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Autopsy

On August 4, 1986, an ambulance was dispatched to 9109 Laura Koppe in northeast Houston, where emergency medical workers found an unconscious 17-month-old named Joshua Kibble. The toddler's 14-year-old mother, Claudette Kibble, explained that he was an epileptic who had suffered a seizure while she was bathing him. Seventeen hours later, Joshua Kibble was pronounced dead at Hermann Hospital's pediatric intensive care unit. By 8 a.m. the following day, his small body was on a stainless steel gurney at the Joseph A. Jachimczyk Forensic Center, his now-rigid features starkly illuminated by the skylights in one of the morgue's four autopsy rooms.

Dr. Eduardo Bellas, a forensic pathologist with the Harris County Medical Examiner's Office, began his autopsy on the 21-pound corpse by making the usual Y-shaped incision across the front of the abdomen. After removing the child's heart and placing it in one of the two overhead scales, Bellas noted that the organ weighed 35 grams. There were no thrombi, or indications of clotting, in any of the organ's four chambers, and the valves were intact. Bellas found nothing unusual about the pancreas -- it had the usual hammer-shaped configuration and size. The child's liver, spleen and kidneys were "smooth and glistening," the pathologist wrote.

Bellas also made incisions along the boy's back and lower extremities that revealed no evidence of contusions or hemorrhages. An examination of the head, which was 19 inches in circumference, did turn up a bit of subgaleal hemorrhaging in the vicinity of the occipital bone, which forms the bottom part of the skull. Removal of the back portion of the dead child's cranium also uncovered evidence of a slight herniation of the cerebellar tonsils and congested brain tissue. But those findings were not sufficient to raise suspicion -- at least by Bellas -- that there was something more to Joshua Kibble's death than what his mother had related. In signing the autopsy report, Bellas ruled that the boy had died of natural causes "as a result of epilepsy." The investigation into the child's death was closed.

In the next four years, the bodies of two more of Claudette Kibble's children would be taken to the morgue to be autopsied. Kibble would tell investigators that those two infant boys, like Joshua, died after suffering seizures that only she had witnessed. On the face of it, that explanation begged belief -- each of the three was born of a different father, greatly reducing the likelihood that they shared some genetic defect that would have contributed to their deaths. Nonetheless, the medical examiner ruled that the demise of the second child, like the first, was due to natural causes. The cause of the third death was listed as "undetermined."

Despite the suspicious circumstances, and in the face of pressure by the Harris County District Attorney's Office and other agencies, the Medical Examiner's Office steadfastly refused to change its rulings. It was not until last September, after Claudette Kibble allegedly had confessed to her own mother and murder charges were filed against the 23-year-old woman, that the M.E.'s Office finally ruled that the three boys were homicide victims.

Kibble's arrest and indictment came less than a month after the retirement of Dr. Joseph Jachimczyk as the county's chief medical examiner. For the previous 35 years, the imperious "Dr. Joe" had run the morgue almost as if it were his personal fiefdom, with little oversight from Commissioners Court.

Jachimczyk's departure occasioned a flood of tributes from inside and outside of county government. It also, for the first time in memory, opened the M.E.'s Office itself to a critical examination, from inside and outside of county government. As it turns out, the autopsies of Claudette Kibble's dead children weren't the only questionable postmortems performed in recent years. And other recent revelations -- of improper tissue-harvesting [See "Bitter Harvest," page 14] and double-dipping pathologists -- are casting a new and harsher light on Jachimczyk's operation of the office.

"Jachimczyk's retirement is recognized as an opportunity to make the Medical Examiner's Office more accountable," says a member of the 13-person committee searching for his replacement. "We're trying to get away from that cult of personality that contributed to that lack of accountability."

Few public servants have a building named after them; fewer still are so honored before they die, or at least retire. But in 1984, Commissioners Court paid homage to the county's longtime chief medical examiner by dedicating the Joseph A. Jachimczyk Forensic Center. The red-brick facility sits on Old Spanish Trail, not far south of the old Ben Taub Hospital, whose crowded, un-air-conditioned basement had formerly served as the county morgue.

