FLORIDA

BERTHA W. HENRY, County Administrator

115 S. Andrews Avenue. Room 409 Fort Lauderdale. Florida 33301 954-357-7362 FAX 954-357-7360
MEMORANDUM
DATE: April4, 2012
TO:
Board of County .
FROM:
Bertha Henry, County
SUBJECT: Medical Examiner Review
As you recall, in response to the issue regarding handling of medication at the Medical Examiner's
Office, I enlisted the assistance of an independent consultant to review the operations and procedures of
the Medical Examiner's Office. County Administration has received the consultant's report and is
working with staff to address the recommendations and timeline for implementation. A copy of the
report is attached for your information.
I am also evaluating retaining additional resources to assist with the implementation of the
recommendations. This implementation can be done simultaneously with our search for a Medical
Examiner. While the report recommends a number of changes to policies and procedures in order to
achieve efficiencies and implement best practices, it does not note any significant deficiencies in the
quality ofthe work or product produced by the Office.
The search for the Medical Examiner is coming to a close. The interview committee convened last
week to conduct interviews. The committee composition included Pam Madison, Kevin Kelleher and a
representative of the Broward Sheriffs Office, State Attorney's Office, Public Defender, the Broward
Police Chiefs Association, the Florida Cemetery, Cremation and Funeral Association, as well as Miami
Dade Medical Examiner Dr. Bruce Hyma, who also serves as the Chair of the Florida Medical
Examiner's Commission.
I am currently working with the executive search firm to finalize the remaining due diligence issues with
the finalists and expect to announce a new Chief Medical Examiner next week.
Pam Madison will be contacting your offices to offer a briefing should you wish to discuss the findings
in more detail.
cc: Pam Madison, Deputy County Administrator
Joni Armstrong Coffey, County Attorney
Evan Lukic, County Auditor
John W. Scott, Inspector General
Broward County Board of County Commissioners
Sue Gunzburger Dale V.C. Holness Kristin Jacobs Chip LaMarca Ilene Lieberman Stacy Ritter John E. Rodstrom, Jr. Barbara Sharief Lois Wexler
www.broward.org
10900 Ulmerton Road
MEDICAL EXAMINER
Largo, FL 33778
District Six
727-582-6800
(Fax 727-582-6820)
Pasco & Pinellas Counties
www.co.pinellas.fl.us/forensics
March 13, 2012
Evaluation of the Practices and Needs of the
District 17 Medical Examiner
As the District Six Medical Examiner and Executive Director of the Pinellas County Forensic
Laboratory, I would like to thank Broward County for allowing us to help with the Medical Examiner
Office's efforts in improving the quality of death investigations for the citizens of Broward County. Our
agency is the second largest Medical Examiner Office employer in Florida and the only Florida Medical
Examiner District that administrates the local crime laboratory. Our Medical Examiner operation is
accredited by the National Association of Medical Examiners and the Forensic Laboratory is accredited by
ASCLAD-LAB to the newest ISO standards. We used our collective experience in 7 Florida Medical
Examiner Districts and years of service to accrediting bodies and commissions in this evaluation. We
began the evaluation of the office on December B'h. We approached this evaluation of the Broward
County Medical Examiner Office as knowledgeable fact finders for Broward County Administration. We
visited the office, interviewed and met with staff members, and discussed our findings with
representatives of Broward County Administration. The implementation of any of our recommendations
is beyond the scope of this assessment.
-Jon R. Thogmartin, M.D.
Executive summary
The District 17 (Broward) Medical Examiner Office is tasked with the determination of cause and
manner of death pursuant to Ch. 406 of the Florida Statutes. Despite being one of the larger
jurisdictions in Florida, the District 17 Office is not accredited by the National Association of Medical
Examiners (NAME). Neighboring District Offices of similar size possess such accreditation. As is typical
for most jurisdictions, decedent transport is handled by a contracted body transport company. The
office is one of a minority of Medical Examiner Offices that manages the county's indigent/unclaimed
decedent disposition program. The Medical Examiner Office is one of only two offices that perform local
DUI testing for law enforcement, and it is the only Medical Examiner Office that is tasked with a local
trauma management service. The District 17 Medical Examiner Office determines the cause and
manner of death appropriately in the vast majority of cases but lacks a coherent operational philosophy.
The death investigations that the office is obligated to perform by Florida Statutes suffer greatly due to
the performance of multiple tasks and functions that fall outside of their official duties. The DUI
program, management of Trauma Services, the indigent/unclaimed body program, frequent autopsy
observers, and acceptance of cases that fall outside of their official duties have significant negative
impacts on the statutory function of the office. After examinations, the decedents are not released in a
timely fashion. The Medical Examiner Office (MEO) takes possession of property and evidence that falls
outside of their statutory duties and retains such property and evidence for a longer period than
necessary. At the time of our initial evaluation, the office had numerous (almost daily meetings) which
take significant time away from official duties. The office possesses standard operating procedures for
many tasks and comprehensive job descriptions, yet the procedures are often not followed, and the
tasks in the job descriptions are often not performed. The MEO needs an experienced Operations
Manager. The Forensic Investigators need to be more involved in independent case decisions. The
office lacks a consistent, systematic approach to death investigations. Such a consistent philosophy
should be applied office-wide, and not based on the individual pathologist's desire for that particular
day. The pathologists have chronically lacked intellectual leadership and severely overuse technical
forensic diagnostic tools such as histology and toxicology to the detriment of the office. The backlog of
toxicology is primarily the result of overuse of service by the pathologists, and this is one of the office's
many obstacles to accreditation. The office would benefit from more efficient placement of employees
within the facility.
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Assessment and Recommendations
We have been assigned to evaluate the 017 Medical Examiner operations in key areas that we think are
essential in the proper operation of a Florida Medical Examiner Office.
Evidence/Property/Medication Handling
Medications: Medications collected as part of death investigations are secured but not routinely
counted. The current medication procedure is complicated and involves too many MEO staff members.
In many cases the MEO collects and retains medication that does not pertain to cause and/or manner of
death.
Recommendations:
The MEO should collect only medications when pertinent to the cause and/or manner of death.
