In the Rush to Harvest Body Parts, Death Investigations Have Been Upended

Part 1 of a 2-Part Series

Part 2: How Organ and Tissue Donation Companies Worked Their Way Into the County Morgue

LOS ANGELES — When 69-year-old Marietta Jinde died in September 2016, police had already been called to her home several times because of reports of possible abuse. A detective described conditions at the woman’s home in Gardena as “horrendous.”

She was so emaciated and frail that the hospital
asked Los Angeles County adult protective services officials to look
into her death.

Yet by the time a coroner’s investigator was able to
examine Jinde’s 70-pound body, the bones from her legs and arms were
gone. Also missing were large patches of skin from her back. With
permission from county officials and saying they did not know of the
abuse allegations, employees from OneLegacy, a Southern California human
tissue procurement company, had gained access to the body, taking parts
that could have provided crucial evidence.

Coroner officials said police did not inform them of
the possible abuse complaints until 10 days after Jinde died. They said
they were able to complete their investigation by using the autopsy
exam, hospital records and photos, and determined that she died of
natural causes including severe heart disease.

After reviewing the autopsy report, Cyril Wecht, a
forensic pathologist who has consulted on many prominent death
investigations, questioned the coroner’s ability to make that
determination when the bones and skin had already been removed.

“We can’t be sure the bones weren’t fractured,” Wecht said. “This could have been a manslaughter case.”

The case is one of dozens of death investigations
across the country, including 29 in Los Angeles and San Diego counties,
that the Los Angeles Times found were complicated or upended when
transplantable body parts were taken before a coroner’s autopsy was
performed.

In multiple cases, coroners have had to guess at the
cause of death. Wrongful death and medical malpractice lawsuits have
been thwarted by early tissue harvesting. A death after a fight with
police remains unsettled. The procurement process caused changes to
bodies that medical examiners mistook as injuries or abuse. In at least
one case, a murder charge was dropped.

Organ procurement before an investigation is legal.
Over the last decade, California and other states passed laws requiring
coroners and medical examiners to “cooperate” with the companies to
“maximize” the number of organs and tissues taken for transplant. In a
handful of states the laws go even further, giving the companies the
power to force coroners to delay autopsies until they have harvested the
body parts.

Procurement companies’ lobbyists helped to write and
then push those requirements into law. As a consequence, the number of
deaths in which body parts are harvested has risen.

The laws have helped procurement companies delay
autopsies so they can remove hearts, livers and other organs intended to
extend the lives of Americans waiting for transplants.

But in far more cases nationwide — the vast majority,
in fact — the companies harvested skin, bone, fat, ligaments and other
tissues that are generally not used for life-threatening conditions.
Those body parts fuel a booming industrial biotech market in which a
half-teaspoon of ground-up human skin is priced at $434. That product is
one of those used in cosmetic surgery to plump lips and posteriors,
fill cellulite dimples and enhance penises. A single body can supply raw
materials for products that sell for hundreds of thousands of dollars.

In lobbying for the laws, the companies pointed to
papers published in professional journals stating categorically that
there has never been a single documented instance of organ or tissue
procurement interfering with a death investigation.

But the papers’ authors included procurement company
executives and others with undisclosed ties to the industry. And the
source of the claim was a short article in a 1994 American Bar
Association newsletter, which did not even discuss the donation of bone
and other tissues.

The expanded reach of the procurement industry has troubled some death investigators.

Melissa Baker, a former investigator in the medical
examiner’s office in Pierce County, Wash., filed a whistleblower
complaint in 2015 after three procurement companies moved into that
county’s morgue to access cadavers.

“One of my biggest concerns … was the mere fact that
someone could potentially get away with murder because evidence has been
bungled, lost or not collected,” she said.

An independent review of Baker’s complaint found
evidence was lost in a homicide case when the procurement team washed
the victim’s hands. Yet it said Thomas Clark, the Pierce County medical
examiner, was following state law by cooperating with the companies so
that parts could be removed without affecting his autopsies.

“No death investigation system is perfect,” Clark
told the Times. “Even in a system without any relationship to a donation
agency there’s a chance that somebody could be inappropriately
convicted. … There’s also a chance somebody is going free. I don’t think
that chance changes at all with donation.”

When someone dies unexpectedly, responsibility for
determining the cause falls to the coroner, according to California law.
At a minimum, a coroner’s investigator must view the body and determine
whether there are signs of trauma or foul play, according to rules
posted on the L.A. County website. But county records show that can be
impossible when bones or skin are missing at the time of that exam.