Having the building in which he worked named after him is just one of many honors bestowed upon Jachimczyk (pronounced ya-HIM-check) over the years. He had arrived in Houston in 1957, after earning degrees in law and medicine and completing a teaching fellowship in legal medicine at Harvard. Three years later, he was appointed the county's chief medical examiner. Armed with his expertise in dual disciplines, Jachimczyk was considered to be on the cutting edge nationally in the field of forensic pathology. At his retirement, he was making $150,000 a year -- the highest salary in county government. His flamboyant character, and the sensational murder investigations in which he participated, would establish him as a local icon.

 

It was Dr. Joe who supervised the autopsy of Howard Hughes. He also led the forensic probe of the grisly mass murders committed by Dean Corll and Elmer Wayne Henley. His work has been portrayed in movies and chronicled in books, including Tommy Thompson's Blood and Money, an account of the deaths of Dr. John Hill and his society wife, Joan.

Jachimczyk is a diminutive, bespectacled man, but over the years he radiated a larger-than-life presence. Often, his own celebrity would transcend his many headline-grabbing investigations. Around the Criminal Courts Building, where he often testified during murder trials, Jachimczyk, with his trademark bow tie, seersucker suit and sometimes blood-stained white bucks, was known as a man with a wry, dark sense of humor. He seemed to relish shocking jurors with graphically gruesome photographs and testimony. But it was his formidable intellect that served him best, especially when he took to the witness stand in a murder trial. It also helped him quash any criticism, scrutiny or second-guessing of his office.

"He developed such a persona, and such a strong personality, that I don't think most people were willing to take him on," says one veteran of county government who did not wish to be identified. "He had an overpowering personality. He was intellectually intimidating."

But what some saw as pure intellect, others viewed as raw ego.
"Actually he wasn't that sharp," says a former homicide detective who also asked not to be identified. "Across the country, he was thought of as an egomaniac. And Dr. Joe is not the only ego out there. They should have built that building a whole lot bigger -- Dome size. But he was basically seen as a god. He had absolute authority. Nobody questioned him."

Jachimczyk first floated the possibility of his retirement in early 1995, during a county budget preparation meeting. Although he was 71 when he began signaling that he might finally step down, his decision apparently caught many in county government by surprise. Still, few were disappointed. When Jachimczyk suggested that the county might want to consider putting him on a retainer as a consultant, providing a nice supplement to his already tidy retirement pay, he was basically ignored. Jachimczyk gave his formal notice last May, a few months after Robert Eckels had taken over as county judge.

Kathy Winkler, an attorney who was an assistant to both Eckels and his predecessor, Jon Lindsay, says she had long been pushing for changes in the operation of the M.E.'s Office. But she found Commissioners Court reluctant to pursue any changes before Jachimczyk announced his retirement.

Winkler credits Jachimczyk with transforming the Medical Examiner's Office into a modern operation, but she says he and his lieutenants, especially chief investigator Cecil Wingo, Jachimczyk's most trusted assistant, were difficult to work with. Routine questions from the county judge's office about contracts, purchases or procedures were viewed not as requests for information, but as threats to their authority. The net effect, says Winkler, was a lack of accountability and an abdication of oversight by Commissioners Court.

"A couple of times I had to gently remind Cecil that the Court needed to know of, and approve of, the action the M.E.'s Office was taking," says Winkler. But Wingo and Jachimczyk, she says, acted pretty much without commissioners' approval when it came to making policy and purchasing equipment. Trying to work with Jachimczyk was a lesson in frustration for Winkler.

"Even though he was a septuagenarian," she says, "he held the reins so firmly that you just couldn't really get in there to see what was going on. And when I would call him up and ask him what was going on, he would go on at some length about something that was completely irrelevant to my question. So it became an endurance contest."

Winkler, who quit Eckels' office to move to Virginia last fall, says the new judge was receptive to her concerns and suggestions. It was she who persuaded him to conduct an exhaustive nationwide search for Jachimczyk's successor.

