just in Yolo, Napa and Solano counties, records show.

The company cut its ties with Gill in December after Yolo County Sheriff-Coroner's officials learned of the doctor's history from reporters and barred him from performing its autopsies. In a written response to questions, Forensic Medical Group said that after Yolo County's decision, it no longer had enough cases to justify employing Gill.

Gill's ability to resurrect his career time and again reflects a profound weakness at the center of the U.S. system of death investigation.

A chronic shortage of qualified forensic pathologists allows even questionably competent practitioners to remain employable. The absence of trained practitioners is so acute that many jurisdictions don't look closely at the doctors they employ. Some of the officials who hired Gill acknowledged they knew about his problems but said they had no other viable options.

In some cases, officials in charge of death investigation are more concerned with costs than with competent autopsies, said Dr. John Pless, a director of the National Association of Medical Examiners and retired forensic pathology professor at Indiana University.

"What the problem is all over and why Tom Gill is accepted is there are people running the system who don't understand the complexity of the medical determinations," Pless said.

Gill, 67, initially declined requests for interviews for this story. Approached by a reporter at his Fairfield home in December, he would not address specific cases or criticism of his work.

"I am a qualified forensic pathologist, and I have testified on numerous occasions," Gill said.

Later, in a written statement, Gill acknowledged that when he joined the Indianapolis coroner's office, "I had no formal training in forensic pathology and therefore made mistakes, particularly in pediatric cases where findings tend to be more subtle and complex."

Gill pointed out that his autopsy findings have not been contested or reversed since 2007.

Dr. Arnold Josselson, Forensic Medical Group's vice president said he had seen Gill's work firsthand and trusted him. "I've observed him doing autopsies, and I think he's competent," Josselson said.

A Troubling History

Gill got his first job as a forensics pathologist in Indiana where the chief medical examiner was desperate for help. The office had bodies stacked up in its refrigeration units.

Gill worked seven days a week during his first several months in Indianapolis, examining four to eight bodies per shift, court and county records show. Signed to a four-year contract that paid $100,000 annually, he performed about 650 autopsies in 1993 alone, more than twice the maximum workload recommended by the National Association of Medical Examiners.

It didn't take long for problems to surface.

In early 1993, Gill ruled that Dylan Petroff, a 17-month-old boy, had died from a blood infection. A second autopsy conducted by a leading specialist hired by Petroff's parents, however, came to a different conclusion.

Petroff had strangled, the specialist determined, caught in the slats of a defective crib at the uncertified day care center run by his babysitter.

A year later, 6-month-old Julian Dorsey ended up on Gill's table. The doctor ruled the infant was a homicide victim, shaken to death by his father. But Gill's boss overruled him, finding that there was no physical evidence the child had sustained a brain injury.

Gill's drinking also became an issue.

Soon after he started in Marion County, another coroner's office employee found him passed out drunk in a loading dock after the end of a shift, Gill acknowledged in written answers during preparation for a 2001 trial.

Gill was told in July 1994 that his contract would end after just 19 months.

He was given 30 days' notice but was unable to complete his final month. Gill was arrested on the charge of drunken driving on his way to the morgue one morning and barred from further work. He was convicted, and Indiana's medical board suspended his license.

Fresh Start In California

Gill moved to California and spent months undergoing treatment for alcohol abuse.

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Then, in early 1995, he landed a one-year fellowship with the Los Angeles County Coroner, an ideal place to hone his training in forensic autopsies and death investigation.

Gill struggled to meet the program's requirements. Nine months into his training, personnel records show, the coroner's office deemed his work deficient, cut his pay in half and demoted him to the equivalent of a medical resident, the same status as rookie doctors 20 years his junior.

Gill was hired in April 1998 by Forensic Medical Group, the private autopsy company with contracts to handle cases for more than a dozen Northern California counties, including Sonoma County.

It was there that Reynolds, the private investigator, began to unravel Gill's past.

