D.C. Plagued By Backlog In Autopsy Reports
Some Cases a Decade Old; 84 Homicides Incomplete

By Cheryl W. Thompson
Washington Post Staff Writer
Saturday, December 31, 2005

The D.C. medical examiner's office has a backlog of 1,037 unfinished autopsy reports, including some cases dating back more than a decade, records show. The agency's slow turnaround has delayed police work and criminal prosecutions, and forced some families to sue the office to obtain the paperwork about their loved ones.

The District's incomplete autopsies include 765 that are at least a year old. Maryland and Virginia, by comparison, have no cases a year old. Among the unfinished D.C. cases are 84 homicides.

"Years ago, they would complete the report and put it in our mailbox," said Tony Patterson, a veteran homicide detective in the District. "Now, it takes an act of Congress to get an autopsy report from them."

The backlog has occurred in an office that has had four of its six chiefs leave amid controversy. Last year, the D.C. Council approved a chief after waiving the minimum qualifications. Several pathologists have left recently. And documents detail several questionable rulings by the chief and deputy medical examiners.

Chief Medical Examiner Marie-Lydie Y. Pierre-Louis, 55, who was appointed by Mayor Anthony A. Williams (D) and confirmed by the council last year, declined several requests for an interview.

Edward D. Reiskin, the deputy mayor for public safety and justice who oversees Pierre-Louis's office, said the agency has made progress, citing a reduction in the backlog, which was 100 cases higher last year. "I think there's been a lot of improvement in that office under her leadership," he said.

The backlog was 1,136 at the end of September 2004, according to records.

A common complaint concerns delays in producing autopsy reports, which list the cause and manner of death and other medical details. Families often need the reports to settle estates or file for insurance benefits. Police and prosecutors rely on them to investigate homicides and bring suspects to trial.

"You want a written record," D.C. Police Chief Charles H. Ramsey said in an interview. "You need that if you are to confirm to a jury or judge that this person died from a gunshot wound or whatever."

When Warren Burnett, 50, died of a blow to the head in early September, D.C. police identified a suspect within days and drafted a warrant for the man's arrest. But officers were forced to wait more than two months before serving the warrant until the medical examiner's office completed the autopsy report.

"We just couldn't move on," said Capt. C.V. Morris, head of the police department's violent crimes branch. "We were sort of stuck."

The medical examiner's office investigates violent deaths and those that threaten public health, occur without medical attention or occur in custody. The office performed 1,163 autopsies last year.

The National Association of Medical Examiners, which inspects and accredits the offices, recommends that medical examiners complete 95 percent of the reports for homicide victims within 60 days and other deaths within 90 days. Last year, the D.C. office completed 47 percent of homicide cases and 34 percent of other deaths within those periods, far below the performance in Maryland and Virginia, according to records.

Dave Schertler, former head of the homicide division in the U.S. attorney's office, said, "It's important to get that [report] and get that early on."

He added, "If the medical examiner says somebody got shot in the back twice and a witness says he saw them get shot twice in the stomach, you know the witness is lying if you have the autopsy report."

The problem of delayed paperwork is not new.

Police couldn't charge a suspect for nearly a decade in the death of Byron Timothy James, who was shot in the head in 1993 in Northwest Washington. An eyewitness named the alleged triggerman. But the man wasn't charged until 2002 because the pathologist who performed the autopsy took a job in another state and left without finishing the report, police said.

"When I looked at the death certificate, it said, 'Cause pending,' " said Patterson, who investigated the case. "The guy had been shot twice in the head. It took nine years for someone to rule this a murder?"

'A Bogus Excuse'

Antoine Williams was desperate to learn what caused his wife's death in August 2003. He said he rushed Shawnda, a young mother of two, to a District hospital when she complained of severe stomach pains, but she died on the operating table.

He filled out paperwork to get the autopsy report, but nearly eight months later, he had not received it.

"Every time I called to get the report, they kept giving me a bogus excuse," said Williams, 27, a groundskeeper at Rock Creek Cemetery in Northwest. "So I had to get a lawyer and sue them to get them to turn it over."

