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Post Mortem
Death Investigation in America

Interview Dr. Marcella Fierro

“You call a death an accident or miss a homicide altogether, a murderer goes free. Lots of very bad things happen if death investigation is not carried out competently.”

You were telling me earlier why you got in this business. Is it because you didn't like to talk to patients?

I like patients. I talk to my patients whether they're dead or alive. When I was treating live patients, I spoke with them. And when I have dead patients, I talk to them, too.

But they don't talk back.

They talk back to me with their physical findings and with their pathology. I ask them, "Tell me your story," and then I do my examination, and they do tell me their story.

Dr. Marcella Fierro

One of America's leading forensic pathologists, Fierro is the model for the Kay Scarpetta character in the popular fiction series by Patricia Cornwell. She retired in 2008 as chief medical examiner for the commonwealth of Virginia. Fierro was a member of the committee that wrote the National Academy of Sciences study that recommended the U.S. abolish the coroner system. "I'm not anti-coroner," she explains. "I'm pro-competency." This is the edited transcript of an interview conducted on June 22, 2010.

As you're cutting them up.

I don't think of it as cutting them up. I think of it as examining their tissues, examining their wounds, examining their injuries. Incisions are simply a means to the end of the examination.

And you never got tired of it in, was it 34 years?

No, I never tired of it. I enjoyed every day I spent in medicine before I retired. I have to say, I never went home and felt like I had a zero day. I might have had some 5s and 4s and many 10s and 9s, but I was never sorry, never.

So if it's such an enjoyable profession and such an enjoyable job, a fulfilling job, why did you join this National Academy [of Sciences] study, which apparently started because of problems in the business?

I don't think that's a safe assumption. I think when you have a lot of experience and when you do something for a long time, you have something to give back. You have the battle scars of having done something and made mistakes and discovered new ways and made progress.

That's valuable when you want to take a look at what it is at the big picture. So I think it's good that experienced people were willing to serve on the committee. Why would I not serve? I was honored to serve.

Well, what's wrong with the business?

There's nothing wrong with the business that can't be fixed. ...

I don't see a drumbeat of popular protests on the nature of death investigations in this country. People aren't demonstrating, saying that the forensic pathologist or the coroners aren't doing their job.

I think that's interesting, but I think it reflects the absence of understanding of what it's all about. I don't think many people have a good understanding of what medical examiners and coroners do.

I think many people only get that realization when it actually touches them, when they have a family member who dies violently and they want to know what happened, or they have someone close to them who dies suddenly and unexpectedly and they want to know what happened.

When there are good answers to those questions, people are grateful and they understand. If there are not good answers, there is no place for them to go to get an answer. So they have to take what's out there.

That was part of the point of the study, is that services are uneven. In some places there's excellence. In other places there's not excellence. In some places there's the budget and will to do it, and in other places there isn't.

People often don't miss what they do not have. And you also have groups of people who are striving very hard, and even though they're striving very hard, they are not doing a good job.

People are striving very hard?

I believe there are people out there trying to carry out death investigations, and they're trying to do them the best they can, but they don't have the training; they don't have the money; they don't have the infrastructure; and they don't have the skill. They make their best effort, but the product isn't there. ...

What kind of consequences are there for the people if you don't have skilled people doing it?

When you have accidents called natural deaths, because someone doesn't recognize that a death is an accident -- that it's a low-voltage electrocution or it's an asphyxia or something like that -- then they're denied their accidental death benefits, period. So it can have a significant effect. You sign out somebody who has died of an infection that originated from an injury as a natural death, you've just given away their lawsuit to recover for a wrongful death. You call a death an accident or miss a homicide altogether, a murderer goes free. Lots of very bad things happen if death investigation is not carried out competently.

Murderers go free.

They're not even recognized as murders.

Give me an example.

Asphyxias, in particular, and poisonings are the obvious examples where they're not recognized if you don't have competent death investigation.

You mean if you don't have training in what to look for or what to test for?

And what to ask for: How to evaluate a history. How has this person been doing the last couple of days? How have they been doing the last month? Have they been sick recently? Is there any history of an injury recently?

