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State medical examiners cut autopsy rates to among lowest in nation

The Commonwealth of Massachusetts Office of Chief Medical Examiner Boston on Albany Street.David L. Ryan/Globe Staff/file

Facing an escalating caseload, the state’s chief medical examiner’s office has sharply reduced how often it conducts autopsies in recent years, opting instead for faster, less-intensive examinations and driving autopsy rates here to one of the nation’s lowest levels among similar offices.

As part of that shift, its medical examiners are increasingly turning to yet another method in its investigations, new data show: viewing photos in lieu of the actual body.

Nearly 1,200 times last fiscal year — or in roughly one of every seven cases the Office of the Chief Medical Examiner investigated — a medical examiner did not examine a body in person before identifying a cause and manner of death, instead relying on medical records and photographs taken by staff, according to a newly released report. It nearly doubled the number of so-called chart reviews from the previous year, and it was an eight-fold increase from just four years earlier, a Globe review found.

That growth under chief medical examiner Dr. Mindy Hull far exceeds the pace at which cases are increasing overall and adds another dimension to a quicker, but less rigorous, approach the office has embraced in determining how people are dying in Massachusetts.

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In each of the past three years, the medical examiner’s office performed autopsies in 26 to 27 percent of cases, trailing its counterparts in other states who, on average, performed them 38 percent of the time. Through the first half of this fiscal year, autopsies accounted for slightly less than one quarter of the office’s caseload.

Instead, examiners are opting to examine the surface of bodies, while conducting toxicology or minimally invasive testing, in more than 50 percent of cases last year, including drug overdoses and traumatic accidents. Chart reviews, once infrequent, accounted for another 15 percent.

It’s a departure from just five years ago. In fiscal year 2017, the last full year under Hull’s predecessor, the agency performed autopsies in 44 percent of all cases, completing 3,192 in total. In Hull’s first year, the number dropped to 2,755; last year, it reported doing 2,177.

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The decline is not limited to Massachusetts, as growing caseloads wrack an industry starving for medical examiners. Hull’s office also said it’s confident its examiners are turning to them when needed — including as cases reached nearly 8,000 last year — and utilizing chart reviews to spare the delay of transporting a body to the medical examiner’s office for other “well-documented” deaths.

Under Hull’s predecessor, the office also routinely lagged in producing timely autopsy reports; now, more than 90 percent are completed within 90 days, meeting a key national standard.

“The Massachusetts Office of the Chief Medical Examiner remains a national leader both in its process to fulfill its mission and [to] address its large caseload volume,” spokeswoman Elaine Driscoll said.

But experts warn that doing fewer autopsies inherently risks missing causes of death that other methods can’t rule out, particularly among suspected overdoses. The primary charge of the office is to investigate the causes of violent, suspicious, or unexplained deaths, as well as to provide information to grief-stricken families.

The office’s approach is stoking concerns among legislators who’ve repeatedly approved more money for Hull’s office — hiking its state allocation by 33 percent in four years — and are being asked to consider another multimillion-dollar hike for next year.

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“For an office that has been expanding its budget, to reduce the share of cases that they’re actually looking into [with an autopsy], I would like to understand more about why,” said Representative Marjorie C. Decker, a Cambridge Democrat who chairs the Legislature’s Public Health Committee and has pushed bills requiring, among other considerations, that Hull personally review cases involving children younger than 2. “It certainly sounds like this would be an interesting conversation to have in the public.”

State officials said they still conduct autopsies in deaths believed to be suspicious or a homicide, in unexplained deaths of infants and children, and in other cases that will likely involve legal proceedings or a request from prosecutors.

They’ve also cited dramatically improved turnaround times in producing autopsy reports since Hull’s appointment in the fall of 2017, making enough progress to secure full accreditation for the first time in 2018 and, recently, having it extended to 2025.

The shift away from autopsies, experts say, also reflects the challenges medical examiner’s offices are facing nationwide. More bodies are flowing into exam rooms because of drug overdoses or homicides, taxing many offices that are regularly seeking new medical examiners.

