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Prelims.qxd 11/14/07 2:28 PM Page i
≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈
JIM FISHER
≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈
No part of this book may be reproduced or utilized in any form or by any means,
electronic or mechanical, or by any information storage and retrieval system, without
written permission from the publisher. Please contact Rutgers University Press,
Joyce Kilmer Avenue, Piscataway, NJ –. The only exception to
this prohibition is “fair use” as defined by U.S. copyright law.
CONTENTS
Preface ix
Acknowledgments xi
Introduction 1
PART ONE
Diagnosing Death: Problems in the
Science and Practice of Forensic Pathology 9
PART TWO
Crime-Scene Impression Identification:
Forensic Science or Subjective Analysis? 101
vii
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viii CONTENTS
PART THREE
Hired Guns, Smoke Blowers, and Phonies:
The Expert Witness Problem 179
Notes 287
Sources 291
Index 317
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PREFACE
I’ve spent most of my adult life investigating crime, teaching criminal inves-
tigation, writing about the subject, and trying to figure out why so many seri-
ous crimes in the United States either go unsolved or lead to wrongful
convictions. I’ve concluded that the law enforcement wars on drugs and ter-
rorism have militarized the police and marginalized criminal investigation
as a law enforcement function. Since forensic science is mainly in service to
criminal investigation, scientific crime detection is not being fully utilized
and so hasn’t lived up to its full criminal justice potential.
In the 1920s forensic science pioneers and their supporters believed that
one day scientific criminal investigation would significantly increase crime
solution rates and at the same time reduce the dependence on the unreliable
evidence produced by the third degree, eyewitness testimony, and jailhouse
informants. This has not happened, at least not to a great enough extent, and
to that degree, forensic science is a failed promise.
While the failure of forensic science to fully achieve its potential
involves many realities beyond its control, there are problems within the
profession that can be fixed by the practitioners themselves. Thinking about
the nature and severity of these problems, how they affect the criminal
justice system, and how they might be solved led me to write this book.
Jim Fisher
February 13, 2007
ix
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ACKNOWLEDGMENTS
I am grateful for the help of Karl Kageff, who read an early draft of the manu-
script and made helpful and important suggestions.
At Rutgers University Press, Doreen Valentine’s strong editorial hand
helped transform a flawed manuscript into a better book. Even experienced
writers can learn from a truly outstanding editor.
I am indebted to criminal investigator and author Robert L. Snow, whose
review of the manuscript led to significant improvements. I would also like
to thank Dr. James D. Fisher for his editorial suggestions. And finally, thanks
to Veronica Fisher for her computer expertise.
xi
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Prelims.qxd 11/14/07 2:28 PM Page xiii
Introduction
1
Intro.qxd 11/9/07 11:34 AM Page 2
test. Smith says no, he doesn’t believe in lie detectors. He does agree to pro-
vide samples of his handwriting and to be fingerprinted. He assures the detec-
tives that he has nothing to hide and that he wants to help the police in their
investigation.
The autopsy reveals that Mary Smith had been shot once in the chest. The
powder-burn pattern on her skin suggests that the shot came from between six
and twelve inches away from her. Based on early signs of postmortem lividity—
light purple discoloration on the anterior plane (front) of her body caused by
the settling of her blood—the forensic pathologist believes that she has been
dead much longer than three hours. This means that Bill Smith could not have
talked to his wife that afternoon at two o’clock. Early stages of rigor mortis—
body stiffening—also suggest a time of death inconsistent with Smith’s alibi
that he was at work when she killed herself. The pathologist has also found, on
the edge of Mary Smith’s right hand, a nick made by a bullet, trauma referred
to as a defense wound, evidence that belies suicide. As far as the pathologist
can determine without a full toxicological analysis, the victim had not been
under the influence of alcohol or drugs when she died.
The next day the crime lab issues the gunshot residue report, which
reveals that Mary Smith’s hands tested negative for traces of gunpowder. But
it’s a different story for her husband: his right hand tested positive, which
means that he, not the victim, had recently fired a handgun. The serological
analysis of his shoes, socks, and trousers reveals traces of AB negative blood,
which happens to be his wife’s blood type. His is A positive. DNA tests are
pending. A footwear identification expert from the crime lab has compared
the bottoms of Bill Smith’s shoes with the bloody impressions in the kitchen.
The forensic impression analyst has concluded that the shoes made these
murder-scene marks. This means that Bill Smith lied about not approaching
his wife’s body in the kitchen.
The fingerprint examiner has found, on the . caliber pistol, several
partial latents left by Bill Smith. There are no fingerprints of his wife’s on the
firearm. The fingerprint expert has also found several of Bill Smith’s latents
on the suicide note, but none from his wife. Based upon ejector and firing-
pin marks on the shell casing, the crime lab’s firearms identification expert
has identified the death-scene pistol as the gun that fired the fatal shot.
A forensic document examiner has determined that the handwriting in
the suicide note looks more like Bill Smith’s than like his wife’s. This hand-
writing expert has also discovered that the signature on a recently purchased
Intro.qxd 11/9/07 11:34 AM Page 3
INTRODUCTION 3
life insurance policy for Mary Smith—naming Bill Smith the $, bene-
ficiary—is not his wife’s. The document expert is analyzing the signature and
Bill Smith’s handwriting samples to determine if he is the forger.
Based on the fingerprint, shoe impression, blood, handwriting, gunshot
residue, defense wound, range-of-shot, and time-of-death evidence, the
forensic pathologist declares Mary Smith’s death a criminal homicide. When
detectives confront Bill Smith with the forensic science findings, he con-
fesses. His wife had been about to divorce him, which would have left him
broke. He had shot her and tried to make the death look like a suicide. He
also admits forging his wife’s signature on the life insurance document.
