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Forensic Pathology

Problems in Massachusetts:
Dr. Mark Flomenbaum

April 2005

Governor Mitt Romney named New York City’s Chief Deputy Medical Examiner, Dr. Mark Flomenbaum, as the Medical Examiner of Massachusetts. Flomenbaum had worked in New York City ten years during which time he had performed 1,800 autopsies and testified in more than 180 trials. As the new medical examiner for the Bay State, Dr. Flomenbaum became head of what was regarded as one of the worst medical examiner offices in the country. Some of the widely reported problems included:

  • Unclaimed bodies cluttering the facility
  • Bodies stored in refrigerated trucks
  • Shortages of body bags
  • Clogged plumbing causing pools of blood on the floor
  • Twenty years of under funding and neglect
  • Hit and miss policy regarding when autopsies were conducted (in 2006 the 65 employee office performed 3,552 autopies)

May 5, 2007

Governor Devel Patrick suspended Dr. Flomenbaum (paid leave of absence) after the medical examiner’s office lost the body of a man found dead on Cape Cod in April. The governor asked the state police to investigate the matter. The missing body had come to the medical examiner’s office on April 23 and was autopsied the next day. The dead man’s sister determined that the body buried under her brother’s name was someone else. In explaining the mix up, Dr. Flomenbaum said his office was under funded and that his people were so busy trying to keep up, they had no time to correct problems that led to embarrassing events such as this.

August 2007

Governor Patrick fired Dr. Flomenbaum after he refused to resign. The governor accused him of being inattentive to the day-to-day operations of the office. In Patrick’s June letter asking for the doctor’s resignation, he accused Flomenbaum of a “failure to maintain minimal professional standards,” and “willful failure to communicate fully and frankly” with his supervisors.

More Problems in Massachusetts
Dr. William A. Zane

Dr. Zane, 54, had worked in the medical examiner’s office since the 1980s. Over the years he had amassed what some would consider a less than sterling record. Some of his problems:

In 2002:

  • In the autopsy of a 3-month-old boy conducted by a colleague, Dr. Zane had sent out the wrong eyeballs for testing.
  • In renewing his state medical license, Dr. Zane failed to report a criminal offense—his leaving the scene of a car accident. He had also been charged with causing property damage in Hyannis, Massachusetts on December 15, 2001. The Board of Registration issued Dr. Zane a “letter of concern.”
  • Dr. Zane was the subject of a grievance filed by fellow employees charging he had “created an unsafe and unhealthy work environment.”

May 2007

The prosecutor of twin brothers alleged to have beaten to death an 19-year-old man in 2005 had to reduce the charges from first-degree murder down to manslaughter because of errors made by Dr. Zane in the victim’s autopsy. Following the autopsy Dr. Zane admitted that he had significantly overstated the trauma to the victim’s brain. A second autopsy, conducted by another forensic pathologist, confirmed this. The defendants were convicted of involuntary manslaughter, a verdict that outraged the victim’s family, and others in the community. Attorneys for the defendants had based their case on Dr. Zane’s mistake.

June 2007

State medical authorities barred Dr. Zane from performing autopsies in potential homicide cases.

Shortages of Forensic Pathologists in Scotland:
Taking Shortcuts

According to Anthony Busuttil, Regis professor of forensic medicine at Edinburgh University, a critical shortage of trained forensic pathologists has resulted in fewer autopsies in cases of sudden, violent and suspicious death. Instead of conducting autopsies in every case, forensic pathologists are performing so-called “View and Grant” procedures which involve reviewing police reports and medical histories and cursory, superficial examinations of the bodies instead of autopsies. Professor Busuttil considers these autopsy substitutes an unreliable method of determining cause and manner of death.

Turning a Blind Eye:
Shortage of Forensic Pathologists and Autopsies in Japan

In Japan, outside urban areas, there is a desperate shortage of forensic pathologists. This, plus a cultural distaste for the autopsy procedure which is looked upon as disrespecting and desecrating the dead, too many cases of highly suspicious death go into the books as natural or accidental fatalities without proper forensic or police investigations. Moreover, police in Japan discourage autopsies that might reveal a higher homicide rate in their jurisdictions, a sign they are not protecting the public. It is standard practice in Japan for the police to pressure forensic pathologists in suspicious death cases to sign the death certificates without conducting autopsies. The doctors comply for fear of police retaliation.

