‘Never seen that done’: 25 Investigates questions Mass. medical examiner performance data

A national accreditation body for medical examiners’ offices has told Massachusetts’ Office of the Chief Medical Examiner to fix discrepancies in its autopsy data, 25 Investigates learned Friday – three months after 25 Investigates first began asking about the way the data was calculated.

The national accreditation standard is completing 90% of autopsies in 90 days.

Chief Medical Examiner Dr. Mindy Hull, appointed to her position in 2017, has long touted winning full accreditation in 2018 – a feat partly due to her office reporting faster autopsy turnaround times.

But the work of a handful of particularly slow medical examiners is now dragging down Massachusetts’ autopsy turnaround rate, 25 Investigates has found.

Dr. Hull removed the work of two poorly performing examiners from the performance data she sent to the National Association of Medical Examiners in December 2022 to renew her office’s accreditation, 25 Investigates found by reviewing dozens of pages of documents obtained through a public records request.

Hull also used a 94-day time period to calculate her turnaround data – a move she said provides time for administrative processing.

When 25 Investigates raised questions about Hull’s data, her office’s spokesperson Elaine Driscoll said the national accreditation body has allowed OCME to exclude some doctors and add four extra days in the past.

But NAME president, Dr. Joyce deJong, tells 25 Investigates, the accreditation body does not allow medical examiners’ offices to add extra days or exclude doctors with lengthy turn-around times.

“Transparency, accuracy, and integrity are fundamental principles that underpin the NAME I&A (Inspection and Accreditation) process and are crucial for ensuring the trustworthiness and credibility of forensic pathology practices,” deJong said in an email. “It is imperative to emphasize that turn-around times must be reported accurately without adding extra days. Additionally, excluding practitioners with excessive turn-around times, even those experiencing personal problems is not permitted.”

DeJong said that her group has asked Hull’s office to fix and resubmit its data.

“We appreciate your diligence in bringing this matter to our attention,” deJong told 25 Investigates.

25 Investigates is awaiting answers from deJong – and OCME – about what that means for the accreditation of Massachusetts’ medical examiners’ office.

DeJong said she understood 25 Investigates questions about the turn-around times and “the subsequent impact on OCME’s accreditation.”

“The OCME knows that turn-around times must be fixed calendar days; adding additional days or excluding certain practitioners is not allowed,” deJong said. “They have taken action to rectify the discrepancies in the reporting, and the full [Inspection and Accreditation] committee will discuss this matter at our next scheduled meeting.”

NAME offers voluntary accreditation to local and state medical examiner offices for a fee.

In the December report to NAME, Hull’s office said that a total of three medical examiners “struggle regularly to meet” the 90% in 90 days benchmark “despite active managerial efforts.”

“The efficient work of the remaining 18 medical examiners is able to absorb the deficiencies of any one of these doctors, but not all three,” the report reads.

Hull’s office asked for NAME to allow the exclusion of certain medical examiners from the turnaround time metric – a crucial benchmark that’s needed for accreditation.

“We do not believe this should negatively influence our turnaround time metrics and, as has been granted in the past, are asking that this exclusion be considered acceptable,” reads the OCME report to NAME. “We would be happy to discuss this further, and also would be interested in how other offices has [sic] dealt with medical examiners with chronic slow autopsy turnaround times.”

The office also asked NAME to again allow Massachusetts to use a 94-day window instead of the standard 90-day time frame.

“Please note that 94 days allows a four-day window for the administrative functions of the OCME to process a completed autopsy report and should be considered “on time” in reference to the 90-day turnaround time metric as it has been in past years,” reads the report.

Hull’s office defended its performance and efforts to improve efficiency.

“Abundant remedial efforts and resources have been allocated to help ameliorate the work performance issues of these physicians,” the report reads.

Hull also removed the work of two medical examiners from her office’s performance metrics in her latest annual report to lawmakers in February. She didn’t mention performance issues with a third medical examiner in that report.

“The reasons for their deficiencies continue [sic] to be personal, confidential, and protected matters and do not reflect a systemic problem within the Massachusetts OCME,” reads the report.

Lawmakers are currently deciding whether to boost funding for the Office of the Chief Medical Examiner as part of budget negotiations.

Hull is already one of the state’s highest-paid officials outside of the public university system.

Her office’s budget has ballooned from $9.7 million in the 2017 budget, to nearly $17 million in the 2023 budget.

That’s a 75% increase.

Democratic Gov. Maura Healey has proposed another boost to OCME in the 2024 budget: to just over $18 million.