The foregoing murder story reflects how police officers, detectives,
crime-scene technicians, crime-lab personnel, and forensic pathologists can
work together to uncover the truth. Unfortunately, this example of forensic
science in action does not represent the way most homicide cases in the
United States are handled. Crime scenes are not always protected from con-
tamination; physical evidence is often packaged improperly, lost, or left unac-
counted for; forensic experts go unconsulted; and mistakes and omissions on
the autopsy table either cut investigations short or send detectives down the
wrong investigative path. These and other problems in the practice of foren-
sic science allow offenders to escape justice and can also lead to the impris-
onment of innocent people. The proper application of forensic science has
the potential to make our criminal justice system work as designed, but until
this potential is realized, our process of identifying and prosecuting offenders
will remain seriously flawed.
INTRODUCTION 5
INTRODUCTION 7
other’s. If forensic science is about hard science, how does one explain this
dueling-expert phenomenon? If there is a battery of forensic scientists for
every prosecutor and for every defense, how can there be credible forensic
science for anyone? When jurors are faced with opposing experts, they tend to
disregard entirely the physical evidence upon which the experts are testifying.
Most of the problems in forensic science are caused by personnel short-
ages, poor quality control, the inherent difficulties of crime-scene investiga-
tion, the pressures imposed by the adversarial nature of our trial process, the
lure of pseudoscience, and the evolving character and complexity of science
itself. The criminal cases and forensic science careers featured in this book,
while illustrating the various problems in scientific crime detection, do not
represent the general state of forensic science in the United States. However,
these examples illustrate problems that are not uncommon. But even those
who view forensic science in the best possible light agree there is a lot of
room for improvement.
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Chap-01.qxd 11/9/07 11:26 AM Page 9
PART ONE
Diagnosing Death
Problems in the Science and Practice of
Forensic Pathology
Forensic pathologists are physicians educated and trained to determine the cause
and manner of death in cases involving violent, sudden, or unexplained fatalities.
The cause of death is the medical reason the person died. One cause of death is
asphyxia—lack of oxygen to the brain. It occurs as a result of drowning, suffocation,
manual strangulation, strangulation by ligature (such as a rope, belt, or length of
cloth), crushing, or carbon monoxide poisoning. Other causes of death include
blunt force trauma, gunshot wound, stabbing, slashing, poisoning, heart attack,
stroke, or a sickness such as cancer, pneumonia, or heart disease.
For the forensic pathologist, the most difficult task often involves detecting
the manner of death—natural, accidental, suicidal, or homicidal. This is because
the manner of death isn’t always revealed by the physical condition of the body.
For example, a death resulting from a drug overdose could be the result of homi-
cide, suicide, or accident. Knowing exactly how the fatal drug got into the victim’s
body requires additional information, data that usually come from a police inves-
tigation. A death investigator, for example, will try to find out if the victim had a
history of drug abuse, or if there were signs of a struggle at the scene of the death.
Had this victim attempted suicide in the past? Did the victim leave a suicide note?
9
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10 DIAGNOSING DEATH
Did someone have a compelling motive to kill this person? Is there evidence of a
love triangle, life insurance fraud, hatred, or revenge? And finally, who had access
to this person at the time of his or her death? These are basic investigative leads
that could help a forensic pathologist determine the manner of death.
When the circumstances of a suspicious death are not ascertained or are
sketchy, and the death was not an obvious homicide, the medical examiner (or
coroner) might classify the manner of death as “undetermined.” Drug overdose
cases that are only slightly suspicious and therefore not thoroughly investigated
often go into the books as either accident or suicide. This is true of other forms of
slightly suspicious death. Because a body is found dead in the water doesn’t nec-
essarily mean this person has drowned. This victim could have been murdered
and then dumped into the water. Even in a death by drowning, the person could
have died after being criminally thrown from a boat or off a pier.
Indeed, there are more sudden, violent, and unexplained deaths in the United
States than the nation’s four hundred board-certified forensic pathologists can
handle. This gruesome workload would require at least a thousand. As a result,
not every death that calls for an autopsy gets one. Because there is also a shortage
of qualified criminal investigators, not every death that requires an investigation
gets the attention it deserves. This means we don’t know exactly how many people
in this country are murdered every year. And of the cases we know are homicides,
about percent go unsolved.
In an obvious homicide—say, when the victim has been shot twice in the back
of the head or stabbed many times between the shoulder blades—there will be at
least a cursory police investigation. The success of that inquiry will often depend
upon what the forensic pathologist is able to determine. An analysis of the fatal
wound may, for example, help identify the murder weapon. A time-of-death esti-
mation may break a suspect’s alibi or place a suspect at the scene at the estimated
time of the murder. An autopsy may reveal that the victim was pregnant, intoxi-
cated, or sexually assaulted. There may be defense wounds on the victim’s hands
and arms that indicate a struggle. The forensic pathologist may find traces of
evidence—hairs, fibers, bodily fluids—that might eventually link the killer to the
crime scene. The proper retrieval of a fatal bullet could lead to the identification of
the murder gun. The forensic pathologist may also be able to tell if a body has
Chap-01.qxd 11/9/07 11:26 AM Page 11
DIAGNOSING DEATH 11
been posed or dragged to where it was found. Perhaps the death occurred miles
from where the killing took place. In cases of bodies found at fire scenes, the
autopsy will reveal if the victim was killed by some aspect of the fire or died earlier
of another cause.
The autopsy, along with the crime-scene investigation, is the starting point,
the foundation, of a homicide investigation. If something is missed or mishandled
on the autopsy table, if the forensic pathologist draws the wrong conclusion from
the evidence, the investigation is doomed.
