-- >> NARRATOR: Every day in America, nearly 7,000 people die.

And when it happens suddenly, it's assumed there will be an investigation, like in CSI.

>> You seeing what I'm seeing, Sid?

>> NARRATOR: But the reality is very different.

>> I myself have worked with a single light dangling over my autopsy table.

>> NARRATOR: Death investigators are struggling.

>> We've had to hire a refrigerated truck to store bodies and body parts, because we just don't have enough room in our refrigerator.

>> NARRATOR: In some states, the person who determines how someone died is an elected official.

>> LOWELL BERGMAN: You've been elected how many times?

>> Ten.

>> BERGMAN: You're a politician.

>> Oh, don't call me a politician.

>>NARRATOR: In some places, there are few qualifications... >> BERGMAN: There was a time when the coroner was blind.

>> Yes, sir, that's correct.

>> NARRATOR:...and there is no national regulation.

>> One pathologist had been arrested for drunk driving on his way to work.

He was giving crazy answers about how he thought people died.

>>NARRATOR: Tonight... >> BERGMAN: The body was found over there?

>>NARRATOR: ...Frontline correspondent Lowell Bergman reports with ProPublica and NPR on death investigation in America.

>> You call a death an accident or miss a homicide altogether, a murderer goes free.

Lots of very bad things happen if death investigation is not carried out competently.

>> BERGMAN: We all die, two and a half million Americans every year.

Sometimes, the cause of death is no surprise.

Sometimes, death comes suddenly-- from accidents, heart attacks, homicides.

There are medical experts whose job it is to figure out why and how people die.

They are called forensic pathologists or medical examiners, and they perform the postmortem, the autopsy, your last physical exam.

(saw buzzing) One of the leading forensic pathologists in America is Dr. Marcella Fierro.

>> When I was treating live patients, I spoke with them.

And when I have dead patients, I talk to them, too.

>> BERGMAN: But they don't talk back.

>> They talk back to me with their physical findings and with their pathology.

I ask them, "Tell me your story."

>> BERGMAN: As you're cutting them up.

>> I don't think of it as cutting them up.

I think of it as examining their tissues, examining their injuries.

I do my examination, and they do tell me their story.

>> BERGMAN: Forensic pathologists like Fierro determine what caused the death.

>> 3168.

>> BERGMAN: Was it natural, an accident, a homicide or a suicide?

>> It doesn't take a great medical mind to figure out someone's got his head blown off by a shotgun.

But it does take special expertise to tell the distance.

Is his arm long enough to do it?

Is there any other activity going on with his body that would have predisposed him to depression?

Does he have marks of defense?

That's pretty sophisticated stuff.

You don't learn that in a week.

>> BERGMAN: You mean, if you don't have training in what to look for or what to test for... >> And what to ask for, so that if a death isn't recognized as being suspicious, say, for violence, and it's released as a natural death, it's buried-- or cremated, whatever the family wishes-- never to rise again.

>> From the world's number one best-selling crime writer... >> BERGMAN: Elite death detectives like Fierro have inspired popular fiction.

She's the model for Kay Scarpetta in the best-selling crime series by Patricia Cornwell.

Is that you?

>> Is that me?

Am I blonde, blue-eyed, and a 105 pounds?

>> BERGMAN: I refuse to comment.

(laughter) >> You seeing what I'm seeing, Sid?

>> Uh, yeah.

>> BERGMAN: But Fierro and many of her colleagues say that the fiction they inspire in novels and on TV shows like CSI have given Americans a false impression.

>> A lot of people see TV and CSI, and they think that's how it really is.

But really, it varies from excellent to absolutely lousy.

I mean, when you look at a case, as a forensic pathologist, and you say, "Oh, oh, there's no scientific basis "for this decision.

It's just complete garbage."

And then, you have a family that looks at it, and it's typed on this neat paper and there's this official seal, and they say, "I guess they know what they're doing."

>> BERGMAN: And you're saying they're producing garbage every day?

>> I'm saying, in this country, many medical legal offices are producing garbage, yes.

>> BERGMAN: In Sonoma County, north of San Francisco, a call came in to 911.

>> BERGMAN: A husband reported that his wife had committed suicide.

>> God, why?

(sobbing) Oh, my God.

>> BERGMAN: Chris Reynolds, a private investigator, was brought into the case by the husband's lawyer.

>> Our client found his wife dead outside.

Her face was down, laying in a bucket of water.

He rolled her over and started doing C.P.R.

and tried to resuscitate her.

And usually, when a wife is found dead, the husband is the first suspect.

And in this case, that's what happened.

>> BERGMAN: The county sheriff ordered an autopsy to determine whether or not the death was a homicide.

Autopsies in Sonoma County are handled by a private company, the Forensic Medical Group, F.M.G.

>> Good morning.

What do we have today?

Okay, go ahead.