“Body was viewed at the (mortuary) and it was noted
that it had been harvested which prevented any further observations,”
wrote an L.A. County coroner’s office investigator after Santiago
Guimary Jr., 58, of Long Beach collapsed at a bowling alley in 2008 and
died shortly after.

In the case of Guimary and other Los Angeles deaths,
executives at the procurement company OneLegacy said they had followed
the law by obtaining authorization from medical examiners before
recovering tissue. Tom Mone, the company’s chief executive, told The
Times OneLegacy has received “no references to problems with autopsies”
from coroners and medical examiners it works with.

Jonathan Lucas, L.A. County’s chief medical
examiner-coroner, said he believed his office’s pathologists had been
able to use hospital records and other evidence to answer questions left
by the procurement of tissues or organs. Asked specifically about
Jinde’s and other cases, he said the autopsies met his office’s
“protocol and the statutory requirements.” He added that, in the opinion
of him and his staff, no criminal investigation or cause-of-death
finding had been impeded by the harvesting of organs or tissue.

The county’s contract with OneLegacy does contain
restrictions. Procurements from victims of suspected child abuse and
officer-involved homicides must be approved by a senior morgue official.

Another notable contract exception: Donation is “generally unsuitable” in cases of media interest, including celebrity deaths.

Cyril Wecht, former coroner of Allegheny County, Pa.,
who has consulted on many prominent death investigations, including
that of Robert F. Kennedy, reviewed the autopsies of Jinde and two
possible homicides, including that of a homeless man who died days after
a fight with a Santa Monica police officer. He said all three had been
compromised by harvesting of tissues or organs before the autopsy.

Wecht said he supported organ donation but not in sensitive cases in which there could be serious legal ramifications.

An L.A. County pathologist eventually ruled Jinde
died a natural death from heart disease. But Wecht said it was
impossible to know whether Jinde had been abused with the bones and skin
removed.

“We can’t be sure the bones weren’t fractured,” Wecht said. “This could have been a manslaughter case.”

Mark Flath of Agua Dulce said he pleaded with
OneLegacy not to take tissues from the body of his 18-year-old son
before the coroner had performed an autopsy. Jonn Flath, who had been a
varsity athlete in high school, sat down and died in 2011 while working
out with cadets in the Army’s ROTC program.

Because the teen had signed up to be an organ and
tissue donor, the family could not stop the procurement. OneLegacy took
bones and other tissues, including his heart for its valves, which are
sold as medical devices. The L.A. County coroner later could not
determine why the teen had died.

“You can’t begin to imagine what it’s like to learn
that they can’t complete the autopsy because they took your son’s
heart,” Mark Flath said.

Flath later sued the coroner and OneLegacy, saying a
deputy medical examiner had told him the county made a mistake in
allowing the company to harvest his son’s heart. But his lawyer
abandoned the case, Flath said, after learning that state law protects
coroners and procurement companies from lawsuits except in cases of
extreme wrongdoing. Flath tried to continue the case without a lawyer,
but eventually a judge agreed to the county’s request that it be
dismissed.

Lucas, the chief medical examiner-coroner, said his
office had received an assessment of the teen’s heart by a pathologist
employed by the company that processed and sold the valves. Those
corporate cardiac exams are more thorough than what coroners can do on
their own, procurement companies have assured death investigators.

After the company shipped what remained of the teen’s
heart back to the morgue, two other specialists also examined it, Lucas
said. It’s uncommon but possible for someone with “a normal appearing
heart” to die of a fatal cardiac arrhythmia, he said.

But even if a company has its pathologist examine the
heart’s remains for coroners — a now common practice — the review will
exclude crucial areas that are sliced off with the valves, Ann Bucholtz,
the former Ventura County medical examiner, warns in her book on
forensic science. And a study in 2007 detailed how the companies’ exam
after the valves have been removed cannot find abnormalities estimated
to cause 3% of sudden cardiac deaths.

“The real cause of death,” Bucholtz wrote, can be missed.

MOVING INTO THE COUNTY MORGUE

In 2007, the year the body parts harvesting laws
passed in California and many other states, the procurement companies
obtained just 2% of donors of bone, skin or other tissues through
referrals by coroners and medical examiners, according to a survey by
the American Association of Tissue Banks. Now, some companies report
that a majority of their donors come from those being wheeled into the
county morgue.