Japan has one of the world’s highest suicides rates, about 30,000 deaths a year. In 2005, by comparison, only 1,392 homicide cases were reported in the United States. In the United States, apparent suicides require autopsies. In Japan, cases of supposed suicide involve cursory, superficial body examinations. Aware that a lot of people in Japan are getting away with murder, leaders in the forensic science community are calling for reforms in the system. (Based on reportage in the Los Angeles Times, November 9, 2007.)

The Forensic Pathologist Shortage:
Autopsy Backlogs in Small Towns and Rural America

Every year, about thirty-five of the 15,000 students who enroll in medical school become forensic pathologists. In 2007, twelve of the country’s thirty-seven forensic pathology fellowship programs will have no students. According to Dr. Greg Davis, forensic pathology, a sub-specialty of general pathology, requires a year of more training. As a doctor trains more, his or her power of earning declines. Dr. Joseph Prahlow, president of the National Association of Medical Examiners, estimates that general hospital pathologists make more than $200,000 a year while some forensic pathologists, especially in rural areas, make less than $100,000.

Most of the country’s 400 forensic pathologists are concentrated in the larger cities. In Illinois for example, there are eleven forensic pathologists in Cook County (Chicago). The rest of the state has less than that. In southern Illinois there is just one forensic pathologist who performs 400 autopsies a year in Illinois and southwest Indiana. (The National Association of Medical Examiners recommends no more than 250 a year.) It can take up to eighteen months in that region to get autopsy results. Local coroners, aware of the shortage, order fewer autopsies. This increases the chance that homicides will be missed.

Some rural forensic pathologists work eighty hours a week. Besides averaging two autopsies a day, and traveling their territory, they have to regularly appear in court. Many burn out or move to more populated areas where the pay is higher and the workload is less. (Based on reportage by Gerry Smith, The Chicago Tribune, October 11, 2007)

Coroner Kenneth Ackles:
Politics and Race in Indianapolis

In Marion County, Indiana, an elected coroner, with the help of certified forensic pathologists, determines the cause and manner of death in cases of sudden, violent, and unexplained death. Dr. Kenneth Ackles, a seventy-year-old chiropractor who ran on the Democratic ticket, took office in January 2005 after defeating his Republican rival, a candidate for office who had a medical degree. The former Marion County Coroner, Dr. Stephen Radentz, had served his two-term limit and couldn’t run for office. Dr. Radentz, a board-certified forensic pathologist, had worked with three other forensic pathologists, on a contract basis. The contract pathologists were associated with Indiana University Medical School. While understaffed and overworked, the coroner’s office had functioned smoothly under Dr. Radentz’s leadership. With the election of Kenneth Ackles, that changed.

In December 2005 Dr. Ackles hired a new group of contract forensic pathologists headed by former coroner Radentz. Six months later Ackles terminated the services of this firm, Forensic Pathology Associates of Indiana (FPA), stating that in the future he wanted to hire in-house forensic pathologists. That December Ackles also demoted then fired John Linehan, the chief deputy coroner, a carry over from the previous administration. Linehan, who is white, accused Ackles, a black, of racial discrimination. Ackles replaced LInehan with Alfarena Ballew, a black woman.

In September 2007, John Linehan filed a racial discrimination suit against Coroner Ackles.  A federal administrative law judge, on November 23, 2007, found that Mr. Linehan had been discriminated against on the basis of race. The judge ordered the Marion County Coroner’s Office to pay Linehan $429,733 in damages. The judge wrote: “It is clear that Dr. Ackles wanted Mr. Linhan out of his position as chief deputy and that he wanted Ms. Ballew in the position instead. Ms. Ballew clearly wished to take Mr. Linehan’s place as chief deputy, and the evidence that she had an agenda of securing ‘in-charge’ positions for African-Americans is strong.”

The judge also questioned Ackle’s decision of canceling the Marion County contract with Forensic Pathology Associates of Indiana. Dr. Radenz and his FPA colleagues have charged, in a separate federal lawsuit, that they had been fired because they were white and to make room for a chief forensic pathologist who was black. (Based on reportage in the Indianapolis Star. For more on Dr. Kenneth Ackles, see Conclusion in Forensics Under Fire.)

Martin Anderson Case:
Dr. Charles Siebert

June 13, 2007

The Florida State Medical Examiner’s Commission met in Tampa to review the findings of a state panel that found missteps in Dr. Charles Siebert’s initial assessment of Martin Anderson’s death. The panel found that Dr. Siebert failed to conduct a thorough examination of the boy’s organs and misrepresented the extent of his work on the case. The panel voted not to recommend renewal of his medical examiner’s appointment.