>> BERGMAN: The forensic pathologist assigned to perform the autopsy was this man, Dr. Thomas Gill.

>> In this case, it was all going to rest on what this forensic pathologist determined was the cause of death.

>> BERGMAN: What did he find?

>> He characterized it as "a textbook case of suffocation."

And in the defense world, when you read something like that, you're like, "Uh-oh," you know, "We're done."

Because when a forensic pathologist makes statements like that, those are very strong words.

And so, at that point, we better figure out if this guy knows what he's talking about.

>> BERGMAN: Reynolds began digging into Dr. Gill's past.

He tracked him from Oregon, where Dr. Gill lost his teaching job at a university, all the way to Indianapolis, where Dr. Gill got his first full-time job performing autopsies.

So, he hadn't been a forensic pathologist before?

>> No.

>> BERGMAN: And he goes to Indianapolis, where they let him do autopsies?

>> Yes, and a lot of them.

He did hundreds and hundreds of autopsies.

I started to focus on Indianapolis, and all of a sudden, my world opened up.

He had been arrested and charged with drunk driving on his way to work early in the morning.

From there, it was story after story about his incompetence, stories about his failure to make proper diagnoses.

Deaths of children, which are the most horrible things anybody should ever have to live through, and he was messing those up.

And so, these families were just ripped apart because he couldn't figure out what he was doing.

>> BERGMAN: These scandals led to Dr. Gill being fired, and so he headed west to a job in Los Angeles.

>> Dr. Gill was failing miserably in Los Angeles.

He could not do competent autopsies.

>> BERGMAN: And that's when Dr. Gill found a job doing autopsies in northern California for the Forensic Medical Group.

>> I am still, to this day, curious as to what they saw in this person that made them reach out and say, "Come work for us and work on high-profile criminal cases."

(phone rings) Hello, it's Chris.

>> BERGMAN: Reynolds and the defense team decided to confront the prosecution with what they had found.

The prosecution refused to drop the charges, but they were worried about Dr. Gill.

>> This case, it all hinges on your testimony.

>> BERGMAN: So they secretly began coaching him on how to answer questions about his past and about the autopsy.

>> We need to really craft some good responses to these things that we know are going to come.

>> BERGMAN: And they videotaped the sessions.

>> This one, I think I really should have... slipped up.

I should have... >> BERGMAN: Once the trial began, the prosecution was forced to reveal the secret videotapes and turn them over to the defense.

>> ...that there are deficiencies in the autopsy.

You know, we have kind of alluded to that, but I can be more specific... >> And we spent the next several days in amazement.

It was the most amazing thing I've ever seen, ever.

>> ...was on the... actually, was on the left side back in here, but... That's what I don't want to say.

>> Dr. Gill was caught on tape lying about his findings, lying about his background to the point that the government could not go forward, and came into court one morning and dismissed all the charges.

>> BERGMAN: But the official record still lists the death as a homicide, leaving the community to wonder what really happened.

Is it possible that a guilty man walked?

>> Not in my view.

There were no classic signs of suffocation.

And I think it's sad that the community is left saying, "Did he or didn't he?"

>> BERGMAN: Because of an incompetent autopsy.

>> Complete incompetence, yes.

>> BERGMAN: A scathing report on the case by the California state bar concluded that the prosecutor was guilty, among other things, of suppression of evidence about Dr. Gill.

The prosecutor was suspended from practicing law for four years.

The report went on to describe Dr. Gill as an "incompetent pathologist."

But there was no suspension for Dr. Gill; he just kept on doing autopsies for the Forensic Medical Group.

The case of Dr. Gill is not unique.

A nationwide investigation by Frontline, ProPublica and NPR found there is no federal oversight of death investigators or the offices where they work.

We found that, in Massachusetts, they've repeatedly lost body parts.

In Michigan, they discovered the body of a prominent banker and missed the bullet hole in his neck.

In Nebraska, murderers went free because of incompetent autopsies, while in Mississippi, botched autopsies helped send innocent people to prison for life.

>> The difference between competent death investigation and incompetent death investigation may be the difference between what side of a state border you're on.

There may be areas where, on one side of the border, you have a statewide medical examiner and competent death investigation; the other side of the border may be a small county coroner with few resources and little training in death investigation.

>> BERGMAN: In more than 1,300 counties across the country, elected politicians called coroners are in charge of death investigation.

>> There are coroners trying to carry out death investigations, but they don't have the training, they don't have the money, they don't have the infrastructure, and they don't have the skill.

I guess you really have to ask yourself, do you want your cause of death and your manner of death to be decided by someone in medicine who has special competency to do that?

>> BERGMAN: Or...?

>> Or take your chances.

>> BERGMAN: Tim Brown graduated from a technical college, and then became a building contractor in Marlboro County, South Carolina.

>> ...inspection or something for a septic tank.

>> BERGMAN: He is also the elected coroner, which means when someone dies unexpectedly, he decides how it happened.