"Oh, they were in a car accident three months ago." "What happened to him?" "He got a couple of fractured ribs." "Where were they?" "On his left side." "Oh. And tell me what happened last night." "He said he felt faint and collapsed."

Well, I'm going to bring him in. There's no question in my mind what happened to him.

Bring him in for an autopsy?

You betcha. I'm not going to sign him out as a heart attack just because he's 45, fat and has high cholesterol.

He's coming in because I know what he's got. He's got a delayed rupture of his spleen, and he is an accidental death. Now, if that was in the course of a hit-and-run, there are court proceedings that could evolve from that.

And that's happened?

Absolutely.

Regularly?

I can't say that it happens regularly. Most errors are buried.

Most errors are buried?

Right, so that if a death isn't recognized as being suspicious, say, for violence, and it's released as a natural death, it's buried or cremated, whatever the family wishes, never to rise again.

Characterize for us your opinion of the quality of death investigations nationally.

I think the quality of death investigation in the country varies. In some places it's very good, and in some places it's very poor.

This is related to lots of things: systems, whether it's coroner or medical examiner system; the quality of education of the people carrying it out -- is this a pathologist? Is it a forensic pathologist? Is this a person who has medical training at all? Is there a sufficient infrastructure to support the death investigation system? Do they have access to toxicology? Do they have access to firearms? Do they have access to any of the forensic sciences to, say, assist with problems in identification? ...

It depends on funding. If the budget for the state or the county or the city is poor that year, they may not get the money that they need.

It's a matter of manpower, too. Do they have sufficient staffing to do it? If you don't have staffing, and you don't have the computer support, and you don't have the budget, and you don't have a facility, and you don't have infrastructure, and you don't have access to the consultants you need, then death investigation, in spite of everybody's best effort, will not be good.

Is there any way to know where you should die, in terms of the quality of investigation?

I would definitely die someplace that had a good medical examiner system and qualified medical investigators, and a police department that the medical examiner trained.

A police department that they trained?

Right. A police department that knows what to do when it comes upon a dead body, knows how to preserve its evidence, how to preserve the scene, how to document the scene, because oftentimes someone will die in the hospital after an act of violence out someplace, and the police evidence techs and police detectives need to know how to document that scene, not only for their purposes, but for the medical examiner to look at, too.

In other words, if a police officer knows something about low-voltage electrocution, if he sees that somebody was working on an appliance when he presumably had his heart attack, then he would recognize that this could conceivably be a case of electrocution. ...

You've said, "The eyes see what the brain knows." Could you explain what you mean by that?

If you don't know what something is and you don't recognize it, you don't think of it. In other words, if I look it at a heart and I don't know about idiopathic hypertrophic stenosis, I will not recognize it or call it or diagnose it on that heart.

If I look at an eye and I see little red dots and I don't know that those are petechiae in my brain, I will never call them. If I never call them, asphyxia as a cause of death will not come into my head. …

[Do you think] that if there's a good medical examiner system in place, that's a better place to be than, let's say, where there's a coroner?

I think so, because I think it goes to the competency of what's up here for the eye to see.

But what if the coroner employs forensic pathologists, as many of the big-city coroners do?

I think the issue there, then, is one of who should decide what is the physiologic cause of death that killed somebody and who should make a decision on the manner being a description of the circumstances.

Those are basically medical decisions. ... I think the person that has the best degree of expertise to make these medical decisions is the pathologist, the forensic pathologist, the medical examiner.

... In places like California, the coroner is the sheriff. In other places, the coroner could be a building contractor.

He could be 18, a citizen and never have been convicted of a felony. The absolute core question is, these are medical decisions; who has the best credentials to make them?

If the coroner employs forensic pathologists, as some do in Las Vegas, in New Orleans, then what's the problem?

He doesn't always agree with the pathologist. Decisions can be based on issues other than the medical aspects. It's a redundant position if you have forensic pathologists.

