"There are no national standards or regulations regarding forensic pathology and practices vary widely from place to place."
June 28, 2011 6:47 AM   Subscribe

The Hardest Cases: When Children Die, Justice Can Be Elusive A joint investigation by PBS Frontline, ProPublica and NPR has found that medical examiners and coroners have repeatedly mishandled cases of infant and child deaths, helping to put innocent people behind bars. (Via. (Article contains descriptions of children that have been killed by abuse. May be disturbing / triggering to some readers.)


The Child Cases: "As part of an ongoing look into the troubled state of death investigation, ProPublica, PBS "Frontline" and NPR identified nearly two dozen cases in the U.S. and Canada in which people have been accused of killing children based on flawed or biased work by forensic pathologists and then later cleared." There is a document timeline available for the case of Ernie Lopez.

From NPR: Parents fight to find the truth behind daughter's death.

Continuing ProPublica investigation: Post Mortem, a "year-long reporting effort into U.S. death investigation uncovered a deeply dysfunctional system that quite literally buries its mistakes." From forensics and autopsies to coroners and medical examiners.

See the PBS Frontline documentary. Accompanying website: Things to Know Before You Go, including "How Qualified is Your Coroner?"
posted by zarq (20 comments total) 19 users marked this as a favorite
This is why we need to do away with coroner systems and have death investigation systems nationwide which are run by board-certified and licensed forensic pathologists, forensic nurses and forensic investigators.

We are past the point where we can elect some ill-educated local yokel schmuck politician to figure out whether a death is due to foul play or not.

I do understand that it will take time, but it needs to start happening NOW so that less innocent people wind up going to jail.
posted by Renoroc at 6:54 AM on June 28, 2011 [7 favorites]

Apart from reforming forensic pathology, the best thing we can do for many cases is to deport Nancy Grace.
posted by Threeway Handshake at 6:59 AM on June 28, 2011 [23 favorites]

We launched the site at midnight, but if you prefer to watch on television, it's airing tonight at 9PM in most American markets. It's a magazine show with two segments: 'The Child Cases" first followed by "Educating Sergeant Pantzke." "Pantzke" is a follow-up to "College Inc." Martin Smith investigates veterans' experiences with the GI Bill and for-profit colleges. The second segment won't be available online until close to broadcast.

"Child Cases" is hard to watch because of the subject matter, but I think that I'm being objective when I say that it's very good.
posted by Mayor Curley at 7:03 AM on June 28, 2011 [13 favorites]

The problem is that people want local control of government officials whenever possible even when you have municipalities that simply can't afford a full time specialist. The result seems to be making due with part time people that simply don't have the skill or experience necessary for modern forensic techniques.

You also have big municipalities that have habitually underfunded medical examiner offices (not to mention crappy labs) so it's not like living in a big city means that you are going to get a timely quality result either.

Until people are willing to spend an appropriate amount investigating crimes as they spend on other elements of public safety I think we will continue to have miscarriages of justice.
posted by vuron at 7:03 AM on June 28, 2011 [1 favorite]

Mayor Curley: "We launched the site at midnight, but if you prefer to watch on television, it's airing tonight at 9PM in most American markets. "

Mayor, thanks for working on this project. It's a tremendous public service. Hopefully it will spur some changes.
posted by zarq at 7:12 AM on June 28, 2011 [1 favorite]

The biggest case in our area was Lori Roscetti. Four inmates walked free a few years back but I haven't heard of one update to the case being reopened.
posted by stormpooper at 7:18 AM on June 28, 2011

No mention of Cameron Todd Willingham?

If anything, that should be the canonical case for this series. There was nothing just or fair about the way that he was tried, imprisoned, and killed.
posted by schmod at 7:21 AM on June 28, 2011 [2 favorites]

My mother, who is an exceptionally tough woman in most other aspects, dropped out of medical training that she had fought so hard to get into as a woman in the 1950s after having to participate in the autopsy of a young boy. She says that she was handling it pretty well until she had to turn his head, which had a halo of the softest, silkiest angelic red hair. Touching that hair made her suddenly very concious of her surroundings and she could never again shake the image nor the humanity of patients and return to a professional distance necessary to perform procedures. She ended up working in a lab where she didn't have to know the people that the samples came from.
posted by The 10th Regiment of Foot at 7:21 AM on June 28, 2011 [4 favorites]

It's great to see this getting wider attention. Mefi's own Radley Balko has done some very good writing about medical examiner bias for reason magazine. A couple of years ago, I wrote up an FPP on Radley's investigation of a medical examiner/prosecution expert misconduct case involving the death of a 23 month old girl.
posted by AgentRocket at 7:23 AM on June 28, 2011

helping to put innocent people behind bars.