June 14, 2007

The nine-member medical examiner’s commission voted unanimously to remove Dr. Seibert from his medical examiners job in Bay County and five other panhandle counties. The Bay County state’s attorney would decide whether to keep Dr. Siebert as the interim medical examiner until a replacement was found. Dr. Siebert vowed to fight to keep his job. “Nobody is perfect,” he said. “I’m getting attacked for mistakes that everybody’s making, but I’m being singled out.”

June 19, 2007

The Bay County prosecutor announced that Dr. Siebert will keep his job for ninety days while a search committee looked for a replacement. Siebert told reporters that he planned to reapply for his job and would appeal the medical examiner commission’s decision to remove him from office.

August 3, 2007

Fresh from his testimony as a defense expert in the Phil Spector murder case, Dr. Vincent DiMaio, the renowned forensic pathologist and author of four books on the subject, said in a radio interview that he and most of his colleagues supported Dr. Charles Seibert. These colleagues did not include DiMaio’s fellow Spector defense expert Dr. Michael Baden. The high-profile forensic pathologist from New York who was hired by Martin Anderson’s parents, said this: “Dr. Siebert has an excellent reputation….The problem is, politics is getting involved in science here….This is a complicated case and everyone wants a simple answer, and they want to blame someone.” Dr. Baden had helped make the case more complicated by disagreeing with Dr. Seibert’s sickle cell cause of death analysis.

Dr. Joseph Prahlow, president of the National Association of Medical Examiners, agreed with Dr. Baden. “There is great concern amongst forensic pathologists when there is essentially a political hatchet job occurring within a state government based on a medical opinion brought forward by one of our colleagues. When political correctness seems to trump our individual evaluations of a case and our ability to form an opinion about a case, that becomes a concern to all of us that answer to a governmental agency in one form or another.”

September 2007

With the manslaughter trial of the seven boot camp guards and the nurse approaching, support for 45-year-old Dr. Charles Siebert in the forensic science community seemed to be growing. “I’m actually looking forward to the trial,” Siebert said to a local reporter. “It’s going to be the first time that all the truth comes out.” In anticipation of the trial, Dr. E. Randy Eichner, a sickle cell expert and retired professor of medicine at the University of Oklahoma, prepared a report in which he concluded that Siebert’s autopsy of Martin Anderson was “scientific, explanatory, and credible.” In a court deposition Dr. Eichner took issue with Dr. Vernard Adams’ findings that Martin Anderson had died of suffocation because his mouth was blocked and he was forced to inhale ammonia smelling salts which caused a blockage of his airway. Dr. Eichner called that scenario a “fantasy.” “It is just as unscientific as you can possibly get,” he said.

October 12, 2007

A Florida jury sitting in Panama City found the seven boot camp guards and the nurse not guilty of criminal homicide in Martin Anderson’s death. Had the defendants been convicted, they each could have faced up to thirty years in prison. The acquittal came despite the testimony of New Hampshire’s medical examiner Dr. Thomas Andrew.  Dr. Andrew testified that Martin Anderson died of organ failure after the defendants repeatedly used ammonia capsules to revive him.  It is Dr. Andrew’s opinion that the ammonia capsules were the “tipping point” leading to Anderson’s “neurological collapse.” Andrews called the guards’ use of the ammonia excessive and inappropriate and said the intoxicating effects of the chemical were heightened by the fact the defendants covered the boy’s mouth while administering it. An attorney for Martin Anderson’s parents called the verdict “a tough pill to swallow.” In arriving at this verdict, the jury rejected a cause and manner of death that was also consistent with the testimony of Dr. Michael Baden and Dr. Vernard Adams, a pair of prominent forensic pathologists who disagreed with Dr. Siebert’s autopsy findings. The verdict was a clear victory for Dr. Siebert, the embattled Bay County medical examiner. The acquittals, while ending the state’s case against the boot camp staff, did not put an end to the controversy surrounding the boy’s death. Shortly after the verdict, the U.S. Department of Justice issued a statement that federal investigators would review the case to determine if state officials had violated Martin Anderson’s civil rights. This statement may have been issued to calm the community following the unpopular verdict. A few local politicians were calling for an economic boycott of Bay County. “I am extremely disappointed in these verdicts,” said state attorney Mark Ober. “My staff has worked ethically, diligently, and professionally on this most difficult case.” (Okay, but what about all the other cases? Is this one an exception? What kind of remark was that?) “In spite of these verdicts Martin Lee Anderson did not die in vain. This case brought needed attention and reform to our juvenile justice system.” Following the boy’s death, Florida closed all of its juvenile boot camps.

