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: The rumors were gruesome. Bodies stacked two a gurney as they waited examination by pathologist. The deceased arriving at funeral homes missing body parts. Families left in the dark for months waiting to hear how their loved ones died. In New Jersey, you didn't have to go far to hear about the dysfunction in the medical examiner's office.
: One of the problems we have with medical examiner systems is that the legislators tend to look at us as handling the dead. But everything we do is for the living.
: Reporters from New Jersey Advance Media spent more than a year pinpointing systemic problems in the medical examiner's office that went back decades. On this week's episode Abby Ivory-Ganja talks with Stephen Stirling and Sean Sullivan about how they dug into a system whose work often goes unnoticed but can have grave consequences.
: It's the kind of thing that really can destroy a family in the worst case because you know a lot of society is sort of propped up by having a good death investigation system even though you might not think about it on a day to day basis.
: I'm Tessa Weinberg and you're listening to the IRE radio podcast. If you asked Stephen Stirling how to find a good story he'd likely tell you to do other stories. Stephen's a data reporter for New Jersey Advance Media and he got tips to look into New Jersey state medical examiner system while working on another investigation called Heroin Town, a reporting project that came out in late 2015 and chronicled New Jersey's growing heroin epidemic. For that project Steven got data on opioid related deaths from the medical examiner's office. Red flags surfaced as he talked to sources and not all of them had to do with an increase in drug use. People were telling him the state's medical examiner office wasn't functioning like it should.
: I started getting tips from medical examiners within the system. It was like, "Hey you should take a look at this."
: Sources described a lack of oversight inadequate resources and a caseload that wasn't getting any lighter. So when the opioid investigation wrapped up he turned his attention to the medical examiner's looping in reporter Sean Sullivan. Their 18 month investigation found New Jersey medical examiners have rejected two thirds of the cases referred to them over the last two decades. If a case was accepted some offices took as long as three months to complete an investigation. Still pathologists were conducting more autopsies with a 20 percent smaller staff than a decade ago. All of this painted a picture of chronic mismanagement going back 40 years and that dysfunction was causing problems for real people. Many accused of unspeakable crimes or coping with the sudden loss of a loved one.
: It's the kind of thing that really can destroy a family in the worst case because you know a lot of society is sort of propped up by having a good death investigation system even though you might not think about it on day to day basis.
: Stephen's first step was to see if the tips he'd gotten while working on Heroin Town could be backed up by data. So he started putting in requests. But of course, getting the data he wanted wasn't so straightforward.
: It was not easy. This occurred entirely under the administration of Gov. Chris Christie. He had a pretty significant reputation for not being a good open data governor in my experience. You know I've been a data journalist in New Jersey for the majority of his governorship and it just got harder and harder to get data so that wasn't terribly surprising. But you know when we initially made the request, you know, the state outright denied us and then we made it a bit differently and we started negotiating, but they kept pushing us off. They initially quoted us several thousand dollars to get the data that we were asking for.
: Attorneys for New Jersey Advance Media got involved and threatened legal action. Ultimately the state backed down.
: And at the end of the day we ended up paying for postage on the cost of the CD that they put it on.
: During this early stage of the investigation. Stephen had been working by himself but just before the state relented and handed over the database he wanted. He reached out to Sean Sullivan who covers criminal justice and the attorney general for New Jersey Advance Media. In New Jersey, the state medical examiner sits under the AG's office. Here's Sean.
: He basically said to me like, "Hey what do you know about the medical examiner's office?" Now I had, I had been on the beat for nearly a year at that point. You know there's a lot of arms of the attorney general's office and this is one of the more obscure ones. So other than knowing that the top medical examiner position had been for years now I think at that point vacant. I didn't really know a whole lot. So we basically set off to kind of get our legs under us and figure out you know how is this system set up? How is it supposed to work and how does it fail?
: Shawn and Steven began researching while negotiations for the data were still taking place.
: They had, at one point, handed over a sort of a sample set which showed that there was some smoke there and we were pretty confident that that was going to be some fire.
: Because none of the problems they were hearing were new.
: I even went so far as to you know read into the clips and going back finding this 1979 report from the state commission of investigation that described widespread dysfunction in the system as far back as the late 70's. And what we were hearing from from sources was the conditions described in that report had persisted to this day.
: The role of the medical examiner is pretty simple. Figure out how and why somebody died. In New Jersey, a forensic pathologist will get involved for a couple different reasons things like murders, suicides, inmate deaths, workplace accidents and sudden infant deaths. But the reporters found that how well a death is investigated often boils down to where in the state that person lived or rather where they died. Here's why. The state's top medical examiner oversees two regional offices Northern and Southern, but those regional offices actually only manage a handful of counties and lack accreditation from the National Association of Medical Examiners. Five counties run their own independent offices and the remaining counties are overseen by three regional offices. That means the majority of the state isn't overseen by the top medical examiner.