In cases of homicide where no autopsy is conducted or the medical examiner
or coroner has incorrectly designated the death natural, an accident, or a suicide,
bringing the killer to justice will be nearly impossible. And medical examiners and
coroners are frequently under pressure from politicians, prosecutors, and homi-
cide detectives to make manner-of-death rulings contrary to what the physical evi-
dence tells them. Prominent people who have died under embarrassing
circumstances have had their deaths sanitized by cooperating police officers, coro-
ners, and medical examiners—for example, a death by drug overdose could go on
the record as a heart attack. Or a detective or prosecutor might ask a forensic
pathologist to estimate a time of death that places the main suspect at the crime
scene at the moment of death. Medical examiners and coroners who think of
themselves as part of a prosecution team are more likely to shade their findings in
the name of law enforcement. Forensic pathologists who believe their first duty is
to science are less prone to tailor their medicolegal findings to suit a prosecutor’s
theory of a case.
Chapter 1 features forensic pathologists whose careers crashed and burned as
a result of incompetence, bias, and dishonesty. They lost their scientific inde-
pendence and objectivity by making cause- and manner-of-death findings based
on factors outside forensic medicine. These practitioners represent the worst of
the worst.
Chapter 2 involves a pair of forensic pathologists who took shortcuts and
made mistakes that damaged their professional credibility. After these patholo-
gists rendered controversial opinions in a pair of politically charged deaths, their
findings were challenged and their credibility questioned. These cases illustrate
the importance of professionalism in the field of forensic pathology and the
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12 DIAGNOSING DEATH
In , twenty-five years after obtaining a medical degree in Mexico, Dr. Ralph
Erdmann moved to Childress in Lubbock County, Texas, and began, on a
private contract basis, doing autopsies for five small hospitals in the county.
He moved to Amarillo in and performed autopsies for hire throughout
the panhandle region—more than , autopsies in forty-one west Texas
jurisdictions over the next decade. In , at the height of his activity, he
performed autopsies. The following year he did , most in Lubbock
County, from which he received an annual fee of $,. In the other,
smaller counties, he charged $ per autopsy. He had a large territory to
cover and was constantly on the move, performing autopsies on the run.
Because he covered a rural area, Dr. Erdmann did not always work under
ideal conditions. In cases of decomposing bodies, many of the smaller hospi-
tals denied him access to autopsy space because of the stink. As a result, he
13
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14 DIAGNOSING DEATH
when he was shot, but it was the bullet that killed him. In another body-
in-the-dumpster case, Dr. Erdmann lost the dead man’s head, the body part
containing the bullet that would have connected the suspect to the crime.
Without the head, or the bullet, the suspect could not be prosecuted.
In a fatal hit-and-run case, Dr. Erdmann testified that the victim had
died instantly of a broken neck. He based this finding on his examination of
the fourteen-year-old victim’s brain. But when the body was exhumed,
another forensic pathologist found that Erdmann had not even bothered
to open the boy’s skull. In the case of a baby who had died in a bathtub,
Dr. Erdmann determined that the victim had been killed by a blow to the
stomach. This led to the arrest of the man who was in the house when the
baby died. After a second forensic pathologist examined the body, the murder
charge was dropped. The baby had drowned accidentally. The cause of death
was asphyxia.
As reported in the ABA Journal, as a result of Ralph Erdmann’s bungled
and incomplete autopsies, the defendants in twenty murder cases had
grounds to appeal their convictions. The panel of experts who had looked at
three hundred of his autopsy reports—a relatively small sampling—found
that one-third of the bodies had not even been cut open. When confronted
with this evidence, Dr. Erdmann explained it away as clerical error. He never
admitted wrongdoing and would continue to insist that he was not dishonest
or incompetent—yes, he had made a few mistakes, but he had been forced to
work under unfavorable conditions. He accused his detractors of being
revenge-minded defense attorneys and characterized the investigation of his
work a witch hunt.
For a criminal justice system to work, its major law enforcement players—the
police, prosecutors, and forensic scientists—have to be hardworking, compe-
tent, and honest. In Florida’s Pinellas and Pasco Counties between and
, the medical examiner’s office was not up to par, and the effect on local
criminal justice was disastrous. Dr. Joan E. Wood, the head of the Pinellas-
Pasco Medical Examiner’s Office, the principal source of the problem,
resigned under fire in September .
A graduate of the University of South Florida Medical School, Dr. Wood
began her career as a forensic pathologist in as an associate in the
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16 DIAGNOSING DEATH
18 DIAGNOSING DEATH
killed Lisa McPherson had been caused by her extreme dehydration and
immobility. He told the investigators that if she had been given proper med-
ical treatment and taken to a hospital when she first became ill, she might not
have died. What she had needed and did not get was water, salt, vitamins, and
extra oxygen. Moreover, her blood-cell count and kidney function should have
been closely monitored. When asked if the blood clot in her leg could have
been caused by the traffic accident, Dr. Podgorny responded emphatically that
such an occurrence would be extremely rare, especially in a thirty-six-year-old
woman. He pointed out that people bruise their legs all the time without get-
ting blood clots. In the doctor’s opinion, the manner of Lisa McPherson’s death
boiled down to improper medical care following the traffic accident.
A Pinellas County grand jury on November , , returned a two-
count indictment charging the Church of Scientology with practicing medi-
cine without a license and abusing or neglecting an adult. The church
believed that the McPherson case was being exploited by forces out to
destroy the institution and, accustomed to fighting for its survival, hit back
hard. One of those on the receiving end was Dr. Joan Wood, the pathologist
who had opened the door to the charges with her ruling of an undetermined
manner of death. In the months that followed the indictment, defense attor-
neys representing the church deluged Dr. Wood with subpoenas, demanding
all sorts of information. These lawyers wanted her to change the manner of
death to accidental on the theory that the blood clot that had killed Lisa
McPherson was the result of her traffic mishap. The church also denied prac-
ticing medicine at the Fort Harrison Hotel and insisted that Lisa had been
properly cared for at the retreat.
In February , more than four years after the autopsy in the
McPherson case, Dr. Wood, while insisting that she had not broken under
pressure, nevertheless changed the manner-of-death ruling to accidental.
