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Thu June 5, 2014
Crisis In The Medical Examiner's Office: Punishing Survivors
On a cloudy day in March 2013, Kimberly Parker, 45, was walking her beloved pair of Golden Retrievers when something went wrong. Her husband Richard told police he found her facedown in the snow outside their two-story East Bridgewater house and called 911. She was pronounced dead at a nearby hospital.
The hospital and a preliminary autopsy found no obvious cause of death.
Parker’s family immediately suspected Kimberly’s husband, who faces charges of assault to murder Kimberly in December 2011, 15 months before her eventual death. His trial is still pending. The Plymouth County District Attorney’s Office confirmed Kimberly’s death is under investigation.
Today, Parker’s family still doesn’t know how she died. More than a year later, the state has yet to produce toxicology and autopsy reports that national standards say should have been delivered within 90 days.
Richard Parker’s attorney, Gerald Noonan, denies his client had anything to do with Kimberly’s death. He said the delayed reports are allowing Parker’s sister, Stephanie Deeley, to slander Parker.
“There is absolutely no medical evidence at all to support her allegations,” Noonan said.
And that’s true without a final autopsy report—a fact that leaves Deeley frustrated.
“It’s a terrible burden to live with, to spend everyday wondering if someone took her—and to extend that burden is just unconscionable,” Deeley said.
Kimberly Parker’s family is one of many waiting for answers. As of early May, autopsy reports on 1,121 deaths had been delayed at least three months—the time period after which they’re considered backlogged. The Medical Examiner’s Office said it did not have more detailed information about how long those cases had been waiting for attention.
An enormous number of lives have been put on hold because of the state Medical Examiner’s inability to timely process death. While state officials have singled out underfunding as a key reason, the New England Center for Investigative Reporting found questionable management decisions and a pattern of lax oversight contributing to long delays in producing death certificates.
The state’s chief medical examiner now says problems are so severe possible homicides are being missed. Prosecutors say court cases are sometimes delayed, although there is no way to know how often this occurs. Some criminal justice experts are also growing increasingly concerned backlogs could result in unequal justice, as some cases with long delays are placed on the back burner.
“We’ve had delays in charging certain cases because we didn’t have their results in timely fashion,” former Middlesex district attorney Gerry Leone said. “Time is very rarely the friend of the prosecutor, whether you’re investigating a case or you’re prosecuting it.”
From 2011 to 2013 the number of death certificates waiting for completion skyrocketed from 58 to 947. Those delays were driven in large part by report wait times that more than quadrupled after the state Medical Examiner’s Office went forward with a plan to send all its toxicology samples to the State Crime Laboratory, which had just shut two facilities following two different scandals.
Such management decisions are rarely scrutinized because the Medical Examiner’s sole oversight comes from an unpaid advisory commission that was unable to muster a quorum from 2011 through 2013. Five of the 13 appointed positions on the commission are vacant.
Another reason for delays is the sheer lack of manpower. The Medical Examiner’s office has only 10 medical examiners attempting to serve a population that warrants 17, according to the National Association of Medical Examiners. As a result, the office has had only provisional accreditation from that organization since 2010. And despite promises by state officials in 2008 to better fund the office after a series of scandals, its budget today is even smaller than during that time period.
Stalled court cases and uncollected insurance policies that require a death certificate are two results, but for thousands of grieving families, the delays prevent a more precious outcome: closure.
Absence Of Information
Bio-safety officer Kimberly Boleza met security consultant Richard Parker in 2002. Boleza had a graduate degree and a promising career; Parker was a divorced father of two and Boston Fire Department captain who searched the World Trade Center rubble after 9/11. The couple married in 2005.
In September 2011, around the time of the 10th anniversary of the terrorist attack, Richard—then a Department of Homeland Security consultant—attempted suicide by ingesting the neurotoxin ricin, said Kimberly Parker’s brother, Ed Boleza. Kimberly found Richard and called 911, then Boleza.
The house “was lit up like the Ohio state fair midway—FBI, local police, couple ambulances, mobile crime labs,” Boleza recalled. “They had moon suits to enter the house.”
Richard recovered after a week in the hospital. A few months later, on Dec. 18, 2011, police responded to another incident at the Parker home. Kimberly told police officers Richard had held her against a wall and threatened with a knife to kill her and her dogs. A grand jury eventually indicted Richard Parker on charges of assault to murder.
“I remain concerned about the threat the defendant poses to his wife,” Judge Frank M. Gaziano said in April 2012, according to court documents.
But Noonan, Richard Parker’s attorney, said Kimberly didn’t cooperate when the Plymouth County District Attorney’s Office charged Richard, who was held without bail for six months.
By mid-December 2012 Parker was living with Kimberly again.
“If we bad-mouthed him, she would defend him,” Stephanie Deeley said.
On March 10, 2013, Richard texted and called Boleza and Deeley to tell them Kimberly was being taken by ambulance to Brockton Hospital. When they arrived, he informed them she had died—collapsing in the snow as she was walking the dogs. Kimberly’s family immediately suspected foul play.