The coroner in Cincinnati, Ohio, who is an OB/GYN who says he's taken a lot of personal training in forensic science, employs board-certified forensic pathologists; his office is accredited, apparently, by every organization, including the National Association of Medical Examiners [NAME]. What's the problem?, he says.

Why do you need him? If he is accepting of the cause and manner as identified by the pathologist, his board-certified forensic pathologists, then why is he there? ... It's a redundant position.

He says that he does things like talk to the public about public health-related issues that the coroner gets involved in, ranging from violence in the community to disease-related.

So do medical examiners. If I had a nickel for every public safety talk and every health and safety talk I gave, I'd be a rich lady. ...

Somebody would say a lot of your colleagues who are forensic pathologists are not exactly people persons.

I would dispute that. I know hundreds. I've been around a very long time. I can't say that I've met any that were weird, that couldn't talk to patients. You can't get through medical school without talking to patients and their families and their friends and anyone else they want you to talk to.

... They also say coroners far outnumber the number of medical examiner offices in this country.

They absolutely do. ...

And they weren't even invited to the table [to participate in the NAS study].

That's not my understanding.

[Clark County, Nev., coroner P. Michael] Murphy in Las Vegas was the only one.

He was the most excellent one we could think of to present the case for coroners.

But he's not a doctor.

No, but he is probably one of the most competent people that I know to actually run an office and to have an understanding of what death investigation is about.

He told us that his participation was basically token and that his recommendations were basically ignored.

That absolutely is not true. If you look at my chapter, or look in the chapter on the medical examiner, I have a section in there right from Mike Murphy.

He says that basically your number one recommendation was abolish coroners.

And that was not a new recommendation. This was the fourth time a national study has recommended that death investigation should be carried out by doctors, and particularly doctors who have special expertise.

This is not a new concept. It just needs to come to fruition finally. I guess you really have to ask yourself, do you want your cause of death and your manner of death to be decided by someone in medicine who has special competency to do that?

Or?

Or take your chances.

... In 35 years in this business, when did you realize that this position that people who call themselves coroners have, the power they have, didn't make sense?

First off, there's an assumption there that I'm not entirely comfortable with. I think I have known since I was trained that to make decisions about why somebody died and the circumstances under which they died required a great deal of expertise.

And as I practiced longer and got better at it and learned a lot more, it became clearer and clearer to me that this is not a part-time job where you just sign a certificate or where you go to the scene of a motor-vehicle accident and you see blood and you say, "OK, this person has a skull fracture." There is just whole lot more to it.

What else is happening? How do we know this person didn't have some sort of medical catastrophe before? Is this hemorrhage in his head due to the accident, or did it precipitate the accident? Is this person who was found dead at home a simple collapse and stroke, or does that little bruise on the forehead indicate an injury from a week ago, and they've been slowly developing a lethal subdural?

It's an accident. Or maybe they got a punch from a robber who broke into their house, and now we're going to sign that death out as a natural death because they're old?

It became apparent to me that there is a lot more in the decision-making process than just hearing: "Yeah, we found an old lady collapsed in her house. Yeah, she's got a bruise on her forehead, but she looks like she's old, so she's got heart disease probably."

Yeah, she's got heart disease. She's probably got kidney disease, too, but that's not the point. The point is, what should she not have that she does have? ...

Are you talking about this phenomenon of gray homicides?

I think gray homicides have probably been underestimated over the years. It's an interesting term, because it suggests that there's a certain grayness about it, that these are folks that have abundant natural disease often. But that doesn't preclude that they've died of some other thing, whether it's an accident --

At the hand of another.

They could have died at the hands of another. They could have died an accidental death. They might even be a suicide. But there's a tendency to assume that because somebody is old that they have died of an old-age-related disease as opposed to something else.

That assumption is not true when you have a 30-year-old who drops dead suddenly or who is found dead suddenly. The presumption then is what? There has to be some other cause here other than disease, because 30-year-olds don't drop dead; 70-year-olds do.

So there's a bias either way there. And I think the caution is, with the elderly, be careful. They're not always going to be natural deaths, even though they have a history of disease that often reasonably could be assumed to account for their death. You have to do very special, very careful examination of the circumstances surrounding these deaths.

