Massachusetts’ understaffed medical examiner’s office has in recent years conducted external examinations, instead of more thorough autopsies, on an increasing number of bodies — a practice the office acknowledges does not meet national standards and could cause it to miss actual causes of death.
The shift in approach is part of an effort to limit demands on overworked medical examiners and to reduce backlogs of unfinished autopsy reports and death certificates that have plagued the office for years. Continued delays in autopsies have left some families with no knowledge of why, or how, a loved one died — and prevented the office from earning full accreditation.
Doing external exams on bodies may save time for other worthy tasks, but it also poses some risks, Chief Medical Examiner Henry M. Nields noted in an annual report submitted to the Legislature in mid-January. Those risks include “that unsuspected internal injuries will go undetected, undiagnosed medical conditions will go undetected, and findings which would determine the manner of death, including homicides, will go undetected,” he wrote.
In the recent report to the Legislature, the office said that a lack of funding has been a key contributor to the lingering inefficiencies. But perhaps more concerning is that even when the office received an infusion of cash last year and launched an “exhaustive nationwide search” to hire more staff, it was unable to find any qualified medical examiners who wanted to join the Massachusetts medical examiner’s office.
No one even applied, officials told the Globe.
Other issues detailed in the report:
■ The office has managed to reduce its backlog of incomplete autopsy reports and death certificates, but it is still playing catch-up. During 2014, the office determined autopsies should be performed on 2,536 bodies, but reports remain unfinished for about 60 percent of those cases. Death certificates are still pending for about 21 percent of all cases accepted by the office.
■ Just 45 percent of autopsy reports are completed within 90 days after initial examination. That is substantially below the national standard set by the National Association of Medical Examiners, which calls for 90 percent of autopsy reports to be finished within 90 days.
■ And while there have been dramatic improvements in how quickly toxicology testing is completed, the results continue to take longer to produce than the office would like.
Daniel Bennett, who as secretary of the state’s Executive Office of Public Safety and Security oversees the Office of the Chief Medical Examiner, acknowledged the shortcomings in a phone interview last week. But he said the office’s current staff is not to blame.
“I’m satisfied that everybody is doing their best at the office on a daily basis,” he said.
He said the office’s problems stem from a shortage of medical examiners nationwide. The state office’s annual report also said that prior blunders and controversies at the office may have scared some away some from applying to openings.
A comprehensive review of the office in 2008 recommended that its staffing consist of 17 full-time medical examiners, including one chief and a deputy chief medical examiner, the report said.
The office currently has the equivalent of about 10 full-time medical examiners — a chief and a deputy chief medical examiner and seven full-time medical examiners as well as two part-time medical examiners, officials said.
A pair of fellows in the office’s forensic pathology training and recruitment program have accepted positions to join the office as full-time medical examiners-in-training in June, when they are scheduled to complete their fellowships.
The report said that after the office’s national search failed to hire any new medical examiners, officials invested the leftover funding elsewhere, establishing a medical records unit and an investigative support unit, which provide additional support for medical examiners.
Officials said the hunt for more forensic pathologists is continuing.
“I’m hopeful we can hire more doctors, but as long as the medical schools don’t produce more medical examiners, there’s going to be difficulty catching up,” Bennett said.
Dr. Gregory G. Davis, chief medical examiner of Jefferson County in Alabama and a professor at the University of Alabama at Birmingham, also described a significantly limited supply of medical examiners nationwide.
He estimated there are between 400 and 450 forensic pathologists across the country, and that ideally there should be 800 to 900 medical examiners to handle the workload.
In Massachusetts, the medical examiner’s office has responded to this shortage by having its examiners perform fewer autopsies on accepted cases, as the office tries to reduce backlogs and limit further delays.
National standards call for medical examiners to perform autopsies on about 80 percent of accepted cases and to conduct external examinations on remaining cases.
No more than 250 autopsies should be conducted by each medical examiner per year to prevent the person from becoming overworked. Medical examiners also often have other duties, including gathering medical and police reports about deaths and testifying in criminal cases.
But since 2008, Massachusetts medical examiners have performed autopsies on just 60 percent of accepted cases, while still maintaining workloads of between 250 and 300 autopsies per medical examiner each year, the report said.
Before 2008, medical examiners were performing up to 800 a year, far more than the national recommendation.
Last year, autopsies were performed on just 48 percent of accepted cases, and medical examiners took on 296 cases on average.
The strategy has helped significantly reduce a backlog of older cases.
The number of incomplete autopsy reports from calendar years 2011 through 2013 was reduced by about 40 percent last year and the number of pending death certificates was slashed by 78 percent, the report said.
Still, 1,436 autopsy cases and 365 death certificates for the years 2011 through 2013 remained unfinished at the end of last year.
On the issue of relying on external exams rather than full autopsies, Davis, the chief medical examiner from Alabama, said that “hard and fast rules” are not necessary when deciding between the two.
“There’s infinite variety in human experience and human dying,” Davis said.
Medical examiners “should be able to give good, sensible reasons why this certain type of case deserves an autopsy and why another does not,” he said.
The Massachusetts office has made some progress in resolving its problems, including reducing the average time it takes to generate post-mortem toxicology test results.
A cost-cutting measure implemented in July 2013 by the medical examiner’s office had caused extensive delays in determining the cause of unexplained deaths, creating a backlog of hundreds of cases and leaving some families waiting several months for answers.
The turnaround time for toxicology testing was about 21 days as of July 2013 and rose sharply after that peaking in January 2014 at 134 days on average.
The office has since reduced the average turnaround time for toxicology testing to 34 days as of December, the report said. Bennett said the rate is now down to about 28 days.
Officials said their goal is to bring the average down to 21 days or fewer.
Even with cuts to workloads, the office still struggles to keep up with the endless stream of incoming cases.
The Massachusetts medical examiner’s office has provisional accreditation, which was renewed for another year in December, according to the report.
Nields wrote in the report that the office’s quest to improve the time it takes to complete autopsy reports and to achieve full accreditation “will continue to be a challenge until additional medical examiners are hired.”