Error of Judgment: The Consequences of Mistakes in Pathology

The human mind is capable of making mistakes. This is an issue that affects people of all walks of life but few disciplines are more reliant upon accurate, infallible judgment than medical science. Whilst it is an indisputable fact that forensic medical examiners have carried out outstanding work which has determined the causes of deaths of countless individuals and helped bring immeasurable numbers of criminals to justice, over the decades whilst forensic medicine has been in use there have been a number of huge errors which should bring shame upon many members of the profession. Their findings have occasionally caused law enforcement agencies to waste a great deal of time and resources. For example in 1988 a murder investigation was initiated when the remains of a black girl were found buried in Jefferson County, Kentucky. Dr David Wolf believed the skeletal remains to have dated from the mid 1970s. However, sixteen years later the truth was determined, and the case closed, when it was shown the bones were at least a century old. However, examiners have also reached conclusions that have resulted in law enforcement agencies not investigating cases where they should have. What has been believed to be an exact science, performed by experts who determine the truth, is often a cause of immeasurable heartache and injustice.

The case of Vickie Bertram is a good example of the errors pathologists have made in the past, errors which might conceivably have resulted in a murderer evading justice simply because the autopsy was performed by an inept examiner.

It was in September 1976 that Vickie, who was aged sixteen years old, fell just over one hundred feet from a rock quarry on Rock Crusher Mountain in the state of Tennessee. It was not until almost four weeks later that her badly decomposed remains were found and autopsied by the late Dr Michael Jackson. A number of Vickie's teeth were missing, as were her hands, feet and left humerus. This was believed to have been the result of rodents, and larger mammals, having gnawed the remains. Jackson recorded in his autopsy report that the deceased had no broken bones, signs of trauma, indications of stab or bullet wounds and there were no lacerations.

Upon completion of the examination Jackson was unable to determine a cause of death, although he suggested it was possible the fall caused Vickie to suffer a heart attack. On the basis of the pathologist's report the police did not consider Vickie to have died in suspicious circumstances, believing her death was merely an accident. Questions remained, however, with Vickie's family desperately wanting to understand how and why her life was untimely ended so that they could find closure. The family could not understand how someone could fall approximately one hundred feet down a quarry, where they died, and yet not break a single bone or sustain any signs of trauma. The state of decomposition would make identification of some injuries more difficult but surely a qualified medical examiner, who is known to have X-rayed Vickie's body, would be able to notice if bones were broken would they not? The questions plagued the minds of Vickie Bertram's family for twenty-four years. Unable to understand, they were unable to move on with their lives.

It was not until 2000 that Vickie's body was exhumed and a new autopsy performed in the hope that something might have been overlooked, by Dr Jackson in the original autopsy, which could lead to the reason why Vickie died finally being discovered. It transpired that Jackson had made monumental errors in his examination; Jackson's findings were contradicted, with it being shown that Vickie did indeed sustain a number of fractures, at the time of her death and following her death. The fractures were predominantly concentrated around the region of one of her hips, suggesting the possibility that it was her hip upon which she landed, and that it was unlikely she fell face down as Jackson concluded. This possibility raises the question of whether Vickie did die as a result of an accident or whether she was the victim of foul play.

The suggestion Vickie was the victim of homicide is not without foundation. At the top of the cliff from which she fell three of Vickie's fingernails were found. If she had merely fallen then how could her nails have broken before she fell? It is highly possible they broke during a violent struggle shortly before she died and if this is the case then there must have been someone else involved in Vickie's death. If Vickie fell then it must have only been because of the presence of an assailant. It seems conceivable, however, that she was pushed and it is not impossible that she had already been killed before her body left the top of the cliff; the body having been thrown over the edge to give the false impression that Vickie's death was innocent, when in reality it does not appear to have been innocent at all.

