Prozor 1

Skyler Prozor

Dr. Guenzel

ENC 1102-0203

October 10, 2018

Research Dossier: The Impact of a Failing Medical Examiner System on the Families of
Victims

Dossier Introduction

As an undergraduate student, I am currently majoring in Forensic Science with the

ultimate goal of going to Medical School and becoming a medical examiner. The hours of
independent research I have done on the profession has prompted me to study and research how
the current failing Medical Examiner System affects the families of homicide/suicide victims.
For the past two decades, forensic professionals, lawmakers, and the families of victims exposed
to malpractice of medical examiners have attempted to solve issues within the system including
extreme staff shortage, underfunding and poor forensic practices. Unfortunately most efforts
have only been temporary and conditions have gone unchanged; hundreds of families a year are
affected emotionally, mentally and financially by medical examiner system inadequacy.
Up to this point in my research process I have narrowed down the sources I will be
implicating into my research, as well as thoroughly breaking down the perspectives, type of
information, genre of source for each individual source of 15. Sources 1 (Chipman), 3 (Clasen-
Kelly), 7 (Hanzlick), 11 (Pearsall), and 14 (Thames) offer background information on the
medical examiner system, its progression and challenges. The major question surrounding my
research and sources that support and/or counter my argument include 2 (Clasen-Kelly), 4
(Friedman), 9 (Loren), 10 (Patel), 12 (Schaper), 13 (Stirling), 14 (Thames) and 15 (Vendel). The
following sources offer potential solutions and solution efforts surrounding the argument: 5
(Giacalone), 6 (Green), 7 (Hanzlick), 8 (Hoban) and 11 (Pearsall). The sources that contribute to
the overall argument include different perspectives that both agree, disagree and offer a new
view for my research argument which in turn helps structure my research around a Rogerian
form of argument.
The broad area of research encompasses many more then 4 perspectives, however, for my
research I will be focusing on 4 major perspectives: Medical/Forensic professionals, families
affected by the medical examiner system, investigative news journalists and analysts, and former
Medical directors as well as former law enforcement. Alternately, the sources can be broken
down into background information on the medical examiner system, evidence which
encompasses primary and secondary accounts of real- life families across the country each
presenting individual stories related to emotional, mental, or financial pain incurred, and
 Prozor 2

methodology as it relates to investigative research studies or the implementation of solutions in

progress.
As the next step in my research process, I will be organizing the information taken from
the sources by type of information rather than separation by source, and eliminating any repeated
information and incorporating the information together. The major roadblock I am still facing,
however, is figuring out exactly how to word my thesis and major research question. I am
worried about stretching the source information to fit my research question or vice-versa and
stretching my research question to encompass all the information in sources. Currently I have
altered my research question three times as source availability played a large role in the
paraphrase of my research question.

Research Map

Research Questions:

-What major issues lead to Medical examination mistakes of victims?

- What effects do families of victims experience due to a dysfunctional medical examiner
system?

Thesis:

Poor forensic practices do not only lead to heavy caseloads for medical examiners but
ultimately also have detrimental effects on families of victims.

Keywords:

· Issues with medical examiner system

· problems with medical examinations
· medical examination mistakes effects on victims’ families
· improving forensic autopsies
· questionable autopsy
· family challenges to medical examiner conclusions
· fixing medical examiner system

Types of Evidence:

● Library: 2 sources
● Internet: 14 sources
● Field: Unfortunately due to time constraint I am unable to use first-hand
interviews with professors who work in forensic science and other forms of field
study that I had previously anticipated incorporating into my research process.

