Autopsy Firm’s High Caseloads, Practices Lead to Errors
by Ryan Gabrielson, Special to ProPublica
Coroners in Northern California are farming out thousands of cases each year to a private firm whose doctors have dissected the wrong body and have given inaccurate testimony that helped send an innocent person to jail.
Doctors with Forensic Medical Group Inc. routinely handle caseloads that leaders in the field of forensic pathology call risky, conducting as many as three autopsies in an hour or nine autopsies in a single shift, an examination of company invoices shows.
Although some of the firm’s doctors have been praised for their skills and professionalism, the Forensic Medical Group also has employed physicians who were fired by public agencies for substandard work. The firm twice hired one doctor deemed incompetent by the California State Bar.
The region’s justice system has come to rely on Forensic Medical Group — more than a dozen California counties (PDF) contract with the firm to do some or all of their death investigations.
Yet the agencies that hire the company often do not check who is performing the work until problems arise, said Chris Andrian, a prominent Sonoma County defense attorney who has twice won the release of clients due to the firm’s mistakes. In some cases, errors by Forensic Medical Group have made it impossible to hold anyone accountable for suspicious deaths.
“They are not being vetted in terms of their backgrounds, their skills, their ability,” Andrian said of the private doctors. “You hire a company, and you take the company as a whole. And you never know what you’re getting.”
The group’s doctors acknowledge they have made mistakes, but say that they have improved death investigation in the region, sometimes under difficult conditions. They often conduct examinations in facilities that are a far cry from state-of-the-art and drive 100 miles or more between cases on a single day.
The firm has tripled its client list over the past 15 years, propelled by a need for its services, said Dr. Kelly Arthur, one of the practice’s owners.
“A lot of cases are getting done,” she said. “And people don’t have a problem with that.”
Forensic Medical Group’s emergence as the dominant provider of autopsy work in Northern California is emblematic of larger flaws in the U.S. death investigation system.
In California and across the nation, a chronic shortage of forensic pathologists has left coroners and medical examiners overburdened and understaffed. A 2009 study by the National Academy of Sciences concluded that the country has fewer than half the number of specialists it needs to competently investigate suspicious deaths.
Many localities rely on uncertified or minimally trained practitioners and look into only a small fraction of all fatalities. Indeed, without Forensic Medical Group, certain types of deaths would go entirely without scrutiny in some of California’s most rural areas.
While most autopsy work in Southern California is done by forensic pathologists on the public payroll, the farther north you travel, the more likely that autopsies are being performed by private doctors, who are paid based on the volume of work they handle.
These physicians typically operate without even the minimal oversight received by their counterparts at public agencies.
“There’s no standard,” acknowledged Dr. Arnold Josselson, Forensic Medical Group’s vice president, when asked if there were rules governing how the firm’s doctors did their work or outside monitors to check it.
Instead, he said, the group polices itself: “If we have a question or a difficult case, we will share it with the group and get other opinions about it.”
The firm has little competition and has raised its prices substantially over the past five years, county contracts and autopsy invoices show.
Its doctors examine about 2,500 bodies a year — more than San Diego County’s medical examiner and more than twice as many as the Riverside County coroner, according to county financial and autopsy records.
“You can’t do that many cases well,” said Dr. John Pless, a National Association of Medical Examiner’s director and retired forensic pathology professor at Indiana University. “You just cannot do it, I don’t care who you are or what you’ve got working for you. You’re going to miss things, there’s no question about it.”
Unusually Heavy Caseloads
Arthur, one of the firm’s owners, was tackling her third case before 1 p.m. on Oct. 9, 2006, when she autopsied one man, mistaking him for another.
Arthur’s schedule called for her to examine George M. Farnsworth III, 51, who had died in a car crash that morning. Instead, she removed a different body from the cooler at the Sonoma County morgue: John Gobbi, 73, who had died after a long struggle with heart disease, county coroner records show.
Gobbi was 40 pounds lighter than Farnsworth and an inch and a half shorter. Arthur pressed forward anyway. On her diagram of external injuries to the body, she noted no discernable bruises or other markings, yet still concluded the deceased had died in a motor vehicle crash, records show. Arthur did observe the man she thought was Farnsworth appeared older than his listed age.
A technician alerted Arthur to the mix-up after she left the autopsy table to begin dictating her notes. Arthur acknowledged that, acting in haste, she had skipped over routine checks designed to prevent such confusion.
“The bottom line is that I made a mistake and I didn’t check a toe tag on a decedent,” said Arthur, in a deposition about the case. “It was the third autopsy that I did of that day and I approached things out of my usual order.”