The medications should be secured to prevent mishandling or theft. A single member of the
MEO staff should retrieve the medications, count and identify them, record the prescription
information, and then secure the medications until disposal.
The medication counts, identifications, and prescription information shall be available for the
purpose of determining cause and manner of death and to aid in determining appropriate
toxicology testing.
The medications shall at a minimum be randomly recounted prior to disposal by a second
rotated and randomly selected member of the MEO staff and disposed of after establishing a
procedure in liaison with law enforcement.
The transport company can be made into an effective gate keeper for shielding the office from
unnecessary medication transport. Unnecessary items could be left at the scene of death or
given to law enforcement.
Broward County may have to develop amended body transport contract language that
discourages unauthorized medication transport.
Property: The MEO collects property of decedents as part of death investigations. The MEO does not
have a consistent practice of releasing property in a systematic and timely manner. The Forensic
Technicians (FTs) are not allowed sufficient autonomy in handling and documenting property.
Recommendations:
Educate the staff of the MEO about the purpose of property procurement, and only when
serving the purposes of Ch. 406 should property or valuables be brought to the office.
The transport company can be made into an effective gate keeper for shielding the office from
unnecessary property storage. All such items should be removed at the scene of death and
given to law enforcement or, when appropriate, left at the location of death.
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Broward County may have to develop amended body transport contract language that
discourages unauthorized property transport.
TheFTs should be utilized more efficiently in documenting and handling property.
Evidence: The Medical Examiner Office often encounters situations where evidence pertinent to the
investigation of a crime is recovered at the scene of death or later at the MEO. The MEO often collects
and retains items of evidence that do not pertain to either cause and/or manner of death or a law
enforcement investigation. Soiled or wet clothing is being dried in a drying room at the MEO. As
described in the body transport contract, upon depositing the decedent in the cooler at the morgue the
transport company removes any sheets/blankets from around the delivered body.
Recommendations:
The MEO should only retrieve evidence pertinent to cause and/or manner of death. They could
assist law enforcement in retrieving other evidence, but this should only be at the specific
request of an investigating agency.
The Medical Examiner Office should encourage the law enforcement agency to retrieve
evidence prior to body transport.
If the law enforcement agency wishes to process the body for evidence at the morgue, the
Medical Examiner should cooperate but with insistence that the agency take the evidence with
them after procurement.
We strongly recommend not utilizing the drying room for evidentiary materials. Any aspirations
in regards to MEO involvement in evidence handling should be coordinated with the locally
funded crime laboratory.
The body transport company should not remove sheets/blankets from bodies after delivery of
remains.
The MEO should develop an evidence procedure in liaison with local law enforcement.
These processes should be part of a written procedure and operating philosophy.
Staffing/Organization
District Medical Examiner (OM E): Broward County is in the process of soliciting applicants for the
position of District (Chief) Medical Examiner utilizing a national search process. A search committee as
described in Ch. 406 will be used in the selection process.
Recommendations:
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Broward County should strongly consider hiring a DME that appreciates how the medical
concept of triage is useful in the practice of all branches of medicine including forensic
pathology.
The DME should be licensed upon hire, board certified in forensic pathology by the American
Board of Pathology, and possess sufficient administrative experience to run the D17 MEO.
Experience with acquiring NAME accreditation would be desirable.
Special attention should be paid to the candidates' knowledge of the mechanics of a medical
examiner operation in Florida, as well as, Florida laws and rules.
Associate Medical Examiners: The D17 MEO has had obvious difficultly with the recruitment and long
term retention of Board Certified Forensic Pathologists as Associate Medical Examiners (AMEs). The
office currently hosts an American College of Graduate Medical Education accredited forensic fellowship
program in which pathology residents are trained in forensic pathology. This program has been a good
source of replacement AMEs lost through resignation. Currently, the position is funded by Nova
Southeastern University, but the salary provided is low. The agreement with the University requires
that the Residency Program Director (RPD) possess appropriate professional and academic credentials,
yet the current AME in charge of the fellow is not board certified in Forensic Pathology.
Recommendations:
Increase the salary of pathologists that are board certified.
Broward County should strive to find a DME that is experienced, qualified, and ready to provide
the consistent operational philosophy and intellectual leadership all competent AMEs crave.
Broward County should ensure that any collective bargaining agreement language is in
alignment with Ch. 406 regarding the appointment of AMEs.
Broward County should consider continuing the fellowship program as it has repeatedly
provided replacements for the chronic loss of competent AMEs. The salary of the fellow may
need to be supplemented to acquire good candidates. The RPD should be a pathologist board
certified in forensic pathology.
The new DME should possess the fortitude to make the tough personnel decisions necessary to
build a staff of good AMEs.
Once the new DME is appointed, all of the AMEs appointments will terminate, and, for them to
continue performing forensic autopsies pursuant to Ch. 406, they must be reappointed by the
new DME. The interim DME is a candidate for the position. If he is appointed, no
reappointments are necessary.
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Administration: The Medical Examiner Office lacks a traditional Operations Manager. This position is
typically filled by an administrator that is skilled in management as well as vastly experienced in death
investigations.
Recommendations:
The MEO needs a knowledgeable Operations Manager who reports directly to the DME and has
extensive experience in death investigations.
The Operations Manager should supervise the non-physician staff members of the office and
have an excellent working relationship with the DME in a working relationship comparable to a
Chief Deputy or Undersheriff serving the Sheriff.
The new District Medical Examiner will likely wish to choose the person that fills this position,
and this is typical of many Medical Examiner Offices.
Investigations: The Forensic Investigators have functioned more as clerks than investigators. The
investigators take little ownership responsibility for their cases with identification, body release, or
follow up. The investigators are allowed no access to the networked autopsy photos or even their own
scene photographs. Two Forensic Investigators are utilized on the weekends; one to perform
investigations and one to answer the phones and release bodies. This is not necessary with the
adjustments we are recommending.
Recommendations:
Allow the Forensic Investigators to view autopsy photographs at work and, certainly, their own
scene photographs.