: The State Medical Examiner who, in title is, you would think, oversees everything, but actually has no power to enact anything over any of the other offices in the state of New Jersey. So you end up with this mishmash of protocols and standards that are being carried out in various capacities some better than others and some not very good at all. But there is no oversight over any of those offices. So if somebody doesn't have an office that's up to snuff. There's nobody that can penalize them or you know take any action to get the ship back on track.
: The state's top medical examiner position had been vacant for years at a time because the system was dysfunctional. Two former state M.E.'s resigned in protest in 2003 and again in 2008 to draw attention to the problem. The job remained vacant for seven years. Across the country pathologists are in short supply and because of that many medical examiners have something called a medico legal death investigator. They're the people who come before the M.E. to decide if a pathologist is even going to accept a case. Stephen says they make up the backbone of the entire system in New Jersey but they're not doctors.
: They go through a training course when they are hired to sort of identify what would be a good and bad case and they ultimately make the call on whether or not a medical examiner's office is going to accept the case.
: The medical legal investigators are often the boots on the ground. In other states, medical examiners will go out to the scene of a death take a look around and have a stronger say in accepting or denying a case. But in New Jersey, understaffing issues meant they rarely have time the investigators notes can weigh heavily on an M.E.'s final ruling. Stephen and Sean found two-thirds of cases are turned away by the New Jersey ME's office, which is much higher than other similar statewide systems. If a case is accepted the medical examiner determines what kind of procedure should be done. Either an autopsy or an external viewing. Data shows New Jersey's pathologists are conducting nearly 30 percent more autopsies than they were 10 years ago while having 20 percent less staff. And there were more red flags. The National Association of Medical Examiners recommends an M.E. conduct no more than 250 autopsies per year. But in 2016, one New Jersey examiner did the equivalent of 444. Journalists had looked at New Jersey's broken medical examiner system over the years. But Sean says most of those stories were anecdotal. Examining a case that was mishandled or poorly investigated.
: Any anecdote can always be excused away and described as an aberration.
: Stephen and Shawn wanted to get at the system's underlying structural issues something no one had done before and the data was key. The State's database included 420,000 sudden death cases dating back to 1996.
: When we got this data set it was irrefutable. It showed how these anecdotes that would bubble up over time pointed to problems in the system. But this showed that those outliers were really just symptoms of systemic dysfunction and that didn't come from a single villain or a single crooked or incompetent person who was in charge. It came from the fact that the state for years had just not put the resources in place to have a functioning system.
: Understanding the systemic problems meant digging into four decades of history surrounding the office.
: I would say this was the most sprawling complicated investigation I've ever worked on and I think Steve would tell you the same thing just because in addition to the fact that we had so much data and there were so many stories out there we just found that this was such a little understood function of government.
: It took them a few months to learn about the system. A big part of their reporting process was just figuring out how things were supposed to work. Who decides which cases get seen by a pathologist, who can turn a case away and who goes to the scene of a death. Stephen examined data from other states to see how New Jersey compared and both of them spoke with experts across the country who could contextualize what was happening in their state. They found that even in New Jersey, some government employees didn't understand the ins and outs of the complex system.
: The State offices is called, you know, office of the state medical examiner. I paid one $130 for records that I thought were appellate decisions involving the office of the state medical examiner and what I picked up was a $130 worth of appellate decisions involving the State Board of Medical Examiners who are the board that decide whether to punish or suspend the license of doctors. So I had tapped into an agency that is so obscure that when I put in a records request I got records for a completely different agency.
: An essential piece of this story involves showing how the systemic dysfunction affected real people. That's where Valentino Ianetti came in. New Jersey Advance Media wrote a few stories about his case over the years. So he came up in a clip search. Starting in 2009, Ianetti spent more than three-and-a-half years in jail accused of murder in the stabbing death of his wife Pamela. A medical examiner initially ruled her death a homicide and Valentino was the only suspect. But the public defender assigned to Ianetti's case thought something didn't add up. So he hired a second pathologist to take a look. His findings revealed Pamela had taken enough oxycodone to lead to an overdose and that her stab wounds might have been self-inflicted. A third pathologist said Pamela's death was likely a suicide not homicide and charges against Ianetti were dropped.
: That was one of the hardest interviews of this whole thing because we had to sit across from him and ask him very graphic details about the death of his wife.
: Ianetti was released from jail nearly four years after his wife's death. Prosecutors said they dropped the charges because they didn't think they could prove them beyond a reasonable doubt. But they didn't declare Ianetti innocent and the ruling on Pamela's death certificate never changed. That means charges could still be brought against him at any time.
: It took a lot of convincing to get him to sit down with us. And I remember at one point in the interview he's sitting across from us he says, "If this story comes out, is this something that could actually help me in my case or is this just something that is going to help other people in situations like this?" And you know I had had to be honest with them and say I don't see how this actually helps your case. But you know the story that we're doing looks at a systemic problem and it might help people in the future and he said, "Okay, well that's good enough for me."
: Sean says Ianetti's case shows the importance of thorough investigations. Medical examiners work with the dead, but their findings can have a powerful effect on the living.
: That sort of gets to the heart of the problem we were trying to demonstrate here is that how important these rulings are and how crucial it is that they have the resources and the standards to make sure that situations like that don't happen.