Research Schedule:
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Mtg.= meeting Blue= Forensic Science Purple= Statistics Pink= Honors Symposium
FSA= Forensic Science Association Red= ENC/(RR=reading response) Green= Chemistry
Research Days- *** Drafting-+++ ____- completed

October

Sunda Monday Tuesday Wednesda Thursda Friday Saturda

y y y y

30 1 2*** 3 4*** 5 6
Week 7 FSA mtg. SPARK Blog post SPARK Clean the
due Quiz 6 mtg. 3 mtg. World
due Circle K Event
Research mtg
Map Due RR 10

7 8 9*** 10 11*** 12 13
Week 8 SPARK Blog Circle k Ch 3 Orlando
due mtg. post 4 mtg. quiz Pride Set
FSA mtg. Midterm RR 12 up
Quiz 7
RR 11

14 15 16*** 17 18*** 19 20
Week 9 FSA mtg. SPARK Blog post Ch 3 Going
due Research mtg. 5 Exam Home
Dossier Circle k (Raider
Draft mtg Comp.)
Exam 2
RR 14
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21 22 23+++ 24+++ 25+++ 26+++ 27

Service FSA mtg. Circle k Blog post
learnin Quiz 8 mtg 6
g RR15 RR 16
results
due

28 29 30 31:
Week FSA mtg. (Peer Halloween
11 due Quiz 9 Review !
RR 17 w/ Circle K
Jordan) mtg
RR18

November

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

1 2 3
Blog Post 7 Ch. 4 Savage
Quiz Race

4 5 6 7 8+++ 9+++ 10
Service RR 19 F2F Workshop Blog post 8 Peer
learning Quiz 10 conference draft review
Reflection FSA mtg (Date may rhetorical WS 2
change) analysis
Circle K mtg
 Prozor 5

11 12 13+++ 14 15 16 17
Veterans Final draft Blog post 9
Day rhetorical F2F conference
Pitch Ted- analysis (Date may change)
Talk Ch. 4 Test
Quiz 11 SPARK mtg
FSA mtg Circle K mtg

18 19 20+++ 21 22 23 24
Service Draft 1 Peer review Blog post 10
learning Research draft 1 paper THANKSGIVING
poster due paper Ch. 6 Quiz
Quiz 12 Circle K mtg
FSA mtg
Exam 3

25+++ 26+++ 27+++ 28+++ 29 30 1

Draft 2 Draft 3/ Self- EC/ Final draft paper/ Review Quiz 14
paper assessment Peer Review Draft JROTC
Quiz 13 Ch. 6 Test 3/self-assessment/ States
FSA mtg SPARK mtg Ted-talk student comp.
Circle K mtg lounge

December
 Prozor 6

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

2 3 4 5 6 7 8
Final Exam Final exam Ted-Talks/ Final Exam
E-portfolio

9
Going W I N T E R B R E A K
home!!!!

Annotated Bibliography
Chipman, J. (2017). Death in the family. [Toronto, Ontario] : Doubleday Canada, [2017].
Retrieved from
https://login.ezproxy.net.ucf.edu/login?auth=shibb&url=https://search.ebscohost.com/logi
n.aspx?direct=true&db=cat00846a&AN=ucfl.035945430&site=eds-live&scope=site

Content: “In a work of vigorous reporting, careful analysis, deep compassion and
unerring integrity, award-winning journalist and documentarian John Chipman
investigates the lives left ruined in the wake of Dr. Charles Smith's ignominious career. In
the mid-'90s, the Ontario Coroner's office decided that death investigation teams needed to
"think dirty." They wanted coroners, pathologists and police to be more suspicious--to
"assume that all deaths are homicides until satisfied that they are not." They were
particularly concerned about pediatric deaths, which historically had been exceedingly
difficult to investigate. There were usually no witnesses; no evidence to gather at the
scene; no outward signs of trauma on the body. If the pathologist did not discover the truth
of what had happened, child abuse could go uncovered. Among those charged to "think
dirty" was Dr. Charles Smith, Ontario's top pediatric forensic pathologist at the time”
[from abstract].

Author: John Chipman is a journalist and author who has traveled all over the world
writing books and creating documentaries. Chipman has two young children and as a
member of the public is sided with putting families in death investigations in high
consideration.
 Prozor 7

BEAM: The source is from the perspective of a journalist, a secondary source on the
outside looking in. The source also provides information on the methodology and
background of medical examiners.