Errors Surface In Sonoma case

Late on the evening of Nov. 7, 1999, a prominent Petaluma physician called 911. His wife was dead, Dr. Louis Pelfini told the emergency operator, adding that he feared she had committed suicide.

Sonoma County Sheriff's Office investigators ultimately came to suspect that Pelfini had killed his wife, Janet.

Gill started his examination of her body two days later. After a month, he ruled that Janet Pelfini had died from asphyxiation. His notes showed abrasions circling her mouth and a bruise on her forehead. Based on his findings, the sheriff's office classified her death as a homicide, and prosecutors filed murder charges against Louis Pelfini.

Gill's certainty about what caused Janet Pelfini to suffocate prompted her husband's defense team to worry, said Reynolds, the private investigator hired by Louis Pelfini's attorney.

But Gill's work on the case had some holes.

Gill did not take pictures of Janet Pelfini's injuries as he autopsied her. He made drawings, but photographs from the scene taken by sheriff's deputies showed they were inaccurate. He failed to note a bruise on the back of her head on the drawings. In his written report, the injury was included, but on the wrong side of her head.

With Pelfini's case resting primarily on Gill's conclusions, Reynolds began running the doctor's name through news archives and calling former colleagues.

When the defense team reported its findings about Gill to prosecutors, however, the state did not re-examine the charges. Instead, they secretly began coaching Gill, arranging for him to meet with a speech therapist to craft his trial testimony.

In the videotaped sessions, Gill acknowledged he would have to sidestep flaws in his casework. "There are deficiencies in the autopsy," he acknowledged.

The tapes also showed Gill and his coach, Jeffrey Harris, trying to downplay his past.

Practicing an answer to the question of why Marion County fired him, Gill said the termination was due to "errors in autopsies and inability to testify in trials."

"OK, timeout," Harris interrupted. "Don't say … I would not say, 'My inability to testify in trials.' I would say, 'My difficulty in testifying effectively,' or 'my inability to effectively communicate the results of my autopsies.' Something to that effect."

Gill is shown on the tape taking down Harris' instructions.

"We always want to be thinking about, how do we counter these allegations, these innuendos that there's something wrong with you," Harris told Gill.

The strategy failed when Pelfini's attorney learned of the coaching sessions and the trial judge ordered the tapes released. Days later, the district attorney's office dropped all charges.

The California State Bar investigated the handling of the Pelfini case and devoted several pages to Gill's errors.

"Unfortunately," it concluded, "Dr. Gill was not a competent pathologist."

A New Beginning

After a stint in Missouri marked by more mistakes, Gill returned to California in 2007 when the Forensic Medical Group hired him a second time.

Dr. Brian Peterson, who was the firm's president for 15 years before becoming Milwaukee's chief medical examiner, defended the decision.

"To my mind, he was always a victim," Peterson said. "Gill's a great guy, and he's a fine pathologist."

The group didn't advertise Gill's background. On its website, it gave resumes and educational histories for all its doctors — except Gill.

In his written statement, Gill said his work since returning to Forensic Medical Group in 2007 had been above reproach. In addition, the doctor said that county officials in the jurisdictions he served were aware of his background.

But several Forensic Medical Group clients say they were unaware of Gill's past.

Presented with records detailing Gill's professional history in late November, officials with the Yolo County Sheriff-Coroner's Office expressed surprise.

"This is an eye-opener for us, to admit humbly," said Yolo County Chief Deputy Coroner Robert LaBrash.

Yolo County subsequently joined Sonoma in demanding that Gill not be used on its cases.

Until December, when Forensic Medical Group says it stopped employing Gill, the doctor remained active. Last summer he gave testimony in a homicide case, a stabbing.

Asked if he intended to continue working as a forensic pathologist and if he was seeking employment, Gill e-mailed back.

"Yes and yes," he said.

This investigation was reported and produced by staff at ProPublica, PBS Frontline, NPR, the Investigative Reporting Program at UC Berkeley, and California Watch. Reporters Lowell Bergman, Andres Cediel and Carrie Lozano contributed to this story.