To improve the quality of information surrounding the death that should be provided to the
forensic pathologist, the investigators should attend every scene of death on apparent violent
deaths (non-natural manner of death) where the body is still located where found or where the
injury occurred. Such a change in scene procedure after decades of minimal scene work would
require a slow process of orientation for both the investigators and the law enforcement
agencies.
The Forensic Investigators should take ownership from acceptance to release of the deaths they
investigate and be as responsible as possible for all aspects of death registration, assistance with
identification, and supplemental reports.
Only one Forensic Investigator needs to be on duty on any holiday or weekend and that a lesser
paid, part-time, non-high risk retirement qualified clerical employee be used to answer the
phone. With changes in the body release procedure, only one Forensic Investigator is needed.
Chief Investigator: The position of Medical Legal Death Investigator Supervisor is currently vacant. If
the job description was followed, this person would be a key functional employee of the investigative
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section of the office. According to the MEO staff, the position in the past dealt primarily with the
disposition of indigent/unclaimed bodies, the unidentified and the occasional destruction of
medications.
Recommendations:
The vacant position of Chief Investigator will need to be filled by an individual that has sufficient
experience in death investigations, Ch. 406 and management.
The new DME may prefer to participate in the selection of the Chief Investigator.
Photographers: Broward County employs a full time photographer and two part time photographers.
The photographers perform multiple redundant and unnecessary photograph backups. The MEO does
not have an up to date photography SOP. The photographers are taking all of the pictures at a higher
than necessary resolution that is approximately lOx more than necessary. This results in the
photographs occupying excessive server space, slow downloads, and increased costs; furthermore, the
high resolution photographs impede the backups that are performed by Enterprise Technology Services
(ETS).
Recommendations:
Eliminate the photography positions and/or incorporate the positions into the FT staff. Train
theFTs to take and upload photographs or have the photographers perform other duties such
as technician work.
Reallocate the funds from the staff reductions to areas of the MEO with functional deficiencies.
ETS performs sufficient backups nightly. The data on the camera SD cards for the day can be
preserved for a day or two and rotated. The pictures could also be saved on a local hard drive.
The multiple daily CD production and watermark production can cease.
The Records Clerk should handle the simple process of reproducing these electronic records.
Forensic Technicians/Morgue Operations: The Forensic Technician (FT) staff aids the pathologists in
performing autopsies. They also perform radiographs, file histology slides, release bodies, and prepare
morgue paperwork. During one of our visits to the office, theFTs performed their duties with an
excellent level of skill and speed. The number of FTs appears commensurate with the workload. The
pay of theFTs appears to be adequate compared to other Medical Examiner Offices.
The body release procedures are unnecessarily complicated and are not completed consistently. The
body cooler inventory process is insufficient and the temperature is not monitored or recorded.
TheFT staff has limited knowledge of maintenance/repair contracts, warranties or vendor information
for critical morgue equipment to include the X-Ray machine and digital X-Ray receiver.
7
The processing of bodies is not complete until mid morning, and this limits the ability of the MEO to
complete the examinations in a timely manner.
TheFT staff and the pathologists are not adequately familiar with Florida Administrative Code 11-G.
TheFTs are underutilized in handling routine procedures within their capabilities and are permitted too
much autonomy in areas that should involve the pathologists. Many of these tradition based
procedures, hamper the routine morgue case throughput.
The MEO does not routinely collect a second set of fingerprints for law enforcement even when
requested.
Recommendations:
Streamline the body release procedure keeping all the paperwork, property and evidence in the
morgue area. Decrease the paperwork and logbooks.
Body release authorization should be verified with LABLynx data.
Do not permit funeral homes to pick up bodies without supervision by an MEO staff member.
Familiarize the MEO staff with all of the appropriate sections of FAC 11-G.
Begin body processing at an earlier hour.
Allow the FTs the appropriate autonomy.
The FT staff should become more responsible for the maintenance of the autopsy equipment.
The MEO should be more cooperative with law enforcement requests for fingerprints.
Organization: The following organizational hierarchy (as displayed in the chart on the following page)
has, time and time again, been demonstrated to be the optimum method of organization of a Medical
Examiner Office.
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District M.E.
I I
~ \
Operations
Manager
I
Deputy Chief M.E.
I
I
Chief
Toxicologist
Associate M.E.s I
I I
Toxicology Lab
I
Forensic
Techs
\
Admin.
Staff
Staff
Chief
Investigator
I
I
Investigators
I
The MEO currently has a gap of communication between the members of the investigative team, and
this is partially due to the way the MEO facility and staffing offices are arranged.
Recommendations:
We recommend a rearrangement of the work locations of the administrative staff and death
investigative staff, as well as, altering the main public access point of the building.
o The morgue (north) building should house the investigators, doctors, morgue staff, and
transcriptionist.
o The south building will become the main public access point. The building is closer to
the parking lot and is more visible and accessible by the public. The lobby of the south
building is larger, secured with glass partitions and has a service window. The south
building should house the majority of the administrative staff and the Toxicologists.
o Some of the cubicles may have to be moved to the morgue building.
o The investigative staff can occupy the space vacated by the receptionists, the space that
is currently public lobby area, and/or the offices and space currently used by the Trauma
Services staff. Some minor architectural alterations may be necessary in the morgue
building. The front area of the south building will easily accommodate the displaced
administrative staff.
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o The Trauma Management staff will have to be relocated (see discussion of Trauma
Services below).
Unidentified: By law, the identification of decedents is the responsibility of the investigating law
enforcement agency (Ch. 406.145).
The written procedure for unidentified remains appears to have been updated within the last 5 years.
An up to date list of unidentified decedents could not be produced. The D17 MEO contact E-mail that is
listed on the National Missing and Unidentified Persons System (NamUs) is not correct. Case files on the
unidentified persons are kept in various locations in the MEO. This makes it difficult to locate a file
when questions on the particular case arise.
The MEO is also somewhat slow in acquiring the information and samples necessary to make
identification possible. NamUs entries were not complete on many oft he unidentified bodies.
The MEO is overly dogmatic with many procedures involving identifying decedents resulting in delays of
body release.