“We’re all competing for the small applicant pool,” said Dr. Jennie Duval, New Hampshire’s chief medical examiner. “There are help wanted ads everywhere [now]. But it’s nothing new for our profession.”

In Maryland, whose chief medical examiner recently resigned, there’s a backlog of more than 200 cases, forcing the agency last month to turn a garage into a makeshift morgue. Other offices have seen their caseloads double in the span of a few years, prompting the industry to rethink some core standards.

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“What’s happening in Massachusetts is happening across the US. We’re all having to make adjustments,” said Dr. Kathryn Pinneri, the director of forensic services in Montgomery County, Texas, and president of the National Association of Medical Examiners, the profession’s accrediting agency.

For example, the group is weighing whether to ease its recommendation that examiners autopsy every drug-related death, recognizing that many offices may not have the staff to do so. “It just keeps getting worse and worse,” Pinneri said of caseloads. “There’s been no end.”

In Massachusetts, several of the contracted physicians Hull’s office relied on to examine bodies at hospitals or in funeral homes are “aging out,” state officials said. There are now just four so-called district examiners statewide — two in the Boston area and two serving Nantucket and Martha’s Vineyard — pushing hundreds of more deaths to the state’s 16 full-time and three part-time medical examiners in recent years.

Many are now being handled as chart reviews, cases in which staff investigators, who are not doctors, will typically examine and photograph bodies and a medical examiner will review the evidence.

They also include cases when a body is no longer available or when officials consider the cause of death to otherwise be “obvious,” such as when an elderly person fractures a hip in a fall and later dies.

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But in a “small number” of cases, state officials said, they’re also used in suspected overdoses — cases the national association still recommends be autopsied. There have been more than 2,000 opioid-related deaths every year over the last half-decade in Massachusetts.

Chart reviews also continued to mount last year, almost doubling from 671 to 1,170 even as cases handled by district examiners held steady at a few hundred.

The move away from autopsies doesn’t worry everyone. Michael O’Keefe, the district attorney for the Cape & Islands and until recently, a member of the medical examiner’s oversight board, said he’s heard no complaints from other prosecutors about fewer autopsies being conducted, especially as turnaround times improve.

“There’s got to be a tradeoff at some level in this work,” he said.

But it also means Massachusetts trails most of its peers in autopsy rates. A Department of Justice report last year found statewide offices on average perform autopsies 38 percent of the time. (Massachusetts was the only one not to produce data for the study.) A separate Globe review of recent data from a dozen statewide systems found that only Maine, at 10 percent, and New Mexico, at 21 percent, had lower autopsy rates.

Governor Charlie Baker is seeking to increase the Massachusetts medical examiner’s office’s $18.8 million budget, proposing a $4 million increase in state funding for what his administration called a “new initiative.” Asked for more details, Driscoll, the spokeswoman for Hull, said the funding would go toward hiring more staff to support a variety of functions.

Since 2018, state funding for the office has climbed from about $9.7 million to $12.9 million this year. The rest of its budget comes from fees it imposes, such as for cremations, which have also increased.

“Certainly the Legislature needs to ensure there is adequate funding [for examiners] to be able do their job efficiently,” said Senator Diana DiZoglio, a Methuen Democrat who has pushed legislation requiring the office perform autopsies in suspected overdoses within three months. “But simultaneously, there needs to be increased accountability to ensure families are getting the information they need in a timely fashion.”

Other states have continued to perform autopsies in the majority of its cases. That includes Connecticut, which, like Massachusetts, has seen dramatic increases in fatal overdoses but where the medical examiner’s office performed more than 3,200 autopsies overall last year.

“We’ve all seen cases that come in and look like a straightforward drug overdose. And then you do an autopsy and find out this person was strangled,” said Dr. James Gill, Connecticut’s chief medical examiner and a past NAME president. “That’s the nightmare scenario. That’s what you don’t want to miss.”


Matt Stout can be reached at matt.stout@globe.com. Follow him on Twitter @mattpstout.