A spokeswoman for the office said the report was delayed by lab results, which did not arrive until March. Williams sued in April. A month later, Williams received the report and learned that his wife died of cardiovascular disease, five days before her 25th birthday.

Tawanda Tatum's son, Kenneth N. Grimsley Jr., 18, was shot in the chest two years ago on Bladensburg Road NE and was pronounced dead 45 minutes later at Washington Hospital Center, according to police records.

Tatum said the medical examiner's office did not give her his autopsy report, and she was forced to go to police for records so she could cash an insurance policy.

"I never got a copy," said Tatum, a special police officer for the U.S. Labor Department. "I figured they'd eventually send it to me, but they haven't."

Patterson, the detective handling the case, said he also hasn't received the report. A spokeswoman for the medical examiner's office said in an Oct. 7 e-mail that the report had not been completed but offered no explanation for the delay.

David R. Fowler, Maryland's chief medical examiner, said he tries to avoid backlogs by tracking cases daily by computer. The oldest pending autopsy reports in his office are "maybe four or five months" old, he said.

"Backlogs are devastating," he said. "Once you get them, they're very difficult to deal with."

The delay baffled Leofric Forbes, whose daughter, Camille, died in 1998 of a blood vessel disease. She was 25, was a recent graduate of the University of Pennsylvania's law school and had moved to Washington to take a federal job a month before her death.

Forbes, who lives in Port Charlotte, Fla., said that after waiting "many months," he enlisted the help of a lawyer and called Porter J. Goss (R), then Forbes's representative in Congress and now CIA director. He eventually received the report.

"We were so distraught," Forbes said.

Turnover in Top Job

The D.C. medical examiner's office, which is in Southeast near the city jail, was considered one of the best in the country in the early 1980s, even as the homicide rate and drug-overdose deaths soared.

"It was a very challenging jurisdiction because it had a lot of complicated cases, but . . . it was considered a very good office," said Garry Peterson, accreditation chairman of the National Association of Medical Examiners.

James L. Luke, the District's first chief medical examiner, said backlogs were nonexistent during his tenure from 1971 to 1983. "We handled the caseload," he said.

During the late 1980s and '90s, the office was plagued by complaints about low productivity and mismanagement. Cockroaches and other pests congregated on autopsy tables in rooms with insufficient ventilation. Bodies in the morgue piled up beyond capacity.

"We had cremated remains waiting to get a contract to get moved out," said Joye M. Carter, who was appointed chief medical examiner in 1992. "We had poor record-keeping. It was awful."

Carter left in 1996 after reports of mismanagement and unacceptable conditions. She said in an interview that she did not have the authority to correct the problems.

In 1998, U.S. Attorney General Janet Reno said she was unhappy with the agency, and Humphrey D. Germaniuk, its chief, departed. District officials then hired Jonathan L. Arden. Recruited from the Brooklyn medical examiner's office and highly respected by his peers across the country, Arden was expected to rejuvenate the office.

He said the challenges were daunting. Staff shortages meant that low-level technicians were assisting in the autopsy room, Arden said. "Several hundred" autopsy reports were incomplete. "Almost everything was in disarray," he said.

Arden persuaded city officials to nearly double his annual budget, to $6 million. He launched an investigative unit, reopened the toxicology lab and improved relations with the U.S. attorney's office, he said.

He also irked staff along the way. Five female deputy medical examiners filed a claim accusing Arden of sexual discrimination and harassment, saying he had belittled them and made suggestive remarks.

Arden, who disputed their charges, said he was forced out. He filed a claim against the District related to his departure, which was settled for $67,596, according to records. The women each received $35,000 in a settlement, records show.

Questions About the Chief

Pierre-Louis, who was among the women to accuse Arden, was named interim chief. But she didn't meet the minimum qualifications for the permanent job -- certification in forensic pathology by the American Board of Pathology -- so District officials launched a national search.

Mayor Williams said at the time that the job was a "very difficult-to-fill position," and he successfully appealed to the D.C. Council to waive the law requiring board certification. That waiver prompted objections from three professional organizations, including the American Academy of Forensic Sciences, which warned that the move was "shortsighted" and would hurt the office's credibility.