Her decision outraged the prosecutor and the police. As far as the prosecutor
was concerned, she had folded under pressure. Some of the journalists fol-
lowing the case speculated that pressure and stress had caused the forensic
pathologist to come emotionally unglued. Whether she had been bullied into
it or not, her manner-of-death reversal destroyed her credibility as an inde-
pendent forensic scientist and ruined her relationship with the law enforce-
ment community. As reported by the St. Petersburg Times, the prosecutor, left
with an accidental manner of death, had no choice but to drop the case
against the church. Dr. Wood resigned shortly thereafter.
Chap-01.qxd 11/9/07 11:26 AM Page 19
Lisa McPherson’s estate in May settled the wrongful death suit for
an undisclosed amount. The case was finally over, but for Dr. Wood, its ram-
ifications would linger long after her resignation.
20 DIAGNOSING DEATH
She responded by informing the prosecutor’s office that she was ill and there-
fore could not appear for the session. A few months later, the sheriff showed up
at her house with another Long case subpoena. He was greeted at the door by a
maid who told him that the doctor was ill and not available. After that, Dr.
Wood dropped out of sight and remained in hiding almost two years.
Meanwhile, David Long sat in jail.
In , Dr. Wood’s replacement, Dr. Jon Thogmartin, and four other
forensic pathologists performed a second autopsy on Rebecca Long and were
astounded by what they found: the baby had died from bronchial pneumo-
nia. They were also shocked by what they didn’t find: evidence of brain or
retinal bleeding, trauma associated with the shaken baby syndrome. A
review of the original autopsy report revealed puzzling contradictions. In one
paragraph Dr. Wood had written, “No distinct areas of hemorrhage,” and in
the next, “The brain . . . has hemorrhage.” In her report, Dr. Wood had also
referred to the victim as a boy.
As a result of the second autopsy, the prosecutor had no choice but to
drop the charges against David Long. He walked out of jail a free man. The
ordeal had cost him his job and had driven him into bankruptcy. He had
been saved by a detective who had asserted his investigative independence,
and by Dr. Thogmartin and the other pathologists who had been willing to
contradict the findings of a colleague. Without their intervention, Long
might have been convicted and sent to prison for a crime he didn’t commit.
her if her disappearance had anything to do with the McPherson case, and if
she planned to get back into forensic science. Dr. Wood denied that her rever-
sal in the McPherson case had anything do with pressure from the Church of
Scientology, but she did admit that after twenty-five years as a forensic pathol-
ogist, the stress of the job had finally caught up with her. She said she still had
panic attacks when she walked into a courtroom. As for her cause-of-death rul-
ing in the Peel case, she was still certain that the baby had been shaken to
death. She said she was back in the field as a private consultant, but a few
months later, she closed her business and went back into retirement.
In July , Dr. Wood voluntarily relinquished her medical license fol-
lowing a state health department declaration that in the McPherson case,
she had become “an advocate for the Church of Scientology,” as Susan Martin
reported in the St. Petersburg Times. Dr. Wood, now sixty, said she had given
up medicine due to the accumulated stress of being a forensic pathologist for
twenty-five years. She insisted, however, that she had not lost her objectivity
in the McPherson case.
Distracted by her own professional problems, Dr. Joan Wood did not run a
tight medical examiner’s office. Forensic pathologist Richard O. Eicher, hired
by Dr. Wood in August , was forced to resign about a month after the rul-
ing change in the McPherson case. A review of his work over the preceding
eight months had revealed serious mistakes in eight of his autopsies.
Dr. Wood had hired the sixty-year-old osteopathic-trained physician
without speaking to his former boss at the medical examiner’s office in
Marathon, Florida. Had she done so, she would have learned that his boss
considered Dr. Eicher disorganized and slow with his paperwork. Dr. Wood
admitted she had neither conducted a preemployment background check on
Dr. Eicher nor closely supervised his work after he was hired. According to
her critics, who were not shy about talking to the media, she had been pre-
occupied with the McPherson case.
One of Dr. Eicher’s cases that came under review involved the death of a
ninety-two-year-old Tarpon Springs woman. She had been found lying face
down on top of boards that had fallen from the broken railing of a deck seven
feet above. It was obvious from the scene that the woman had fallen through
the deck railing and was killed by the fall. That she had died from blunt force
Chap-01.qxd 11/9/07 11:26 AM Page 22
22 DIAGNOSING DEATH
trauma to the chest confirmed that the manner of death was accidental. Dr.
Eicher had ruled the cause of death coronary artery disease and the manner
of death natural.
Arriving at the correct manner-of-death conclusion, even in a case
where no one suspected foul play, is always important. In this case, the con-
dition of the deck railing, and the fact the woman had fallen through it,
might have been relevant in a wrongful-death action.
In another of Dr. Eicher’s cases, one chronicled in the St. Petersburg
Times, a thirty-seven-year-old man was found dead in the water next to his
burning boat. He had been shot in the head. Dr. Eicher ruled this death a sui-
cide because he believed the man had been shot, point-blank, in the face. In
fact, the man had been shot in the back of the head. In addition, he had been
recently charged with raping an eleven-year-old girl, another fact that
pointed to murder. The person who had killed him may also have set fire to
his boat. This death certainly wasn’t suicide. Perhaps Dr. Eicher had made a
rookie mistake and confused an angry-looking point-blank entrance wound
to the head with an exit wound. In any event, his mistake may have allowed
someone to get away with murder.
The mistake that may have sent Eicher packing involved the case of a badly
burned teenager. As reported by the St. Petersburg Times, the Pinellas Park Fire
Department, in response to a vehicle fire, found the body of seventeen-year-old
Brannon Lee Jones inside the flaming car. Without knowing what had caused
the vehicle fire, Dr. Eicher ruled the death a suicide. This confused the police,
who considered this a strange way to take one’s life, but because the death
had been ruled a suicide, they did not conduct a homicide investigation. This
failure to investigate infuriated the victim’s family. When a second autopsy
revealed that Brannon Lee Jones had been beaten to death and then set on
fire, the police opened the case as a homicide, but the trail had gone cold.