Finding Jachimczyk's replacement has proved to be a slow process, however. A search committee wasn't formed until shortly before his retirement became effective at the end of August. Jachimczyk is said to have refused a request to stay on the job until a new chief medical examiner could be hired, reportedly because he was miffed about not being retained as a consultant. In the interim, Eduardo Bellas, the pathologist who performed the autopsy on the first of Claudette Kibble's children, has been acting chief medical examiner. Bellas and the remaining five assistant medical examiners are all reportedly seeking the top post. (The Press attempted on several occasions to contact Jachimczyk, who did not re-spond. Wingo, who also has since retired, says Winkler's contention that the M.E.'s Office operated without much oversight is untrue.)

 

Although the search committee has not released the names of those who have applied, several chief medical examiners in other Texas cities have expressed interest in the job. Among them is Dr. Vincent Di Maio, who heads the Bexar County Medical Examiner's Office in San Antonio. Di Maio already has had firsthand experience with the work of the Harris County M.E.'s Office.

In 1990, after the third of Claudette Kibble's children had died mysteriously, Marie Munier, who then headed the district attorney's child abuse division, took the unorthodox step of asking Vincent Di Maio to review the autopsy reports on the deaths. The prosecutor, who was convinced that the children had been murdered, hoped that an outside expert such as Di Maio could help her build a case that would force Jachimczyk to change the rulings of his pathologists and enable her to bring murder charges against Claudette Kibble.

Munier refused to be interviewed for this story, explaining that she may eventually have to testify against Kibble. However, Di Maio confirms that he reviewed the Kibble autopsies and was dismayed by the conclusions reached by the Harris County pathologists, especially after the second and third deaths. He says it's reasonable that the cause of the first death was misdiagnosed, but not the last two -- especially the third one.

"The third one is a different ball game," says Di Maio. "This is the third kid in four years. All young. All dying suddenly. All having seizures or cardiac arrests that only happen when the mother is around.

"If you read the medical records, they tell you three things: the kid came in with retinal hemorrhages. And with retinal hemorrhages, you always thinks of something traumatic. Two, it's the third death. Three, all had different fathers. You're not dealing [with something] genetic. So, this third one, I would have definitely called a homicide. One, two, three, and you're out."

Although Di Maio told Munier that there was little doubt that all three boys had died as a result of homicides, the district attorney's office decided not to bring charges against Kibble without a ruling of homicide from its own county's medical examiner. And Jachimczyk and his assistants refused to budge, despite prodding from the D.A.'s Office, the Houston Police Department and Harris County Children's Protective Services -- all of which suspected foul play.

In fact, CPS officials were so sure Kibble was killing her children that immediately after the death of the third child, Quenten, the agency took custody of his fraternal twin, Quentenett, who eventually went to live with her grandmother.

Exactly three years later, in February 1993, Kibble gave birth to a fifth child, Calvin. CPS, which learned of the birth ten months after the fact, made no immediate attempt to remove Calvin from Kibble's custody, though the agency did decide to monitor the child's health closely and build a case file. (CPS officials say the agency was not informed of the death of Edward, the second child; if it had been, they say, the third death might have been prevented.)

In June 1994, 16-month-old Calvin was suddenly rushed to LBJ Hospital after his mother claimed that he, like his three dead half brothers before him, had suffered a seizure. Calvin was luckier than his half brothers: he survived, and CPS quickly won a court order to obtain custody of him. In the wake of the latest Kibble mystery, though, the M.E.'s Office still resisted changing its rulings in the three deaths.

"The Harris County Medical Examiner's Office used to be one of the best in the nation," sighs one frustrated CPS official. "I don't know what happened."

Last September 20, the day after Claudette Kibble allegedly confessed to her mother, representatives of CPS, the Houston Police Department's homicide division, the Harris County Sheriff's Department, the District Attorney's Office and the Medical Examiner's Office conducted a joint press conference at HPD headquarters to explain how the young woman could have gotten away with intermittently killing three of her children over the course of four years.

 

The other agencies delicately, but clearly, laid the blame at the doorstep of the M.E.'s Office.

"Without her confessions, I don't believe the cases would have cleared," HPD Sergeant David Ferguson said of Kibble.

CPS's Judy Hay was more direct.
"It's horrifying," Hay acknowledged, "but without the medical examiner's findings, our hands were tied."