We've been told by medical examiners, coroners, that homicides in places like nursing homes is a huge problem.

I don't know how huge it is. I haven't seen a study that actually gives a number. But it's certainly at risk. People who are sick and who are inconvenient are at risk. ...

But in most cities, even if there's a medical examiner, you don't get to see everybody who dies.

We don't get to see everybody, but oftentimes an investigator will go out, and that's where the benefit is in training law enforcement.

We spend a lot of time training law enforcement so that they are able to understand the risk factors for the various age groups so that they recognize that somebody found near the foot of stairs could, in fact, have been a fall. ...

Or somebody was found dead in the kitchen, and the plate shows that they were eating. That's a risk for asphyxia due to aspiration of a bolus of food. That's an accidental death. And so we work with law enforcement to recognize those things in the circumstances that denote risk. ...

Tell me about the two hats and why that's important.

The forensic pathologist, the medical examiner, wears two hats. He wears a hat that most people know about, and that's the hat for the criminal justice system, that of the medical detective -- figuring out why people die violent deaths, what kind of violent deaths, and answering the questions related to the violent death.

But they have an equally important role in the public health. The second is the public health officer hat, and that's because medical examiners and coroners develop the data, the counts, the percentages, the actual numbers of people who die of the various causes of death.

That's why it's so critical to have a correct cause of death and a correct manner of death, because at the end of the year you tally all that information up, and what does it show you? It shows you where your health problems are. It shows you why people died.

When you identify that people die of particular things, then it's a public health officer who thinks population-wise in terms of medicine, of treating people. Then you can develop an intervention.

If you have an inordinate number of drug-related deaths, then you need to be developing some drug programs, rehab programs, education programs, treatment programs, whatever, or you're not going to change that. It's just going to get worse. And it's worth saving those lives. ...

If you find kids are drowning because they don't have swimming lessons, then how would you like to prevent drowning? Talk about it? Dream about it? Think about it? No. You institute swimming lessons in school, particularly if you're in a community that has loads of swimming pools.

Now, supposing you have kids that are hit by bikes, or supposing you have children that are getting hit by cars. They're driving their bicycles, and they get hit by cars. Now, is it a sensible thing for that locality to think about bike paths, or are we just going to write off five kids a year riding their bikes and 75 years of life lost per child? ...

As we go around the country, we see different levels of reporting of statistics. There is a major city; they haven't reported their death statistics in four years. We've seen places that don't have equipment, don't have space. We've seen coroners without refrigeration for bodies.

That's correct. ... The infrastructure needs help; the training needs help; staffing needs help. The point of the report was not to say, "This is so bad it's no good." The point of the report is to say: "It's uneven. It needs help. It could be better." ...

The spokesperson for the National District Attorneys Association [NDAA] talked about your report and said that the recommendations deeply offended him.

I think he did not read the chapter on medical examiners and coroners carefully.

The head of the International Association of Coroners and Medical Examiners [IAC&ME], Dr. O'dell Owens, sat in an interview and said you're "coroner haters"; that's what that report was about.

I don't hate coroners. I don't hate anybody. I admire anyone who tries, but there are ways to make things better.

And that is not by electing someone who's 18, a citizen of this country, having had no felony convictions and assuming that that person with his best effort or her best effort is able to make competent decisions on why people died and whether the circumstances under which they died are natural, accident, homicide or suicide.

I'm talking about competency and credentials. I am not talking about people's best effort.

I am not talking about whether or not a prosecutor is happy with the testimony of the medical examiner. ... The medical examiner's mission is not to convict people of crimes. The medical examiner's mission is to tell the medical aspects of the death. That's it. He's not pro-prosecution; he's not against prosecution. He's not anti-defense; he's not pro-defense. His mission is to elucidate the medical aspects of the case. That is all.

... We were in one jurisdiction in New Orleans where the attorneys there say if there is an autopsy performed involving law enforcement shooting somebody or an in-custody death, and the autopsy is done by the New Orleans Coroner's Office and their forensic pathologist, they routinely will get a second autopsy.