Mone, the CEO of OneLegacy, which operates in seven
Southern California counties, said about 63% of organ donors and 51% of
tissue donors came from the company’s partnerships with morgues in 2017.

“The law,” he said, “has been very beneficial.”

Although the numbers have risen, the cases still
amount to a small fraction of the total coroners investigate each year.
In the L.A. County morgue, where scores of toe-tagged bodies wrapped in
plastic are stacked on metal shelves in refrigerated crypts, there were
140 organ donors and 376 tissue donors in 2013, amounting to about 6% of
deaths investigated that year.

To increase the supply of harvested body parts, the
companies have embedded procurement teams inside government morgues
across the country.

Morgue officials often give the corporate employees
key cards so they can come and go, any hour of the day or night. The
companies rent rooms inside the morgues, including suites where surgical
teams harvest donors’ tissues.

In a growing number of counties nationwide, the
companies can log into government computer files on the newly deceased,
allowing them to swiftly find potential candidates for procurement.

In Michigan, a company called Gift of Life said
donations of bone and other tissues soared after its foundation gave
some coroner offices iPads loaded with special software to record
details of a death at the scene, which are transmitted instantly to the
company.

For several decades, federal rules have required
hospitals to alert procurement companies when anyone dies inside their
walls. With the new connections to government morgue computers, the
companies also know immediately about deaths outside hospitals — and
have contacted families when the body of a loved one is still at the
scene, according to written complaints made to supervisors by morgue
staff in Los Angeles and Tacoma, Wash.

“I was inside the residence performing my
investigation and the family was standing by outside,” Kim Pavek, an
L.A. County coroner investigator, wrote in an internal complaint about
OneLegacy after a suicide in 2008. “The decedent’s mother asked me why
someone from my office would call her cellphone during such a distraught
time. … She explained to me that someone from OneLegacy said they were a
representative from the coroner’s office inquiring about ‘donating
parts.’”

Anthony Maldonado, a OneLegacy executive, said the
company’s employees would never present themselves as working for the
coroner.

COMPANIES AID IN AUTOPSY WORK

The companies — and many coroners and medical
examiners who have partnered with them — say tissues and organs can be
procured with no harm to the death investigation when the two sides work
closely together. The companies say their employees can take photos of
the bodies and the harvested organs. And they offer to have their
employees testify at trials about the body’s condition.

The companies also have agreed to quickly alert
coroners when they find unexpected injuries or signs of abuse and then
document what they find for use by investigators.

“If there’s something they encounter that they don’t
know what to do about, they stop and call us and we tell them that they
can either proceed or that they can’t proceed,” said Clark, the medical
examiner in Pierce County, Wash.

One result is that many coroners increasingly depend
on the procurement teams — who have little if any training in forensic
investigation — to gather crucial evidence, even in possible homicides.

In Ohio, Lorain County Chief Deputy Coroner Frank
Miller said in a 2017 deposition that he regularly relies on information
from surgical technicians at Lifebanc, a procurement company, to help
prepare his autopsy reports. The deposition was taken in a lawsuit filed
by the family of 17-year-old Vanessa Webb, who had died unexpectedly.
Vanessa’s mother had given Lifebanc permission to harvest her organs
before the autopsy — under pressure from the company and the coroner,
she says. Miller could not determine why the healthy teen had died.

“This is what we’re always on Lifebanc about — are
there clots, is there blood, is there an accumulation of blood, is there
anything else unusual,” Miller said in the deposition. “So they know to
look for it, and they’ll preserve it if they find it.”

Miller said he was able to do a full autopsy with aid
from the procurement companies. A Lorain County lawyer said the
government couldn’t comment on the litigation, which is still pending. A
lawyer for Lifebanc said the group disputes the lawsuit’s allegations.

In his deposition, Robert Rolley, a former Lifebanc
employee who harvested Webb’s tissue, explained how Miller, the coroner,
had called him during the procurement for descriptions of the lungs and
heart.

“I was on the phone with him, somebody was holding
the phone to my ear as I was looking in the chest,” Rolley recounted
during another deposition.”I was on the phone with him, somebody was
holding the phone to my ear as I was looking in the chest,” Rolley
recounted during another deposition.

Rolley said he told Miller he wasn’t a pathologist
and didn’t want to be held accountable. Asked by the lawyer whether he
felt he had been appointed an assistant coroner, Rolley replied, “That’s
kind of the unfortunate position I was put in.”