That Arthur was working at a swift pace was no surprise.
Forensic Medical Group, which now has five doctors, does all autopsy work for Colusa, Contra Costa, Sonoma, Sutter and Yolo counties. The firm also provides a share of services to nine other counties, covering a sprawling 21,000-square-mile territory that stretches from Humboldt to Merced.
Forensic Medical Group’s doctors handle at least 300 cases annually (PDF); several of its practitioners have autopsied more than 400 bodies a year. Experts recommend no more than 250 a year and argue that examining upwards of 325 leads to exhaustion and a higher incidence of errors.
Because it operates across county lines, the firm’s clients have little ability to monitor its doctors’ caseloads. For several years, one partner in the firm, Dr. Mark Super, held a full-time job as Sacramento’s chief forensic pathologist, handling an average of almost 500 examinations a year, while doing roughly 100 cases a year on the side for Forensic Medical Group.
The firm charges (PDF) up to $1,250 per autopsy and $600 for external examinations, which involve no cutting. It collects additional fees for travel time, court testimony and responding to death scenes.
The firm has won a reputation for its willingness to take on even the most daunting assignments. In 2008, when Merced County’s in-house forensic pathologist quit and bodies began to back up, most of the firm’s doctors traveled to Merced’s morgue and performed a total of 21 autopsies in a single day.
Forensic Medical Group also offered to fill in temporarily for Monterey County’s forensic pathologist, independent contractor Dr. John Hain. But there was a catch: The firm wanted Hain to agree that all the work could be done on a Saturday. Hain turned the offer down.
“They can’t do all the cases in a week on one Saturday and do a good job,” he said. “I thought, ‘These people are crazy.'”
Josselson, the firm’s vice president, shrugged off such concerns. “Most of the cases are straightforward,” he said, adding that natural deaths required little examination time.
Each day, sometimes even on weekends, the firm’s office manager calls Josselson at 7 a.m. with the latest cases. He divvies them up, dispatching doctors to sites that can be hundreds of miles apart, invoices show.
On a day in March 2009, Super conducted two autopsies in Sutter County and then drove 100 miles south to San Joaquin County for three more.
Dr. Brian Peterson, who was the company’s longtime president before becoming the chief medical examiner for Milwaukee in 2007, said his work schedule with Forensic Medical Group was daunting at times.
“I can remember one time driving up to Humboldt County, and that was a five-hour drive, to do three autopsies including an infant and drive back the same day to be at work the next morning,” Peterson said. “It was wear and tear.”
Dr. Bruce Levy, Tennessee’s former chief medical examiner, is a major proponent of privatizing forensic pathology — just not the way Forensic Medical Group does it.
Nearly 15 years ago, Levy’s private company took over the Nashville’s medical examiner office. He hired a team of certified forensic pathologists, autopsy technicians and death scene investigators, replicating the system he worked within in New York City.
The company also became the first private firm to earn full certification from the National Association of Medical Examiners, a nonprofit group that sets standards for forensic specialists and morgues. Levy’s operation later took over death investigation for all of Tennessee.
Levy said his doctors perform no more than 250 autopsies a year, and government agencies pay the company a flat annual fee for services, so there is no financial incentive to increase caseloads.
Levy said that he had respect for Forensic Medical Group’s doctors, Super and Peterson. But he does not endorse the firm’s mode of operation.
“To me, that’s the kind of workload that would lead me to burn out after a period of time,” he said.
A Shortage of Qualified Doctors
Although some of Forensic Medical Group’s doctors are held in high regard, several were hired despite troubling track records or a lack of basic qualifications.
One of the firm’s most prolific practitioners, Dr. Ikechi Ogan, is not certified as a forensic pathologist by the American Board of Pathology, a measure of basic competence in the field.
From 2007 through 2009, records show, Ogan had performed dozens of autopsies for counties whose contracts specified that Forensic Medical Group send only certified forensic pathologists to do its work. The doctor completed a year of specialized training in Detroit’s medical examiner office 12 years ago.
The firm also has hired doctors who have been dismissed from other autopsy jobs.
In 1998, it took on Dr. Thomas Gill, a pathologist who had been fired by the coroner in Indianapolis for misdiagnosing causes of deaths in several cases and drinking on the job. He was later demoted for poor performance during a fellowship with the Los Angeles County Coroner’s Office.
Peterson said that the firm, like forensic pathology offices all over the country, struggles to find qualified doctors. To him, Gill was not a troubled practitioner so much as someone needing a second chance.
