Advocates call for more oversight of medical examiners

Dr. Henry Nields is the chief medical examiner in Massachusetts and his office has 12 other medical examiners.
Dr. Henry Nields is the chief medical examiner in Massachusetts and his office has 12 other medical examiners. Ted Fitzgerald/pool

Top child-advocacy and pediatricians’ groups are calling on the governor to introduce more oversight of individual state medical examiners, saying the current system of giving each of them exclusive power to issue — or revise — homicide rulings undermines confidence in their findings.

“How is it that a single medical examiner can make a unilateral decision on the cause of death of a child, and even change their mind later, without ever having to account to anyone?” said Jetta Bernier, head of Massachusetts Citizens for Children, a longtime nonprofit focused on abused and neglected children. “That’s untenable.”

These proposals come in the wake of a Boston Globe article on Sunday that explored three retracted shaken-baby homicide rulings within 18 months, an unprecedented set of revisions that occurred after three medical examiners received reports from — and in some cases were actively lobbied by — defense attorneys before trial. In each case, the medical examiner revised the findings to an “undetermined” manner of death, derailing two murder prosecutions in the past two years, and seriously undermining a third.

The Globe report found a decentralized agency in which its forensic pathologists are given wide leeway in making — and revising — their decisions, without any scrutiny of the factors that may have influenced them, including potential conflicts of interest.


For instance, one of the three forensic pathologists, soon after issuing a homicide ruling, left government work to expand a consulting practice devoted to helping defense attorneys in shaken-baby cases, a business he started while working with the state.

Child-abuse specialists, as well as prosecutors and defense attorneys, are now urging the governor’s office to look into a number of possible changes, including requiring all autopsy reports and amendments to be signed off on by a second medical professional. They are also urging more training on infant-death investigations and the latest in forensic science, and more robust vetting of potential conflicts of interest.


The Office of the Medical Examiner has 12 full-time medical examiners — physicians with additional training to become forensic pathologists — who conduct autopsies in suspicious deaths, among other tasks.

Governor Charlie Baker’s office declined to directly address the controversy surrounding the management and potential conflicts of interest within the medical examiner’s office, deferring comment to the spokesman for the Executive Office of Public Safety and Security, which oversees the medical examiner’s office.

“The administration values the extremely difficult work the medical professionals in the Office of the Chief Medical Examiner perform . . . to render impartial, evidence-based assessments with the best available information and a deep understanding of the facts of each individual case,” Felix Browne said in a one-sentence written statement.

The chief medical examiner, Dr. Henry Nields, and Health and Human Services Secretary Marylou Sudders, who oversees the state’s child-protection agency, declined requests for comment.

But Maria Mossaides, who heads the Office of the Child Advocate and is appointed by the governor, suggested a look at best practices in other medical examiner’s offices. Mossaides said she believes, minimally, the office should explore having some mandatory review of all revisions of homicide rulings.

That would be similar to a system in the Philadelphia’s medical examiner’s office, in which the chief and deputy chief must sign off on any revision, according to a spokesman there. In Maryland, the chief medical examiner co-signs all homicide reports or “undetermined” findings, and in New York City, a colleague must initial each homicide report.


Middlesex District Attorney Marian Ryan — whose office handled all three murder prosecutions affected by the retracted findings — said she thinks some form of co-signing is a good idea. She would also like to see medical examiners assisted by a strong multidisciplinary medical team as they make — or review — their decisions.

Ryan is currently awaiting the autopsy results of a Woburn toddler who died last week; his twin sister was also injured. Her office has declined to give details on the case, which involves a babysitter caring for the twins.

Advocates for child-abuse victims as well as criminal defendants both emphasized the need for additional training, though differed on the focus.

Defense attorney Chauncey Wood, who also serves on the board of the Massachusetts Association of Criminal Defense Lawyers, said medical examiners should be better equipped to ensure that the original death certificate is right, so innocent people are not charged with murder.

He said some infants who die with brain and eye injuries aren’t abused, and medical examiners need to be educated about alternative causes of such deaths.

“More training would be a good thing for medical examiners,” Wood said.

Some top child-abuse specialists, however, said training should focus on helping medical examiners exclude what they say are fringe theories often proposed by the defense.

Dr. Robert Sege, a Boston child abuse pediatrician speaking for the American Academy of Pediatrics, said the alternate causes cited by the defense in two of these reversed cases — Ehlers-Danlos syndrome, which affects connective tissues, and von Willebrand disease, which affects blood clotting — are illogical explanations of these babies’ catastrophic brain and eye injuries. He said there is no published medical literature to connect those disorders to the grave injuries suffered by these infants, and the medical examiners should have done enough research to know that.


“These medical examiners, by taking these so-called medical experts from the defense at face value, circumvented the system of justice,” Sege said.

He also said he worries that these reversals undermine the important public health message that shaking a baby is never safe.

Sharon Beckman, a professor at Boston College Law School and director of its Innocence Program, said she welcomes the idea of having the governor improve the operation of the medical examiner’s office, which she thinks must keep up-to-date on the latest medical knowledge about infant deaths.

“I support it in the context of strengthening forensic science,” she said.

Patricia Wen can be reached at patricia.wen@globe.com.