Since Jachimczyk had retired three weeks earlier, it fell to his chief investigator, Cecil Wingo, to face the heat. Wingo, known around the morgue for his volcanic temper and among detectives for showing up at murder scenes in a white lab coat ("He thought he was Quincy," says one former lawman), bristled at a reporter's suggestion that the M.E.'s Office had "dropped the ball" in the Kibble investigation.

"You know, we've been carrying this confounded ball since 1990," barked Wingo, ignoring the fact that the first death had occurred four years earlier. "So it has been dropped since then. We've been carrying it since that time, and we've been doing our very best. We knew something was wrong, we just didn't know where to go to find out."

Wingo said his office had no way of knowing that investigators and doctors had been relying solely on Claudette Kibble's account of the seizures in each of the three deaths. Of course, all the other investigative agencies were aware of that fact, at least by 1990. And in the autopsy report on the final Kibble death, the M.E.'s own investigator almost screamed that there was something very suspicious about the death.

"Dr. Fowler [at the hospital] stated that decedent was examined and found to have retina hemorrhage, which is consistent with whiplash or shaking," wrote the since-deceased Ellis Means in his investigator's report.

Bellas, however, still contends there was not enough information available to make a determination of homicide in the three deaths. "If someone suffocates a child with a pillow, there will not be any signal any pathologist will have to verify, unless he has a confession or a witness. Without that, it is something that only God and the people who did the crime will know."

Since her arrest last September, Kibble has been incarcerated at one of the county jails, where she awaits trial sometime this spring. So far, few details of her statement to police have been made public, and HPD homicide detectives haven't explained exactly how, in their opinion, Kibble killed her children.

Her lawyer, Ricardo Rodriguez, says that Kibble has neither confirmed nor denied responsibility for the killings and will plead not guilty when she comes to trial. Rodriguez says the three pathologists who performed the autopsies on her children will be among the first witnesses called in Kibble's defense. The lawyer says he'll try to persuade a jury that those first rulings were correct.

"Those guys are very thorough and they are probably some of the best in the nation," says Rodriguez. "Their conclusion was that they could not pinpoint it. They can't say 100 percent that the deaths were caused by drowning or caused by strangulation, which is something the state is going to try to prove."

Rodriguez's strategy explains the reluctance of the D.A.'s Office to bring Kibble up on charges without homicide rulings from the medical examiner.

"When we have other evidence that perhaps the M.E. is not aware of," says District Attorney Johnny Holmes, "we go back to them and explain to them that we have a problem. If they still maintain their position, basically, we're stuck with it."

While Holmes allowed Munier to seek Di Maio's opinion on the initial autopsy reports, he says he wasn't comfortable relying on the testimony of an out-of-county medical examiner in a Harris County court. "First of all," explains Holmes, "he didn't see the body. He didn't see the tissues. All he did was review work-product of the guy performing the autopsy."

But last year, an assistant district attorney in Brazoria County bucked that wisdom in another case involving an autopsy by the Harris County M.E.'s Office -- and won.

Renee Goode, an active, blond-haired two-year-old, had gone to her father's home in Alvin for a sleepover on January 22, 1994. Her two half sisters and a female cousin were also there. It was a rare event, since Goode's mother and father had divorced before she was born. Shane Goode hadn't even expressed a desire to see his little girl until she was 18 months old. But when he asked his ex-wife, who lived in Clear Lake, if Renee could attend the slumber party, she agreed.

The girls had a grand time that night. They drank soft drinks, watched late-night television and stuffed themselves on pizza and s'mores. But the next morning, when the other girls woke up, Renee didn't. They discovered Renee's body on the floor near a sleeping bag, a bloody froth around her mouth.

 

Since Brazoria, like the majority of counties in Texas, does not have its own medical examiner, the local justice of the peace ordered that Renee's body be transported for autopsy to the Harris County M.E.'s Office, which, for a fee, conducts autopsies for 14 surrounding counties. As in the death of the first Kibble child, the autopsy would be assigned to Dr. Eduardo Bellas.

Since there were no obvious signs of trauma on Renee's body, Bellas removed the dead girl's chest plate by making the usual Y-shaped incision. An examination of her vital organs found nothing remarkable, with the exception of the windpipe. There, according to Bellas' report, "abundant bloody froth was present in the trachea and bronchial lumen." Bellas also noted there had been herniation of the cerebellar tonsils, which, like the irregularity found in the lungs, pointed to some kind of asphyxiation. In summarizing his findings, however, Bellas reached no conclusion.