: Throughout the investigation and Sean was also keeping up with daily stories on his beat covering criminal justice and the Attorney General's Office.
: With these longer term stories, inevitably there's a lot of waiting that goes in. I file hundreds of records requested a year and it takes time for those to come back. There's always parts in your day where you're waiting for a source to call you back or you're waiting for your editor to finally give you feedback on your copy. And those down moments are sort of the time that you need to squirrel away to do the small things that build into a big investigation. Things like checking in on your records request things like finally reading that report that it had been sitting on your desk. That's really the only way to sort of build towards this bigger project.
: Sean and Stephen's reporting process wasn't exactly smooth sailing. Sean said there was another set of obstacles. He called it typical obstruction on behalf of the state. The reporters had data experts and victims, but there was one piece of the puzzle they could never put into place. Sean and Steven never got to see an autopsy performed or get inside the facilities where sources told them bodies were stacked two to a gurney.
: You know the government doesn't really want to give you any more than they legally have to give you particularly in a case like this where there is a pretty clear indication of dysfunction.
: They also had trouble getting interviews with top state officials who could provide insight into how the system became so unruly. It took months of requests but eventually they got an interview with the state's top medical examiner.
: I had sources in state government telling me, "there's no way you're ever going to get that guy. What interest do we have in sitting him down with you?" And eventually we were able to make the case like, "look if you guys are doing something about this you need to lay it out here because the story that we have pieced together so far points to you know decades and decades of neglect and dysfunction. And so if there's a story to tell about efforts to fix that it's in your interest to sit down and tell" that eventually they relented and gave us an interview with the state medical examiner who really it was the first time since his confirmation hearing that he had really spoken publicly about this.
: The state's top medical examiner was confirmed in 2016 and since then things have started moving in the right direction. The state hired more pathologist and support staff, improved turnaround times on autopsies and brought in an outside agency to study the system and recommend changes. Still, sources told the reporters it's going to take time and some political capital to see significant improvement.
: There wasn't a person that we spoke to that was like, "No, I don't really, you know, they've got a good system there. I don't think this is a problem, you know, across the board." People said that New Jersey was a laughingstock in this arena and had been for a long time.
: There were moments in the investigation when Sean said they felt like they didn't have a path forward and that can be frustrating. But those moments can also work in your favor.
: But this is a situation where the State was telling us how impossible it would be to give us what we were looking for and eventually we were able to figure that out and get the database out of them and then we had to set out to find exactly how this process worked. And that was very discouraging because nobody really knew. So we had to sort of chart our path there and that sort of lack of a clear paper trail can be very discouraging to you as a reporter. But it can also be an indication that you're really on to something that nobody's really looking at because clearly this was a problem that people were aware of. And it was just a matter of figuring out the road map to connect all of these disparate dots.
: New Jersey Advance Media called the investigation Death and Dysfunction and it was published in December.
: You know I think most reporters will tell you that more often than not, there is some platitudes and then it falls by the wayside. The reception to this story was something else.
: It came out right when New Jersey's governor elect Phil Murphy was about to take office.
: I think it was within 15 hours of our story going up. Murphy pledged to support wholesale reform of the system.
: The story got a reaction from the State Senate too.
: Suddenly a Senate bill that had been introduced year after year and another version in the assembly. Year after year and going nowhere had some steam and within weeks of our story going up they actually held a public hearing where the medical examiner who was for month to month kept away from us now sat in front of a Senate committee at a public hearing and said, "Yeah this is a structural problem. We don't have the resources that we need. My people are underpaid. The heat is going out in my building. Somebody needs to step in and fix this." And so you know I've never worked on a story where the public reaction to it was sort of so swift and so robust.
: Stephen says the most memorable part of the investigation took place at the Senate hearing. One of his sources, a mother, came up to him. Her daughter had been featured in this story as an example of a questionable death investigation.
: The most powerful thing to me is the hug that I got from her because she felt like I advocated on behalf of her daughter. She felt I gave her daughter a voice which she felt this system and the people in charge of it have not. Ultimately, you know, whenever I do something like this those personal impacts are always the largest things for me. They're always the most rewarding things, are always the things that stay with me longest.
: Thanks for listening. Take a look at our episode notes for links to New Jersey Advance Media's investigation as well some additional reporting resources. On our next episode Allister G and Julia Carey Wong of the Guardian discuss how they confirmed a rumor about homelessness in America's largest cities. They found that in some cities officials had decided the solution was as simple as giving their homeless a one way bus ticket out of town.
: There's just a sense that some of the people in greatest need of help in one of the richest cities in the world are not getting it. And the evidence of that is all around you.
: You can subscribe to the podcast on iTunes, Stitcher or Google Play. Or wherever else you get your podcasts and you can spend hours listening to the stories behind some of the best investigative reporting in the country. IRE.org/podcast. The IRE radio podcast is recorded in the studios of KBIA. Abby Ivory-Ganja reported this episode. Blake Nelson draws our art for each episode. Sarah Hutchins is our editor. From Columbia Missouri. I'm Tessa Weinberg
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