Forensic Pathology in Western Alabama:
The Sad Case of Dr. Glenn

In 1999, a 56-year-old family doctor named Johnny Glenn began working as the lone state medical examiner in the rural, western third of Alabama. He had no training in forensic pathology and worked without professional supervision. Dr. Glenn tried but was unable to pass the examination to become certified by the American Board of Pathology. In Alabama that didn’t preclude Dr. Glenn from functioning as a state forensic pathologist. In hundreds of cases Glenn failed to follow up the autopsy with a report, and in many cases he missed important forensic clues pertaining to cause and manner of death.

In 2004, suffering from severe depression, Dr. Glenn abruptly resigned his medical examiner position. Three years later, a review of his work put an untold number of criminal cases into jeopardy. His incomplete autopsies have affected at least three homicide trials. Dr. Jim Lauridson, a former Alabama pathologist brought in to complete some of Dr. Glenn’s work, found several hundred unfinished cases stuffed in boxes sitting in the former pathologist’s office. (Associated Press, St. Petersburg Times, April 4, 2007)

Problems in Canada
Dr. Charles Smith

Louise Reynolds of Kingston, Ontario, was convicted on June 12, 1998 of stabbing her seven-year-old daughter to death. The prosecution’s star witness, Dr. Charles Smith, a renowned expert in the field of forensic pediatric pathology, had testified that the victim had been stabbed eighty times. Dr. Smith described the wounds on the victim’s upper arms, neck and head as having been made by a pair of scissors. The killer had used these scissors to partially scalp the victim. The defense countered that the victim had been attacked by a pit-bull terrier owned by the girl’s stepfather.

The defense, in support of the dog attack theory, put two experts on the stand. Dr. Rex Ferris, a British trained forensic pathologist from Vancouver, called Dr. Smith’s analysis wrong and oversimplified. Dr. Robert Dorion, a forensic dentist from Montreal, identified the wounds as dog bites. “Imagine,” Dr. Dorion testified, “the scenario if it were stab wounds. Can you imagine someone stabbing so many times on the outside of the arm, and then lifting up the arm and stabbing as many times on the inside of the arm? It doesn’t make sense.”  The jury, selecting Dr. Smith’s testimony over the other two experts, found the defendant guilty.

In 1979, Dr. Smith began working as a surgeon at Toronto’s Hospital for Sick Children. Two years later, without the benefit of special training,  he began performing child autopsies. In 1992, the Ontario Coroner’s Office created a pediatric forensic pathology unit at the Toronto Hospital for Sick Children and Smith was installed as the director. He was not qualified for the position and had no business functioning as a forensic pathologist. By the late 1990s Dr. Smith had become Canada’s most active forensic child pathologist having performed more than a thousand child autopsies.

In 2000 Louise Reynolds’ homicide conviction was set aside after Dr. Smith’s work in the case was thoroughly discredited. Ontario’s chief forensic pathologist, Dr. David Chiasson, had performed a second autopsy in July 1999 and had concluded that the stab wounds were indeed dog bites. Dr. Smith attended the reautopsy and agreed that he had misidentified the wounds. The victim’s bones were sent to tool mark expert and anthropologist Steven Symes in Tennessee who concluded that there were no sharp instrument marks on the victim’s bones.

In 2002, following a series of questions regarding the quality of Dr. Smith’s cause and manner of death conclusions in several other homicide cases, the Ontario College of Physicians and Surgeons issued Dr. Smith a “letter of caution” on the grounds he had become “dogmatic” in favor of prosecution cases and had exhibited a “tendency towards overstatement.” In June 2005, Ontario’s chief coroner started reviewing forty-five of Dr. Smith’s child autopsies. That year Dr. Smith resigned from the Toronto hospital. A forensic pathology position in Saskatoon soon opened up for him. Three months later Dr. Smith was fired from the Saskatoon job then was reinstated without his medical license which meant he could no longer perform autopsies.

In April 2007, Ontario’s chief coroner released a report of Dr. Smith’s work that was based on a review conducted by an independent panel of forensic experts. According to this panel, Dr. Smith had made mistakes in twenty of the forty-five cases reviewed. As a result, more than a dozen homicide defendants may have been wrongfully convicted.

Canada has no system for accrediting forensic pathologists. Like Dr. Smith, many of them are self-taught and learn on the job. Following the revelations about Dr. Smith, many forensic pathologists in Canada started going through accreditation programs in the United States and Britain.