"It is my opinion," the pathologist wrote, "that the cause and manner of death of the decedent, Katherine Renee Goode, are undetermined."

The family of Renee Goode, however, refused to accept that opinion. "Kids just don't drop dead for no reason," says Sharon Couch, Renee Goode's maternal grandmother.

After Bellas' report was released, Couch, a former private investigator, began her own inquest into her granddaughter's death.

Over the next several months, she would spend countless hours in local libraries, poring over medical texts and publications, hoping to find an illness or disease that matched the circumstances of Renee's death. She called authors of medical reports around the country. Whenever she thought she might have a clue, Couch would contact the Harris County M.E.'s Office. Usually, she spoke with chief investigator Wingo, who showed great patience while attempting to answer her questions. But each time she offered up another hypothesis on her granddaughter's death, Wingo would dissect and then disregard the theory. At one point, says Couch, Wingo even suggested that perhaps Renee had died after suffering a heart attack during a bad dream, a phenomenon that reportedly has somehow been recorded by doctors in the Philippines. He also suggested that perhaps Renee had suffered a fatal allergic reaction to a dust mite bite.

Although Couch's exhaustive research turned up no pathological reasons for Renee's death, it was not unfruitful.

"Every expert we spoke with always asked if it could have been asphyxiation," says Couch, adding that, each time, she would run that same question past Wingo. Each time, says Couch, Wingo -- who is not a doctor -- dismissed the possibility.

From the beginning, Couch says, she and her daughter had suspected that Renee's father was responsible. After ruling out almost every organic possibility for the girl's sudden passing, Couch decided to seek advice from a friend's brother who worked as a homicide detective for the Orlando Police Department. The detective referred Couch to Dr. William Anderson, an assistant with the Orange County, Florida, Medical Examiner's Office, who specializes in pediatric forensic pathology. After reviewing photographs of the death scene and the autopsy report, Anderson became intrigued by the case and agreed to perform a second autopsy if Renee's body could be exhumed. Brazoria County authorities, who had since learned that Shane Goode had taken out a $50,000 life insurance policy on Renee, naming himself as beneficiary, arranged for the exhumation.

In October 1994, after Renee's remains were unearthed from her grave near Hallettsville, Anderson began searching for the clues that might have been left behind by her killer. He wouldn't have to look far. A posterior incision, or a cut along the back -- something not done by Bellas during the first autopsy -- revealed evidence of hemorrhaging near the lower portion of the diaphragm, the muscle between the chest and abdomen, which was the result of "a sustained blunt force." Renee Goode had died from asphyxia or, in other words, she literally had been squeezed to death.

"The diaphragm was not actually cut out during the first autopsy," says Anderson. "It normally is. Therefore, they weren't able to see the area of the bruising. It should have been seen." The reason it was not, Anderson says, is that the autopsy was performed hastily.

Despite Anderson's findings, the M.E.'s Office refused to change its ruling. Sharon Couch says that when she asked why, she was told that what Anderson identified as hemorrhaging was simply the result of lividity, the pooling of blood in an area of the body after death.

The problem with that explanation, says Couch, is that Renee had been found lying on her stomach. If there had been lividity, the blood would have gathered in front of Renee's abdomen, not her back. And, since all of Renee's blood was drained from her body when it was embalmed, there was nothing left to produce lividity after she was buried.

 

Couch, obviously, is no forensic expert. But Dr. Linda Norton, who reviewed Anderson's report along with the photos of the death scene and autopsy tissue, is. And she concurred with Couch's opinion in a December 1994 letter to the Brazoria County District Attorney's Office. "The manner of death is, of course, homicide," wrote Norton, a noted private pathologist from Dallas who participated in the highly publicized 1981 exhumation of Lee Harvey Oswald's corpse. "Embalming would in no way create the muscular and soft tissue hemorrhages documented in the exhumation autopsy."

Later that month, Shane Goode was indicted by a Brazoria County grand jury. He was convicted of capital murder last August and sentenced to life in prison.