Recommendations:
All D17 ME unidentified cases should be listed on NamUs, these entries should be complete, and
M EO contact information should be updated.
The Investigators should take ownership of their cases, including the unidentified, and should
perform all procedures that are reasonably necessary for identification in a timely manner.
TheMEO staff should become familiar with 406.145 and cooperate fully with law enforcement
as it pertains to decedent identification.
The MEO should employ science and common sense in assisting law enforcement in decedent
identification.
Tissue samples: The MEO retains routine tissue samples from autopsies as part of their official duties.
Some tissues samples are retained in the office longer than necessary. In some cases, the retained
tissue is not examined.
The office reuses containers and several of the older containers have the wrong name or have more
than one name and case number. On several containers the label was placed on the lid only, and this
could result in mislabeling at any time the lids are removed and switched.
Recommendations:
The office should write and implement procedures that govern the retention of tissue and
manages their destruction in compliance with Administrative Code 11-G.
Tissue storage containers should be consistently labeled.
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Histology: The Medical Examiner Office performs routine histology on almost every autopsy with little
discretion. The office pays an average $73,000 per year. FAC 11G requires histology in certain infant
deaths otherwise histology is performed purely at the discretion of the Medical Examiner. If samples
are taken for histology, they have to be processed ($9-10 each), read by the doctors, and filed.
Furthermore, the individual glass slides have to be archived forever. It is evident that the prepared
slides were not always examined. The MEO pays 2 Yz times more per slide than most Florida Medical
Examiners and pays for pickup and delivery.
Recommendation:
The pathologist should only perform histology when it is pertinent to cause and/or manner of
death and write a report of the findings.
Broward County should shop for a more affordable histology laboratory.
The cost saving should be applied to areas of the MEO that are deficient.
Media Relations: The MEO is a small office as compared to the Sheriff, but the frequency of media
interest in case work can be much higher than a law enforcement agency. The MEO has a reasonable
written SOP regarding media relations but in practice has an extremely poor process of dealing with
release of information to the media. The poor media relations practice has resulted in over reactive
changes in policy or establishing new policy in response to the erroneous release of information in the
past. The policies regarding "Police Holds", separation of homicide case files, and the policy of the MEO
shredding suicide notes all relate to poor media relations practices.
Recommendations:
For the time being, the MEO should designate a responsible person as the primary media
contact.
The MEO should hire a knowledgeable Operations Manager who would have the capability to
take control of media relations on a day to day basis and become a reliable trusted media
contact person.
Toxicology
Similar to histology, toxicology tests and quantifications are over utilized by the pathologists. This is the
underlying cause of the current and historical backlog of toxicology cases. The pathologists of the D17
MEO were disciplined by the Medical Examiners Commission approximately 10 years ago because of the
backlog. We estimate that at least 30% of the laboratory testing has no significant forensic value and,
considering the total cost of the Toxicology section is about $1.3 million, the excess cost is likely
significant.
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Recommendations:
The toxicology laboratory does need improvement in their policies and procedures (see
attached laboratory evaluation for detailed recommendations including grant and equipment
information).
Toxicology services should not be out sourced unless the backlog of cases continues.
The pathologists should order toxicology testing only as appropriate to determine cause and/or
manner of death or to remain in compliance with FAC 11-G.
Records: The public records at the MEO are stored in multiple areas and this includes MEO case files.
There is no formal designated flow for the case files. There is no formal written and implemented policy
regarding records, specifically the process of the case file, public record requests, and the day to day
functions of the Records Clerk. The MEO has no designated and cross-trained person that functions as
backup for the Records Clerk during times of absence, vacation, etc. Records searches are impeded by
the limitations of the LABLynx database.
A policy was established in 2007 designating that medical records obtained pursuant to Ch. 406 will be
destroyed after 2 years. This destruction policy was implemented to save space in the records room.
In response to an erroneous records release incident, the MEO established a policy where all copies of
suicide notes are destroyed after being reviewed.
Periodically, individuals that are not employed by the MEO are allowed unrestricted access to the MEO
case file room where public and confidential records are stored.
The MEO has no plans or discussion for developing electronic records in the future to replace the paper.
Local law enforcement agencies developed a procedure where they place cases on "Police Hold" as a
simple straightforward method of ensuring that Medical Examiner employees do not release
information to the media or family members of the decedent that would compromise their criminal
investigation. This "Police Hold" procedure appears to stem directly from the MEO's lack of a coherent
media relations policy and lack of familiarity with Ch. 119.
Recommendations:
All of the MEO staff should become more familiar with Ch. 119.
The MEO should develop and implement a records policy that includes a description of case file
flow.
Active and recent MEO case files should be stored in one area under the control of the Records
Clerk.
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A clerical staff member at the MEO should be cross trained to perform the duties of the Records
Clerk.
Medical Records should be retained longer than 2 years.
Suicide notes should be retained with the case file for a period in compliance with standard
retention schedules.
The MEO should not allow unrestricted access to the records room that are not employed at the
MEO.
The "police hold" procedure should be reexamined and cases currently being withheld from
release should be audited.
The MEO should consider electronic archiving of records perhaps with the assistance ofthe
county clerk.
Contractual and Other Relationships
Body Transport: Broward County contracts with a body transport company to transport cases that fall
under Medical Examiner jurisdiction, and for transport and storage of indigent/unclaimed bodies. The
fees are similar to many other Medical Examiner jurisdictions that rely on a private contractor to
perform body removal services. Utilizing private contractors for body removal is the most common
arrangement that counties use for body removal.
Routine auditing of transport invoices is not facilitated with the use of the MEO LABLynx database.
The D17 MEO receives reports of death of unclaimed bodies that fall outside their jurisdiction and
calls/dispatches for their removal and storage by the same contracted company that is contracted to
transport Medical Examiner cases.
The transport contract specifications do not require the contractor to possess a valid body transport
license. Fortunately, the contractor does indeed possess a transport license. The contract does not
require that the contractor have a valid/active license as a refrigeration facility or any other license
required to store deceased persons, and the contractor does not appear to possess such a license. The
contractor reportedly utilizes another company's refrigeration facility, and this third party company
does have the required license.
