Inadequate Coroners and Examiners May Hurt Justice Body of Evidence

July 09, 1995|By MARK HANSEN

Ronald L. Goldman's family cried as Dr. Lakshmanan Sathyavagiswaran, the Los Angeles County chief coroner, described how Mr. Goldman's killer taunted his victim with knife cuts to the throat before severing his jugular vein.

Dr. Lakshmanan theorized that Mr. Goldman was gravely wounded early in the struggle and his assailant held him from behind while making swiping wounds on his throat. Eventually, the killer slashed Mr. Goldman's throat and sliced his aorta.

For eight days, Dr. Lakshmanan laboriously laid out his gruesome evidence in the O. J. Simpson trial. The fact that his testimony lasted that long is an awesome acknowledgment of the power that coroners, pathologists and medical examiners have in murder cases.

Among court witnesses, to be sure, coroners and medical examiners are more equal than others.

But inadvertently, Dr. Lakshmanan's testimony picked the scab on a problem that has been festering in America's criminal-justice system.

Just how reliable is the testimony given by coroners and medical examiners "to a reasonable degree of medical certainty"?

At the start of his testimony Dr. Lakshmanan promptly acknowledged autopsy errors by Dr. Irwin Golden, the deputy medical examiner.

But, he hastily added, these mistakes were irrelevant to the final conclusions in the case.

Still, prosecutors announced, they would not call Dr. Golden as a witness. This prompted the defense to suggest that Dr. Golden's mistakes so embarrassed the prosecution that they were hiding him.

Interviews with more thanthree dozen coroners, medical examiners, forensic pathologists, legal experts and people who have been victimized by the system paint a disturbing picture of a process that is, at best, woefully inadequate; at worst, often inept.

"We're still living in the dark ages" when it comes to death investigations, says Dr. Michael Baden. "It's a national disgrace."

Dr. Baden, director of the New York state police forensic sciences unit, has been retained by the Simpson defense team as an expert witness.

Dr. Werner Spitz, the former chief medical examiner for Wayne County, Mich., and a consulting forensic pathologist near Detroit, estimates that up to 70 percent of the country is poorly served by its system for investigating unnatural deaths.

Of the nearly 2.2 million deaths reported in the United States in 1992 almost 7 percent, or nearly 143,000 deaths, were classified as unnatural, according to the U.S. Department of Health and Human Services' Division of Vital Statistics.

The importance of a proper death investigation cannot be overestimated, up to and including the possibility that it could lead to a criminal prosecution.

A death certificate can either compound a family's grief or bring peace of mind. It is used to resolve a range of legal issues, from insurance coverage to death benefits to civil liability.

The idea that a doctor should be in charge of the process of certifying deaths only took root in the 20th century.

Yet only a handful of states and large U.S. urban areas with

medical-examiner systems require that death investigations be conducted by board-certified or board-eligible forensic pathologists -- specialists with advanced training that enables them to analyze traumatic injuries, such as those from gunshots, stabbings, poisons or blunt force.

Maryland is among a handful of states that require a medical examiner to be a doctor. In North Dakota the requirement applies only to counties with more than 8,000 people. And Louisiana makes an exception for parishes in which no doctor is willing to serve.

As a result a disproportionate number of coroners are actually funeral-home directors who have fallen into their line of work because they happen to be in the business of transporting bodies.

Sheriff's deputies, school bus drivers and tow-truck operators also have served as coroners. So have gas station attendants, bar owners, jewelry salesmen and accountants.

Small wonder that in one Kentucky county every four years the hardest-fought race is the one between the same two rival funeral directors who want to be coroner. The winner's funeral parlor gets all the coroner's business.

Many coroners operate on a shoestring budget, which forces them to cut corners whenever and wherever they can. Too many rely for autopsies on hospital pathologists, who are trained to study the ravages of disease, not to reconstruct how somebody died.

"Asking a hospital pathologist to do an autopsy on the victim of a violent death is like asking a dermatologist to perform brain surgery," Dr. Baden says.

Medical-examiner systems come with their own set of problems, not the least of which is the shortage of highly skilled personnel.

Of the nearly 671,000 doctors currently licensed to practice in the United States, fewer than 3 percent, or 17,149 doctors, are specialists in pathology, according to the American Medical Association.

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