Although Vickie's body had undergone four weeks of decomposition as a result of her being exposed to the elements, nothing could excuse the incompetence that saw so many injuries being missed. Todd Matthews, who pressed the authorities for an exhumation order and fresh autopsy, believes that if Jackson's original examination had been performed properly then the reason why Vickie died could have been determined almost three decades ago. "If it had been done right it might have either gave some definite answers to the case, or at the very least saved the family years of turmoil and grief.", he says. If the possibility that Vickie had died at the hands of another had been considered in 1976 then a police investigation might have helped uncover the truth, but because there were no grounds for suspicion arising from Jackson's examination no proper investigation took place; the brief 1976 investigation was merely a formality. Matthews is hopeful that a police investigation, if initiated, could still resolve the case. If Vickie did struggle with someone, and this is the reason why her fingernails broke, then they might have her assailant's DNA upon them. With Low Copy Number DNA analysis only a small amount of genetic material would need to be present to match against any suspect. Unfortunately whilst the Tennessee Bureau of Investigation are willing to reopen the case the District Attorney refused the request.

One might think that with the advances in medical science, better equipment and training that the errors of the past, such as those exemplified by Vickie Bertram's case, would no longer occur. Sadly the problem of substandard medical examinations is ongoing.

Between 1983 and 1993 Dr Charles Harlan carried out thousands of autopsies whilst he was the State of Tennessee Chief Medical Examiner. Following his demotion in 1993 he continued to undertake examinations, both whilst working at the State Medical Examiner's Office and whilst working within his own pathology company, named Forensic Pathology Associates, P.C., which he opened in 1994. Despite having been relieved of his duty as Chief Medical Examiner Harlan continued to perform autopsies whilst illegally claiming to be the State Medical Examiner, as evidenced by a number of advertisements and a sign over the doorway of his medical offices. In spite of a number of legal proceedings Harlan continued to lie about his position as to provide the false impression that he was a competent medical examiner, when in reality his work left a great deal to be desired and caused immeasurable damage to a number of individuals. By claiming to be working on behalf of the State of Tennessee Harlan misled the public into believing he had the approval of the Department of Health, which was not true at all because they had refused to renew his contract.

In addition to his criminal behaviour in wrongly promoting himself as the Chief Medical Examiner, during the period in which he enacted his deception Harlan seemingly committed a number of other offences, which show the State Department of Health was right not to allow Harlan to carry on his work at the State Medical Office. It would appear that his examinations were often inadequate and in January 2002 thirty-nine disciplinary charges were brought against Harlan, by the Tennessee Health Department, in relation to him having failed to complete autopsies, for him having mishandled evidence, for incorrectly determining the cause of death in a number of cases and, even more worryingly, having wrongly attributed an identity to numerous deceased individuals. Other charges relate to instances where Harlan ruled a death accidental, only for a second autopsy to discover the death was anything but an accident. Conversely it is believed in many cases he played a major role in the convictions of a number of individuals accused of murder when in reality death was accidental. One error that he made, which has recently emerged, led a woman having been charged for murdering her daughter by administering an overdose. It later emerged that the daughter, who suffered from Cerebral Palsy, had not been given a higher dose of drugs used to treat her illness than what she had been prescribed. Harlan had not only failed to accurately determine the level of drug but he also failed to determine the true cause of death; restrictive pulmonary disease, secondary to cerebral palsy.

The charges against the former medical examiner predominantly relate to his work between 1994 and December 2001 when he was deceitfully claiming to be Chief Medical Examiner for the State. The proceedings against him are still ongoing and, unfortunately for those who believe him to have carried out misconduct, Harlan continues to perform autopsies to this day. One can only fear that his continued work will result in further wrongdoings as a result of his incompetent approach to his examinations.

Whenever it emerges an examiner has made mistakes the relatives of others examined by that individual are forced to question whether what they have been told regarding the circumstances of the death of their loved one was correct or whether they died as a result of an alternate scenario. It is difficult to imagine, for example, the consternation felt when someone who had been told their son or daughter had died in an accident is forced to consider the possibility they might have been the victim of a homicide because they are aware the medical examiner was prone to making errors.