The homicide went into the books as unsolved.
Dr. Eicher had made too many substantive mistakes over too short a
period. He had to go, and he did.
After eighteen years in the Santa Clara County, California, coroner’s office,
seventy-three-year-old Dr. Angelo Ozoa, a Filipino American, had performed
six thousand autopsies since being hired in as an assistant medical
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24 DIAGNOSING DEATH
Palo Alto police, guns drawn, stormed Galbraith’s house in January
and hauled him away on the charge of first-degree murder. In August ,
almost three years after his wife’s death, Nelson Galbraith, who had been
allowed to make bail, went on trial for her murder. The prosecution’s key
witness, Dr. Ozoa, told the jury that in all his years as a forensic pathologist,
he had never heard of a woman killing herself by ligature. Suicide by ligature,
however, is a well-recognized method of death that is documented in text-
books and scientific journals.
The defense called forensic pathologists who disagreed with Dr. Ozoa
and argued that the defendant could not have physically committed the
crime. Following two and a half weeks of testimony, the jury deliberated for
one day and returned a verdict of not guilty. Following the acquittal, the dis-
trict attorney’s office sought the opinion of a forensic pathologist in the
Santa Clara Coroner’s Office regarding the manner of Josephine Galbraith’s
death. The pathologist agreed with the defense experts: the poor woman had
killed herself.
Nelson Galbraith, convinced he had been maliciously prosecuted, sued
Doctor Ozoa for $ million. To bolster his case, Galbraith spent $, to
have his wife’s body exhumed and sent to Salt Lake City to be examined
by Dr. Todd Grey, the medical examiner for the state of Utah. According to
Dr. Grey, Dr. Ozoa’s incorrect finding of homicide was predicated upon an
incomplete autopsy, as Loren Stein notes in a long and detailed article on the
Galbraith case. Dr. Ozoa had, among other things, neglected to dissect the
dead woman’s neck, a procedure that could have helped determine how long
it had taken her to die. He had also failed to interpret the swelling in the vic-
tim’s brain and the broken blood vessels in her face and eyes as evidence of
a slow death. Dr. Ozoa, when confronted with Dr. Grey’s opinion of his work
in the Galbraith case, insisted that he had performed a complete autopsy and
that the woman had been murdered.
In July , almost seven years after Dr. Ozoa’s autopsy in the Galbraith
case, the Medical Board of California, citing Dr. Ozoa’s work in that case,
voted to suspend his license to practice medicine in the state. The doctor
was seventy-seven. Two months later, Nelson Galbraith died. He was eighty-
three, and his lawsuit was still pending in the courts.
In January , Dr. Gregory Schmunk, who had replaced Dr. Ozoa as the
head of the Santa Clara Coroner’s Office, resigned after another civil grand
jury issued a blistering report critical of his managerial skills. According to
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26 DIAGNOSING DEATH
reporter William Dean Hinton, had the officials responsible for his hiring
looked into Dr. Schmunk’s background, they would have learned there was
an outstanding warrant for his arrest in Wisconsin in connection with an
alleged theft of textbooks and clothing from his previous employer. The
grand jury’s investigation also disclosed that in , Dr. Schmunk, in an
application to get a concealed gun permit, had failed to mention that in
a Sacramento man had sued him for making threats. The suit was settled for
$,. During Dr. Schmunk’s six-year tenure with the Santa Clara coroner’s
office, as reported by the San Jose Mercury News, he had billed the county
$, in travel expenses for conferences and seminars across the country
and overseas, an amount many considered excessive.
While problems continued to haunt the Santa Clara County Coroner’s
Office, Dr. Ozoa was busy organizing medical missions in the Philippines,
operations staffed by volunteer Filipino American physicians from northern
California. Nelson Galbraith’s lawsuit, taken over by one of his sons, was
thrown out of federal court in . At present it is pending before the Ninth
U.S. Circuit Court of Appeals.
Had Dr. Ozoa not classified Josephine Galbraith’s death a homicide,
Nelson Galbraith would not have been put through hell trying to stay out of
prison and to clear his good name. But Galbraith’s ongoing tragedy wasn’t all
Dr. Ozoa’s fault. His homicide ruling did not force the district attorney to
prosecute a shaky case, weakened by the debate over the cause and manner
of death and the absence of a confession, an eyewitness, and any physical
evidence incriminating Galbraith. If that weren’t enough, the prosecution’s
key witness was a forensic pathologist who was under a grand jury recom-
mendation to resign. The prosecutor had nothing to prosecute with, yet the
case went forward.
What saved Nelson Galbraith, denied the protection of solid forensic sci-
ence and sound prosecutorial discretion, was the safety valve of the criminal
justice system, a jury of commonsense people. Although Galbraith was lucky
in having a good lawyer, he did not come out of the case a winner. Anyone
wrongfully accused of a crime loses, regardless of the outcome of the trial.
Every so often a forensic pathologist comes along who performs badly in all
aspects of the profession. Dr. Charles Harlan, a forensic pathologist who had
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28 DIAGNOSING DEATH
Every year in the United States there are thousands of sudden, violent, and
unexplained deaths in the form of homicides, suicides, traffic fatalities, drug
overdoses, infant deaths, industrial accidents, and poisonings. Each of these
deaths requires an autopsy, and there aren’t enough qualified people to do
them. This is a serious problem. Too many unqualified people are perform-
ing autopsies; among those who are competent, many are stressed,
exhausted, or burned out. Too many bodies that should be autopsied are
buried without the procedure.