DAMAGED INVESTIGATIONS IN SOUTHERN CALIFORNIA

A body is the primary evidence in a death
investigation, and protecting it from being contaminated is so crucial
in sensitive cases that families aren’t allowed to touch it, according
to written procedures at the L.A. County coroner. If there is a
potential criminal investigation, families are discouraged from even
seeing the body. “The body should not be disturbed in any fashion,” the
guide states.

Meeting those guidelines can be difficult when the deceased becomes a donor.

To determine the effect of the companies’ work inside
Southern California morgues, The Times reviewed thousands of digital
death records obtained from medical examiners in L.A. and San Diego
counties to identify those mentioning procurements and obtained the
autopsy reports, some dating from the early 2000s.

Neither county would provide a complete list of those
deaths. Three other large California counties also refused to provide
that information. At least two counties — Los Angeles and Sacramento —
made that decision after discussing The Times’ requests for documents
with the procurement companies.

Despite the limited review, The Times found at least
29 cases in which the procurements made it harder to determine the cause
of death. In 12 of those cases, coroners were unable to conclude either
why or how the person died. The cases included possible homicides,
highway accidents, deaths after surgeries, a drug overdose, a suspected
suicide and a death that followed a fight with a police officer. The
deceased ranged from homeless people to members of wealthy families,
although more were poor than rich. Most were middle-age or younger. One
was a child.

In at least five cases, the documents show that
companies harvested body parts without reporting what appeared to be a
death from a crime, an accident or suicide to coroner officials.
California law requires any person in charge of a body who has knowledge
that the death may have been from unnatural causes to immediately alert
the coroner.

A crematory employee called the coroner nine days
after William Paul Kennedy died in 2012 to report that the cause might
have been an auto accident. The coroner found evidence of the crash —
multiple rib fractures, as well as bruises on his chest and eyes — even
though a procurement team had already taken bones and sections of skin.

It is impossible to know how many other suspicious,
violent or accidental deaths have not been reported or investigated as
companies hurried to procure organs or tissues before they became
unusable for transplant.

Lucas, the L.A. County medical examiner, said his
office “cannot control when a death is reported.” Mone, the OneLegacy
executive, said the company had been informed that Kennedy’s death was
not a case for the coroner.

The Times found that Southern California medical
examiners give approval for the procurement of organs even when
detectives are investigating the death as a possible homicide.

Many forensic experts say organs can be donated with
no effect on the autopsy when the cause of a homicide is obvious — such
as a gunshot to the head. In those cases, the procurement surgery
happens away from the fatal wound.

But Southern California medical examiners have also agreed to donation in cases in which the cause of death is not clear.

Guillermo Valencia, 39, was found lying unconscious
in an alleyway in East Los Angeles, blood streaming from a 2-inch gash
in the back of his head in 2008. His nose was fractured. His left eye
was red with blood. Even though deputies were investigating whether
someone had beaten him to death, OneLegacy got approval from his family
to harvest his organs and tissues.

In the autopsy report, Louis Pena, a deputy medical
examiner, detailed how he found internal injuries but could not tell
whether they were caused by violence, an accident or by technicians
harvesting organs. He also wrote that because the technicians had
procured most of the heart’s aorta he could not rule out that Valencia
had suffered an aneurysm, possibly causing him to fall and leading to
the injuries. That would have cleared the suspicions of foul play.

Pena eventually concluded that Valencia died of
blunt-force trauma to his head but said he did not know whether it was a
homicide, accident or natural death.

OneLegacy said the coroner had allowed the donation.
Lucas, the chief medical-examiner-coroner, said he reviewed the case and
did not believe the procurement affected Pena’s investigation.

Pena, now a medical examiner in San Francisco, declined to comment.

IN SAN DIEGO, A BRUTAL BEATING OR ACCIDENT?

At UC San Diego Medical Center in February 2013,
doctors and nurses suspected violence as paramedics wheeled Christy
Rettenmund’s battered body into the emergency room. Upon seeing a head
wound that had left her unconscious and bruises on her chest, arms and
legs, they called police.

The police thought they had a suspect. Just weeks
before, her boyfriend had been arrested on suspicion of domestic
violence, one of repeated incidents involving the couple. This time her
boyfriend’s account of the night had “numerous inconsistencies,”
according to a San Diego County medical examiner’s report.

