In NC medical examiner system, heavy autopsy caseloads raise risk of mistakes
11/17/2013 12:12 AM
11/17/2013 9:29 AM
Accurate autopsies help ensure that murderers don’t go free, that suspects aren’t wrongfully prosecuted and that spouses receive the life insurance payments they deserve.
But in North Carolina, heavy caseloads are raising the risk of errors, an Observer analysis has found.
Pathologists in North Carolina’s thinly staffed medical examiner system do as many as 10 autopsies in a single day, records show. Experts say thorough autopsies typically take two to four hours each, so it’s hard for pathologists to do more than four in a day.
The Observer also found that pathologists in the state’s chief medical examiner’s office in Raleigh routinely do more than 250 autopsies a year – heavy caseloads that experts say can lead to mistakes.
Among those who’ve handled excessive caseloads: Dr. Clay Nichols, the state’s former deputy chief medical examiner.
On Christmas Eve last year, he did 10 autopsies, including three cases ultimately determined to be homicides.
Heavy caseloads, he said, leave North Carolina pathologists “overworked, over-tired and over-taxed.”
Nichols recently lost his job amid a State Bureau of Investigation probe into allegations that he mishandled evidence.
The Orange County district attorney announced Friday that he would not pursue criminal charges but said he had questions about Nichols’ work, including how he documented evidence.
In an interview Friday, Nichols denied any wrongdoing and said the state moved too quickly to dismiss him from his job.
Dr. Gregory Schmunk, president of the National Association of Medical Examiners, an organization that sets standards for forensic autopsies, said he was troubled to hear pathologists in North Carolina were handling as many as 10 autopsies in a day.
“Oh my God ,” he said. “What you’re describing to me would be very concerning.”
The quick and the dead
When pathologists conduct that many autopsies, Schmunk said, “the quality of work product is severely called into question.”
Experts and state officials point to two key reasons for the heavy caseloads: inadequate funding and a national shortage of forensic pathologists, which has slowed additional hires.
A 2007 NAME survey found statewide systems typically spend about $1.76 per person annually on death investigations. North Carolina has historically spent less than $1 per person, according to a retired chief medical examiner, Dr. John Butts.
To help handle the current overload, the state has temporarily reassigned its chief medical examiner, Dr. Deborah Radisch, to focus on performing autopsies. The state has also contracted with two pathologists – including Butts – to do autopsies on weekends.
Butts said the move is meant to help the agency cope with short staffing until two new forensic pathologists are added early next year.
Ricky Diaz, spokesman for the N.C. Department of Health and Human Services, which oversees the medical examiner system, said the crunch has not led to errors or affected the quality of autopsies overall.
Some experts disagree.
Dr. Patrick Lantz, a longtime forensic pathologist at Wake Forest Baptist Medical Center, is among those who have sometimes performed more than the recommended number of autopsies.
“If I have a lot of cases something has to be shortchanged a little bit,” Lantz said.
When that happens, he may not have time to interview relatives and family doctors to learn about a deceased person’s history.
“You’re not going to be doing the in-depth investigation that is often required in these cases,” Lantz said.
Standards not followed
Autopsies are the most reliable way to determine the exact cause and circumstances of suspicious deaths. The procedure typically involves an external and internal examination of the body, along with a series of tests to check for the presence of diseases, alcohol and drugs.
NAME recommends that pathologists do no more than 250 autopsies a year. In a 2004 report, the National Institute of Justice, the U.S. Justice Department’s research arm, said that pathologists who do more than 250 autopsies a year “may engage in shortcuts ... or make mistakes.”
In cases where pathologists do more than 350 autopsies a year, the NIJ report said, mistakes are more likely to be “flagrant” – and more likely to result in faulty attributions of blame, wrongful prosecutions and missed homicides.
In a review of records from 2008 to the present, the Observer found that 11 North Carolina pathologists have done more than the recommended number of annual autopsies.
Among the findings:• Nichols, formerly the second-highest ranking official at the chief medical examiner’s office, did more than 415 autopsies in 2012.