Assistant district attorney Jeri Yenne was the lead prosecutor, and she admittedly was apprehensive about trying a murder case by relying on an out-of-state pathologist rather than one from Harris County, as she usually does. But, she says, "There just comes a point in time when you've got to get out on that tree limb and let them saw it off."

"I don't fault the findings of the Harris County Medical Examiner's Office," adds Yenne, "but I didn't have to accept them. I went to the child death expert. To not do that would have been like having a child with a life-threatening illness and not looking further for the answer. I knew that some things weren't adding up. It would have been easier to ignore it, but it would not have been justice."

Sharon Couch says her experience showed her that Jachimczyk's office was above outside scrutiny and criticism. Because of that, she wonders, how many other mistakes may have gone undetected over the years?

"I didn't appreciate the fact that it was almost unprecedented to take on the Harris County Medical Examiner's Office -- to question them," Couch says. "I guess I was just foolish and naive because I didn't care what they said."

Bellas declined comment on the Renee Goode autopsy, other than to say, "Iaccept any mistake, and I'm not afraid to say, 'I don't know.' " Wingo said recently that the medical examiner's ruling in the child's death was not the result of a "professional deficiency" in the M.E.'s Office or a "failure to follow through on something."

"It was a professional difference of opinion," he explained.

Each month for the past two years, representatives from agencies concerned about the Houston area's high child mortality rate have met in hopes of getting a better idea of why children have died -- and what can be done to prevent future deaths.

The Child Fatality Review Team includes Children's Protective Services, the Harris County Child Assessment Center, the city of Houston and Harris County health departments, the police departments of Houston, Baytown and Pasadena, the Houston Fire Department and Emergency Medical Service, and the district attorney's and sheriff's offices.

The Medical Examiner's Office also is, ostensibly at least, part of the team. But the office hasn't been sending a representative to the team's meetings for more than a year, explaining it was too busy to do so and already had its own internal review process.

"They see no justification for participating," says Dr. Victor Ilegbodu, an epidemiologist from the city health department who chairs the task force.

That would seem odd, given Cecil Wingo's defense that the Medical Examiner's Office "knew something was wrong" in the deaths of Claudette Kibble's children "but just didn't know where to go to find out."

The team's goal, Ilegbodu explains, is to ensure "that the final cause of death really is what it is supposed to be" in cases it undertakes for review. To do that, each of the agencies supplies its records about the selected cases, with an eye to ascertaining whether there are discrepancies that might raise questions about the deaths.

Ilegbodu says the team's reviews have led it to request that the M.E.'s Office reconsider its rulings in several deaths. He declined to say whether the office had agreed to do so.

When Jim Mickelson of Children at Risk, a children's lobby group that supports the work of the review team, learned that the Medical Examiner's Office had stopped sending a representative to the monthly meetings, he fired off a letter to then-county judge Jon Lindsay. He got no response. A similar letter to Eckels a few months ago apparently will prove more fruitful: according to Ilegbodu, the county judge's office has instructed the medical examiner to resume its participation.

 

"Everybody's afraid to deal with the M.E.'s Office," says Mickelson. "One of the things that I was hoping that the team would be able to do is to dig in and ask some of these hard questions and to find out whether or not the Medical Examiner's Office is doing sloppy work."

Ilegbodu is more restrained in his appraisal of the M.E.'s Office, but his comments suggest that he, too, shares Mickelson's concerns about the quality of work at the morgue.

"We all have skeletons in our closet," Ilegbodu says, smiling. "But if we can do anything to prevent child deaths, even if it takes three, four or five reviews, I think it's worthwhile. It's certainly cheaper than the aftermath, the cost to society. The potential that's lost can't be measured."

Recent criticism of the Medical Examiner's Office hasn't been limited to law enforcement and social service agencies.

Texas law requires that someone acting in the capacity of a medical examiner be at the scene of murders or other trauma deaths before a body is moved. In Harris County, that is the job of the investigators who work for the medical examiner. Typically, they go to a scene, roll the body over and write down in their reports what the police say happened. Over the years, some homicide detectives have complained that there is no good reason for the M.E.'s Office to have its own investigators, since the information they compile is almost all secondhand and provided by police investigators.