Overtime has skyrocketed: from $277,000 paid in 2017 to $712,526 paid in 2022, according to 25 Investigates’ analysis of state payroll data.

Hull’s office has faced scrutiny for years.

Backlogs have left families waiting for years for answers about suspicious and unexpected deaths, as 25 Investigates has revealed.

Hull has refused to sign onto a bill to have her office sign off on pediatric autopsies, according to bill sponsor Democratic state Rep. Marjorie Decker.

Meanwhile, medical examiners in Massachusetts are performing autopsies at a slower and less frequent pace, 25 Investigates has found.

The state performed autopsies in 22.4% of cases in 2022.

That’s down from 27.4% in 2019, 25.9% in 2020, and 27.3% in 2021, according to OCME.

The national average was 38%, according to a 2021 U.S. Department of Justice Bureau of Justice Statistics report that relied on 2018 data. 

Former Gov. Charlie Baker, a Republican, reappointed Hull in October for another five-year term.

Decker told 25 Investigates that it’s time for Healey’s administration to hold Hull accountable.

“It’s been an office that’s full of a lot of excuses that really has a very strong resistance to accountability,” Decker, of Cambridge, said.

Decker said she’s heard from constituents frustrated with delays and responses from Hull’s office over the years.

“We’ve seen the reports that have come out that show that Massachusetts continues to fall short, comparing us to not only the national average but even to states like Connecticut,” Decker said. “We are not meeting the needs of families who are grieving and really deserve to understand why their loved ones died when it’s not clear.”

The Executive Office of Public Safety and Security declined repeated requests by 25 Investigates for an on-camera interview with Hull this year. In an email, an OCME spokesperson did say the office  “has publicly documented a detailed explanation of the analytical methods regarding administrative timeframes and related personnel matters.”

PARTIAL DATA

25 Investigates reviewed years of Hull’s annual reports to lawmakers – in addition to accreditation records obtained through a public records request – to look at how Hull is measuring and presenting her office’s performance.

Hull’s February report says that her office’s 21 medical examiners completed 94% of their work – autopsies, views and chart reviews – in 94 days or less for the fiscal year ending in 2022.

She then says that 19 examiners completed 91% of their autopsy reports within 94 days or less.

Hull’s report doesn’t state her office’s rate of completing autopsies alone.

In a footnote, Hull said she removed the work of two low-performing medical examiners’ data from that estimate because of their comparatively low performance.

“The work of two full-time medical examiners has been excluded from the autopsy report turnaround time analysis, having only completed a combined 62 (30%) of the assigned 142 autopsy reports within 90 days or less, far below the percentages of those of their peers,” Hull said in the lawmakers report.

Pathologist Bruno Dispasquale said it’s standard procedure to investigate when medical professionals fall below voluntary accreditation standards.

“Removing those certainly improves the statistics,” Dispasquale said of Hull’s calculations.

Eric Eason, a forensic pathologist who’s worked at medical examiner’s offices in Georgia – as well as Chicago at the height of the COVID-19 pandemic – said he’s not familiar with the practice of removing some medical examiners but not others from performance metrics.

“I’ve never seen those numbers excluded from an annual report before, never seen that done,” Eason said. “So I don’t know what that means.”

It’s not the first time Hull’s use of partial data has boosted her statistics.

In her March 2021 annual report, Hull told lawmakers that the national accrediting body let her exclude one medical examiner with a “health-related issue.”

“The small and temporary decline in on-time autopsy report completion reflects a health-related issue particular to one medical examiner, whose work output NAME allowed not to be factored into OCME turnaround time for accreditation purposes,” reads the report.

Hull’s report says her office sent an accreditation status report to NAME in December 2022 and received notice of continued accreditation from NAME in January 2023.

25 Investigates obtained copies of those records.

In the December report, Hull’s office went into further detail about the low-performing medical examiners – including noting that a total of three medical examiners were dragging down the turnaround rating.

“In total, the OCME recognizes three medical examiners, otherwise excellent at their work, that struggle regularly to meet the 90% completion of their autopsy reports in 90 days metric despite active managerial efforts; these medical examiners are the same ones repeatedly documented in this section of the annual report,” reads the report.

Hull’s office asked NAME for flexibility again: “We do not believe this should negatively influence our turnaround time metrics and, as has been granted in the past, are asking that this exclusion be considered acceptable.”

OCME spokesperson Driscoll defended the use of partial data for accreditation purposes to 25 Investigates.