>> Well, this is just kind of behind the house.

>> BERGMAN: There was a time when the coroner was blind, right?

>> Yes, sir, that... that happened here in Marlboro County.

We had Mr. Francis Stanton.

He was a blind gentleman.

>> BERGMAN: He was there for, what, 40-something years?

>> You know, I don't really know, but he'd been there for a long time.

Yes, sir.

>> BERGMAN: So you got elected, and you just sort of, if you will, dove into the subject?

>> Yes, sir.

That's correct.

Off the deep end.

I've been elected seven times.

>> BERGMAN: Coroner Brown would find himself in the national spotlight after he got a phone call that a body had been found near the state line.

And the body was found over there?

>> Yes, sir, somewhere right in that area, right there.

You see where that old log is across?

>> BERGMAN: Uh-huh.

>> And we didn't find any identification.

We didn't find a wallet.

We didn't find a watch, a ring, a necklace.

>> BERGMAN: Nothing.

>> Nothing.

No, sir.

>> BERGMAN: If the body had been found just a few feet away, the investigation would have been handled by a fully-equipped state medical examiners' office in North Carolina.

But the body turned up in South Carolina, so Coroner Brown was in charge.

Like most coroners, Brown does not do autopsies.

He had to ship the decomposing body to a private forensic pathologist more than a hundred miles away.

>> The autopsy was done outdoors in a old garage behind the hospital.

It was sometimes very hot, particularly this time of year, like in August.

And recognize that, once a body start decomposing, it's almost accelerated with heat.

>> BERGMAN: So, you... you did this autopsy in the garage.

>> Correct.

And then, we sent the body back to Tim Brown.

>> BERGMAN: Based on that autopsy, Brown declared the death a homicide.

But he faced a dilemma-- he did not have a refrigerator in which to store the decomposing body of the unknown victim, and he didn't have the funds to bury the man.

And so he had the remains cremated.

>>...still developing story here tonight about the father of basketball star Michael Jordan.

James Jordan has been missing now for three weeks, and... >> A few days after I elected to cremate the body, I was watching the CBS Evening News.

The father of Michael Jordan was a missing person, and I thought, "Well, that might be my John Doe."

>> BERGMAN: Might be?

>> Might be.

Could be.

I said...

I think I said, "That might be my man."

>> Authorities announced that the body of... >> BERGMAN: Dental records confirmed that the body Tim Brown found was, in fact, Michael Jordan's father.

>> ...which will obviously complicate the FBI's investigation.

>> BERGMAN: Two men were ultimately convicted of the murder.

But the Jordan family was left with only ashes to bury, leading to a media outcry that Coroner Brown should not have cremated the body.

You made do with the resources that you had?

>> I did, yes, sir.

And I...

I still believe that the decision I made was a professional decision.

>> BERGMAN: Many people say, because of this incident, things have changed.

>> Well, it's directly attributed to this situation, there's no doubt about that.

>> BERGMAN: Have the qualifications changed for being a coroner?

>> You know, I really can't speak to that, because I've kind of been grandfathered in.

>> BERGMAN: Today, coroners in South Carolina have limited access to a refrigeration unit.

And there's a new requirement to be a coroner-- you have to have a high school diploma.

>> The major problem in this country is the coroner system, in that, essentially, what you're doing is electing somebody with no experience, and it's absurd.

How often do you think people go to the polls and say, "I'm going to vote for Mr. Jones because he's a good coroner"?

In some communities, you could run a dead man for coroner, and he'd get elected if he was on the right ticket.

>> BERGMAN: I first encountered an elected coroner nearly 20 years ago, when I was reporting a story in New Orleans about crime and violence in the police department.

The New Orleans coroner back then was an obstetrician, Dr. Frank Minyard.

20 years later, Dr. Jazz, as he's known, is still in office, the longest-serving big city coroner in America.

It's not a very large facility.

>> No, no, it's not.

>> BERGMAN: During Hurricane Katrina, Coroner Minyard became part of the city's folklore when he swam through the storm water to get to work.

>> There was ten feet of water here where these boats are coming.

There I am standing there, and you can see my John Wayne pistol.

>> BERGMAN: Minyard's exploits helped win him re-election.

>> ...no food and no water.

>> BERGMAN: You're the elected coroner.

>> Yes.

>> BERGMAN: And you've been elected how many times?

>> Ten.

>> BERGMAN: Ten times?

>> Ten four-year terms.

>> BERGMAN: Well, you're a politician.

>> Oh, don't call me a politician.

I don't think I'm a politician.

I'm more of a community servant.

>> BERGMAN: But you're not a forensic pathologist.

>> No, no.

No, I was in ob/gyn practice before I became coroner.

I have five forensic pathologists who work for me.

>> BERGMAN: But it's Coroner Minyard who interprets his pathologists' findings, and he decides whether or not a death is a homicide.

And some of those decisions have been very controversial.