That's unfortunate, because it implies that their cases are not credible. I've always, always thought, particularly in the police shootings and those that are related to law enforcement, that the best friend law enforcement could have would be an objective, honest, straightforward, careful autopsy. …

If we see a coroner or even a medical examiner's office where there's a failure to do autopsies in general, a very low rate of autopsies -- and I'm thinking here of Massachusetts -- what does that mean?

I think you have to ask those medical examiners, what are their decisions being based on? Is it a problem of funding? We would go through periodic awful cuts in funding here, and we had to make very close professional decisions about what case to autopsy and what case not to autopsy.

Actually, it wasn't a problem with autopsy. It was a problem with transportation costs. Pathologists are always willing to do the autopsy; it's just the cost of several hundred dollars to move a body a distance to bring it into the office. ...

Dr. Owens said he wants to raise standards. He wants things to be better across the board; he doesn't want it to be as uneven as it is. But by taking on the coroners as a primary plank in the recommendations of the study, you're diverting a lot of energy and being totally impractical. Why don't you enlist the coroners and educate them and lift them, especially because money is so tight in this country?

… I think it's wonderful to lift coroners, but on their best day, if they do not have the training, the skills, the infrastructure, the facility, the access to forensic science, they can't do a good job.

It's a question of competency. How can you train someone who is not a physician -- or even if he is a physician or even if he's a pathologist -- to develop the skill set, the knowledge, the skills and the abilities of the forensic pathologist?

I'm not anti-coroner. I'm pro-competency. …

Since 9/11, with the anthrax attacks, there has been a little bit more consciousness about the risk of bioterrorism. How well equipped are the medical investigators in the United States?

... The medical examiner may be the first one to recognize a bioterrorism death.

If we use the discovery of the hantavirus, the first recognized cases of that was in New Mexico, when deaths of two people who were close to one another were recognized as occurring very quickly. ...

They recognized that this was, in fact, very unusual that two people should die of this form of pneumonia, that that was extremely uncommon. That's a red flag that something's going on here. That's a public health recognition issue right off the bat.

But you have to have a certain level of competence to determine that.

Absolutely. I would say the odds of that happening medically are single digit or less that two people associated with one another would die of such an uncommon pneumonia. That is so uncommon that my focus right away would be that we're dealing with some kind of biological agent that, if not a bioterror agent, has the possibility for epidemic. And a major public health investigation should begin. And that's exactly what happened. …

Do all coroners' offices as well as medical examiners do this training?

I have no idea whether they do or not, but I know a lot of medical examiners' offices do. ...

But I'm saying that the building contractor or the sheriff or the coroners around the country couldn't do that screening, could they?

I'm not aware that they do. ... But if you tell me that a coroner has a MEDEX screening process in place, I say: "Good. That's great."

What if he doesn't?

Then those deaths will be missed. They will be signed out like their look-alikes, like pneumonia or heart disease. ...

Many people say you were the inspiration for [author Patricia Cornwell's character] Kay Scarpetta. True?

I think the work was the inspiration, because Cornwell worked in this office. She was hired as a technical writer, and then she worked with the program to set up our very first computer database.

... Then her books began to sell, and she worked part-time for a while. And then she became too busy and didn't work for us anymore.

Did you ever read her books?

Absolutely.

How good are they?

They're good.

Is that you?

Is that me? Am I blonde, blue-eyed and 105 pounds?

I refuse to comment. ... Can you talk a little more about why it's important to respect the way old people die?

If you're old, yes, you're going to die. Part of the human condition is death. But you ought not to go out as a violent death that is unrecognized, and your death should somehow not be of less interest or less value than the death of someone younger.

There is much to be learned from the deaths of older people. What's actually killing them? We know now that if you treat high blood pressure, you can extend people's lives and reduce the number of strokes dramatically. And it's simple to treat high blood pressure.

We know now that simple things like diet can improve people's lives by reducing the incidents of arthrosclerosis and early coronary disease. And now that we have lipid-lowering drugs like Lipitor, we're seeing fewer heart attacks.