“My thinking at the time was, if I don’t give this guy a chance, who will?” Peterson said.
After Gill made critical errors in a Sonoma County case, causing homicide charges to unravel, the firm replaced him in 2002 with Dr. George Bolduc.
Bolduc came with baggage, too. During a stint at the Orange County Sheriff-Coroner’s Office, he allegedly based his findings in a homicide case on a police report rather than medical evidence. After losing that job, Bolduc worked at Kinko’s and a Safeway. He also delivered newspapers and was a census taker before Forensic Medical Group hired him.
Bolduc stayed at the firm less than a year, joining a different company in Merced after Sonoma County officials raised concerns about his past.
Forensic Medical Group subsequently rehired Gill, even though two counties would not allow him to conduct autopsies for them or to testify in court. The company finally cut ties with Gill in December after a third county refused to work with him after the coroner learned of the doctor’s history from reporters.
The firm’s owners said they no longer had enough examinations to justify employing Gill full-time.
Mistakes Lead to Murder Charges
Errors by Forensic Medical Group helped put Corbin Easterling behind bars for 18 months, charged with a murder he did not commit.
Easterling’s wife, Jennifer, drowned in San Pablo Bay’s frigid water during the pre-dawn hours of Oct. 12, 2004.
The couple’s personal watercraft (similar to a jet ski) had broken down two miles from shore. U.S. Coast Guard rescuers found them after 19 hours. According to a medic on the scene, Corbin, shaking uncontrollably, had pulled himself onto the disabled watercraft, looping his arms into his wife’s life vest to keep her afloat. Despite his efforts, Jennifer, 35, had died.
Dr. Gregory Reiber, now president of Forensic Medical Group, conducted her autopsy two days later. He found clear evidence that Jennifer Easterling had drowned. There was murky water in her stomach and foam in her airways. The question was why.
Based on bruising on her neck, mouth, torso, arms and legs, Reiber concluded that Jennifer drowned as a result of being suffocated. Coroner’s officials listed her death as a homicide, theorizing that her husband had pushed her head under water.
The Easterlings had a history of domestic violence, as well as drug- and alcohol-related arrests, adding credence to the story. Corbin Easterling was charged with killing his wife.
But Reiber’s statements during the autopsy were contradictory. Some of Jennifer’s bruises were old, and others had emerged after her death, he said. Later, he added that none of them indicated a struggle.
Corbin Easterling’s defense team argued that Jennifer had drowned after passing out from hypothermia, prompting the Sonoma County District Attorney’s Office to send her file to Dr. Alan Steinman, the U.S. Coast Guard’s former surgeon general and an expert on hypothermia.
“Steinman felt there were ‘a lot of inconsistencies’ in Reiber’s testimony,” assistant district attorney Bud McMahon wrote in aJuly 2005 internal memo. “In particular, he felt Reiber was inconsistent and inaccurate with his use of rates of warming and cooling, etc.”
Steinman told prosecutors he could not rule out hypothermia as a contributing factor in Jennifer Easterling’s death.
Reiber also made his determination without asking for reports from the scene describing where and how the Easterlings were found. Deputies had not transcribed the Coast Guard medic’s interview that noted the couple was in water too deep to stand or that cited the husband’s efforts to save his wife.
Agreeing that the account undermined Reiber’s conclusions, Forensic Medical Group changed its ruling in June 2006, concluding that Jennifer Easterling’s death had been an accident. Prosecutors dropped the charges against Corbin Easterling, freeing him after 18 months in jail.
Reiber did not respond to repeated interview requests. In a written statement, the firm acknowledged that death scene information would have led him to a different conclusion.
“Difficult cases may have multiple seemingly contrary ‘conclusions,’ none of which is necessarily wrong,” the firm wrote. “As forensic pathologists we are charged with determining the cause of death to the best of our collective ability given the information available, our training and experience.”
The firm continues to handle all of Sonoma County’s autopsy work. In a written statement, officials with the sheriff’s department said they were satisfied with the firm’s work, “and we do not feel it would be appropriate to publicly comment on any past cases where they have performed pathology services for us.”
Corbin Easterling struggled after his release. He overdosed on methamphetamine 11 months later.
“It was so horrible,” Richard Jevarian, Jennifer Easterling’s father, said of the case’s effect on the family. “This makes or breaks the lives of anyone who’s involved with this.”
This investigation was reported and produced by staff at ProPublica, Frontline, NPR, the Investigative Reporting Program at UC Berkeley, and California Watch. Reporter Lowell Bergman of PBS “Frontline” and the Investigative Reporting Program at UC Berkeley contributed to this report.