In the first of a multi-part series in the Fort Worth Star-Telegram, reporter Yamil Berard writes in “With little oversight in Texas, autopsies often careless” that lack of training and lack of oversight over Texas medical examiners who conduct autopsies creates a ripe situation for inaccurate forensic conclusions that can result in innocent people being convicted and even sent to death row.
A woman was on her way to Death Row in Alabama after a medical examiner now working in Texas said she had suffocated her newborn. The sad truth, other experts said, was that the baby was stillborn.
An Austin baby sitter has spent years on Death Row for a baby’s murder. The medical examiner whose testimony helped put her there now says the baby’s death may have been an accident.
The medical examiner is the doctor-detective who is supposed to extract truth from the hodgepodge of details about a death. By examining body tissues, organs and fluids, gathering data from a crime scene and examining lab results, the medical examiner provides insight into how and why someone has died. Those judgments are of consequence for violent or suspicious deaths, as well as for unexplained deaths and those that might result from negligence or improper care.
County officials say the state’s system works well by unraveling questions surrounding death at a reasonable cost to taxpayers. In the courtroom, much of the work, they say, stands up to scrutiny.
But over the years, Texas medical examiners have misidentified bodies, botched examinations and had to do a double take on cases of individuals later exonerated by law enforcement. That has opened the door for innocent men and women to go to prison and killers to go free. The slapdash work of some medical examiners could also allow public health threats, wrongful deaths and preventable medical errors to go undetected, experts warn.
“The work of the medical examiner’s office is just so slipshod,” said Tommy Turner, the former special prosecutor who put a Lubbock medical examiner behind bars for falsifying autopsies.
Critics say the medical examiner’s office is “the last bastion of junk science.” The problems, they say, are similar to those that plagued the state’s crime labs for years: lack of performance standards, poor documentation, a shortage of qualified personnel and lax oversight.
“The state does not keep track of MEs in any shape, form or fashion,” Bexar County Chief Medical Examiner Randall Frost said. The state doesn’t even know how many certified forensic pathologists work in government offices, he added.
And a medical examiner doesn’t have to be trained in forensics or pass a specialty exam to do an autopsy. All that’s required is a state medical license. That’s akin to having your family doctor do brain surgery, says a growing chorus of medical examiners.
One significant weakness: Texas law doesn’t require medical examiners to take notes, produce body diagrams or photograph evidence.
Such documentation is essential, said Dr. Ray Fernandez, chief medical examiner for Nueces County. Without it, a medical examiner can’t back up an autopsy in court or show the validity of conclusions if challenged.
“A good report is based on how well that person documents their observations, so that another pathologist looking at the photographs, the diagrams, the report — looking at all of it — can at least assess the accuracy of what was done,” said Dr. LeRoy Riddick, a retired forensic pathologist who is a professor at the University of South Alabama. “The interpretations are something else.”
In one of the state’s most high-profile cases — the 1991 murders of four teenage girls at an Austin yogurt shop — pathologist Tommy Brown, who did the autopsies for Travis County, told jurors that he did not take crime scene photographs but relied on those taken by police.
He also said that “a lot of times” information he dictated didn’t get into his autopsy reports or he didn’t dictate information that should have been included. Two men convicted in the slayings, based largely on their confessions, were released this summer after new DNA tests showed that another man could have been involved.
Bayardo told the Star-Telegram that he never took notes because he feared they would be subpoenaed.
“That’s always a problem,” he said.
Instead, he would create an autopsy report by dictating information on tape.
In another case that drew in the Tarrant medical examiner’s office, capital murder charges against a young couple were dismissed two years after their baby’s death when some evidence apparently disappeared.
That case offered up a merry-go-round of opinions.
Bayardo declared the cause of death undetermined. Peerwani, who was asked for a separate opinion, released a report saying that the baby died of head trauma and that the case was a homicide.
Bayardo questioned how Peerwani — who didn’t examine the brain because it was apparently misplaced — came to that conclusion.
“How can you say she died of head injuries when you have no brain?” Bayardo said in a recent interview.
Peerwani has said he had slides with brain specimens and sent them to a specialist for review. The charges were dropped when the slides could not be found.
In a recent interview, Peerwani supported his preliminary finding of homicide: “A kid that little doesn’t have so many rib fractures.”
The Texas Medical Board did take action after whistle-blowers complained about former Harris County Medical Examiner Joye Carter. Initially, it sought to revoke or suspend her license after finding that she used an unlicensed pathologist to conduct hundreds of autopsies. Eventually, though, she was fined $1,000.
Questions about her work continued to be raised.
Numerous pathologists, including Dr. Lloyd White of the Tarrant County medical examiner’s office, have questioned Carter’s findings in the slaying of Conroe college student Melissa Trotter.
The time of the woman’s death was a critical piece of evidence. Carter said the young woman had been dead for 25 days or more when her body was found north of Houston. That helped persuade a jury to convict an ex-con. He could not have committed the crime if the woman had been dead a shorter time, because he was in jail for traffic violations.
But forensic pathologists testifying for the defense pointed to evidence that they said showed the body could not have been in the forest for more than two weeks. The young woman’s weight before she died was just 4 pounds more than when Carter performed the autopsy. Had Trotter been dead for 25 days, her body would have been in more advanced stages of decomposition and weighed much less, the pathologists said.
Dr. Glenn Larkin, a former medical examiner in Pennsylvania, also called Carter’s autopsy “sloppy,” “irresponsible” and “misleading,” noting that key medical records were missing and that some tissue samples had disappeared.
After the criticism, Carter signed an affidavit agreeing that Trotter could not have been dead for more than two weeks. She blamed problems on not having key evidence during the autopsy. A video of the crime scene and medical records were not available to her, she wrote.
Carter did not respond to repeated requests for comment.
The convicted man’s execution was postponed, but prosecutors are standing by Carter’s original autopsy report. The defense team, clamoring for the appeals court to intervene, points out that the state is rejecting opinions from some of the very pathologists prosecutors have relied on in other criminal cases.
“If all [these] medical examiners are all wrong on Melissa Trotter, how can they be right on all other cases?” said private criminal investigator Tina Church.
“There’s no room for error when somebody’s life depends on their findings.”