Take the case of Adolph Archie.

>> BERGMAN: 20 years ago, Adolph Archie fled after killing a police officer.

>> Suspect is going from La Salle to Chartres on foot.

>> BERGMAN: When the police captured Archie, an ominous message came over the radio.

>> BERGMAN: By the next morning, Adolph Archie was dead.

Coroner Minyard's office performed an autopsy, which found that Adolph Archie had a fractured skull, a broken rib, blood in his lungs, lacerated lips, and other injuries consistent with what happens when someone is violently beaten to death.

But initially, Coroner Minyard left the classification of the death blank, and then said publicly that Archie had died when he fell over backwards by accident.

There's been a long history where you've been accused of being biased on the side of law enforcement.

>> Correct, yes.

>> BERGMAN: To the point that you had a friend, who was an officer involved in one of the more famous incidents... >> Yes.

>> BERGMAN: Adolph Archie.

>> Adolph Archie.

>> BERGMAN: You wound up getting the police an undetermined cause of death when he was in the custody of the police department.

>> Right.

What's wrong with that?

>> BERGMAN: In a very violent... >> Yeah, but what's wrong with that if it's the truth?

>> BERGMAN: After an outcry over his calling Archie's death an "accident," Minyard classified it a homicide.

But then he continued to publicly say it was accidental.

With the medical evidence in dispute, no charges were ever filed against the police officers involved.

(siren wailing) >> That was kind of a watershed incident in this city.

It felt to me like, if Adolph Archie could be beat to death kind of in broad daylight here in front of this whole community, and nothing happened as a result of that, a very powerful and extremely damaging message was sent out to this community that anything goes.

>> BERGMAN: That turned out to be true in the aftermath of Hurricane Katrina, when the New Orleans police spun out of control.

When the body of Henry Glover was found in this burned-out car, evidence pointed to police officers being responsible for his death.

But Coroner Minyard did not classify it as a homicide, and so there was no criminal investigation.

A burnt up body inside a burned-out car... >> Well, to begin with... >> BERGMAN: ...behind a police station.

>> Okay, look at it that way.

Now, look at it from my point of view-- we can't say.

There... there's no way I can say that that is a homicide.

There's no way of telling how, why this man died.

>> BERGMAN: But last year, an extraordinary federal probe found that the death of Henry Glover was in fact a homicide, and a New Orleans police officer has now been convicted in the killing of Henry Glover.

As a result, some in the community perceive that law enforcement has a greater influence over, let's say, the determination of the classification of death?

>> To that I say, bull (bleep).

The police has nothing to do with my classification.

And we have had battles with the police and the district attorney, and we always come out on the Palace of Truth.

You've got to keep that in the back of your mind-- Palace of Truth.

The point is, the truth is what we peddle.

The truth is what we peddle, and we don't care who wins and who loses.

>> BERGMAN: But we have found new cases that reveal cracks in Coroner Minyard's "Palace of Truth," like the case of Cayne Miceli.

On the morning of January 4, 2009, here at Tulane Medical Center, 43-year-old Cayne Miceli came into the emergency room suffering from a severe asthma attack.

When the staff tried to discharge her, even though she was still having trouble breathing, Cayne, who had a history of psychiatric problems, resisted, and the hospital called the authorities.

They took her here, to the psychiatric ward of the house of detention, run by the sheriff.

Despite her asthma attack, prison staff put her in five-point restraints, a series of straps that bound her flat on her back on the bed in her cell.

According to the house of detention's own records, Cayne told the staff that she couldn't breathe.

As she struggled, she began to get free, so four guards held her down.

Only when they could no longer find a pulse were paramedics called.

They rushed Cayne to the hospital, and that's when her father, Mike, was notified.

>> We got down here as quick as we could.

The doctor told us that, you know, there was no hope.

And we got together and talked, you know, and decided to... take her off the respirator and the thing.

As soon as they did, she quit breathing right then.

And it took about five minutes for her heart to just slowly fade away.

>> BERGMAN: After Cayne died, two of the doctors at the hospital asked to talk to Mike Miceli in private.

>> We were taken into another room by two of the doctors.

They locked the doors.

They sat us down, looked me straight in the face, and said, "Mr. Miceli, you need to have this looked into.

"This should not have happened.

Something's wrong."

>> BERGMAN: Cayne Miceli's body was sent to Coroner Minyard's office, where they decided to do an autopsy, and assigned a veteran pathologist, Dr. Paul McGarry.

He is the same person who performed the autopsy in the death of Adolph Archie and other controversial cases.

In the Miceli case, Dr. McGarry noted needle marks on Cayne's arm, and despite the fact that tests showed no drugs in her system, he reported to Coroner Minyard that she had died because of drug abuse.

Dr. Minyard classified the death as "accidental."

To Mike Miceli, that meant one thing.

>> Cover-up.

>> BERGMAN: So you decided to look into this.

>> Oh, yeah.

