Improper autopsy procedures that may raise doubts about the accuracy of death rulings in homicide cases are among a series of allegations regarding the operation of the San Francisco Office of the Chief Medical Examiner, which struggled with a backlog of cases in recent years.
The latest developments concern a pair of technicians who reportedly performed autopsies without supervision on victims of homicide and other crimes in early 2013, according to a statement from a former pathologist obtained by the San Francisco Examiner.
The Medical Examiner’s Office declined to comment.
If the autopsies were performed by non-doctors, Public Defender Jeff Adachi said it could mean his office would have to review all of the cases involving autopsies performed in San Francisco during that time.
“It would raise grave concerns about the integrity of the work that was done,” Adachi said.
The allegations stem from a statement from Dr. Judy Melinek to prosecutors in April 2013, before her resignation later that month.
The claims were forwarded to the City Attorney’s Office, which opened an investigation and found them to be unsubstantiated, according to the District Attorney’s Office.
Matt Dorsey, a spokesperson for the city attorney, could not confirm or deny the existence of an investigation, citing longstanding policy.
The allegations appear to suggest there was more to the demotion of Dr. Amy Hart — from chief medical examiner to pathologist — in 2014 than a backlog of death cases, some of which took months or even years to complete. The backlog slowed the judicial process in The City’s courtrooms and left the families of the dead in the dark.
Hart was the doctor who allegedly directed the technicians to perform the autopsies before leaving the room, according to the statement.
“Sometimes [Hart] was in there for long periods of time, like during the cutting of the organs,” Melinek told prosecutors. “But sometimes she’d just send [the technicians] in to take these homicides, X-ray them, document the injuries, unclothe them, and she wasn’t even physically in the room during that time.”
David Fowler, the president of the National Association of Medical Examiners, said it’s not unusual for technicians to perform these procedures, except for documenting injuries, but not without direct supervision.
“An autopsy is a practice of medicine that has to be done by a licensed medical practitioner,” Fowler said. Best autopsy practice is for a doctor to stand on one end of the table, observing and documenting as the technician performs tasks, he said.
Jana Tawney, one of the amateur technicians, was a part-time public service aide with a bachelor’s degree in anthropology and forensic identification. During the time she worked at the Medical Examiner’s Office, she was also a barista at Peet’s Coffee & Tea, according to her LinkedIn account.
The other technician, Kristopher MacFerren, was a medical examiner’s investigator who still works at the office. Melinek said MacFerren also does not have any sort of advanced degree in forensic anthropology.
“They’ve never been trained as technicians except for on-the-job within the auspices of our office,” Melinek told prosecutors. “Both of them were basically doing the autopsies from what I can tell. They were writing down the notes; they were documenting the injuries.”
At the Office of the Chief Medical Examiner in Maryland, which he heads, Fowler said he would not allow technicians to document injuries since he is accountable for the autopsy when on the stand.
There are places however where “scribes,” which are non-doctors, are used to document injuries, he said.
When reached over the phone at work on Tuesday, Tawney denied the allegation she had performed autopsies in homicide cases without supervision. She declined to comment further before press time.
Both Tawney and MacFerren complained to another doctor in the office that “they were uncomfortable with being asked to do all of this,” Melinek said. “That they were basically operating outside of the realm of their comfort level and expertise.”
Melinek told prosecutors that a medical examiner investigator, like MacFerren, should not have been removing evidence from bodies, because the removal of evidence is part of interpreting injuries.
“If you go to coroner offices or other offices, you might find situations where the technicians are removing evidence off the body,” she said. “But not in a situation where they haven’t been trained, they’re uncomfortable about it and it’s not the practices of any other doctor in the office.”
In another instance several months prior, Hart reportedly directed Tawney to try to identify someone using dermestid beetles, which eat the flesh off of bone to expose the bone for inspection.
“At the very minimum you really need a master’s in forensic anthropology in order to be able to be identifying remains on a regular basis,” Melinek said. “I think that Dr. Hart is having her do beyond the scope of [what] she’s trained for.”
Melinek was expressing her concerns about the accuracy of conclusions in death cases to then-Assistant District Attorney Jerry Coleman of the Trial Integrity Unit, DA investigator Mike Kloss and former homicide prosecutor and current San Francisco Superior Court Judge Harry Dorfman.
The DA’s Office offers Melinek’s statement to the defense as part of discovery in relevant cases, such as when Melinek or Hart performed the autopsy in the case, DA spokesperson Alex Bastian said.
In her statement, Melinek said she was not able to decide whether the cases had been compromised because, as an expert, she would have had to review each report on a case-by-case basis.
Melinek said she was not allowed to review the reports at the office since Hart was her superior.
“One gets retaliated against in various ways for raising any kind of criticism of any of the practices at the office,” she said. “So I’ve intentionally kept blinders on and closed my ears to things I found uncomfortable because I had to survive.”
‘A minimal, a handful, of autopsies’
When Melinek resigned from her position in The City after blowing the whistle on the state of the Medical Examiner’s Office, she cited numerous reasons for leaving, including “poor management with disrespectful, unethical, fraudulent and sometimes illegal behavior,” according to her resignation letter.
Many of those reasons centered around Hart.
One of the highest paid city workers in San Francisco, earning $383,746 in 2013 according to government records, Hart reportedly performed far less than her job duties, Melinek said.
In the almost nine years that Melinek was employed at the office, Hart “performed a minimal, a handful, of autopsies” — about two to three dozen of them.
“Typically if you look at offices of this size nationwide, a chief medical examiner performs way more autopsies than what happens here,” said Melinek.
A pathologist is expected to perform between 200 to 250 autopsies a year, while a chief medical examiner is expected to perform about half the load, Melinek said.
Fowler said there is no standard for how many autopsies a chief medical examiner conducts.
When Melinek was working for the chief medical examiner of Santa Clara County in 2003, the chief was fired for not performing enough autopsies, she said. “In the last year he was present, he performed about 40 to 50 autopsies, which is way more than Dr. Hart has performed in the past nine that I’ve seen.”
Hart also allegedly misrepresented the number of autopsies she performed, listing herself as conducting autopsies that were in reality performed at the UC San Francisco Medical Center, according to Melinek.
Hart is still a pathologist in The City and was the second highest paid city worker in San Francisco in 2014, making $479,652.21 as an assistant medical examiner, according to government records.
While most of the potential wrongdoing falls on the lap of Hart, Melinek told prosecutors about another instance in early 2013, when a technician, whom she only identified by the first name of “Octavio,” had “very minimal training” and was cutting a heart open.
“In my office, that would not be something that would be acceptable,” said Fowler, who has been performing autopsies since 1986. “Because that is a detailed diagnostic procedure.”
At the same time, Dr. Ellen Moffatt, a current assistant medical examiner, was busy performing the autopsy and distracted looking inside the person’s body cavity.
“I remember seeing him flop [the heart] around on the autopsy table like a fish,” Melinek said. “I think that’s what caught my attention was the plain flopping sound and I looked over and I was shocked to see Octavio flipping over and cutting it open while she’s not looking.”
Correction: The original version of this article mischaracterized the nature of the statement. The statement to prosecutors was not taken under oath.
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