Recommendations:
An audit report should be developed in the LABLynx database for body transport.
The Chief Investigator or Operations Manager (not an administrative clerk or purchasing agent)
should review the transport invoices and correlate those with documented transport times and
information gained from the investigators handling the death investigations.
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A system of communication with law enforcement agencies should be developed for them to
report delayed transport responses.
As previously discussed, the transport contract should contain sections about the unauthorized
transportation of unwanted medication, property, and evidence (see
Medication/Property/Evidence).
The Broward County Attorney Office should examine the assignment clause ofthe transport
contract and the storage facility arrangement.
Broward County should regularly inspect any refrigeration facility within which
unclaimed/indigent bodies are being stored.
Indigent/Unclaimed contract: This contract has currently gone out for bid as it does annually and deals
mainly with final disposition by cremation. The fees specified in the contract are commensurate with
similar contracts in other Florida counties. The current contractor has reportedly performed
indigent/unclaimed dispositions admirably. The contract is currently out for bid.
The time involved and burden for MEO staff in dealing with indigent/unclaimed bodies is not
insubstantial. The MEO has no current written and implemented procedure for the handling of
indigent/unclaimed remains. Only one MEO staff member remains that is acquainted with the
indigent/unclaimed program. The loss (or the temporary absence) of this MEO staff member would
paralyze the disposition of indigent bodies.
The current indigent/unclaimed program has no incentives for timely duty performance, and, according
to MEO staff, unclaimed bodies (that had fallen under Medical Examiner jurisdiction) have lingered in
the body cooler for excessive periods oftime. The current indigent/unclaimed arrangement has
resulted in the storage of cremated remains at the MEO.
The current contract removes all financial incentives for funeral establishments to bid on the service.
The current contract essentially is for low cost cremation. All financial incentives for participation are
removed and are absorbed (primarily to the detriment of the taxpayers) by the terms of the decedent
body transport contract.
Recommendations:
Remove the indigent/unclaimed program from the MEO (see discussion below).
Remove all unclaimed cremated remains from the MEO.
The contract should be made on a longer term basis.
Revamp the body transport arrangement where the decedent body transport company only
transports Medical Examiner cases.
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Create a new contract arrangement for unclaimed/indigent bodies that provides for removal
and storage of unclaimed bodies and tasks the funeral home provider with indigent
investigations and, when applicable, appropriate taxpayer reimbursement for cost.
Forensic Anthropology: Broward County has a contract with Florida Gulf Coast University (FGCU). This
contract involves a $250 monthly payment to the University and teaching of forensic anthropology
students by the Medical Examiners. In return the Medical Examiner Office receives forensic
anthropology services. In addition to the monthly cost to FGCU, Broward County pays its own contract
body transport company for each trip to FGCU ($400 one way). At our office, we pay nothing to our
local University for forensic anthropology services. The MEO had an inaccurate inventory of cases that
were currently being examined by the anthropologist.
Recommendations:
Other forensic anthropology options are available to the MEO, and these should be considered if
a cost reduction can be realized without a compromise in service quality.
The MEO must keep an inventory of the cases located at the anthropology facility.
Forensic Odontology: Broward County has a similar agreement with Nova Southeastern University for
forensic odontology services. The agreement does not require that the dentist possess board
certification by the American Board of Forensic Odontology (ABFO). Eight months after the agreement
was initiated, it was amended to require Broward County to pay $250/month for the performance of
this service ($3000/year). The current Dentist being utilized by the D17 MEO does not have board
certification by ABFO and the reports are of inadequate detail. The MEO appears to overuse dental
identification to some degree. As a cost comparison our District that has a slightly larger volume of
cases, yet paid an ABFO certified Odontologist consultant a total of $950 in all of last fiscal year and
$2,255 in the prior year.
Recommendations:
The MEO should consider cancelling the Nova agreement.
The MEO should utilize one of the local ABFO certified Odontologists that would provide a
formal report and reliable dental charting for NCIC and NamUs entries of the unidentified.
Visitors to the morgue: The MEO hosts many autopsy observers. In our opinion, the frequency of the
visits is excessive, distracting, libelous, and of limited benefit to the office. The office is a death
investigation agency, and the lack of focus on this simple fact appears to be a recurring theme
hampering the operation of the office.
Recommendations:
A clear consistent SOP should be developed pertaining to what types of visitors should be
allowed into the morgue during examinations.
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Visitors should be limited specifically to those individuals that have or will have a direct
involvement in death investigations in Broward County. It is our understanding that such a
policy is being developed.
Security/Facility
The two separate buildings that comprise the Office of the Medical Examiner & Trauma Services possess
multiple recorded security cameras both interior and exterior, a monitored security intrusion alarm
system, and programmable and auditable card reader door access. The main public entry on the north
(morgue) building does not have controlled access once the person is admitted. Unreasonable visitors
would have open access to the DME, AMEs, and the morgue without physical barriers and we have
addressed this under Organization.
The contracted body transport company has significant access to the MEO facility. They have non
monitored access to the body cooler and open access to morgue and cooler areas during business hours.
Transport company personnel have the ability as needed to enter the demographic information on the
decedent into the computer system via a login that reportedly limits their access to the database.
Recommendations:
The north (morgue) building should not be the main public access point.
We recommend that Broward County confirm the limited login computer access and audit any
alarm codes the transport company personnel possess.
Alarm: Every employee is supposed to be assigned their own unique alarm code for the MEO facility;
however, seven employees do not have their own alarm codes. They share codes with others. Alarm
codes of terminated employees are not routinely removed from the active alarm code list. No audits are
performed of current alarm users and assignments. The delivery system of alarm codes to employees is
not secure. As of the date of our initial evaluation, there was no MEO staff on the alarm activation
notification list in the event there is an activation of the security alarm system due to intrusion.
Recommendations:
Every alarm code assigned to the MEO facility should be reset as soon as feasible.
The MEO should perform routine audits of the codes assignments.
The periodic audits of the alarm code assignments could be a task for the new Operations
Manager.