Mm-hmm.

>> How bad were her asthma attacks?

>> BERGMAN: Miceli turned to veteran civil rights lawyer Mary Howell, who has been investigating deaths at the hands of the authorities in New Orleans for decades.

>> They really are downplaying here any of the stuff with the asthma.

>> BERGMAN: Dr. McGarry, who has worked for Dr. Minyard... >> Right.

>> BERGMAN: ...for many years, are his autopsies, his findings, a regular problem that you run into?

>> Yes, yes, they are.

If I know that Dr. McGarry has done the autopsy, and if I know that it is an in-custody death, I am routinely going to do a second autopsy.

Because the information, the experience that we've had dealing with the office here is... is so unreliable.

And... and we have found really shocking things when we've done those second autopsies.

>> BERGMAN: You know Mary Howell, right?

>> Oh, yeah.

>> BERGMAN: What she says is that there's a consistent series of cases, many handled by Dr. McGarry, where second autopsies showed that there was, in fact, a different cause of death... >> Mm-hmm.

>> BERGMAN: ...than what he had.

>> I have to believe what my pathologists say.

I couldn't do this job if... if I didn't believe them point blank, 100%, no questions.

But McGarry never has given me a reason, you know, not to believe him.

>> BERGMAN: But we have learned that when Coroner Minyard made that statement to us, he was aware of serious flaws in Dr. McGarry's work.

Mike Miceli exposed one of those flaws by arranging for his daughter's body to be flown to Alabama, so that she could be examined by an independent forensic pathologist Miceli hired, Dr. James Lauridson.

>> The medical examiner saw needle puncture marks on her arm and came to the conclusion that this was a drug-related death.

But, in fact, all of the needle puncture marks were therapeutic-- drawing blood, IVs, that sort of thing.

And, in fact, her cause of death was something completely different, unrelated to any intake of drugs.

As I examined her lungs, it was very clear right away that her lungs and all of the airways were completely filled with mucous.

I went ahead and did microscopic examinations of those tissues, and that confirmed the fact that this was a very severe-- in fact, fatal-- case of bronchial asthma.

>> BERGMAN: That simple?

>> It was that simple.

>> BERGMAN: When you discovered that, in fact, she had been put in five-point restraint, as an asthmatic, what was your reaction?

>> To put an asthmatic flat and then tie them down during an acute asthma attack is nearly the same as giving them a death sentence.

If you're not going to treat them medically, and you lay them back and tie them down, it's almost a guarantee they're going to die.

>> BERGMAN: In 2010, Miceli filed a lawsuit against the sheriff and his employees who were allegedly involved in Cayne's death.

He also sued Coroner Minyard's forensic pathologist, Dr. McGarry.

>> And you know that they're now classifying it as natural.

>> BERGMAN: With that lawsuit pending, Coroner Minyard reviewed McGarry's autopsy and changed the cause of death.

>> This is what the new death certificate supposedly is going to look like.

Even though they misspelled "asthma," you know, we know what they're talking about there.

>> BERGMAN: But the authorities in New Orleans have, so far, declined to pursue a criminal investigation into the death of Cayne Miceli.

>> There's no reason for a family to have to go through this.

It seems to me that... that this pathologist and the coroner are enablers.

They find what the sheriff or the police department want them to find.

>> BERGMAN: Despite repeated attempts, Dr. McGarry refused to talk to us.

Dr. McGarry?

I'm Lowell Bergman.

I've been trying to talk to you for a couple of days.

Would you talk to us?

So I take it that you don't have any comment?

After changing the cause of Cayne Miceli's death, Coroner Minyard has, after 30 years, stopped working with Dr. McGarry.

In addition to the Miceli, Glover and Archie cases, there are others involving law enforcement where an independent autopsy has challenged Coroner Minyard's findings.

That's what people point to when they say that you're close to law enforcement; that you're... because you're an elected official with some political dues to pay, you'll help law enforcement when they're in a jam.

>> Well, we help anybody who's in a jam-- anybody, to a degree.

But, of course, I wouldn't break the law helping people.

That's for sure.

These things have a way of looking bad, like you are reporting it, you know, but those people you're talking about just now, I don't even know who they are.

>> BERGMAN: At Coroner Minyard's request, we gave him a list of the other controversial cases, and then he told us they were all "under investigation" and he would not be able to comment on the record.

In New Orleans, attorneys there say, if there is an autopsy performed involving law enforcement shooting somebody or an in-custody death... >> A police shooting or in-custody, okay... >> BERGMAN: ...and the autopsy is done by the New Orleans coroner's office and their forensic pathologists, they routinely will get a second autopsy.

>> That's unfortunate, because it implies that their... that their cases are not credible.

I've always, always thought, particularly in the police shootings and those that are related to law enforcement, that the best friend law enforcement could have would be an objective, honest, straightforward, careful autopsy.