Clasen-Kelly, F. May 1, 2013. Butts: Body Swap ‘regrettable, but not violation of N.C
policy. Retrieved October 7, 2018 from https://www.charlotteobserver.com/news/special-
reports/nc-medical-examiners/article9088730.html

Content: In this specific North Carolina case, medical examiner Ronald Key sends
wrong corpse to grieving family in New Jersey. The victim’s family is suing the state for
mental and emotional distress; this is one of the first attempts to hold a state liable for a
M.E mistake. Key did not verify the identity of the body before sending it to New Jersey,
however, Key did not actually do anything wrong. M.E’s are not supposed to perform
autopsies and investigations on all victims especially if law enforcement had already
confirmed the victims and cause of death. Attorney states that with a proper investigation,
the M.E should have been able to distinguish the victims bodies.

Author: The author although a news reporter, quotes directly information objectively
from a former medical examiner. As a former medical examiner, primary source
information is given about the true issues with the medical examiner system.

BEAM: The source coming from a former medical examiner is bound to be bias in either
direction. In this case the former medical examiner recognizes the issues with the medical
examiner system however also does not put blame on his old position. The source
addresses exhibit source and contributes to my research argument.

Clasen-Kelly, F. November 17, 2013. In NC medical examiner system, heavy autopsy

caseloads raise risk of mistakes. Retrieved September 18, 2018, from
https://www.charlotteobserver.com/news/special-reports/nc-medical-
examiners/article9092573.html

Content: North Carolina M.E’s do about 10 autopsies a day, however, in order to ensure
thorough examinations the optimal autopsies a day is usually around 4. The two major
reasons for such heavy caseload build up are inadequate funding and short staffing of
forensic pathologists. Despite the persistence of the idea that heavy caseloads lead to
increased mistakes, the spokesman for the department of health insists that heavier
caseloads do not increase the risk for mistakes. There are only around 600 pathologists to
serve the entire country and due to this N.C major cities are performing well above the
maximum amount of 250 autopsies according to national standards. Solutions have begun
to unravel as lawmakers agreed to raise salaries for forensic pathologists.
 Prozor 8

Author: Clasen-Kelly is a news analyst for the Charlotte Observer, whom has published
many articles and journals for the Charlotte Observer.

BEAM: The source is from the perspective of a news reporter and analyst, which in turn
for the most part highlights an objective stance on the information. The source provides
background on the issues with the medical examiner system.

Friedman, Josh. April 23, 2017. SLO medical examiner tied to another questionable
autopsy finding. Retrieved October 8, 2018 from https://calcoastnews.com/2017/04/slo-
medical-examiner-tied-another-questionable-autopsy-finding/

Content: A man by the name of Donald Hill was taken into custody after a family report
that he was getting out of hand. Law enforcement restrained Hill for 36 hours who died
shortly after being released due to a blood clot that had travel from his leg to his lung.
The M.E ruled the manner of death unknown and the cause of death a natural one. The
deceased family filed a wrongful death claim. This source story although rather short will
help expose yet another issue with the objectiveness of trained medical examiners.

Author: Josh Friedman is a news analyst out of California, whom has published multiple
news journals and articles.

BEAM: The source is written from the perspective of a news analyst, which in turn is
another objective source for my research topic which will provide details that will agree
and disagree with my argument. The source provides a specific example of a case that
affected the lives of family members.

Giacalone, J. July, 26, 2016. NY state passes law requiring medical examiners to use
Namus. Retrieved October 7, 2018 from http://joegiacalone.net/ny-passes-law-
requiring-mes-use-namus/

Content: In recent years the state of New York has passed a law that requires medical
examiners within a 60 day limit input unidentified persons into a system known as
NAMUS. NAMUS stands for the National Missing and Unidentified System and not only
is the site for medical examiners and law enforcement to communicate with one another
but families of missing persons can also aid and assist in the investigations.