Given the sometimes gruesome nature of the work, and the pressures
and responsibility that go with it, it is not surprising that people with med-
ical degrees may not be drawn to forensic pathology. The practitioners pro-
filed in this chapter were able to work as long as they did because there
weren’t qualified people to replace them. As was the case with Dr. Erdmann,
their tenure may be extended because prosecutors find them useful, turning
a blind eye to incompetence and dishonesty. Forensic pathologists like Drs.
Wood and Eicher showed their fallibility as humans susceptible to stress,
exhaustion, and the errors that make forensic pathology, as practiced, some-
thing less than an exact science.
When forensic pathologists have problems and make mistakes, people suf-
fer. This eventuality makes checks and balances in the form of independent-
minded detectives and prosecutors essential. The criminal justice system
requires detectives who are not afraid, and prosecutors who can rise above
their political ambitions.
The problem of the forensic pathologist from hell would be solved with
at least double the current number of board-certified practitioners in the
field. Until that happens, autopsies will be bungled, bad manner-of-death
determinations will be made, and the people affected by these bad calls will
suffer.
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A Question of Credibility
Bad Reputations and the Politics of Death
29
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30 DIAGNOSING DEATH
A QUESTION OF CREDIBILITY 31
and had ruled the death a homicide. This finding would automatically lead to
a criminal investigation to determine who had killed the inmate. The inves-
tigation, however, came to a stop after Dr. Berkland took over the case and
changed the cause of death to massive blood loss from cuts made by
the razor-ribbon fencing. The public defender who had represented the pris-
oner before his death, suspecting that Dr. Berkland might be part of a correc-
tions facility cover-up, asked Dr. Young to review Mitruka’s autopsy and
Dr. Berkland’s subsequent role in the case.
Dr. Young found that the victim had lost some blood, but not nearly
enough to cause his death. He also discovered that Dr. Berkland had not vis-
ited the death site, examined the victim’s clothing, or looked at the death-
scene photographs. Berkland had also failed to question the paramedics who
had responded to the scene. Dr. Young ruled that the inmate, as a result of a
beating and his attempt to escape, had overtaxed his heart. Notwithstanding
this ruling, no charges were filed in connection with this death.
Dr. Berkland had been on the job less than two years when, in
February , Dr. Young fired him. Shortly after losing his job in Missouri,
Dr. Berkland was hired as an associate medical examiner in Florida’s First
Judicial District by the acting medical examiner, Dr. Gary Cumberland.
Dr. Berkland, who had assured his new boss that the Missouri firing had been
politically motivated, would be headquartered in the panhandle city of
Pensacola and responsible for performing autopsies in Okaloosa and Walton
Counties.
Back in Jackson County, Berkland’s replacement, Dr. Sam Gulino, and
Dr. Michael Young were making startling discoveries as they reviewed
Dr. Berkland’s work. They found that percent of Dr. Berkland’s autopsies
were, in one way or another, incomplete. In , he had failed to follow up
twenty-eight autopsies with a report, and in eight autopsies, he had falsely
reported that he had sectioned the corpses’ brains. The reviewers also sus-
pected that no autopsies had been conducted in several cases in which
autopsy reports in fact consisted of details copied from autopsy reports in
other cases. As a result of Dr. Berkland’s nonreporting and false reporting,
nine criminal cases were at risk of being overturned on appeal. It seemed
that Michael Berkland had made a forensic mess in Jackson County,
Missouri.
Dr. Young filed a formal complaint with the Missouri Administrative
Hearing Commission, the state administrative body in charge of oversight in
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32 DIAGNOSING DEATH
matters involving the state’s medical examiners’ offices. He and Dr. Gulino
testified before the administrative panel in January , and a month later,
in reaction to this testimony, a circuit court of Jackson County issued an
injunction barring Dr. Berkland from performing autopsies in Missouri. As
journalists Chris George and Denis Wright report in “Unwrapped,” the court
held that Dr. Berkland “poses a substantial probability of serious danger to
the health, safety and welfare of his patients, clients and/or the residents of
Missouri.” The judge characterized the pathologist’s job performance as “fraud,
misrepresentation, and unprofessional conduct in the practice of medicine.”
The court injunction didn’t affect Dr. Berkland directly because he was
in Florida performing autopsies in and around Fort Walton Beach. Not until
the spring of , when the Missouri Administrative Hearing Commission
revoked the doctor’s license to practice medicine in any capacity in the state
did Dr. Stephen Nelson, the chair of the Medical Examiner’s Commission for
the state of Florida, become aware of Dr. Berkland’s status in Missouri. On
July , , based on Dr. Nelson’s recommendation, the Florida Board of
Osteopathic Medicine placed Dr. Berkland on temporary suspension for not
informing his boss, Dr. Gary Cumberland, of the loss of his license to practice
in Missouri.
As George and Wright reported, Dr. Berkland, testifying before the osteo-
pathic panel, referred to the plagiarized autopsy passages as “proofreading
errors,” called his superiors in Missouri politically motivated, and decried
the fact he had not been allowed to defend himself against the charges. To an
AP reporter inquiring about Dr. Berkland’s future in Okaloosa and Walton
Counties, Dr. Gary Cumberland, his boss, said that he still had full confi-
dence in the pathologist and had no plans to replace him. The osteopathic
board issued Charles Berkland a “letter of guidance” and lifted his suspen-
sion. Dr. Berkland, considered dangerous and dishonest in Missouri, was
back in action in Florida.
A QUESTION OF CREDIBILITY 33
at the scene two hours later, the area was swarming with police officers,
emergency personnel, and TV reporters. A law enforcement spokesperson at
the scene informed the media that it appeared as though Lori Klausutis had
died sometime the previous evening. According to detectives, there were no
signs of a struggle and no evidence of a break-in or robbery. Exactly how she
had died would not be known until after the autopsy. But based on appear-
ances, there was no reason to suspect foul play.
