State’s Medical Examiner Office says it’s making progress, but grieving families say more is needed

BOSTON — Delays in issuing autopsy reports and death certificates have plagued the State’s Office of the Chief Medical Examiner for years. Now, the agency says it’s well on its way to clearing the backlog.

But some families still searching for answers about a loved one’s death say the OCME needs to do better.

This week, grieving families took their concerns directly to the chief medical examiner, Dr. Mindy Hull, during a virtual meeting of the Commission on Medicolegal Investigation, which oversees the OCME.

“My wife passed away in 2015. I have written several times, I’ve asked for any notes, anything regarding her case. And I’ve received nothing,” said Michael D’Ambrosio, a widower from Charlestown who spoke during the meeting’s public comment portion.

25 Investigates first interviewed D’Ambrosio early in 2020.

He had been waiting for more than four years to find out how his wife, Debra, died after a sudden illness in 2015. Following our reporting the agency told D’Ambrosio her death was the result of internal bleeding. But he questions that finding because he said an autopsy was never performed on her, and he is continuing to press the OCME for answers.

“There’s absolutely no closure on this. It’s, you know, one day my wife was there the next day, she wasn’t with no answer. No explanation. It’s an impossible situation to be in,” he said.

The National Association of Medical Examiners (NAME) requires most autopsy reports be completed in 90 days.

As 25 Investigates reported last year, the OCME was working hard to meet the requirement because its accreditation depends on it. Cases that exceed 90 days – like Debra D’Ambrosio’s – no longer count toward the highly coveted accreditation. At the time, two sources familiar with the OCME told 25 Investigates that Dr. Hull, the Chief Medical Examiner, does not prioritize older cases because they don’t help her with accreditation. Internal emails provided by one of the sources showed Dr. Hull highlighting cases in jeopardy of missing the 90 day mark.

Maggie Mancuso, a Dorchester mother who waited nearly three years to find out the cause of death of her newborn son, also addressed the Dr. Hull during the Commission on Medicolegal Investigation meeting.

In 2019, 25 Investigates reported on Mancuso’s experience with the OCME. She told investigative reporter Ted Daniel that an OCME staff member told her on a few occasions that her baby’s case was “not a priority.”

Since then, Mancuso has made it her mission to improve the way the OCME communicates and treats grieving families.

“Hearing from a doctor would ease the family so immensely,” she told the commission and Dr. Hull. “It’s not an extensive phone call. It would just be a few minutes, just to tell the family exactly what’s going on at that moment.”

The chief medical examiner was receptive to Mancuso’s suggestion and assured her that it would be “taken into consideration.”

Dr. Hull also assured D’Ambrosio she would review the particulars of his wife’s case and “get back” to him.

“All I’m looking for is answers for my family,” said D’Ambrosio.

During the virtual meeting, Hull also laid out a number of recommendations to improve interactions with grieving families, including implementing a recorded phone line and the hiring of a communications coordinator.

In an email, a spokesperson for the OCME tells 25 Investigates:

“The Office of the Chief Medical Examiner remains focused on its core mission of determining the cause and manner of deaths that occur under violent, suspicious, or unexplained circumstances. Under Dr. Hull’s leadership, OCME has reduced the number of open cases preceding her appointment by more than 70%, while completing 96% of autopsy reports and death certificates on new cases within 90 days. OCME staff have made it a priority to deliver these necessary services in a shorter period of time without sacrificing accuracy, including prioritizing cases whenever possible for family members seeking information on their loved ones’ deaths.”