“The 80 cases not completed within 90 days by the 2 doctors in question represents less than 1% (80/8458 * 100) of the total OCME caseload,” Driscoll said in an emailed statement. “While autopsy turnaround time is an important metric for NAME completion standards, this fact does not have an overarching effect on the quality or timeliness of work performed by the OCME.”

“OCME has always shared their rationale openly with NAME,” Driscoll said. “As an agency, we are committed to fully resolving any performance issues that arise while supporting our staff through difficult times. "

But Decker said 25 Investigates’ findings of Hull’s use of selective data in her performance metrics raises concerns about her leadership.

“I think that there have always been excuses,” Decker said. “She kind of makes up her own rationales. And quite honestly, at this point, it’s really Secretary Reedy and Gov. Healey that need to be asking these questions and demanding answers and holding her accountable. I’ve been baffled at what is a pattern over the years that I and my colleagues have experienced. And I’m just hoping under a new governor that we will see a different kind of accountability, even if it’s with the same secretary of public safety.”

Decker said she’s been asking similar questions of Hull’s leadership of her office for years to no avail.

“I’ve been asking these questions for years, and I have been met with a stonewall and it’s been enabled and it’s been allowed and empowered,” Decker said.

Hull defended her move and management of her office in her annual report.

“These medical examiners are assigned a very reasonable yearly workload and provided abundant workplace support,” Hull said in her February report to lawmakers.

And Hull denied any “systemic” problems: “The reasons for their deficiencies continue [sic] to be, confidential, and protected matters and do not reflect a systemic problem within the Massachusetts OCME. It is not unusual in such a large state-wide medical practice to experience individual work performance issues.”

As of January, the national accrediting body has stopped giving leeway to examiners’ offices who have been overwhelmed amid COVID-19.

“During the COVID-19 pandemic, the I & A Committee decided not to penalize an office solely because of temporary deficiencies related to case numbers and/or report turnaround times resulting from the direct and indirect impacts of the pandemic,” reads the inspection and accreditation section of the NAME website. “Please be aware that, effective January 1, 2023, this forgiveness will no longer be in effect.”

Hull’s office, however, didn’t see a huge increase in cases amid COVID.

The number of annual cases referred to her office ticked up slightly from 17,102 for the budgetary year ending in mid-2018, to 18,366 by mid-2021.

That’s a 7% increase.

The number of accepted cases also rose slightly: from 7,246 in fiscal year 2018, to 7,947 in 2021.

That’s up 10%.

Hull’s office also hasn’t reported problems filling vacant positions – a key issue in other states fueled by the persistent shortage of forensic pathologists nationwide.

90 DAY BENCHMARK

Hull has long touted the national accreditation group’s 90-day turnaround standard for autopsies as the key indicator of her office’s success in improving its performance.

“No measure illustrates the agency’s success more than its commitment to exceed the NAME national accreditation standard that medical examiners complete at least 90% of the death certificates and autopsy reports in 90 days,” she said in her February report.

In another section of that February report, Hull said her office has maintained “the national accreditation standard of completing 90% of autopsy reports in 94 days or less, which includes a four-day administrative period to finalize reports.”

But the standards for the National Association of Medical Examiners only state that the national standard is 90% of autopsy reports alone in 90 days or less.

Hull’s office defended its use of a 94-day period for accreditation purposes and pointed to NAME’s policy that provides inspectors “discretion and latitude” when weighing an office’s accreditation.

“From its first review of FY17 OCME data, the NAME Inspection and Accreditation Committee has always included the 4-day administrative period in the calculation,” OCME spokesperson Driscoll said.

But in her first annual report to lawmakers, Hull didn’t mention a 94-day period.

Hull said the OCME completed 58.3% of autopsy reports in 90 days from late October 2015 through September 2017.

From January to June 2018, Hull said the autopsy report completion rate was 85.4%.

She stressed her office was planning to meet the national standard “that requires 90% of autopsy reports be completed in 90 days of the postmortem examination.”

Hull pointed to “temporary circumstances of two full-time medical examiners (including extended leave) and adjustment of a prior full-time medical examiner to part-time contract work.

But Hull said the autopsy rate would rise to 90% for the full 2018 year once medical examiners resumed their duties and the office brought three more medical examiners on board.

Hull’s office won full accreditation in July 2018.

Starting in March 2020, Hull told lawmakers in her annual report that her office was providing medical examiners an extra four days to finish autopsies – and told NAME it was doing so.

“As noted to NAME in 2019 prior to receiving continued accreditation, OCME allows physicians a four-day procedural window to account for administrative processing,” reads her fiscal year 2019 report.