>> BERGMAN: It was because of that perception of bias and other problems that plague death investigation nationally that Dr. Marcella Fierro joined in a recent study by the National Academy of Sciences.

Your number-one recommendation was abolish coroners.

>> And that was not a new recommendation.

This was the fourth time a national study has recommended that death investigation should be carried out by doctors, and particularly doctors who have special expertise.

This is not a new concept.

It's a question of competency.

I'm not anti-coroner, I'm pro competency.

>> All right, 3156 is a 37-year-old white female.

She was last seen alive... >> I've been a practicing forensic pathologist for more than 35 years, and I'm still amazed that there are many parts of the country where we don't have competent death investigation systems.

>> BERGMAN: Dr. Ross Zumwalt of New Mexico was one of the co-authors of the study, which recommended national standards requiring that every office in the country be inspected and accredited.

>> It amazes me that such an important aspect of our government as medical legal death investigation doesn't have to have accreditation.

I mean, everything else is accredited.

Hospitals are accredited.

Barbers are accredited.

You would think that a medical legal death investigation system would have to go through a periodic inspection and accreditation.

We need a federal or a national standard, because there is so much variation between the states.

>> BERGMAN: To meet the new standards, death investigation offices would be run by a medical examiner, not a coroner.

But coroners say that many of their offices do an exemplary job, like the one in Las Vegas.

>> I am not concerned as much about who's running the office as their integrity, their business experience, and their abilities.

>> BERGMAN: Murphy's office in Las Vegas was the model for CSI, and he was the only coroner the National Academy of Sciences invited to testify.

The National Academy of Science's study, you contributed testimony to it.

>> Yes, sir.

>> BERGMAN: You support its recommendations?

>> Not in its entirety.

>> BERGMAN: What do you object to?

>> I guess one of the things I'd have to say is the elimination of the coroner office, per se.

You know, it was a pretty broad stroke.

Can you do it with a nuclear approach?

>> BERGMAN: "A nuclear approach."

They want to blow the whole thing up?

>> I think they want to say, "Wipe all this out and go this direction."

And I'm going to tell you that...

I think there's a Chinese proverb that says, "Be careful what you ask for."

I don't think the system could... could function without the coroners at this particular time.

The first thing you're going to have to do is make sure you have enough forensic pathologists.

And if you don't have that, I think the system would... would start to crumble.

There's a huge demand, and there's very little supply.

>> BERGMAN: It would take at least a thousand forensic pathologists to handle death investigations in this country, but the National Academy of Sciences says there are fewer than half that number practicing today.

>> For many years, the medical legal systems have been so poorly financed that the salaries were not competitive and the facilities were terrible.

There was a survey done a few years ago, and 10% of the offices didn't have X-ray.

Now, think about that.

They don't have X-ray.

The X-ray is a 19th century device, and... and medical exam... these offices didn't have X-rays?

What I'm saying is, if you have poor facilities and low pay, you're not going to attract people.

>> BERGMAN: According to the National Academy study, it will take the support of the federal government to reform death investigations.

Currently, the U.S. government provides virtually no funding to either medical examiners or coroners.

>> One of their grants was for one office to get a new refrigerator, because their current refrigerator was closed by a belt.

(laughs) You know, that's how poorly funded.

I, myself, have worked in an office where it was a converted garage with a single light dangling from the... from the... the roof.

A single light bulb over my autopsy table.

Without the federal government having a voice for forensic pathology, we have largely been orphaned.

>> BERGMAN: Los Angeles County has one of the busiest and biggest offices in the country, but because they don't have the resources, they see only a fraction of fatalities.

>> We deal with approximately 20,000 deaths a year, but that's only a small percentage of all the deaths in Los Angeles County.

There's probably 60,000, 70,000 deaths a year.

>> BERGMAN: So you still only see, at most, one out of three people who die in the county in a given year.

>> Correct.

>> BERGMAN: And, in fact, there are a lot of homicides going on you don't know about.

>> Correct.

When you only see one in every three cases, the possibility that a homicide's going to be missed are pretty great.

I don't have the staffing or the funding available to investigate, to respond to all of those deaths.

I can barely handle what I have now.

>> BERGMAN: One of the groups whose deaths are least likely to be investigated is also among the most vulnerable-- the elderly.

>> There's a tendency to assume that, because somebody is old, that they have died of an old-age related disease as opposed to something else.

But what's actually killing them?

The caution is, with the elderly-- be careful.

They're not always going to be natural deaths.

>> BERGMAN: On November 6, 2007, Elmore Kittower, age 80, passed away.

He had been living here at Silverado, a high-end assisted living facility in Los Angeles County.

According to his death certificate, he stopped breathing, his heart failed-- natural causes.

No one reported anything was amiss.

>> It's kind of an honor system.

I would love to have the staff available to respond to every nursing home death.

They're fraught with potential misses.

But if anything was to go wrong in those facilities, unless somebody says something, there's a good chance that the case will pass through the system without ever being seen by the coroner.

