25 Investigates: Medical examiner focused on completing new cases while old, unfinished cases sit in limbo

Sources familiar with the Medical Examiner’s office told 25 Investigates that the chief medical examiner is hyper-focused on keeping her office’s accreditation by completing all new cases within 90 days, while older cases remain pending and families wait.

BOSTON — Backlogs and delays have long plagued the State’s Office of the Chief Medical Examiner (OCME). In 2017 when Dr. Mindy Hull took the helm of the office, she made reducing the caseload and shortening turnaround times her mission. But, as 25 Investigates learned, that has come at the expense of older cases not getting the attention they deserve.

Two sources familiar with the Medical Examiner’s office tell 25 Investigates’ Ted Daniel that Hull is hyper-focused on keeping her office’s accreditation with the National Association of Medical Examiners (NAME). To keep that accreditation, NAME requires that medical examiners complete most autopsy reports in 90 days.

Internal emails obtained by 25 Investigates show Hull is prioritizing cases that are within that 90-day window. In one, Hull highlights cases that are in jeopardy of missing the mark. Cases that exceed the 90 days can no longer be counted toward accreditation, and may even jeopardize the agency’s status. And that means some families may end up waiting a long time to learn how a loved one died.

Content Continues Below

Michael D’Ambrosio of Charlestown has been waiting for more than four years to find out why his wife of 32 years, Debra, 59, died over Columbus Day weekend in 2015.

“They were doing emergency procedures on her. They were doing CPR and all kinds of other things and we were about 15 feet away when she passed away,” he said.

D’Ambrosio says he still does not know if Debra’s pre-existing health issues contributed to her unexpected passing. After repeated calls to the OCME, D’Ambrosio finally got a death certificate earlier this year, but the cause of death was listed as “Pending.”

“I got angrier as time went by. Each time that I called, and I was just given a fluff answer. ‘We don’t know why...We don’t have any answers for you. You can call back’ And I kept calling back and calling back and still have no answers after four years,” D’Ambrosio said.

Sources familiar with the Medical Examiner’s office told 25 Investigates that the chief medical examiner is hyper-focused on keeping her office’s accreditation by completing all new cases within 90 days, while older cases remain pending and families wait.

25 Investigates recently obtained a photo, taken over the summer of 2019 inside the OCME, which shows several boxes filled with cases dating back to 2012.

A spokesperson for the OCME says Hull is working to clear the backlog, and has significantly reduced it since taking over.

But, according to two 25 Investigates sources, older cases like Debra D’Ambrosio’s may not be considered pressing because they no longer help toward the coveted accreditation status.

“I’m just flabbergasted as to why it takes four years and still no answers and I wonder if I ever will get an answer for my edification and my children,” said her husband Michael.

An OCME spokesperson told 25 Investigates that Debra D’Ambrosio’s cause of death was determined last month. But, according to her husband, he has not heard from the OCME about a cause of death.

The D’Ambrosio story is a familiar one. Last February, 25 Investigates reported on two Massachusetts parents who waited years to find out how their babies died. Maggie Mancuso of Dorchester and Jodi and Jason Bissonnette told 25 Investigates’ Ted Daniel that on several occasions they were told by the medical examiner’s office that their cases were “not a priority.”

Last year, NAME threatened to pull the OCME’s fully accredited status because not enough cases were being completed by the 90-day period. But the OCME spokesman told 25 Investigates the office remains fully accredited, and in an emailed statement added:

“The Office of the Chief Medical Examiner is focused on providing comprehensive reports to family members, as promptly as possible, after thoroughly investigating cases. Under Dr. Hull’s leadership, OCME has made significant strides in reducing the number of open cases that had built up over years before her appointment, reducing this caseload by more than half, while shortening turnaround times in the new cases that come in every day. Dr. Hull has made it a priority to deliver these necessary services in a shorter period of time, and her staff has made significant progress in doing so, including prioritizing cases whenever possible for family members seeking information on their loved ones’ deaths.”

Related

Do you have a tip for a story that you think needs investigating? Contact 25 Investigates or leave us a message at (800) 883-6925. If your story is one we think we can dig into, we’ll contact you back.