On TV crime shows, autopsies yield unmistakable answers about how a patient died. In the cases that come before the dozen-odd medical examiners in Massachusetts, the evidence isn’t always as clear-cut. Yet the decision to classify a death as a homicide rests with a single examiner, who isn’t subject to outside review and has wide leeway to revise that decision later. “A jury of one,” a Globe headline recently declared. The system needs more checks and balances.

The Globe’s Patricia Wen has reported on an unusual number of retracted shaken-baby homicide rulings in the state in an 18-month period. The decision to revise the cause of death to “undetermined” thwarted murder prosecutions in two of the cases and undermined a third. In each case, defense attorneys had sought to introduce doubt about the original conclusion. The examiner who oversaw one of the autopsies now does consulting work for defense lawyers in shaken-baby cases. Are these cases capitulations to outside lobbying, or honest changes of heart?

Either way, the revisions highlight the disproportionate amount of power Massachusetts invests in each medical examiner. The very fact that examiners are allowed to revise their rulings shows that initial conclusions aren’t foolproof, that some cases are debatable, and that new information sometimes emerges.


That’s why medical examiners’ offices in some other jurisdictions require that at least two professionals sign off on homicide reports, and that revisions be subject to review from higher-ups. Especially because criminal prosecutions are at stake, Massachusetts should recognize that tough cases benefit from more eyes.