Author: Joe Giacalone is a retired NYPD Sergeant and the commanding officer of the
Bronx cold case homicide squad. Giacalone has trained investigators all over the world
 Prozor 9

and wrote a book on all of his investigative training skills. Joe is a highly decorated
NYPD officer including recieving a medal of valor.

BEAM: The source is from the perspective of a law enforcement professional who
worked closely with medical examiners. It provides solutions to a different aspect of
medical examinations that is not my primary research, however, it will be useful in
formulating further possible solutions that haven’t already been attempted.

Green, E. December 16, 2015. S.F Medical Examiner tackles backlog, giving families
closure. Retrieved October 7, 2018 from https://www.sfchronicle.com/bayarea/article/S-
F-medical-examiner-tackles-backlog-giving-6679974.php

Content: In the past couple of years, Hunter has dramatically turned around the time it
takes to perform and autopsy and determine the cause of death, however, there is
skepticism by some attorneys and other M.E. offices as to whether that is a good or bad
thing. Hunter’s goal was to tackle the backlog of 600 cases that were all over 3 months
old, which violated the 90 day maximum national industry standard. Hunter also made
the change to have death certificates issued before the cases were completely closed and
things like toxicology reports even came back.

Author: Author Emily Green, a secondary source, relays information from the chief
medical examiner in San Francisco. Chief medical examiner Michael Hunter was only
recently hired in the past couple of years after much of his work was performed in the
state of Florida.

BEAM: The source perspective is that of a current chief medical examiner, it provides
specific solutions and practices that Hunter has implemented into San Francisco’s
medical examiner office. This information will contribute to exhibit and methodology of
a current solution taking form in and individual M.E office and also help with countering
my argument with temporary solutions to a much larger problem.

Hanzlick, R., MD. (n.d.). An Overview of Medical Examiner/Coroner Systems in the

United States. Retrieved September 18, 2018, from
http://sites.nationalacademies.org/cs/groups/pgasite/documents/webpage/pga_049924.pdf

Content: The source describes the history of the creation of the medical examiner system
from the previous coroner system. It also shows the progression from appointed untrained
civilians as death investigators to certified forensic pathologists. Hanzlick, however,
highlights the lack of medical examiners in all states across the country. Around 400-500
forensic pathologists practice annually and full time compared to the approximate
 Prozor 10

requirement of 1000 medical examiners based in caseloads. Hanzlick offers solutions to

issues including the shortage of medical examiners. This source is very useful in
explaining the background and progression of the American Medical System and
showing the stagnation of the system in the past three decades.

Author: Randy Hanzlick is a Medical Director out of Atlanta Georgia whom has
published many scholarly articles and resources on the top of medical examiners and the
medical examiner system.

BEAM: The source offers the perspective of a Medical Director who oversees medical
examiners. It offers an objective source for background information on the medical
examiner system and its current statistics as it relates to different states across the country
as well as offering solutions to fixing the dysfunction.

Hoban, R. September 30 2014. Lawmakers Address Need for Improvement in Medical

Examiner System. Retrieved October 7, 2018 from
https://www.northcarolinahealthnews.org/2014/09/30/lawmakers-address-need-for-
improvement-in-medical-examiner-system/

Content: The source offers a broad understanding of what lawmakers do not realize
about the Medical Examiner system. Senator Tucker quotes that he did not realize that
the quality of technology and resources seen on television shows like NCIS and CSI is
quite the opposite from the true conditions. North Carolina morgues have small autopsy
rooms, outdated software, extremely low government funds and a shortage of staff.
Solution suggestions made in 2001 were unable to be implemented due to underfunding.
By approving more funding to medical examiners, there is more money to be spent on
each victim autopsy decreasing the likelihood of error.

Author: Author Rose Hoban is an editor for North Carolina Health news and has written
many articles for the News outlet.