Five other people applied, all of whom were board certified, but none was contacted by the District, the applicants said.

"They never even acknowledged my application," said Richard Harruff, chief medical examiner for King County, Wash., which includes Seattle.

Reiskin, the deputy mayor, could not explain why the other candidates were not interviewed. "Maybe someone decided the person in place is better than those out there," he said.

Pierre-Louis, who had worked at the morgue since 1985, was hired to fill out Arden's term until 2007, making the District one of the few major cities where the chief is not board certified in forensic pathology, according to Fred B. Jordan, president of the National Association of Medical Examiners.

D.C. Council member Adrian M. Fenty (D-Ward 4), one of two who voted against waiving the law for Pierre-Louis, said she "isn't qualified" to run the agency. "My general concern is about competency," said Fenty, who is running for mayor.

Last year, Pierre-Louis was paid $178,011, including $25,757 in "premium" pay for on-call duty and for working Sundays and nights, according to payroll records from the office of the chief financial officer.

Questions concerning Pierre-Louis's rulings as a pathologist came up after the 1994 autopsy of Andre Wheeler, 2. At the time, the autopsy found five bruises on his head, and Pierre-Louis listed the manner of death as "undetermined." The man who had been caring for the boy had told police that he mistakenly left the child in a bathtub. Pierre-Louis later changed the ruling to accidental drowning.

Three years later, after the toddler's sister was fatally beaten by the same man, the medical examiner's office reopened the boy's case and changed the ruling to homicide, according to court records.

"Because it looked like an accident and [the accused] appeared remorseful, when the medical examiner gave her ruling, that's where it stayed," Assistant U.S. Attorney June M. Jeffries said at the time. "You did not have the level of investigation that we would have liked."

In 1997, Pierre-Louis performed an autopsy on Robert Charles Williams, 11. The boy's father, Robert Charles Gordon Jr., had told D.C. police detectives that he punched his son twice in the chest with a closed fist after the boy gave him incorrect answers while learning to tell time, according to court records. The youth, who was moderately retarded, collapsed after the second punch and never regained consciousness. Police charged Gordon with second-degree murder, aggravated assault and cruelty to children.

Pierre-Louis ruled that the boy had died from manual strangulation with brain swelling, court records show. After that ruling, a hearing commissioner refused to allow prosecutors to move forward with second-degree murder charges.

Because Pierre-Louis's ruling contradicted Gordon's account, an outside pathologist examined the body, determining that the boy died of heart arrhythmia caused by a blow to the chest. That ruling allowed authorities to get a second-degree murder indictment, which was dropped in exchange for Gordon's guilty plea to involuntary manslaughter.

One of the first things Pierre-Louis did when she took over the office as temporary chief was to rehire pathologist Vincent Hill. She had worked with Hill for several years in the D.C. office. Hill had been forced out in 1999 by Arden, who said in a recent interview that Hill "wasn't performing his duties adequately, and he wasn't producing competent work."

In 1998 and 1999 memos from Arden to Hill, which were obtained by The Washington Post from a source other than Arden, the former chief medical examiner expressed concern about Hill's handling of several autopsies. In the case of Camille Forbes, Arden wrote in a memo that Hill wanted to wrongly attribute her death to hemorrhagic gastritis.

In the case of a 56-year-old woman who was not named in the memo, Hill certified her cause of death as a brain hemorrhage due to hypertensive cardiovascular disease, and an autopsy report was sent to the woman's family. Arden wrote in a memo that Hill's conclusions in the death were wrong and that the case should be reopened.

"The consequences of your incompetent work and the resulting incorrect conclusions have been magnified significantly because the autopsy report has been sent to the next of kin," Arden wrote.

Sharlene Williams, general counsel for the office, said Hill is the only full-time medical examiner in the office who does not perform autopsies on homicide victims, duties he performed before he left the office in 1999.

Hill, who was rehired at an annual salary of $123,500, did not return phone calls seeking comment.

Staff researchers Bobbye Pratt and Alice Crites contributed to this report.

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