>> BERGMAN: Mr. Kittower was buried, but the next day, his family received a phone call.

The anonymous caller claimed that Mr. Kittower had been beaten by a caregiver at Silverado, and the beating resulted in his death.

The only way to know if that was true was to exhume the body and perform an autopsy.

>> They found a myriad of injuries.

They found bruising on his face, on his chest, bruising on his arms.

We actually brought in an expert radiologist, as well, who consults with the coroner's office.

There were 28 separate rib fractures on Mr. Kittower.

He had a fracture to his sternum, a fracture to his larynx, and he had crushed toes.

>> Crushed toes?

>> Yes.

And the crushed toes, those aren't falling injuries.

That was a crushing injury, like a brick.

The injury to the larynx, that's not the kind of injury you would get from falling.

That's more likely the injury, according to the coroner, that you'd get if somebody was doing a C-clamp.

They were choking you.

>> BERGMAN: Armed with the autopsy results, the district attorney subpoenaed Silverado's employees, and they revealed what the caregiver, Cesar Ulloa, did to Mr. Kittower.

>> One person, just a few days before his death, saw Mr. Kittower straddled in bed by Mr. Ulloa.

They saw him put a blanket or sheet over his head, and punch him repeatedly in the upper body and head.

>> BERGMAN: What you're describing, it sounds like supervisors or others must have had some idea of what was going on.

>> I would think that somebody should have known.

>> When we first heard about the... the likelihood that there... there could have been a problem, we just didn't believe it.

We felt that this particular caregiver was a... a model caregiver.

He was given the caregiver of the month award.

>> BERGMAN: Loren Shook is the C.E.O.

of Silverado.

You say you have a medical director on site?

>> Yes.

>> BERGMAN: And you have physicians who visit, I guess, the patients.

>> We have physicians who visit, and we have licensed nurses 24 hours, seven days a week.

>> BERGMAN: Given the kind of care you're talking about at Silverado-- the surveillance of the patient; the fact that, as you say, you have, nurses and doctors and a medical director, how could people miss all the injuries to his face and so on?

>> There were not that many outward evidences of... of any kind of injury to Mr. Kittower.

He couldn't speak very well, so he couldn't tell us his... his story.

>> BERGMAN: Mr. Kittower's death certificate did not tell his story, either.

That's because the doctor who signed his death certificate wasn't his physician and never saw his body.

That's legal in California.

>> Things are getting missed, because there's just either insufficient staff to look at all of them, or the reporting system, the honor system that exists has broken down.

>> BERGMAN: Only because of that autopsy of Mr. Kittower did the truth emerge.

And as a result, Mr. Ulloa was convicted of torture and sentenced to life in prison.

>> If we had not exhumed Mr. Kittower's body, we could not have done anything.

The autopsy led to everything else.

>> BERGMAN: Competent death investigation not only helps catch criminals, but can save thousands of lives.

Forensic pathologists identified the anthrax terrorist attack, defective cribs that kill babies, and lethal infectious diseases.

>> It is important to have a quality, competent death investigation system.

If you don't, you run the risk of having an out-of-control epidemic.

You run the risk of not identifying hazards in the community due to toxins or environmental poisons.

I think the medical examiner system in any community is a safeguard for that community.

>> It's going to cost you.

It's going to cost you about $2.25 to $2.50 a person in your community per year, which is probably less than what you pay for a Coca-Cola in a movie theater.

And that's... that's what... at this time, roughly the price of a... a good medical examiner's office is.

>> BERGMAN: Economists call medical examiners and the autopsies they do a "public good," like the fire department, because autopsies can save lives as well as solve crimes.

But unlike the fire department, there's little public awareness of their value.

I don't see a drumbeat of popular protests on the nature of death investigations in this country.

People aren't demonstrating, saying that the forensic pathologist or the coroners aren't doing their job.

>> I think many people only get that realization when it actually touches them, when they have a family member who dies violently and they want to know what happened.

And when there are good answers to those questions, people are grateful.

If there are not good answers, there is no place for them to go to get an answer, so they have to take what's out there.

>> This one, I think I really should have... slipped up.

I should have done... >> BERGMAN: Remember Dr. Thomas Gill, who was coached in that murder case in northern California and was called an "incompetent pathologist" by the state bar?

A year after that trial, he left northern California to do autopsies in Kansas City, Missouri.

In Kansas City, Dr. Gill made news again.

An independent second autopsy revealed that a man Dr. Gill said committed suicide actually died from an injury sustained in a car accident.

>> Deputy Medical Examiner Gill told KCTV 5 in March, "Mistakes happen."

>> At times, even though we do our best, new information arises which necessitates an amendment being made.

>> BERGMAN: Eventually, Dr. Gill left Kansas City, and that's when he made the most surprising move of his career.

(phone ringing) >> Good morning, Dr. Gill.