Hull said 86.6% of autopsies were “completed on time” from July through December 2018, with 90% of autopsies “completed on time” from January through June 2019.

Examiners conducted 88% of autopsy reports “on time” from July 2019 through June 2020, according to Hull in a report.

“As reported to NAME prior to receiving official notice of continued accreditation in January 2020, the OCME allows a four-day procedural window to account for administrative processing of reports,” reads her report.

Then from July 2020 through June 2021, she said 20 medical examiners completed 90.5% of autopsy reports “within 94 days.”

In this year’s annual report, Hull began to describe her 94-day time frame as the “national accreditation standard.”

“These efforts continue to be successful in maintaining the national accreditation standard of completing 90% of autopsy reports in 94 days or less, which includes a four-day administrative period to finalize reports,” the report reads.”

‘WELL-INTEGRATED PUBLIC AGENCY’

OCME spokesperson Driscoll said NAME confirmed that Massachusetts met its “‘90 in 90′ standard” in the latest round of accreditation.

“After a comprehensive review and analysis conducted by the independent accrediting body, NAME has continually praised OCME for its excellent forensic pathology services and confirmed that the agency is meeting its “90 in 90″ standard, which is a benchmark for accreditation,” Driscoll said in an email.

Driscoll emphasized that the two lower-performing doctors completed 80 autopsies outside of the 90-day standard – a small fraction of the office’s total caseload of thousands of autopsies, chart reviews and views.

NAME declined multiple requests for an on-camera interview with 25 Investigates over the past year.

In mid-March, Dr. Barbara Wolf, chair of the Inspection and Accreditation committee at NAME, sent 25 Investigates an emailed statement defending Hull’s office.

“[T]heir inspector did report that the OCME is a well-integrated public agency and its management is committed, not only to the high quality of service to their taxpayers but also to sensitivity and to preserving the functional integrity of each of their professional staff member,” Wolf said in an email to 25 Investigates.

But in response to follow-up questions from 25 Investigates, NAME President deJong sent a June 15 email that made clear that the group does not allow offices to exclude doctors from or add extra days to their autopsy turnaround rates.

DeJong praised Massachusetts’ medical examiners’ office for agreeing to fix discrepancies in their data.

“The dedication of the Massachusetts OCME, despite facing staffing challenges and handling a significant caseload, to delivering exceptional work is commendable,” deJong said. “The swift response and commitment to transparency and accuracy in rectifying the reporting discrepancies highlight their dedication to upholding the highest standards of forensic pathology practice.”

BACKLOGS, DROP IN AUTOPSIES

Hull inherited a substantial backlog of 1,612 autopsies following her October 2017 appointment.

Still, more than five years later, hundreds are waiting on autopsies in Massachusetts.

Under Hull’s leadership, the office slashed the backlog to 469 as of early 2021 – down from 708 a year earlier, a roughly 50% drop.

But the office’s pace has slowed in recent years: 381 cases remained unfinished as of February.

That was a 9% drop from 419 in February 2022.

And 25 Investigates finds Massachusetts is conducting thousands fewer autopsies each year.

Her office completed 1,903 autopsies in 2022.

That’s down 40% from nearly 3,200 in 2017.

And it’s down from 2,177 in 2021.

Instead, Hull’s office is doing thousands more examinations that don’t require dissection.

The number of such external examinations has increased from 2,728 in 2017 to 4,708 in 2022.

That’s a 72% increase.

The drop in autopsies in Massachusetts is in line with a growing trend in other states and countries worldwide.

Bruno Dispasquale, a pathologist, said when facing overdoses and a rise in COVID cases, external examinations can save time and money – especially for cases backed by lots of medical records.

But Dispaquale said autopsies can rule out foul play in deaths that may seem like overdoses.

“However, there is a chance that cases that appear to be an overdose or accidental death may actually have a foul play,” Dispaquale said.

OCME spokesperson Elaine Driscoll said in cases of suspected overdose supported by evidence, medical examiners decide whether an autopsy is required.

“In most cases, an external examination, toxicology, and thorough review of medical and investigative records are sufficient for a medical examiner to determine how a person died, therefore autopsies are conducted when necessary to determine the cause and manner of death,” Driscoll said in an emailed statement to 25 Investigates. “In certain cases, however, OCME performs autopsies even when cause and manner are readily apparent: these include suspicious deaths, homicides, unexplained deaths of infants and children, and other deaths in which criminal or civil legal proceedings are likely.”

About 60,000 people die in Massachusetts each year, according to OCME.

