Families can wait months, even years, for autopsy results from medical examiner

BOSTON — For more than a year, Jodi and Jason Bissonnette sought answers from the Medical Examiner’s Office about how their three-month old son died.

A happy and seemingly healthy baby, Thomas, died suddenly in his sleep in his father’s arms on February 4, 2018.

“I woke up and he was gone. He was gone,” said Jason through tears.  “I tried CPR; I did whatever I could."

Jason and Jodi were left racked with guilt. For 369 days, they wondered if they had missed a sign or did something wrong.

25 Investigates found the Bissonnettes are not alone. Many families across Massachusetts wait a long time to get answers – and death certificates – from the Medical Examiner’s Office.

The office of the Chief Medical Examiner is a state agency responsible for investigating all unusual and suspicious deaths.

In 2014, 25 Investigates revealed families waited months to find out how loved ones died.

Two years later, another 25 Investigates report exposed that delays persisted. Then in 2017 an independent audit found hundreds of overdue death certificates.

In each case, the ME’s Office said it was working to reduce the backlog.

But 25 Investigates found many grieving families are still waiting months, even years, to learn how loved ones died. Some have even been told flat out that their cases are not a priority.

“On top of thinking that you killed your son to have to deal with this extra - these phone calls, getting different answers, getting no answers, getting the run around - it's just too much,” said Jodi. “It's just one added thing on top of your worst nightmare.”

A police investigation found no evidence of foul play, and the Bissonnette case was assigned to Medical Examiner, where an autopsy was immediately performed. That was more than a year ago.

“They’ve never contacted us. No matter how many times we’ve contact them,” said Jodi, adding that she’s reached out to the ME’s office on at least six occasions.

For Maggie Mancuso of Dorchester, whose three-week-old son Ambrose died suddenly, the wait for answers was even longer.

“871 days I waited for a death certificate and the phone call that I received lasted less than one minute,” said Maggie, mother to three other children. “Less than a minute and they hung up on me.”

Maggie says the wait would have been longer had her State Representative, Dan Hunt, not gotten involved. After nearly three years of lack of answers from the Medical Examiner’s Office, she contacted her office for help. Just days after Hunt’s office contacted the ME demanding answers, Maggie finally got answers and a death certificate. Ambrose’s cause of death was listed as Sudden Unexpected Infant Death.

“In the beginning the conversations were cruel,” recalls Maggie. “Every time I called the overwhelming, overwhelming message, and it was said numerous times, every phone call I had was the baby is not a priority. Well, my baby is a priority. He’s my son, and he has a family that misses him dearly.”

Guidelines established by the National Association of Medical Examiners (NAME), the organization that governs medical examiners and forensic pathologists, require that “90% of all postmortem examinations be completed within 90 calendar days from the time of autopsy.”

According to figures the ME’s office provided 25 Investigates through a public records request, the 90 days requirement is being met in all categories except for children under the age one.

The data shows that 16 of the 56 infant death investigations assigned to the office in 2017 are still pending, and 26 of the 57 cases received in 2018 still have not been completed.

Jonathan Arden, president of NAME, say pediatric cases, by their very nature, require a more thorough investigation.

“They routinely take longer to complete than most adult cases,” said Arden. “You have to perform some additional studies and procedures on babies that you would not necessarily do in every adult autopsy. Pediatric autopsies more often require consultation by additional supporting experts.”

The Medical Examiner’s Office declined our request for an on-camera interview. But, in an email, said: “While some cases are more complex than others, the Office of the Chief Medical Examiner has taken steps to better serve the public by hiring more staff to improve caseloads and implementing a new oversight system to closely monitor turnaround times. The office understands that the loss of any family member can be deeply traumatic and will continue to focus on making sure all reports are as thorough and responsive as possible.”

25 Investigates’ Ted Daniel brought the stories of Thomas and Ambrose to Governor Baker, who in 2017 appointed Dr. Mindy Hull as the state’s Chief Medical Examiner. The Governor tasked Hull with clearing the backlog.

“She has done a very good job with the backlog that she had but obviously there is work that remains to be done there. Families shouldn't have to wait for three years, no,” said Baker.

A day after 25 Investigates inquired about Thomas Bissonnette’s case, his guilt-ridden parents say they finally got the answer they have been waiting for. His death certificate lists Sudden Unexpected Infant Death as the cause.

That has allowed the Bissonnettes to let go of some of the guilt, while holding on tight to the memory of their son.

The ME told 25 Investigates that as part of the ongoing changes under the new leadership they are working to improve communications with families and have hired more staff to ease caseloads and implemented a new oversight system to monitor turnaround times.