Innocent? Innocent of what?

I am inclined to think that this is one of those cases where the American won't-someone-please-think-of-the-children obsession reaches its zenith (or nadir, depending). When a child is the victim of a crime, I think there is huge pressure to put someone behind bars. Doesn't much matter who. We can sort that out after.
posted by ricochet biscuit at 7:36 AM on June 28, 2011 [2 favorites]

No mention of Cameron Todd Willingham?

If anything, that should be the canonical case for this series. There was nothing just or fair about the way that he was tried, imprisoned, and killed.

FRONTLINE did an entire show essentially dedicated to the Willingham case: Death By Fire, and he's certainly gotten coverage on NPR. I would expect that ProPublica has done some work there too.
posted by Mayor Curley at 7:44 AM on June 28, 2011

A blood-clotting disorder runs in my family, so we often have ugly bruises just because we did something mild like bumped into a table. Before we had genetic tests that diagnosed it, we were often questioned very sternly by doctors. I'm glad we got it diagnosed because it can be very serious during surgery, but also because a member of my family was reported to child services because of it! I don't know why they don't test children for these things at birth.
posted by melissam at 8:41 AM on June 28, 2011 [1 favorite]

Renoroc: This is why we need to do away with coroner systems and have death investigation systems nationwide which are run by board-certified and licensed forensic pathologists, forensic nurses and forensic investigators.

We've got people working on that.

Disclaimer: One of these people is my dad.
posted by ES Mom at 9:03 AM on June 28, 2011 [1 favorite]

I don't know why they don't test children for these things at birth.

Not at all to dismiss the problems you had with your clotting disorder going undiagnosed (I have a similar condition, coincidentally enough, though not to the extent that anyone was ever reported to social services), but there is literally no way to test children at birth for the countless genetic diseases and disorders that exist. (Once a family's been identified as carrying a particular gene, though, of course it becomes a lot easier to know what tests to run and what conditions it would be useful/essential to know about from birth.)

Also, lots of things just aren't so simply diagnosed with single tests. My own clotting disorder went undiagnosed into my 30s till I nearly bled to death during a surgery, and even then it wound up being misdiagnosed as one condition, then assumed to be a second condition, till finally being definitively diagnosed as the actual condition 5 years later.

posted by scody at 10:00 AM on June 28, 2011

er, "no way to test children at birth for all the countless genetic diseases and disorders that exist"
posted by scody at 10:02 AM on June 28, 2011

Anybody who is even remotely aware of current events in Ontario knows the name Dr. Charles Smith.

He was the go-to expert in child death cases. He wasn't some "ill-educated local yokel schmuck politician" (to use a phrases already on the page).

Of course his expertise turned out to be whatever the each opposite of what expertise should be, and he ruined plenty of lives with his testimony.

An Ontario coroner's inquiry reviewed 45 child autopsies in which Smith had concluded the cause of death was either homicide or criminally suspicious.

The coroner's review found that Smith made questionable conclusions of foul play in 20 of the cases — 13 of which had resulted in criminal convictions. After the review's findings were made public in April 2007, Ontario's government ordered a public inquiry into the doctor's practices.

That inquiry, led by Justice Stephen Goudge and concluding in October 2008, found that Smith "actively misled" his superiors, "made false and misleading statements" in court and exaggerated his expertise in trials.

Of course many of the people he testified against spent years and years behind bars. Smith himself, of course, has escaped a similar fate.
posted by sardonyx at 10:57 AM on June 28, 2011

It took four trials, but they finally convicted my friend and sent him to prison for life. The ME concluded that instead of the head injury sustained by his girlfriend's daughter after a fall in front of witnesses and a subsequent accidental re-injury while being held by her mother on the afternoon of her death, it must have been my 165 pound friend's fists hitting her with the force of a 90 mile an hour fastball since he was the last person alone with her.
posted by ob1quixote at 4:16 PM on June 28, 2011

Morning Repetition and All Things Repeated were even more repeat-filled today as they had a lot of reports from the morning show being followed-up or explored further in the afternoon. This overarching topic was one of them, and I heard the full reports in both the morning and the evening. The Ernie Lopez story is particularly heartbreaking.

Cunningham is a different kind of case altogether. He was accused of burning his children to death, but there was no time at which the medical examiner looked at their corpses and said the children had been shaken or beaten or sexually assaulted.

The results are the same -- an innocent adult is punished by a legal system which is operating on assumptions rather than researched fact, and even is ignoring provided facts so the expected narrative is fulfilled. But the cases are quite different once you get beyond that similarity.

In all these cases, we're realizing that we truly don't know as much as we've always believed our "experts" could tell us about situations. I shudder to think about how many lives may have been ruined by bad expert testimony or glossy assumptions made by investigators who "just knew this is how it played out" and thus ignored anything which didn't fit their mental picture.