Of that number, about 8,000 are within the office’s jurisdiction.

Of those, about 2,000 receive an autopsy.

Driscoll said that Massachusetts’ medical examiner’s office also received more reported cases than the national average.

Massachusetts had 18,355 cases reported to the medical examiner’s office in 2022.

States saw an average of 7,180 reported cases in 2018, according to a 2021 Department of Justice report.

The DOJ report found states accepted 62.6% of cases on average.

Massachusetts accepted 8,458 of 18,355 reported cases in 2022 – or 46%.

A BALLOONING BUDGET

In 2018, Hull told lawmakers the department needed a bigger budget to keep up with the demand.

“[T]he OCME is facing an increased caseload, due in part to the opioid epidemic and staffing constraints,” the February 2018 report reads. “In recognition of these challenges, the governor’s FY 19 House 2 budget will include $1.75 million in new funding to reduce caseload burdens, improve turnaround time for completion of death certificates and autopsy reports, and more efficiently deliver services.”

Over the past five years, her office’s spending has risen 75%: from $9.7 million in the 2017 budget, to nearly $17 million in the 2023 budget.

Rep. Decker said she’s not satisfied with Hull’s explanation for why her office is doing fewer autopsies.

“This is an office whose budget has consistently gone up by the millions in the last several years,” Decker said.

“Why won’t you take accountability and to ask to explain why we are falling so short of the national average and our sister states nearby,” Decker said. “And yet money can’t be the issue because at one point several years ago, that was the issue. Well, that budget has gone up by millions every year.”

“So we’ve empowered her with things that she said at one point was a challenge or an obstacle,” Decker continued. “And yet the results not only are they not the same. They’re actually worse.”

Meanwhile, the number of employees in Hull’s office has increased from 89 as of early 2018 to 153 as of early February. 

Her employees were among the top paid state officials in 2022 outside of the public university system, according to 25 Investigates’ review of state payroll data.

Hull made about $417,000.

Medical examiner Janice Grivetti made $421,000 -- with $128,500 in overtime.

And medical examiner Anand Shah made nearly $401,700 – including about $125,000 in overtime.

Grivetti and Shah alone accounted for 36% of 2022 overtime.

So far in the 2023 budgetary year, Shah has made nearly $100,000 in overtime, while Grivetti has made roughly $60,000.

In her February report, Hull said her office has made strides in hiring despite a shortage of forensic pathologists nationwide.

Her office has invested in new technologies, including a telepathology service that allows medical examiners to analyze medical records, scene reports, autopsy images and other documents remotely.

And OCME wants to expand a pilot project to bury unclaimed or unidentified deceased people following examinations.

Her office has also expanded services in the Sandwich office from five to seven days per week and dedicated a new Westfield office for western Massachusetts.

AUDIT IN THE COMING WEEKS

A 2017 state audit found that under Hull’s predecessor, her office wasn’t completing autopsies within benchmarks needed for national accreditation.

The National Association of Medical Examiners’ accreditation standard for completing autopsies is 90% of autopsies in 90 days.

“NAME established these timeframes to promote the timeliness of death investigations, as delays may create financial hardships by holding up life-insurance payouts and other benefits to families and could hinder criminal investigations,” reads the 2017 audit.

The Office of the Chief Medical Examiner downplayed such concerns at the time.

“[A]gency reports and the admissibility of testimony in courts of law are not affected by NAME accreditation,” the office said in the report.

“While the OCME voluntarily sought accreditation by NAME, it did so in an effort to survey its operations so as to identify its existing deficiencies and garner information that would be useful in resource allocation,” the office said. “Additionally, while the OCME has chosen to adopt some of the NAME standards as goals for casework completion, there is no legal or formal requirement that it do so.”

“[A]gency reports and the admissibility of testimony in courts of law are not affected by NAME accreditation,” the office said.

OCME also disputed some of the audit’s findings and said it had overhauled its policies and procedures.

The 2017 audit found the Medical Examiner’s Office officials didn’t keep adequate records of data to support the information provided to lawmakers in annual reports.

“As a result, there is inadequate assurance that the information provided in these reports is complete and accurate,” reads the audit.

Auditor Diana DiZoglio told 25 Investigates Reporter Ted Daniel that her office will launch a planned follow-up audit of Hull’s office in the coming weeks.

“Overall, we’ll follow the money,” DiZoglio said. “Obviously, we’ll look at performance challenges. And obviously, you know, anytime serious concerns are raised, our office takes those concerns very seriously.”

This is a developing story. Check back for updates as more information becomes available.

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