The DME or new Operations Manager (or both) should have the ability to go to the keypad,
enter a "manager's code" and add new users or delete users as needed.
A hierarchical list of appropriate MEO staff members should be developed for alarm activation
notification purposes.
16
Security Access Cards: The MEO has no ability to assign, activate, deactivate, or audit the persons who
have access to the facility via magnetic access cards. This is controlled by the Facilities Maintenance
Division. Requests to deactivate individual(s) access cards are not performed in a timely manner. No
routine or random audits are performed on who has access to the MEO via the cards. The exterior
doors are not being locked with a dead bolt or a key. If the card system malfunctions, the building
would not be secured.
Recommendations:
Designated MEO staff should be provided the computer access necessary to view and audit the
security card access database for the MEO facility.
The MEO access cards should only allow employees appropriate access to the areas essential to
their job descriptions.
The MEO should consider a process where redundant locking mechanisms are engaged on the
exterior doors.
Fire: The building has a Knox-box for use by Fire Rescue to gain entry in case of fire. This box is not
alarmed, yet it contains exterior door keys and security access cards for the building. The key cards in
the Knox-box do not allow access to all controlled entry doors.
The north (morgue) building does not have a fire alarm system. The north building has duct detectors
and local type annunciation as its fire alarm but has no fire panel or fire monitoring. The main
refrigerator has fire sprinkler protection and an outside bell. There are fire extinguishers present. This
is currently the public access building and has a large conference room where the Trauma Conference is
held, yet no fire alarm pull stations are present. Reportedly FMD has a planned project to install a fire
alarm system in the north building. The south building has a complete fire alarm system and fire
suppression with a backflow preventer. The records room and toxicology lab instrument room in the
south building has water sprinkler suppression and fire detection which monitors the system with flow
alarms and tampers on the valves.
Recommendations:
The Knox-box should be alarmed and monitored as soon as feasible.
A complete audit of all entry doors that allow Knox-box card access should be performed.
A detailed review of the fire alarm system and HVAC system of the north (morgue) building is
necessary.
The south building should become the main public access point.
Broward County may wish to consider a different type of fire suppression system in the
toxicology section and records room(s).
17
Body Cooler Temperature: The body cooler has no temperature monitor or alarm. No manual logbook of
body cooler temperatures is kept. Some type of body cooler temperature log is necessary for NAME
accreditation.
Recommendations:
o A monitoring system should be installed with electronic notification of MEO staff and facilities
staff. The system should record periodic cooler temperatures during each day.
o A manual logbook of cooler temperatures should be immediately implemented until such an
automated system is in place and functioning.
Medical Examiner Database/Computers
The MEO has 41 budgeted positions yet has 60 desktop computers to include multiple computers in the
morgue area and at vacant workstations. Many of the computers (at least 25) have dual flat panel LCD
monitors to include the computers in the Forensic Technician's office. In addition to the desktop
computers, each investigator has a take home laptop computer assigned to them.
Recommendations:
o Broward County should consider reducing the number of computers assigned to the MEO.
o The cost savings should be reallocated to other areas of need within the office.
LABLynx Database: Until recently and only following the missing medication incident, any MEO LABLynx
user was able to delete any data field, and these data changes or deletions were not tracked or audited
in any way.
The database has a limited ability to generate searches and reports to the M.E. staff. Custom searches
to comply with public record requests, research projects, public health concerns or annual statistical
data requested by the Medical Examiners Commission have to be done by ETS and cannot be done by
M.E. staff utilizing LABLynx.
The MEO should have the ability to produce a current inventory of bodies residing in the body cooler.
The MEO staff has no way to know via LABLynx the status of bodies present in the building at any given
time. For instance the LABLynx database should be able to show which bodies are present, which ones
have been examined, which are ready to be released or if any are on hold, and where they are going. If
the body has been released, LABLynx should be able to provide where it went and when.
The narrative investigative report is generated within the database with limited word processing
functions, yet autopsy reports are a separate Microsoft Word document. The reports from the Forensic
Investigators are limited in their content due to LABLynx. The Forensic Investigators are further
hampered in their job duties by their inability to view autopsy photographs or the scene photographs
that they create.
18
LABLynx is a relatively new database for the office and has basic essential functions and capabilities that
the MEO staff has not thought to request or utilize. In essence, LABLynx has massive untapped potential
just like the entire MEO. The MEO pays $32,000 a year and pays for Y, FTE from ETS for maintenance
and support of the LABLynx database.
Recommendations:
Data deletions should be tracked and be available for audit. Reportedly this feature has been
added and an audit should now be performed at regular intervals and in response to any
incident.
The LABLynx investigative entry should be a general brief case synopsis for quick entry and
review.
Allow narrative investigative report to be generated using Microsoft Word to allow for use of
editing features and link access to this document using LABLynx. LABLynx could have a similar
link to autopsy and scene photos for the investigators and others to conveniently review.
Broward County should reexamine the cost of support for the LABLynx database.
Document & Image servedsl: The file/print server is located within the histology storage room that
contains documents, autopsy reports, photographs, etc. A master key (currently possessed by at least 5
persons) is required to enter the storage room. Backups on MEO data are done once a day during
nighttime due to large file size and slow data transfer rate due to the inordinately large photograph size
issue previously discussed. Reportedly there is no current formal policy by ETS to secure autopsy
photographs from unauthorized access.
Recommendations:
Reduce the digital photograph size.
Ensure that ETS develops an adequate policy to secure access to autopsy photographs.
MEO/Trauma Services web site: As of 12/08/11, upon initial request to conduct the administrative and
procedural review of the Broward County Medical Examiner, the office website had not been updated.
With one notable exception involving the public documents of a prominent death investigation, there
are only 2 sentences about the Medical Examiner, with multiple paragraphs devoted to Trauma Services
and additional pages providing detail on how Trauma Services works. This is a small piece of credible
evidence demonstrating the disparity of performance between Trauma Services and the Medical
Examiner. The website is essentially a brochure.
Recommendations:
The website should provide more functionality such as online report requests and links to office
statistics.