Dr. Charles Smith:
The Public Inquiry

The commission if inquiry into twenty pediatric deaths in which Dr. Smith is believed to have made serious autopsy errors that led to criminal charges against the parents of these children, got underway in Toronto at the Ontario Court of Appeals on November 12, 2007. The first witness, Dr. Smith himself, confessed to making mistakes and apologized for those errors. His attorney characterized Dr. Smith’s errors and bad cause and manner of death calls as honest mistakes, noting that forensic pathology was an “inexact science.”

Not everyone in attendance at the hearing felt good about Dr. Smith’s apology. A man who had spent ten years in prison after the forensic pathologist incorrectly concluded that his four-year-old niece had been murdered said, “I don’t hold much stock in his apology. I think he just did it for his public image.”

Ontario’s former chief coroner and the province’s chief forensic pathologist testified that in 1995 the coroner’s office issued a directive that forensic pathologists should assume foul play in cases of sudden, unexplained, and suspicious deaths until proven otherwise. They were told to “think dirty.” That cause and manner of death determination presumption has, in recent years, been abandoned. Now, according to the chief forensic pathologist, Ontario’s forensic pathologists are to “search for the truth and think objectively.”  Hearing testimony also revealed that low salaries for forensic pathologists has made it difficult to attract highly qualified practitioners.

Documents and testimony from the commission of inquiry revealed that most of the people falsely accused of murder in Dr. Smith’s cases were low-income, unstable parents. Some of the cases involved evidence of foul play independent of Dr. Smith’s cause and manner of death findings. Several of the mothers and fathers criminally charged were chronically unemployed and dependant on welfare. Others suffered from depression or were mentally unstable at the time of the deaths. In other words, they were not good parents.

A review of documents pertaining to the twenty child deaths cases studied uncovered the following problems with Dr. Smith’s work:

  • False conclusions that some of the babies had been shaken to death.
  • Incorrect diagnoses of criminal suffocation.
  • Trial testimony that was too emotional, unreasonable and misleading.
  • Delays in providing written autopsy reports.
  • Lost postmortem slides.
  • Identification of natural postmortem changes in the body as injuries inflected before death.

On November 15, Ontario’s former acting chief coroner, Dr. Barry McLellan, testified that it hadn’t been his job to supervise and oversee Dr. Smith’s work. He insisted that the former chief coroner, Dr. Jim Young, had been responsible for that role. McLellan said that when he became acting chief coroner in 2002 he wanted to relieve Dr. Smith of many of his duties, but was overruled by Dr. Young. When Dr. McLellan took over as chief coroner in 2003, Dr. Smith had just been fired from his position as director of the Hospital for Sick Children Pathology Unit. (Based primarily on reportage in The Globe and Mail, November 13, 2007)

The Cremation Paper Mill:
Dr. Putnam Breed

February 2005

State police shut down the Bayview Crematory in Seabrook, New Hampshire where 2,000 cremations had been performed between 2000 and 2001. Under state law, a medical examiner must view each body before cremation and sign off on the procedure. But during a thirteen month period, the operator of Bayview paid a former Massachusetts medical examiner $50 to sign the death certificates of 1,900 people cremated at the facility. The former medical examiner, 68-year-old Dr. Putnam Breed, earned close to $100,000 without actually viewing any of the bodies. Because he wasn’t a New Hampshire medical examiner, he had no authority to sign-off on these deaths.

January 9, 2007

Dr. Breed went on trial charged with thirteen counts of falsifying cremation certificates at Bayview. If convicted, Breed faced the maximum penalty of three and a half to seven years on each charge.

January 17, 2007

The jury found Dr. Putnam Breed guilty of signing cremation certificates without looking at the bodies and taking money from New Hampshire as a Massachusetts resident. Six months later the judge sentenced Dr. Breed to six months in prison, fined him $4,000, and order him to pay $1,800 in restitution. On personal recognizance bail, Dr. Breed said he would appeal the conviction. The doctor’s conviction was part of a larger scandal involving Seabrook’s Bayview Crematorium. Authorities had found a body in a broken refrigerator and urns of unidentified bodies. At the time of his relationship with Bayview, Dr. Breed was working as a surgeon in Hampton Falls, Massachusetts.

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This page was last updated on: Tuesday, January 22, 2008

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A. James Fisher
Dept. of Political Science & Criminal Justice, 146 Hendricks Hall
Edinboro University of Pennsylvania, Edinboro, PA 16444
e-mail: jfisher@edinboro.edu blog: http://jimfishertruecrime.blogspot.com