The Office of the Medical Examiner took jurisdiction, as it does in deaths involving infants, suspicious circumstances or otherwise healthy people. The long wait for answers began.
In the meantime, Noonan points to Kimberly’s history of seizures caused by a traumatic brain injury. He said in January 2013 she had one episode while walking the dogs. Noonan said he’s tried to tell the Medical Examiner Office about the condition.
“I’ve attempted to speak to them to provide some medical background and history in regard to Mr. Parker’s wife, and they have refused to speak to me,” Noonan said.
In 2007, a series of scandals rocked the Medical Examiner's Office. There were missing corpses, unclaimed bodies piled in overcrowded facilities, and pools of blood on autopsy room floors. A review by the Executive Office of Public Safety found the Medical Examiner needed an $11.5 million annual budget and 17 full-time medical examiners. Chief Medical Examiner Henry Nields said he’s asked for that funding every year since then.
Those levels are “where we feel we ought to be functioning as required by law,” he said during an April meeting of the office’s oversight board, the Commission on Medicolegal Investigations.
In fiscal 2014, the office's budget was $7.5 million. Gov. Deval Patrick has requested a $2 million increase in fiscal 2015, some $2 million less than what Nields said is needed.
“With the economy rebounding, the Patrick administration has refocused on increasing resources for the Medical Examiner,” the governor’s office said in a statement.
Lack of funding has certainly made it difficult for the office. A $5 million Sandwich satellite office built in 2009 to serve the Cape Cod area sat mostly unused until it opened in July 2012. There is limited use of a rented Holyoke facility to examine deaths in Hampden, Hampshire, Franklin and Berkshire counties because it needs $60,000 in upgrades to equipment, plumbing, electricity and ventilation.
“They fund other things before they fund the dead,” said commission member Patrick Leahy.
The office compensates for understaffing by doing fewer autopsies and more “views,” or exterior inspections, Nields told the commission. Based on the commonwealth’s population, the office should have done more than 4,000 autopsies in 2013, he said. Instead it performed 2,363 autopsies and 2,844 views.
“It’s possible you could miss manner of death," Nields said at the meeting. "It’s possible you can miss a case that appeared natural is, in fact, a homicide.”
Office of Public Safety Undersecretary for Forensics Curtis Wood, who oversees the Medical Examiner’s Office, says when the office chooses to do autopsies, they’re completed within 24 hours. But his overtaxed staff can take months to gather the documentation from police and other agencies to complete autopsy reports and death certificates. Meanwhile, families like that of Lincoln resident Rick Golay wait in confusion.
The 62-year-old died Oct. 14, 2013, while biking, and there was no immediate cause of death. His family thought it could be a genetic condition, and worried his fraternal twin Ron was also at risk. Golay’s wife, Lauren Sloat, contacted the Medical Examiner Office’s family liaison.
“He was the first one to tell me it could take six months—and I was appalled,” Sloat said. “He said toxicology reports have a long turnaround time.”
But the office didn’t say why the turnaround time was so long. In the fall of 2012, the Office of the Medical Examiner began planning to switch from a private firm for toxicology services to the State Police Crime Laboratory in order to save $600,000 annually. The office went ahead with that plan in 2013, even as the Crime Lab was shuttering facilities in Jamaica Plain and Amherst after discoveries of a chemist stealing drugs and analyst Annie Dookhan tampering with evidence.
The Medical Examiner’s Office realized too late that the Crime Lab didn’t have room for the additional influx, Wood told the medicolegal commission in April. It was forced to transfer samples yet again to another expensive private facility. Toxicology report turnaround times went from 15 days in January 2012 to 134 days in January 2014.
“It was their failure, unwillingness to be honest with me that made it even more outrageous,” Sloat said.
Still, the move to the State Crime Lab will help the Medical Examiner’s Office be more efficient in the long run, Wood said.
Thirteen days after NECIR asked about Golay’s case, the Office called Sloat to say her husband died of a vascular disease and his death certificate would be mailed in a few weeks. Golay’s brother quickly made an appointment with his physician, and Sloat was finally able to claim Golay’s two insurance policies and pension.
In a thus-far unsuccessful attempt to help waiting families like Golay’s, Undersecretary Wood has talked with the Massachusetts Attorney General’s Office about convincing insurance companies to release death benefits without a final death certificate. And in an attempt to eliminate the backlogs, he said a large group of old cases is being tested at private labs.
“They may just be sitting there because they were there and we moved on to another one and nobody’s called,” Wood told the commission. He said that after the backlog is addressed, toxicology turnaround times would decrease.
Commission vice chair Frederick Schoen, a Harvard professor of pathology, said he believes only close to full staffing—17 medical examiners—will eliminate systemic backlogs.
“It’s hard to believe that just a few weeks of a slightly different approach will fix a chronic problem,” he said.
The New England Center for Investigative Reporting is a nonprofit news outlet based at Boston University and WGBH News in Boston. NECIR interns Rebecca Lee and Madelyn Powell assisted with the research for this story.
An earlier version of this story described Parker as a "retired Boston Fire Department Lieutenant". He was not retired.
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