19
Law and Rule Compliance
Ch. 406, Part 1: In reviewing files from the office in a random manner, it was apparent that the office
accepts jurisdiction on cases that fall outside of Ch. 406.11. For example, the office accepts all
decomposed remains regardless of circumstances. The office accepts jurisdiction on a significant
number of attended natural deaths.
Recommendations:
The MEO should not automatically accept jurisdiction on decomposed bodies regardless of the
circumstances of death.
The MEO staff should be trained on the nuances of jurisdiction for borderline Medical Examiner
cases.
The pathologists should be explicitly restricted from using autopsy photographs in educational
lectures unless compliance with Ch. 406.135 is assured.
The MEO should restrict educational activities to cases that do not involve active criminal
investigations.
Rule 11G: The MEO staff members appear to perform their duties based on the traditional office
practice of the D17 MEO. Autopsy performance and morgue procedures are in general compliance with
Rule; however, the MEO should use FTs in a more limited fashion in the performance of autopsies.
The contents of reviewed autopsy reports display the standard format seen in many Medical Examiner
Districts. They are generally consistent in content. The vast majority of cases reviewed had acceptable
cause and manner of death determinations. One item that was included in virtually every autopsy
report was a written opinion as to the history, circumstances and opinions regarding the death. Some of
these case opinions were lengthy and unnecessary.
In some of the cases we reviewed, histology slides were not examined and the findings of toxicology had
not been incorporated into the cause of death. We notified the M EO staff and the cases were amended
as appropriate.
Recommendations:
The MEO staff should acquaint themselves with the minimal operational standards described in
Rule 11-G.
The pathologists should review and consider the toxicology findings in determining cause and
manner of death and amend cases as necessary.
A quality assurance program for the MEO should be developed.
20
Ch. 382 (Vital Records Act): The office generally complies with this law. On most deaths the MEO does
file the appropriate death certificate, but such filings are not always timely.
The Office of Vital Statistics sends quarterly E-mails listing incomplete cases from Florida Medical
Examiner Offices. In the Broward MEO, these E-mails do not make it to the investigator in charge of
these backlogged cases. To the MEG's credit, they developed a written logbook of these backlogged
cases where the delivery of finalized death certificates to the local Vital Statistic Registrar is
documented. The local Registrar apparently has difficulties of their own in properly for.warding the
completely death certificates to the State Office of Vital Statistics in Jacksonville.
Another cause for many of the unfinished or non-filed death records is the "Police Hold" policy. The
MEO receives a request to hold the cause of death, yet the MEO staff fails to follow up with the agency
pursuant to the MEO SOP. Our review of a sample of "Police Hold" indicates that withholding
certification of these deaths is rarely warranted.
Recommendations:
The death certificate issued by the D17 MEO for each death investigated should be completed in
a timely manner with completion of the permanent record as soon as possible.
The MEO should notify the Office of Vital Statistics of the correct E-mail address to send the
quarterly pending death certificate reports.
The MEO should bypass the local Registrar and deal directly with the Jacksonville Office of Vital
Statistics on these backlogged cases.
An audit in cooperation with the Office of Vital Statistics should be performed to ensure that all
deaths handled by the D17 MEO over the years have been appropriately registered.
The "Police Hold" procedure should be phased out.
Ch. 112: This law in conjunction with Broward Ordinances and policies mandate that outside
employment and other conflicts of interests are to be avoided. Employment with agencies or
companies that may interact with the MEO could present unanticipated conflicts. We could find no
evidence of nepotism.
Recommendations:
Broward County should examine each employee's outside employment disclosures and perhaps
interview the employees for details regarding each employment relationship.
The office should not accept gifts from outside agencies or vendors.
The MEO should be mindful of conflicting employment of their pathologists that could violate
Ch. 112.313. This should apply to the AMEs from other Districts that hold cross covering
appointments.
21
Budget/Finance
Financial Relationship with Broward County: The office currently is organized as a county department.
All employees are county employees and receive county benefits with a significant portion of the
employees eligible for special risk retirement benefits. This direct county relationship is actually not
typical of Medical Examiner Offices. Most Florida counties have a contractural relationship with the
Medical Examiner. The State of Florida requires counties to provide funding for the local DME while the
performance of the Medical Examiners is regulated by the Medical Examiners Commission. The Medical
Examiners Commission can discipline and/or remove the District and Associate Medical Examiners even
in Home Rule Districts. County control and influence is essentially redundant and subservient to state
control and regulation. Most contractual Medical Examiner Offices also indemnify the taxpayers and
typically operate at substantially less cost (including saving on administration cost outside of the MEO).
In Districts with direct employment relationships like Broward County, the indemnification is reversed
with the taxpayers indemnifying the Medical Examiner.
Recommendations:
Broward County should continue the direct county employment of the MEO staff.
If difficulties continue in the D17 MEO, Broward County should consider a contractual
relationship with the MEO.
Budget: The MEO has an adequate overall budget as compared to other similar offices. Under the
current county employee arrangement, the majority of the staff is entitled to special risk retirement
benefits pursuant to Ch. 121.0515. This accounts for much of the cost of benefits to the county. The
MEO budget has several line items that clearly are not routinely expended, and these act as reserve
funds for other budget line items that may be depleted during a budget term. The MEO takes good
advantage of grant funding using grants primarily for education of the professional staff.
Recommendations:
The office does have areas where the budget can be reduced and/or reallocated. Broward
County could choose to decrease the office budget in response; however, due to areas of poor
functioning within the office, we recommend that any cost savings in one fund area be
reallocated to areas of deficiency.
The previously discussed elimination of the photographer positions would save tens of
thousands of dollars that could be allocated to other areas of the MEO.
Utilizing a part time clerical person on the weekend to answer phones instead of a more highly
compensated Forensic Investigator will reduce costs.
22
Estimates of cost savings (some previously discussed):
Current Adjusted $Change+/(-)
Histology $73,000 $15,000 ($58,000)
Toxicology $1.3 mil $1 mil ($200,000)
Toxicology (outsourced) $1.3 mil $500K ($800,000)
Cases Accepted -1800 -1700 ($30,000)
Laundry $29,000 $9,000 ($20,000)
Comment: We do not, at this time, recommend out sourcing all of the toxicology. The estimate for savings in toxicology from decreased
testing (triage) should be reapplied into resolving the backlog and hiring a quality manager for the laboratory.