Ironically, that complaint is echoed by lawyer Joel Androphy, who is suing the city of Pasadena on behalf of the family of a man who was found dead in his cell at the city's jail.

"People are too willing to take other people's word for what occurred," says Androphy, who is representing the widow of Moises DeLao in her $8.75 million lawsuit.

According to the report by the medical examiner's investigator, the 35-year-old DeLao, who had been arrested for public intoxication and jailed after it was discovered he had $1,000 in outstanding traffic fines, was found hanging in an isolation cell with an electrical cord around his neck. He was scheduled to be bonded out of jail later that day. His death was ruled a suicide.

DeLao's family believes he actually was beaten to death by Pasadena police (the department refused comment, citing the pending suit). The family's suspicions were raised by the details of the autopsy -- and what the autopsy report does not contain.

The M.E.'s Office determined that DeLao had three broken ribs, although none had been detected during an x-ray taken at Ben Taub Hospital after a fight with officers the day before his death. At the hospital, doctors stitched a cut under DeLao's left eye. But the autopsy report records what postmortem photographs also revealed: that DeLao had large contusions all over his face, especially around his right eye.

The medical examiner's report makes no mention of bruises or broken bones in DeLao's hands or fingers, even though, as Androphy points out, the inmate would have had to break a thick piece of Plexiglas in the ceiling of his cell to reach the electrical cord that supposedly was around his neck.

The lawyer argues that all the M.E.'s Office really had to base its conclusion of suicide on was the word of Pasadena police officers.

"What they had was a guy hanging," says Androphy. "The only contact that the Medical Examiner's Office had was with their own investigator. And his only contact was with the Pasadena Police Department. How do you determine it's a suicide unless you do an independent investigation? If they don't have the time to conduct their own investigation, they shouldn't be giving an opinion."

State law actually gives medical examiners the authority to conduct their own autonomous investigations into any suspicious deaths within their jurisdiction. A recent study by the Harris County Auditor's Office, however, suggests that the M.E.'s Office doesn't have sufficient personnel to perform the volume of work it's already burdened with.

The office's six pathologists performed a combined total of 2,851 autopsies, an average of 475 each, in 1994. The National Association of Medical Examiners recommends that a pathologist perform no more than 300 autopsies a year. To be certified by the national group, Harris County would, among other steps, have to more than double the number of pathologists, or assistant medical examiners, it employs.

By comparison, pathologists with the Dallas County Medical Examiner's Office perform an average of 330 autopsies a year. In Bexar County, assistant medical examiners conduct approximately 300 autopsies annually. When pathologists' caseloads exceed 350 autopsies a year, a medical examiner's office starts to take on characteristics of "a body mill," says pathologist Linda Norton, who testified in the Goode trial.

 

Pat Banks, who replaced Cecil Wingo late last year as the chief investigator for the M.E.'s Office, takes issue with any suggestion that corners are being cut at the morgue. Banks does acknowledge that the office is understaffed, but says that problem is at least partly the result of a hiring freeze implemented countywide by Commissioners Court.

However, the auditor's report on the M.E.'s Office revealed that the overworked pathologists have been giving priority to the autopsies they perform for 14 nearby counties. In a random sample of 31 in-county autopsies from April 1995, the auditor found that the reports on ten of them had not been completed after 180 days. Reports on the remaining 21 were issued 12 to 24 weeks after the bodies were examined. Meanwhile, reports on the so-called "private" out-of-county autopsies were issued within three to five weeks after the examinations. The auditor's findings were confirmation of a situation that District Attorney Holmes had long suspected.

"The whole idea about justice is that it be swift, sure and certain," says Holmes. "It is, I think, subject to legitimate criticism. You don't want cases lying around."

Generally, says Holmes, when a cause of death is fairly obvious prior to the issuance of a report by the medical examiner, his office will gamble and obtain a verbal verification from a pathologist to present to a grand jury. That's not a practice with which he's comfortable.

"[The pathologists] are pretty well pinned downed to [their opinions] when it's in writing and signed off on by the M.E.," he explains. "But you get into a swearing match if you say to the grand jury that [the victim] had no other problems, other than the gunshot wound to the abdomen, and later we discover from the report that he had an enlarged heart, a herniated liver and all the things that can contribute to death.