• Radisch did about 440 autopsies in 2010, the year she became the state’s chief medical examiner. Her caseloads dropped the following two years. Experts recommend that chief medical examiners do fewer autopsies because they have administrative duties.
• Dr. Samuel Simmons, also of the chief medical examiner’s office, did nearly 420 autopsies in 2010.
• Three pathologists at Wake Forest Baptist Medical Center and one in Mecklenburg County also did more than the recommended annual number of autopsies.
• Since 2008, there were about 120 instances in which North Carolina pathologists handled what some experts consider a crushing caseload: more than five autopsies in a single day.
“If they are doing those types of numbers, they are not abiding by the standards of our profession,” Schmunk said.
Dr. Gregory Davis, a nationally known expert and professor of pathology at the University of Kentucky, said he was saddened to hear about problems in North Carolina’s medical examiner system.
The state has a great legacy, he said, but if pathologists are doing more than 400 autopsies a year, “it cries out they need more staff.”
“It’s a system that places unrealistic expectations on its people,” he said.
Hectic Christmas Eve
On Dec. 24, 2012, a mild winter day when many families were preparing Christmas Eve dinners and wrapping presents, Dr. Clay Nichols was performing autopsies.
He was the only pathologist in Raleigh performing autopsies that day. And he wound up doing 10.
Three of those cases were found to be homicides, where justice and the fates of defendants were at stake.
Among those cases: an Army staff sergeant shot to death by a hunter who told authorities he thought he was shooting at a deer; a 46-year-old woman shot in the head by her boyfriend after a dispute; a 21-year-old man killed in a shooting at a Robeson County apartment complex.
Nichols said there was plenty on his mind that Christmas Eve. He got news that day that his first grandson was born – and that his sister had died.
But he said he was forced to work because the office was staffed with only three full-time pathologists and a resident in training. He said he had to perform autopsies assigned to him and supervise those conducted by the trainee.
He said he couldn’t recall many details of his work that day.
But Nichols was blunt in describing the volume of work.
“It’s too much,” he said. “It’s a lot of physical work. It’s even more paperwork. Over the years we learned to be a volume autopsy service.”
Nichols praised Radisch as “a wonderful administrator.” But he said this of the state medical examiner system as a whole: “You can definitely tell it is starting to get cracks.”
Pathologists do triage
In North Carolina, more than three quarters of autopsies for suspicious deaths are performed at the chief medical examiner’s office in Raleigh and at regional facilities in Charlotte, Winston-Salem and Greenville.
The Raleigh office, which also oversees the medical examiner system as a whole, is by far the state’s busiest – and the one where excessive caseloads appear to be most pronounced. Today, that office performs autopsies for 30 of the state’s 100 counties, but has only three full-time pathologists, the state said.
Of the 11 pathologists who performed more than 250 autopsies annually in recent years, seven worked in the Raleigh office.
Butts, who was chief medical examiner from 1987 to 2010, said that when he was in charge, the office had six pathologists, including a fellow in training.
Because of a lack of staffing, Butts said he carried a “full clinical load,” sometimes autopsying as many as seven bodies a day. He said he often handed over day-to-day administrative tasks to a dependable staffer.
State pathologists treated autopsies like “triage,” Butts said, sometimes “opting not to do one that is iffy.”
Diaz, the state spokesman, acknowledged that caseloads for some pathologists were excessive and said the state was making moves to reduce them.
“The workload is going to improve” when two new full-time pathologists begin in January, Diaz said.
State officials said a shortage of pathologists nationwide has made it hard to keep the medical examiner’s office adequately staffed. Experts estimate there are fewer than 600 full-time board-certified forensic pathologists in the United States.
Diaz said state administrators have successfully lobbied lawmakers to allow higher salary offers to pathologists and other health care professionals. .
“The ability to recruit and retain talent, we know it’s crucial for the long-term sustainability of the medical examiner system,” Diaz said.
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