One of the most difficult things about losing her son was not knowing why. Rosanne Carruthers needed to understand how an active, outdoorsy man with no apparent health problems could drop dead at 34.
Carruthers, a nurse, performed CPR after her son, Neil, collapsed in their suburban Boston home. For more than a year, she wondered: Was there something more she could have done? And were her daughter and her grandchildren at risk, too?
For the Carruthers family and others across the country, long delays in receiving death certificates and autopsy reports from medical examiners can not only compound grief, but also can create financial hardships by holding up life insurance payouts and other benefits. The delays are driven largely by underfunding, a severe shortage of medical examiners and relatively low pay when compared with other medical specialties.
"It needs to change," Rosanne Carruthers said. "Families should not have to wait like we had to wait to find out things that could affect other family members."
- In Rhode Island, the chief medical examiner resigned in August after the state's national accreditation was downgraded. An inspection found there weren't enough staffers to handle death investigations - just five people to handle more than 1,200 cases in 2014.
- In Montana, state officials had to send bodies elsewhere for autopsies last summer after the state's only two forensic medical examiners qualified to assist county coroners quit. A review found "serious deficiencies" with a half-dozen child autopsies done by a former associate medical examiner, including missed, ignored or discounted brain injuries that should have prompted further investigation.
- In North Carolina, after an elderly couple died in a hotel room in 2013, it took the office six weeks to determine the cause was carbon monoxide poisoning. No one warned the public before an 11-year-old boy asphyxiated in the same room two months later. Police said blood tests on the couple were initially inconclusive and did not explain the delay.
In Massachusetts, it took more than a year for the Office of the Chief Medical Examiner to determine that Neil Carruthers died of complications from an undetected congenital heart condition. While his family waited for answers, his life insurance provider refused to turn over a $45,000 payout from the estate of his wife, who lost her battle with brain cancer two days after he died.
The chronically understaffed, mismanaged office has been beset by scandals that reached a crisis point in 2007, when the office misplaced the body of a man who was later found buried in a grave meant for another man.
The state's chief medical examiner was fired after a report found that the office had been so mismanaged it was "on the verge of collapse."
A 2008 review recommended 17 full-time forensic pathologists to deal with the volume of autopsies. Seven years later, the office has just nine full-time pathologists and two part-timers.
Medical examiners say that even if their legislatures allocated more money, they would still have a hard time finding enough forensic pathologists. The National Commission on Forensic Science estimates there are about 500 board-certified pathologists in the country, fewer than half of the 1,100 to 1,200 or more needed to keep up with autopsies.
The Massachusetts medical examiner's office has been trying for two years to hire more forensic pathologists, but not a single candidate has applied.
"It's icky work," said Dr. Todd Grey, Utah's chief medical examiner. "It's not something a lot of people are comfortable doing."
Another deterrent is the money. Pathologists who work in medical examiner's offices earn significantly less than those who work in hospitals - an average of about $185,000 compared with $335,000.
With many doctors facing heavy medical school debt, lower-paying government jobs are often not appealing. Federal recommendations approved in August would promote the profession and entice medical students by boosting salaries and forgiving student loans.
In Massachusetts, the medical examiner's office has taken steps to speed up and streamline, including conducting external examinations instead of full autopsies on an increasing number of bodies.
Doing external exams saves time but also carries some risks, "namely that unsuspected internal injuries will go undetected, undiagnosed medical conditions will go undetected and findings which would determine the manner of death, including homicides, will go undetected," Chief Medical Examiner Henry Nields said in a report to the Massachusetts Legislature this year.
Stephanie Deeley believes Nields' office should have done more to determine a cause of death for her sister, Kim Parker, who died at age 45 in March 2013 while walking her dogs. After nearly three years, the cause remains undetermined.
Deeley suspects her sister's husband, Richard Parker, killed her because he had been charged with throwing knives at her about two years earlier.
Kim Parker suffered from seizures, but Deeley said the medical examiner told her the autopsy did not reveal a natural disease that would account for her death.
Prosecutors instructed the medical examiner to test Kim Parker's blood for ricin because police had been called to the house in 2011 after Richard Parker tried to kill himself in 2011 with ricin he made, according to Deeley. But that test came back negative.
Nields also told Deeley in an email that if she had reason to suspect her sister was exposed to a particular toxin, his office would test for that.
"Why is it my job to find out? Isn't it their job to determine the cause of death for a 45-year-old woman?" Deeley said.
A spokeswoman for prosecutors said the death investigation remains open "pending any new information." Richard Parker denies any involvement in his wife's death, his lawyer said.
Improvements are being made, said Massachusetts Public Safety Secretary Daniel Bennett, whose agency oversees the medical examiner's office. Earlier this year, the medical examiner's office began hiring support staffers who collect medical records, police reports and information from families, sparing medical examiners leg work that can delay autopsy reports. The state has also hired a recruiter to try to hire more forensic pathologists.
"When you're a loved one waiting for that information, that's heart-breaking," Bennett said. "We understand how frustrating it is."