The headless, handless body of a woman covered with green algae was fished out of a lake in upstate New York. The hospital pathologist who performed the autopsy judged the slim, athletically built victim to be in her 20s and said she had been dead three weeks. A few days later, medical examiner Michael Baden autopsied the body and came to a startlingly different conclusion. Bone spurs on the woman's spine and her atrophied ovaries revealed that she was about 55 years old, and microscopic study of the algae indicated that the body had been in the water at least 1 1/2 years.
Far from being an isolated outrage, such a botch-up is shockingly common, claims Baden, co-director of the forensic sciences unit of the New York state police. In a new book, Unnatural Death (Random House; $17.95), he and co- author Judith Adler Hennessee present a fascinating and disturbing picture of a shamefully inadequate U.S. coroner system. About 7% of the 2 million Americans who die annually meet an untimely end, by murder, suicide or accident. By law, such deaths must be investigated. Though the public may believe that every coroner is a skilled sleuth like television's Quincy, fewer than 400 forensic pathologists -- medical doctors with advanced training in anatomy, laboratory testing and legal-medical investigation -- are on public payrolls; twelve states do not employ any medical examiners at all.
Often the coroner is a funeral-home director and sometimes even a tow-truck operator, whose primary ability is transporting bodies. The coroner frequently hires hospital pathologists to do the autopsy. Those unfamiliar with signs of violence may confuse gunshot entrance and exit wounds or may be unable to tell whether a fractured skull was caused by a fall or a blow. Or they may ignore important evidence, such as the contents of a victim's stomach or hairs and fibers left on clothing or skin.
As a result, the guilty often go free. People get away with murder in about a third of the 20,000 deaths identified as homicides each year; other murders go undetected. Misinterpreted evidence can also lead to the innocent being punished. Even worse, people are sometimes jailed for crimes that never occurred. The classic example: when an alcoholic dies after a fight, the police often assume that the assault killed him, but a careful autopsy may show a lethal level of alcohol in the blood. Bungled investigations can also create lasting controversies. Mistakes in the autopsy of John F. Kennedy fueled charges of a conspiracy and cover-up.
Moreover, public health is damaged by the lack of trained medical detectives. M.E.s are usually the first to sound the alarm about faulty product design, new diseases or social problems like child abuse. Says Dr. Donald Reay, Seattle's chief medical examiner: "Look how much the public knows about cocaine and firearms. That's because people are dying from drugs and gunshots."
Still, much valuable knowledge is being lost, according to the Centers for Disease Control in Atlanta, because there is no uniform method for collecting information on unnatural deaths. Increasing numbers of M.E.s believe their expertise can also serve the living victims of assaults. Dr. Charles Petty, chief medical examiner of Dallas, regularly checks bruised children brought to a county hospital to see if they are being battered.