"That's not very responsible, to not have that stuff when we proceed to obtain a first-degree felony indictment. It's been the source of some concern and aggravation for a long time."

The auditor's report suggests that the reason reports on private autopsies are issued more expeditiously is because pathologists are paid extra to do them. Outside counties pay $900 for an autopsy performed by Harris County, and the pathologist is allowed to keep $400 of that fee. In 1994, those extra jobs provided the county's six pathologists with an average of more than $57,000 in income, on top of their annual salaries of $121,500.

"The ideal world would be," says Holmes, "pay the people what they're worth. And then their decisions won't be influenced by that. If Montgomery County [for example] wants us to do their autopsies, fine, sign up and pay your fair share of the cost. But this way, who gets the short shrift -- the Harris County citizen who comes in to the morgue with a gunshot wound to the head, or the guy that comes from Montgomery County for [extra money]?"

Controversies such as the Kibble case, the double dipping by the pathologists and, especially, the unauthorized tissue harvesting have moved County Judge Eckels to go public with his criticism of the Medical Examiner's Office. It's virtually the first time any of the M.E.'s operations have been questioned since the infamous Wanstrath case of the late 1970s, in which dogged homicide investigator Johnny Bonds refused to accept Jachimczyk's ruling of a double murder/suicide and later proved the deaths were performed by a hired killer.

"The tissue issue was especially troublesome," says Eckels. "I support the donor system, but the relatives are due more respect than having someone contact them after the fact saying, 'Oh, by the way E.' That is unacceptable."

It was Eckels who ordered the audit of the Medical Examiner's Office after questions were raised about the pathologists receiving extra income for private autopsies. Eckels favors abolishing the practice and seeing that pathologists' salaries cover their extra work. The audit also showed that the Medical Examiner's Office is seriously deficient when it comes to computerization. One former county official says Jachimczyk even resisted placing his employees on the county's computerized payroll system. Eckels wants to bring the office on-line.

He's also considering more sweeping changes. One idea Eckels is entertaining is the creation of a regional medical examiner's office to ensure that other counties pay their fair share of tests and autopsies, which the audit suggests they currently are not doing. Eckels also has given thought to privatizing some duties of the office, such as farming out pediatric autopsies to Texas Children's Hospital.

"Everything concerning the Medical Examiner's Office is on the table," says Eckels.

 

Meanwhile, Jachimczyk's replacement is not expected to be picked until the release next month of another review of the office by outside auditor Peat Marwick.

The 13-member selection committee appointed by Eckels and other members of Commissioners Court has been screening applicants, and three candidates already have been brought into Houston for face-to-face interviews. They are Vincent Di Maio, the chief medical examiner for Bexar County who reviewed the Kibble autopsies; Jeffery Barnard, Dallas County's chief medical examiner; and Joye Carter, the chief medical examiner of Washington, D.C. Carter, according to one member of the search committee, was especially impressive during her visit earlier this month. She was said to have been dismayed to learn that the assistant medical examiners receive extra money for private autopsies.

That there is at one least candidate for the job who looks askance at the double dipping is encouraging to Holmes. But the district attorney believes that Eckels may be engaging in micromanagement by trying to address the problems at the M.E.'s Office himself.

"Does [Eckels] want to be the M.E. and run it or do you want to hire somebody to do that?" asks the district attorney. "If I'm a commissioner, I'm not going to tell that person how to run the M.E.'s Office. First of all, I'm not qualified to. I wouldn't use this to install my particular philosophy in the Medical Examiner's Office. What you need to look for, and what I am looking for, is someone with the kind of talents, management skills and ability to take an office of that nature and run it in a responsible and appropriate manner."

But Eckels says now is the time for Harris County to determine precisely what kind of operation it wants.

"The people who are working the hardest on the search committee are the people who are going to be using the services the most," he says. "We want those groups to feel like they have a Medical Examiner's Office that is user-friendly and is in a partnership with those offices."

These days, the anxiety reportedly is high at the morgue as employees await the naming of Jachimczyk's replacement. "About half the people around here want the new medical examiner to shake things up," says the head of one division in the office, "and the other half doesn't. I want somebody to come in here and clean house.


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