We know now that colonoscopy is a most valuable procedure because colon cancer can be cured if you get that polyp early. We know that now because the number of deaths from colon cancer has dropped.

You're saying a lot of this information, a lot of these changes, are due to forensic pathology.

Due to hospital and forensic pathology for the natural deaths. The hospital pathologist contributes a great deal, the hospital autopsy.

But for the violent deaths, for the unexpected deaths, certainly the forensic pathologist is providing the data. You want to save lives? You want years of life lived instead of lost? Look at those numbers and collect them. If you don't collect them, that's a shame. That information should not go unappreciated.

... As a medical examiner in Virginia, can you testify or work for the defense?

Absolutely. It doesn't matter who calls us; our story is the same. Why doesn't the defense call you very much? Because the prosecution has already called you. They know you're going to be there. Certainly if the defense subpoenas the medical examiner of Virginia, you're there. …

Do [defense attorneys] routinely get second autopsies?

They don't get them often, but they do sometimes. I don't have an issue with that either. Not very often.

Have you been wrong? Has your office been wrong?

I can't think of a case where our autopsy was wrong.

I can think of some cases where a forensic pathologist engaged by, say, a defense attorney was able to point out aspects of a case that were not fully elucidated at the time of autopsy.

Ever had a case where a forensic pathologist in your office did an examination but failed to look at the lower half of the body?

Never.

Ever had a case where a forensic pathologist said that it was death due to adrenaline-induced delirium and it turned out the second autopsy said it was strangulation?

No, never.

If that was happening, what would you think?

It's entirely possible for the defense to get somebody to testify to something that's absurd, but the case will be sufficiently well documented that another forensic pathologist can look at it and come to the same conclusion. Problem cases are always reviewed by another pathologist and maybe several pathologists.

In your office, you mean?

If there's a question and if you really don't know, the honest answer is undetermined. I'll tell you, bias is a tricky game. You can't be biased.

So that's why the recommendation is that medical examiner offices be independent of law enforcement.

Absolutely, because you can't even have the perception. No matter how careful and how honest you are, you cannot avoid the perception that there could be a conflict of interest.

You cannot get your paycheck from the same people who pay the police. And the police recognize that, because nothing you say in a police shooting has any credibility if you're on their payroll. Even if you're right and perfectly truthful, it doesn't matter. It's the appearance. …

So if you were to grade the state of death investigations and forensic science -- not your office, but nationally -- what grade would you give it?

I don't know how to because it's not uniform. You have islands of excellence, and then you have people who are striving, but are not excellent, and then you have, I assume, a group of people who are neither here nor there, but do the job. But I accept that there are people who are out there striving their very best, but on their best day they can't do it well.

So some people are failing, even though they're well meaning?

Absolutely. I might try and do neurosurgery on your head and try my very best, but I'm not very good at it, and I shouldn't be doing it. ...

I think we could fix this. Florida has a good model: Three or four counties come together to fund an office and the doctors, and they get excellence in their service.

Or [there's] a Virginia or Maryland model, where you have a statewide system. Ours is regionalized. Maryland's is one region. Virginia has a nice regionalized system with four offices so that people don't have to travel.

New Mexico has such a sparse population they can't support more than one office and have the added advantage of actually being housed within a university, which is lovely.

I like to see a close association between the forensic pathologist in the medical examiner's office and the pathologist in a pathology department, because we're in the business of medicine, and that's where our excellence should be, in medicine. And it should be with our colleagues who are the subspecialists. There are renal pathologists and cardiac pathologists and hair pathologists and all pathologists. Pick an organ, there's a specialty there, and that person has special expertise to offer. And we need to be able to get to them because we need to do what? A good job.

It doesn't take a great medical mind to figure out someone has got his head blown off by a shotgun, but it does take special expertise to tell the distance, the survival. Is his arm long enough to do it? Is there any other activity going on with this body that would have predisposed him to depression? Does he have marks of defense? That's pretty sophisticated stuff, and you don't learn that in a week. ...

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Posted Feburary 1, 2011

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