BEAM: The article relays the perspective of two lawmakers, Senator Tommy Tucker and
Senator Don-Davis. The article offers a new perspective of the Medical Examiner system
and offers solutions to the research argument.

Loren, J. May 26, 2011. Former employees speak out on problems at Oklahoma’s ME’s
office. Retrieved October 8, 2018 from http://www.news9.com/story/14736879/former-
employees-speak-out-on-problems-at-oklahomas-mes-office
 Prozor 11

Content: Former employees of the Oklahoma Medical Examiner Office speak out about
the challenges faced in the office and the effect it had on victims families. As of the date
published 702 families in Oklahoma had far over waited fors answers about the death of
their loved ones. Joe and Donna Turned had waited eleven years to get a correct death
certificate and fought 11 years to get it. The death certificate, along with other mistakes,
ruled the couple’s daughter's death a suicide and the couple fought for certain that the
death was not by suicide. Shandra had been shot in the chest but the ME/s office refused
to do an autopsy and ruled it a suicide. The former chief ruler the death a homicide
framed to look like a suicide 10 years later. All the former employees were either let go
or quit due to questioning the dysfunction of the system. The Turner family took their
issue to the capital and got a reform act passed over a decade after the murder of their
daughter.

Author: Oklahoma Impact writer Jennifer Loren is an award-winning journalist. She has
13 years of experience as a TV news anchor and reporter.

BEAM: The source is from the perspective of former employees of the Oklahoma
Medical Examiner Office, who experience first hand the medical examiner system. The
source discusses the effects on families of system issues and mistakes, as well as an
individual exhibit example.

Patel, T. March 20, 2014. Mixed-up morgue mistakenly tells family that dead woman
‘not your daughter’. Retrieved October 7, 2018 from
https://q13fox.com/2014/03/20/family-of-accident-victim-angry-at-medical-examiners-
mistake/

Content: Pierce county Medical Examiner's office in Washington state misidentified the
body of a woman killed in a traffic accident. Jade Aubrey’s parents had called the
coroner’s office worried about their daughter who was staying in the area where the
accident occured, the coroner told Mrs.Aubrey not to worry because the body had already
been claimed. The body was misidentified as Samantha Kennedy and it wasn’t until three
days after the accident that Mrs. Kennedy heard from her daughter who was still alive.

Author: Tina Patel has been a Q13 Fox news reporter and anchor for 5 years and prior to
had also been a reporter all across the country.

BEAM: The source is from the perspective of two families involved in one victim’s
homicide case. As a family who was emotionally affected by a M.E. mistake, the article
presents a very strong argument as to improving the medical examiner system. This case
will be used to support my primary research argument.
 Prozor 12

Pearsall, B. March 3, 2011. Improving Forensic Death Investigation. Retrieved

September 18, 2018, from https://www.nij.gov/journals/267/pages/investigation.aspx

Content: In the journal article, J.C Upshaw Downs, regional medical examiner,
acknowledges that fragmented and dysfunctional system that is the medical examiner
system. The National Association of Medical Examiners along with NIJ both have the
goal of replacing all morgues with medically licensed professionals and adequately
trained medical examiners.There are,however, coroners that disagree with the proposal
and the justifications. Medical Examiners alike quote that lack of communication is the
largest hurdle in their daily work.

Author: Beth Pearsall is a freelance writer and frequent contributor to the NIJ ( National
Institute of Justice) Journal.

BEAM: The perspective of the article is from a frequent journalist for the justice
department and is very knowledgeable first hand on the fragmented Medical Examiner
system. This source offers both background and solutions to the issue. This will be useful
in both agreeing and disagreeing with my argument.

Schaper, D. February 2, 2012. Families suffer through Chicago morgue backlog.