Matthews understands the concerns relatives can have. In addition to his work on the Vickie Bertram case, he has been approached by the families of two individuals Harlan examined, in the hope that he might be able to resolve the issues they have. It is unknown whether Harlan made large errors in these two particular cases, but the family have certainly been left with a number of questions, which they are struggling to find answers to, and the reports fail to adequately address a number of issues.

One of the cases Matthews has been asked to look into is that of Deborah Allred, who died at the age of forty-two, in November 2002. Upon completing his examination Harlan wrote that the case of Allred's death was an overdose of fentanyl; a narcotic painkiller between fifty and one hundred times stronger than morphine, which provides short-term pain relief.

Whilst fentalyn can be injected, it is also available in the form of patches adhered to an individual's skin to allow a release of the drug over a lengthier period of time. It was pan patches that Debbie Allred used to combat the pain she suffered from and so in order to overdose from the drug Debbie must have had a number of patches on her body. It was never believed Debbie committed suicide. Instead it was believed she could have died simply because she used to many patches without realising it was dangerous to do so. Her sister, however, does not accept Debbie would use more than one patch at a time because she only received a one-month supply at a time and so if she had used more than one then she would not have had enough later in the month. Debbie felt she could not live without using a patch each day and so she would not, her sister claims, have used more than one patch when that would mean she had to go without a patch at some other point in time. Patches were found on Allred's body. There was one finding of the autopsy, which has as yet defied explanation; there was a small puncture wound on Debbie's neck. It would appear most likely that this was the result of an injection but despite seeing the wound, and indicating its location on a diagram, Harlan failed to mention what the wound was or could have been? As Debbie only had drugs administered by patches then what is the explanation for the puncture wound? If indeed it does represent an injection who administered the injection? Of course, Debbie could have injected herself in her neck but the vagueness of Harlan's report does not allow the alternate hypothesis, that someone else injected her with a fatal dose of fentalyn, to be ruled out.

The puncture wound was not the only mark upon Debbie's body which pointed to death having been caused by a means other than an overdose of fentalyn from pain patches. Although the presence of certain injuries and marks upon a corpse are not necessarily indicative of violence having taken place at the time of death, any such injuries must be taken into consideration. There were certainly a number of injuries upon Debbie Allred's body, which have not adequately been explained. Whether they were the result of an assault or of an accident is open to debate. However, there were a number of bruises over her body, including bruising to the backs of both hands. Additionally there was a cut on the bridge of her nose, between the eyes, blood in her nostrils and large amounts of her hair had been lost. Someone presumably pulled it out.

Interestingly there was a family connection, albeit a distant one, between Debbie Allred and Vickie Bertram. However, there might be a greater connection between these two women; it is known Allred frequently expressed her belief Vickie had been murdered. A man, who shall be referred to simply as 'Chuck', was also interested in the circumstances surrounding Vickie's death and threatening towards Matthews. Chuck lived with Debbie and he was indeed the last person to see her alive. Chuck was in a relationship with the deceased, although it was a stormy one and Debbie was intending to leave him on the day that she died. Debbie occasionally discussed her fear of what would happen if she left Chuck, with her having told her sister, one day before her death, that she was scared she would be killed if she left him. Shortly afterwards she died in what does appear to have been a suspicious manner. Following the death the man told Debbie's sister that the cause of death had been an overdose of fentalyn, before the results of the autopsy had been published. Furthermore his comments to the relatives of Debbie Allred, regarding the incident, are highly conflicting. For instance he told Debbie's daughter that her mother was in the car waiting for her, to take her to school, whilst later he told Debbie's sister that she was still asleep.