Rettenmund died two days later. Despite the ongoing
police investigation, a medical examiner allowed the procurement group
Lifesharing to harvest her lungs and kidneys. During the organ recovery,
surgeons made an incision down the middle of her chest, where there
were multiple large bruises and abrasions, according to the autopsy
report.

A county pathologist later ruled that Rettenmund died
from her head injuries but said he did not know whether it was a
homicide or an accident.

Chief Deputy Medical Examiner Steven Campman told The
Times that he believed the organ donation had no effect on the autopsy.
“She died from head trauma, and we documented that well,” he said.

San Diego Police Lt. William Todd Griffin said his
office presented the case as a homicide to the county district
attorney’s office. “The D.A. made the decision not to accept this case
because the medical examiner could not make a final determination of
cause of death — accidental injury v. homicide,” he wrote in an email to
The Times. “Therefore there is no homicide case to prosecute.”

Wecht, the forensic pathologist in Pennsylvania,
reviewed the case for The Times and raised questions about its handling.
He said the medical examiner lost crucial evidence by allowing the
organ harvest.

“You don’t know the nature and extent of the
injuries, including to the internal organs,” he said. “When you have
someone who is suspected to have been beaten, you don’t give permission
for organ or tissue donation.”

Said her father, Merv Rettenmund, a former Major
League Baseball player: “I’ll be driving around and just cry for no
reason. You say to yourself, ‘Why would something have to happen like
that?’”

The boyfriend’s mother said she has no way to contact
her son and believes he is now homeless. The Times could not reach him
for comment.

HINDERED INVESTIGATION OF DEATH AFTER SURGERY

When performing autopsies of deaths after abdominal
surgery, guidelines say, investigators should examine the surgical site
with everything in its original place. That didn’t happen when Lilia
Verdugo, 40, died in 2003 after an elective hysterectomy at Sharp Chula
Vista Medical Center.

By the time Bethann Schaber, a San Diego County
deputy medical examiner, began an autopsy, Verdugo’s abdomen was little
more than a shell. Another medical examiner had authorized Lifesharing
to harvest her kidneys and liver, but the procurement group took more
tissues than agreed. .

The autopsy report said Verdugo’s bladder had been
cut accidentally, causing her to lose a pint of blood. George Lundberg, a
pathologist and the former editor in chief of the Journal of the
American Medical Association who reviewed the report for The Times, said
the “anatomic mayhem” caused by procuring organs next to the surgical
site made it impossible to tell what connection, if any, the accident
had to the death.

Campman, the chief deputy medical examiner, told The
Times he believes organ donation had no effect on the death
investigation. Sharp Chula Vista and Lifesharing said they could not
comment because of privacy laws.

PROBLEMS IN AUTOPSIES OF YOUNG CHILDREN

Medical examiners say among their hardest decisions
is whether to allow companies to recover organs or tissues from bodies
of children when there are suspicions of abuse. Crucial evidence can be
destroyed as surgeons extract organs. Previous, partially healed
injuries to ribs can re-fracture. Patterned skin injuries — where an
object used to abuse the child leaves an identifying mark — can
disappear as the surgeon cuts open the chest.

CT scans of the child’s ribs before the procurement
surgery can show fractures, but direct examination is often required to
determine when the injuries occurred and whether there were multiple
episodes of abuse, forensic experts say.

The procurement process can also change the body and
lead investigators to mistakenly believe they are seeing evidence of a
crime. When organ donors are left on ventilators for days, their brain
can fall apart, making it look like a child was shaken or abused, said
Jan Leestma, a forensic neuropathologist in Chicago.

Such errors can have catastrophic consequences. In
Montana in 2015, the parents of Harbor DeWaard, 6, faced a barrage of
questions from Gallatin County investigators, asking how their son had
suffered a head injury that a medical examiner said had led to his
death.

Three months later, another forensic expert said the pathologist had been misled by the disintegration of brain tissue that occurred after the boy’s death as his body was maintained on a respirator for two days until organs could be procured. The boy instead died of a virus, the expert determined.

Part 2: How Organ and Tissue Donation Companies Worked Their Way Into the County Morgue

———

Los Angeles Times staff writer Gus Garcia-Roberts and Times researcher Scott Wilson contributed to this report.

———

©2019 Los Angeles Times

Visit the Los Angeles Times at www.latimes.com

Distributed by Tribune Content Agency, LLC.