Lori and her husband, Timothy Klausutis, a Ph.D. employed at Elgin Air
Force Base, had just purchased a house in nearby Niceville. She had been
active in Young Republican groups and had worked in the representative’s
office a little over two years. At the time of her death she was working as a
constituent services coordinator in the Fort Walton Beach office.
Dr. Berkland performed the autopsy that afternoon in the presence of a
Fort Walton Beach detective, who took notes. The next day, a Saturday, the
police told the media that the autopsy revealed no signs of physical trauma.
In speaking to reporters himself, Dr. Berkland said that until he received the
toxicologist’s report, the results of his autopsy would remain “inconclusive.”
He also said, “Based on physical evidence, I feel comfortable moving the time
of death back to the previous day.” Although this was not his official call,
Dr. Berkland said that Klausutis’s death was in all likelihood “accidental due
to natural causes.” He said, “She has a past medical history that is signi-
ficant, but it remains to be seen whether that played a role in her death.”
Dr. Berkland also mentioned that the deceased had been involved in a
serious car accident as a teenager and may have been bothered by lingering
medical ramifications from this trauma. He said he expected to have the
toxicologist’s findings by the first of August.
The day after Lori Klausutis was found dead, the story, as shaped by the
police, Michael Berkland, and perhaps staffers in Scarborough’s office, featured
the victim’s history of bad health. Tales of her ill health tended to throw
water on the idea that she might have been the victim of foul play. And other
than suicide or some bizarre office accident, what else could explain the sud-
den death of a twenty-eight-year-old woman? According to an employee of the
local ABC television affiliate, Representative Scarborough called the station
three hours after the discovery of the body to inform them that Klausutis
had a “complicated” medical history that included “stroke and epilepsy,” as
journalists Chris George and Denis Wright reported. Scarborough’s press
secretary told the media, without providing details, that Klausutis had not
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34 DIAGNOSING DEATH
been in perfect health. The Fort Walton Beach chief of police confirmed that
his detectives were investigating the victim’s medical history. Members of
the Klausutis family, however, were denying that Lori had been unhealthy.
She had belonged to a track club and had just posted a good time in an eight-
kilometer race.
On August , two and a half weeks after Lori Klausutis’s death, Dr.
Berkland held a press conference to announce his findings. His revelation
that the victim had sustained a “scratch and a bruise” on her head evoked
questions as to why he had originally denied any signs of physical trauma. Dr.
Berkland explained that his original denial had been “designed to prevent
undue speculation about the cause of death,” reported the Pensacola News-
Journal’s Derek Pivnick. Apparently Dr. Berkland thought it was his responsi-
bility to prohibit speculative thinking, a role not usually associated with
forensic pathology. “The last thing he wanted,” Dr. Berkland said, “was forty
questions about a head injury.” The pathologist went on: “We know for a fact
she wasn’t whacked in the head because of the nature of the injury.”
According to Doctor Berkland’s analysis, Lori Klausutis, due to a valvular
condition in her heart, fainted and fell, bumping her head on the corner of a
desk. Even if she hadn’t struck her head, she could have died from her heart
condition. So her death had been either natural or accidental, or perhaps a
combination of both. When asked if she had ever been treated for the heart
problem, Dr. Berkland said that to his knowledge, she had not.
Dr. Berkland had intentionally misled the media regarding the condition
of the victim’s body, once again calling his credibility into question. For that
reason, the media wanted to see a copy of the autopsy report. Given Dr.
Berkland’s history, there was a possibility that he had yet to write it. Three
days after Dr. Berkland’s press conference, Ralph Routon, the editor of the
Northwest Florida Daily News, filed a written request for the report. In Florida,
autopsy reports are matters of public record, available to anyone, for any rea-
son. In this case, however, the state denied Routon’s request. On August ,
one day after Routon wrote an editorial criticizing the authorities for with-
holding a public document from the press, Dr. Berkland’s autopsy report was
released. Five days later, the Northwest Florida Daily News published the
details of his autopsy.
Had Ralph Routon not made an issue of the autopsy report, Dr. Berkland
might never have completed it and certainly would not have handed it
over to a newspaper, because the report was embarrassing. It revealed that
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A QUESTION OF CREDIBILITY 35
Dr. Berkland and the police had misled the public from the beginning. It also
showed that when the pathologist finally admitted in his August press con-
ference that there had been physical trauma—a scratch and a bruise on the
victim’s face—he was still manipulating the public. Instead of a scratch and a
bruise, Lori Klausutis had suffered a massive head injury that included a
seven-and-one-quarter-inch fracture across the top of her skull, an “eggshell”
fracture inside her skull above her right eye socket, a scalp contusion on the
back of her head, and a subdural hematoma on the left side of her brain that
caused it to swell and herniate—break out of—the left side of her skull.
Doctor Berkland interpreted the subdural hematoma—called a contracoup
injury because it was on the opposite side of the head from the point of
impact (causing the brain to slam against the other side of the skull)—as evi-
dence that the victim’s moving head had struck a stationary object. He chose
this scenario over one more suggestive of foul play: the possibility that a
moving object, such as a baseball bat or metal pipe, had struck her head.
According to Dr. Berkland’s postmortem analysis, Lori Klausutis had suf-
fered a “cardiac arrhythmia” that had “halted her heart and stopped her
breathing.” On the way to the ground, her head hit the desk and that “blow
to the head had contributed to the death because blood pooled at the point
where the fracture occurred.” The victim, however, had continued to breathe
after falling to the floor, a fact supported by the presence around her mouth
and nose of a “foam cone,” a bubble of froth made up of mucus and blood. (In
drowning victims, this bubble consists of a mixture of breathing passage
mucus and water, an indication that the victim had been alive when he or
she entered the water.)