Bizarrely a large amount of jewellery, including several rings and bracelets, had been superglued to her skin. What is the explanation for this? It is known Chuck asked Debbie's sister whether the jewellery was still on the victim at her funeral. It is also known that he told the sister that the jewellery, which he had bought Debbie, had been superglued so that she would never lose it. Did Debbie superglue the jewellery to herself or did some other individual carry out this task? Is it merely a coincidence that at around the time of her death Debbie suffered a number of injuries and had jewellery glued to her? Suspicions must surely be roused by this bizarre aspect of the case.

Despite all of the questionable issues surrounding Debbie Allred's death Harlan, in his infinite wisdom, decided that there were no grounds for suspicion and that surely it was a simple case of an overdose. It was, he believed, an open and shut case. The question is, was he correct to reach this opinion?

It is not surprising that the family of Debbie Allred have been left unable to fully understand how death came about when the medical report is unclear and the evidence leaves room for doubt as to Harlan's conclusion. Therefore should efforts not be made to help explain the terminology used in the reports as well as what they can do, should they be dissatisfied with the procedures? Should resources not be made available to help answer any questions or concerns that the relatives might have, so that they are not forced to endure years of suffering?

There is a real need for a change in the current system and modern technology can help afford this change. Great consideration should be made for the formation of a coordinated state website and an agency to support the website. Together these could provide the information and support that those whose loved ones are deceased need in order to understand the way that medical examinations take place. As Matthews says, you cannot just hand a report to a family and expect them to accept the conclusions if they cannot understand what is said. The average person will not be familiar with the system and so efforts should be made to provide the support to the relatives so that they can understand what has taken place and what conclusion has been reached. While ever there is a lack of understanding questions will always remain, and people will always grieve, because they do not know what happened. A state website and agency could assist people in understanding medical reports and help resolve grievances they might have. In the majority of cases an explanation of the process and the provision of information will answer a family's concerns. However, for those who are still left with questions and worries the site could explain what they can do for the case to be looked into.

It is clear there are fundamental problems with the current state of medical examinations for those whose identities are known, but the problem is even more pronounced for the often forgotten, nameless dead; the John and Jane Does. The NCIC includes the cases of forty-six unidentified remains in Tennessee and this is believed to only be the tip of the iceberg with it being recognised there are probably far more 'Does' that have so far not been added to the database.

Strides are being made in the creation of a State database for unidentified remains. In June 1999 the House of Representatives passed a bill known as Jennifer's Law, which was created to help resolve the issue of locating missing children. The law provides states with the resources required in order for important information such as the fingerprints and DNA of the remains of unidentified people to be stored. The information stored in the database can then compared with the known details of a missing person, taken from a national database, so that it can be determined whether or not the remains are of that individual. Whilst Jennifer's Law has provisioned for resources to help combat the problem, huge hurdles are still to be overcome. At present only information relating to missing persons is added to the database, whilst details of unidentified remains are not listed. The problem with this is that any John or Jane Doe cannot be compared to a missing child because the information is not there to allow comparisons to be made. Therefore if a missing child is deceased the family of that child are less likely to ever know what happened to their loved one than if all the available data was recorded. Surely it is wise to have the maximum amount of information in the database because what is the use of a database if it does not provide all of the data?

Unfortunately at present the State of Tennessee Medical Examiner's Office currently refuses to undertake the creation of a state website on the grounds that they solve most of their cases as they get them, but it is clear mistakes have taken place and it is likely that mistakes will continue to be made and so is the office correct to say that a website is pointless? Matthews does not believe the office understands the issues of concern, with a representative failing to know approximately how many cases of missing persons and unidentified remains there are in Tennessee.

It has been said that examiners have misidentified bodies, with this being one of the allegations against Harlan, and this is a tragic situation. Although there are a number of volunteer organisations, such as the Doe Network, whose tireless work for the missing and unidentified has provided the names to a number of 'Does', the general apathy towards the issue of unidentified remains means that so frequently these people will not receive justice and if a medical examiner makes an error of judgment then the mistake is unlikely to be recognised let alone resolved. As Matthews asks, "If they [medical examinations] are so flawed for the known, with the families screaming for justice, what hope do the unidentified have?"