Truly shocking and terrible. It's sad to listen to, will be sadder still to watch once my DVR grabs Frontline, and it's truly awful to think about how many echoes of these circumstances likely exist across the history of our court system.
posted by hippybear at 7:28 PM on June 28, 2011 [1 favorite]

Anybody who is even remotely aware of current events in Ontario knows the name Dr. Charles Smith.

I know Charles Smith personally. When the issue was coming to a head, soon after he had broken up with his wife, he left her and four adult kids and bolted to the west coast, where he hooked up with a former high school / college sweetheart of his, who also happened to be a friend of mine. He was living under a partially assumed name (Randy), and while he did tell my friend K. that there was an investigation into his activities as an Ontario forensic pathologist, he clearly was at the very least "economical with the truth". He was out here for a year or more, they even bought a house together.

Anyway, at first I certainly bought into his story too. He has a fair bit of personal charm - he's a quiet, very tall and gangly man with an easy smile and soft, inoffensive, body language. Certainly when he asserted that the media was getting lots of things wrong and sensationalizing it, and that the truth would come out, it did sort of ring true. I mean, every time I have had direct contact with the press, the resulting stories have been fairly significantly wrong, or incomplete, or the chosen emphasis of the reporter has been such that it distorts the story. So, I was inclined to believe Randy. I had dinner with him a number of times, helped him get wood for his wood shop (his hobby was wood turning, "I am a wood turner" he would rather pompously tell people), gave his jeep a jump start on occasion, hung on the patio with him while K messed around in the kitchen. Not really friends, but as the boyfriend of a friend, respect was given and relations were friendly. And honestly, once the smokescreen was set in, then it wasn't like we'd sit around saying, "but Randy, you MUST have done SOMETHING wrong", instead, well, it just wasn't really talked about.

One day the press found him and doorstepped K., and while she defended him I know that doubt started to settle in. Inconsistencies in what he had told her started to leak out, and his tightly wrapped cover began to unravel. Soon after, he started frequently having to go back east to the hearings. She stood by him through the first of this, and indeed it wasn't even the mounting evidence of his incompetence that did their relationship in, it was his lack of communication and concern for her (he would be gone for weeks and never call; cancel trips without reason etc).

His story became one of "incompetence", or, "mistakes were made" vs. a frank admission of being in cahoots with the police, say. And in a way I still believe there is an element of that. It's a fact that it's a job that no one wants to do. They have a great deal of difficulty hiring and training people to do this and so there is a lack of oversight of the ones doing the job. This is true and in a small way it explains (not excuses) Randy's ability to be incompetent for so long.

But the real explanation, I think, is that Charles is just fundamentally a weak person. He struck me as a "pleaser", a man who wants people to like him and be happy with him, and especially he needed that from authority figures. So long as he could have that, then he could deceive himself that the world was ordered the way it should be.

Equally, then, as a weak man he ran for a known shelter and hid behind the incredibly strong and tough K. When the heat was too high, rather than "displease" her through frankness, he just disappeared and became remote and distant.

I mean, I wouldn't label him a psychopath or anything, though there must be something wrong in his soul that allowed him to be in such denial about the consequences of his incompetencies. I think he muddled through, with no oversight, seeking validation, inching himself further and further out a long plank of half-truths and denial, even long past the point on the plank where he was hanging, magically unsupported, for longer than it would seem possible, until all the lies were hung on his neck at once, and he could no longer sustain the illusion.

I guess it'd be the closest I have come in my own life to seeing firsthand the "banality of evil". He put himself and the needs of his weakness first, and so through selfishness as much as anything he destroyed dozens of lives in the most heartbreaking way possible. He wasn't actively evil I don't think so much as passively so, by failing to recognize his incompetencies and/or by being too cowardly to admit to mistakes or to uncertainties which might be seen as a weakness or to engender disapproval from those in authority. To the extent he lied to his superiors it was, I suspect, motivated by a desire for "daddy approval" than by a desire to screw the victims.

Passive vs active evil is a distinction without a difference from the point of view of the victims, I understand.

As for K., well, she forced him to sell his share in the house (he missed two years of payments), she made him sell off cheap his jeep and his corvette that had been crowding her driveway, she sold his planer and his lathe and his pile of unusual woods, and she has moved on, wiser.
posted by gnome de plume at 8:52 PM on June 28, 2011 [2 favorites]

zarq's link to Pro Publica's work on this story gives summaries of the 12 Canadian cases in which courts have concluded that, due to Dr. Smith's testimony, the defendants were wrongfully charged with or convicted of a child's death. They make for shocking reading.
posted by virago at 10:07 PM on June 28, 2011

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