Although officially the death had been ruled accidental, it is hard to
know from Dr. Berkland’s report if the manner of death was accidental or
natural. The key factor in determining that she had not been murdered had
to do with the source of the head injuries. Because he had sectioned the
brain as part of his autopsy, Dr. Berkland knew that the head trauma had
been caused by a fall instead of the wielding of a blunt object. Since photo-
graphs of the death scene that showed blood and hair on the corner of the
desk were never released for public inspection, and there were no death site
sketches attached to the autopsy report, one had to take Dr. Berkland at his
word. But just how good was his word? He had lied about sectioning eight
brains in Jackson County, Missouri, and in the Klausutis case, he had repeat-
edly misled the public.
Exploring the Variety of Random
Documents with Different Content
selfish, impudent, and without pride of character. To a girl this
number foretells an unhappy marriage, and misfortune by that
means; but if she remains single, and keeps clear of lovers, she will
avoid the ill omen.
Fifteen. If you are a speculating character—a buyer of lottery
tickets or lottery policies, or are engaged in any games of chance,
such as gambling, horse-racing, shooting at a mark, betting, or in
fact any scheme that you expect to win money by, this number
foretells bad luck and discomfiture. If you try to test your luck in any
such matters, and this number turns up, you may be sure you will
lose, and had better give up at once. If you want to buy land, you
will be apt to get a good bargain and be fortunate. This number
foretells good luck to a farmer putting in his crops, and the same to
a girl choosing a husband; for though she may not get a rich man,
yet he will be industrious, thrifty, comfortable, and good-hearted. To
consumptive people this throw is not a favorable one, as in many
cases it predicts a short life to them.
Sixteen. This is an unlucky number to a merchant, a banker, or a
mechanic. It foretells bad luck of some kind, though it is generally a
forerunner of a brisk and profitable business. An excellent run of
business may come first, and the bad luck afterwards, or vice versa,
but the misfortune is sure to come in somewhere. To a farmer this
throw foretells abundant crops, and to a gold-digger good luck and
plenty of the precious metal. A young girl who throws it will get a
thrifty husband, and have a numerous family.
Seventeen. If you are a girl, and think of getting married, you will
be apt to lose your lover unless he is a farmer, a gardener, a well-
digger, a gold-miner, a brewer, a coal-heaver, a grave-digger, or
some occupation that makes him use a shovel a good deal. If you
think of marrying any such man, this throw is a good one. For a man
of any other occupation, it foretells disappointment. To a young
man, this number shows that by perseverance and industry he will
do well in the world—that his luck will be good if he only tries his
best to get along. If you have had anything stolen from you, or have
lost valuable property while walking or riding, this throw is
unfavorable; you will probably never recover what you have lost.
Eighteen. People who throw this number may congratulate
themselves, as it foretells riches, honors, and a happy and contented
life. It predicts unexceptionable prosperity in all kinds of business,
good luck in love matters, and advancement to those who are
honorably ambitious. To rogues and dishonest people it is an omen
of discomfiture, detection and punishment.
PALMISTRY,
OR TELLING FORTUNES BY THE LINES OF THE
HAND.
Many people think the predictions from lines in the hand are all
guess-work, but it is a mistake, for they are determined by simple
rules and long observation. Let us explain the matter:
In the first place each finger has its name.
(See Engraving.)
1. Linea Vitalis.
2. Linea Naturalis.
3. Linea Mensalis.
If it is well defined it indicates an amorous temperament; if
accompanied by a side line, it signifies good fortune in love and
wedlock. If it is very broad, happiness in domestic life. If it is
interrupted it denotes that sad calamity, infidelity.
4. Linea Hepatica.
5. Linea Rascetta.
1. Memory.
2. Causality.
3. Benevolence.
4. Approbativeness.
5. Painting.
6. Energy.
7. Imagination.
8. Inclination to Melancholy.
9. Mischievousness.
(See Engraving.)
FORTUNE-TELLING BY MOLES.
These little marks on the skin, although they appear to be the
effect of chance, or accident, and might easily pass with the
unthinking for things of no moment, are nevertheless of the utmost
consequence, since from their color, situation, size, and figure, may
be accurately gathered the temper of, and the events that will
happen to the person bearing them; though moles are, in their
substances, nothing else than excrescences, or ebullitions which
proceed from the state of the blood whilst the fœtus is confined in
the womb, yet they are not given in vain, as they are generally
characteristic of the disposition and temper of those that bear them;
and it is also proved by daily experience, that from the shape,
situation, and other circumstances, they bear a strong analogy to
the events which are to happen to a person in future life. But before
I presume to give any directions to those who are to form the
prognostic, who are desirous to be duly enabled to pronounce an
infallible judgment, I shall, in the first place, teach you herein the
common prognostications by moles found in the various parts of the
body, according to the doctrine of the ancients. And, first, it is
essentially necessary to know the size of the mole, its color, whether
it be perfectly round, oblong, or angular; because each of these will
add to or diminish the force of the indication. The larger the mole,
the greater will be the prosperity or adversity of the person; the
smaller the mole, the less will be his good or evil fate. If the mole is
round, it indicates good; if oblong, a moderate share of fortunate
events; if angular, it gives a mixture of good and evil; the deeper the
color, the more it announces favor or disgrace; the lighter, the less of
either. If it is very hairy, much misfortune may be expected; if but
few long hairs grow upon it, it denotes that your undertakings will
be prosperous.
We shall further remark only, that moles of a middling size and
color are those which we are now going to speak of. The rest may
be gathered from what we have just above mentioned, but as it may
frequently happen that modesty will sometimes hinder persons from
showing their moles, you must depend upon their own
representation of them for your opinion.
SIGNIFICATION OF MOLES.
If you find a blade of straw lying in your chamber, you may expect
a visitor that same day. If there is one grain upon the straw, the
visitor will be a gentleman, if not, a lady.
When the cat licks and trims herself, it is a sign of visitors, but this
is probably known to most of my readers already.
SIGN OF VISITORS.