Retrieved October 8, 2018 from http://news.wbfo.org/post/families-suffer-through-
chicago-morgue-backlog

Content: The Cook County morgue in Chicago was incredibly far behind on burials and
had nearly lost track of all the corpses. Peggy Wilkins, sister of Raymond Hudgens who
passed away had been waiting 4 months to rest easy because her brother was still sitting
in the morgue. She was never informed of the date he would be put to rest nor was she
able to see her brother. Photographs had been released of the morgue's conditions where
bodies were piling up one on top of the other around the surrounding walls. Because of
this Illinois restored funding, however, the backlog still remained. The Hostetler received
weeks of false hope and fear after searching for their brother who had died over a week
before and had yet to be processed in the morgue, the morgue even told the the
Hostetler’s that they did not have their brother. The source offers more specifics into the
case that will be useful in describing the families emotional and mental distress.
Author: Writer David Schaper is a NPR National Desk Reporter based out of Chicago
Illinois.
 Prozor 13

BEAM: The source offers examples of the affected family of a victim that will contribute
to the argument of my research. The source is from the perspective of both a news
reporter and the families of victims.

Sterling, S and Sullivan, P, S. December 14, 2017. Death & Dysfunction. Retrieved
September 24, 2018 from http://death.nj.com/10/

Content: This source in the journal death and dysfunction is New Jersey’s main source
of news articles and statistics as it relates to the state’s medical examiner system. The
journal includes several news stories that all tie in to the basic message that is “How New
Jersey fails the dead.” The source includes examples of family stories due to medical
examiner issues, as well as graphics and charts that show the large ratio of autopsies to
personnel. New Jersey compared to all other states has the most deaths per professional
and along with the same issues found in other medical examiner systems.

Author: Author Stephen Sterling is an investigative reporter who over an 18 month

period performed personal research and obtained internal records. He has worked for
New Jersey advanced media for 9 years.

BEAM: The source is from the perspective of two reporters who have personally based
their research around the medical examiner system in New Jersey. This source is an
extreme example of issues in the M.E system, supports my argument involving victims
families along with providing methodology for the writers research.

Thames, Rick. May 16, 2014. Untrained medical examiners fail families, imperil justice.
Retrieved October 7, 2018 from http://insidestoryobs.blogspot.com/2014/05/coming-
sunday-untrained-medical.html

Context: The source highlights the importance of death certificates as it pertains to

families, the death certificate helps with getting the right insurance after a loved one's
death and gives some type of closure to a victim's family. In North Carolina, 10,000
death cases are sent to medical examiner offices. Due to the very little required training
and low salaries, there is not enough hands to remotely exam that number of cases
thoroughly. It often falls on grieving loved ones to launch their own private investigations
which in turn causes a financial burden on top of the already emotional one. One
potential solution that has began to come into play is that of a team of journalist that has
analyzed over 130,000 cases in depth since 2001, it is defined as the most comprehensive
analysis ever done in the state.
 Prozor 14

Author: Rick Thames is the executive editor of the Charlotte observer, he oversees every
story from news to sports to video features that go through the Charlotte Observer.

BEAM: The source carries the perspective of a news journalist who sides with families
when medical examiner mistakes are made. The sources offers both background of issues
as well as support for the overall research argument.

Vendel, C. November 10, 2013. A Question of Homicide: Rulings by Medical Examiners

raises doubts about protocols. Retrieved October 7, 2018 from
https://www.kansascity.com/news/local/article331394/A-question-of-homicide-Rulings-
by-medical-examiners-raise-doubts-about-protocols.html

Content: The source opens with the Jackson County Medical examiner’s office incorrect
suicide ruling, the young woman’s killer confessed 10 days after the M.E ruled suicide.
Three fourths of all suspected suicide victims were not autopsied to ensure death was by
suicide. Problems with time and incorrect rulings came apparent when Dudley, a new
medical director was hired. The source goes on to exemplify tens of controversial cases
that came across the Jackson county medical examiner office and the effects of the mis-
rulings and unperformed autopsies.

Author: Author Christine Vendel investigates public safety stories in Pennsylvania

BEAM: The source comes from the perspective of an investigative news reporter. The
source is biased towards highlighting a need for change in the Jackson County Medical
Examiner system.