How are you today?

>> BERGMAN: We found Dr. Gill back in northern California, performing autopsies for the same company he was working for before-- the Forensic Medical Group, or F.M.G.

>> He may have had problems in the past-- I know he had a problem with drinking-- but it... he doesn't have that problem anymore.

>> BERGMAN: Dr. Arnold Josselson is one of the owners of F.M.G.

You think Dr. Gill is a competent forensic pathologist?

>> I do, yes.

>> BERGMAN: And you believe he performed well in Sonoma County?

>> Yes, I do.

>> BERGMAN: Records show that trial fell apart because he was being coached to create answers in his testimony.

>> Yes, I'm aware of that.

>> BERGMAN: You haven't read the state bar report.

>> No, I haven't.

I didn't even know there was one.

>> BERGMAN: Did you ever look at those tapes-- they're available-- of what was going on in that coaching, what the issues were?

>> I've been told what happened, yes.

>> BERGMAN: But you haven't independently gone to look?

>> No, I haven't.

>> BERGMAN: And F.M.G., as an organization, hasn't checked that?

>> No.

>> BERGMAN: Or the records in Kansas City?

>> I haven't checked them.

>> BERGMAN: So he was hired back, but you're not sure why...

I'm trying to get a sense of... from what we've had people say to us is that he not only didn't tell the truth, but he didn't really know what he was doing.

>> All I can say is, when I've observed him and read his reports, he's very competent, and I think he's a good forensic pathologist.

>> BERGMAN: At the Forensic Medical Group, do you do quality control?

Does someone check your work?

>> Well, every jurisdiction doesn't do that.

Some of our jurisdictions do that.

>> BERGMAN: Some of the places you work for ask that someone check your work.

>> Yes.

>> BERGMAN: But others don't.

>> Right.

>> BERGMAN: So there's no standard there, either.

>> There's no standard.

>> BERGMAN: If a coroner who has a contract with you decided that they didn't want Dr. Gill, would you send them somebody else?

Is that basically how you operate?

>> Yeah.

He does not go to Sonoma anymore.

>> BERGMAN: But F.M.G.

does autopsies in 14 other counties in northern California, and public records allowed us to find Dr. Gill performing autopsies in one of them-- Yolo County, near Sacramento.

Though Dr. Gill declined numerous requests for an interview, he sent us a letter saying that, since he returned to California, there have been no questions about the quality of his work.

In northern California, F.M.G.

works for elected coroners, who are also the sheriffs.

In Yolo County, it's Ed Prieto.

Do you do background checks on the forensic pathologists who come to work here?

>> We a background investigation to make sure for criminal activity... if they've been involved in any criminal activity.

We make sure that their... their... their qualifitate... qualifications or certifications are valid, that they come with some reference.

So, yes, we do... we do that.

>> BERGMAN: Because we got the name of Dr. Gill, and he's had serious problems all over the United States.

>> Oh, really?

>> BERGMAN: And in 2006, out of a case that he was involved in in Sonoma County, the state bar concluded... well, they have a whole chapter here.

I can give it to you.

It says "incompetent pathologist."

>> Huh.

News to me.

I did not know that.

And I think you've alerted me to something that I... again, I always depend on the experts, and sometimes the experts don't really give you the right information.

So I think this is really... have alerted me to look into this a little bit further.

>> BERGMAN: After that interview, Sheriff Coroner Prieto requested that F.M.G.

no longer send Dr. Gill to Yolo County.

Then, F.M.G.

sent us a letter saying that "Dr. Gill no longer works for F.M.G., "as there is not the volume of work available to support him as a full time staff member."

Just before we went to air, Dr. Gill told us he's looking for a new job.

And remember Dr. Paul McGarry, the forensic pathologist in New Orleans who no longer works for Coroner Minyard?

Dr. McGarry never stopped working.

He's been doing autopsies for coroners in nearby Mississippi.

>> You can get a job in a medical examiner's office, in a coroner's office in many areas, because the political entity running the office doesn't care.

They have a set amount of money, and they're going to hire somebody.

They're going to fill the slot.

Now, if the person's not fully qualified, well, so what?

>> The problem is the powers to be are satisfied with the services that we give.

When the powers to be who control the pocketbook are satisfied with the services you give, you're not going to get change.

Now, the other problem is-- and I want you to put this on the screen in big, bold letters-- "Dead people don't vote."

Period.

Dead people don't vote.

If dead people voted, you know, I'd be elected governor, or president or something.

>> This investigation continues on Frontline's website: what the system looks like in your state.

>> I'm not anti-coroner; I'm pro competency.

>> Experts discuss how they would fix the problem.

>> Can you do it with the nuclear approach?

>> And basic facts of death explained.

And there's much more on Frontline's website.

Watch nearly 100 programs from our archive; explore interactive timelines and maps; and follow ongoing Frontline investigations.

Then, join the discussion at pbs.org.

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