Our estimates for savings on histology could be greater, but it is our opinion that the pathologists will require some time to adjust down their
histology samples to refect the true diagnostic need. Any savings on histology should be reallocated to the pay of competent board certified
AMEs.
The MEO currently accepts jurisdiction on cases that fall well outside Ch. 406. Our best estimate is that the office accepts approximately 200
extra cases per year. However, if the MEO improves the quality of death investigations by concentrating on the official duties described inCh.
406, it is likely that additional deaths (perhaps 100) that fall under Medical Examiner jurisdiction will be detected and accepted resulting in a
net change of 100 fewer cases per year. The reduced cases would result In $15,500 per year savings on body transport alone. The morgue
work, toxicology and ancillary costs will easily account for the remaining portion of the $30,000 per year savings.
The laundry service (washing and providing towels, scrubs, gowns, and coats) cost $29,000 per year. To give a frame of reference for the scope
of laundry costs, over 22 months the MEO spent $18,000 on laundering lab coats, $10,000 on towels, and $30,000 on scrubs. By the nature of
Medical Examiner work, the employees often have down time. The FTs have hours of down time per week that could easily be used to wash
the reusable linens and clothing. The MEO will need to purchase and install a dryer and two washers in MEO facility. After the initial outlay of
funds for the machinery and the linens, the savings year after year will be significant.
Additionally, it is our opinion that the amount spent on biomedical waste appears excessive. We would estimate that if a non-S BE qualified
vendor was used the MEO would save about $8,000 per year.
Other productivity losses: The MEO has other multiple areas where small inefficiencies occur. The new
medication procedure and the multiple photography backups are good examples. If the SOP from the
MEO is followed, an average of 10 various weekly MEO staff meetings would occur. This includes
pending case meetings, the general staff meetings, scene review meetings, difficult case review
meeting, trauma meeting, and police hold case meeting. On top of these mandated meetings are the
recently added daily morning meetings where all work stops for discussion of even the most routine
cases. These morning meetings also include a toxicologist and occur 5 times per week. During our initial
visits, an additional afternoon case meeting was being proposed (another 5 meetings per week). These
meetings may be beneficial to some employees, but the majority of attendees merely lose this
potentially productive time. Clearly, the full array of meetings described in the SOP does not occur.
Meetings have a place in any organization, but too many are burdensome. Numerous other small areas
of waste pervade the operation such as excessive production of hard copies of records and printing
documents in color as opposed to black and white.
23
The current structure of pending meetings is centered on a multi-headed microscope and histology
slides. Only the pathologists participate.
Recommendations:
The number of meetings should be reduced. This has been discussed with the interim DME, and
reportedly he has reduced these meetings significantly and admits to increased productivity.
The pending meetings should concentrate less on the histology slides and more on the
photographs, circumstances and case discussion. The meeting should include the participation
of the toxicologists and investigators and be held on a less frequent basis.
Miscellaneous income sources and testimony: The MEO sends invoices for DUI testing and provides
invoices to the Broward Circuit Court for expert witness fees in criminal cases. The courts then attempt
to recover these costs as investigative and prosecution costs from convicted defendants.
In deaths and DUI cases accepted by the office that later are part of civil litigation, the MEO bills
attorneys in these civil cases for expert witness testimony. The current arrangement is that the
pathologists and toxicologists perform the work and report the billable hours to the administrative staff
for follow up billing. The payments go to Broward County not to the experts giving the testimony. With
the incentive for billing removed, a significant portion of the expert testimony and consultation being
performed for civil attorneys is never recorded or invoiced.
The MEO SOP manual has a section titled "Requests to Examine Living Persons" which describes the
occasional requests from law enforcement agencies to examine the injuries of living persons. The
procedure reads "Such requests should be invariably accommodated".
According to the MEO staff, in a situation analogous to pathologists consulting on living persons, the
toxicologists are sometimes asked by local law enforcement to consult local cases where the laboratory
testing was not performed at the MEO laboratory.
Recommendations:
The practice of invoicing expert witness fees in criminal cases for later defendant cost recovery
should cease immediately.
We recommend that the experts be permitted to bill for the services and receive the payments.
This direct billing would provide an incentive for consistent billing and aid in recruitment (again
by way of a financial incentive) of competent pathologists and toxicologists without raising the
salaries of these employees (also avoiding the accompanying special risk retirement costs). Of
course, Broward County should demand a reasonable hourly rate for use of the MEO facility for
depositions and conferences. The fees for use of the MEO facility for consulting and depositions
should not be punitive, because it is to the office's benefit to keep these key individuals close at
hand.
24
The pathologists at the D17 MEO should not evaluate living persons within the District.
The toxicologists should not evaluate local toxicology cases where the testing was not
performed at the MEO laboratory.
Ancillary programs: The Medical Examiner's official duty is the reliable determination of cause and
manner of death. All other functions are and should certainly be considered secondary. If a Medical
Examiner Office (or any county department) is not performing its official duties in a satisfactory manner,
functions outside of the official duties should be stripped from the office and housed at appropriate
county departments that are properly functioning.
Indigent/Unclaimed Program: The contracts involved in this program have been previously discussed.
The Medical Examiner Office has managed the indigent/unclaimed decedent disposition program for
Broward County for many, many years. Broward County utilizes the same decedent transport company
that is utilized to transport Medical Examiner cases to transport and store unclaimed bodies prior to
cremation or (rarely) burial by contracted funeral directors. Some cremated remains are stored at the
Medical Examiner Office.
The traditional system of handling unclaimed and indigent bodies utilized by Broward County is not
optimal. Indigent/Unclaimed bodies fall outside of the official duties of the Medical Examiner, and this
service has traditionally occupied a great deal of time and energy from the senior investigative staff at
the MEO with significant negative impacts on death investigations.
Recommendations:
The Indigent/Unclaimed service should be removed from the MEO. We have made
recommendations to the MEO and Broward County for resolving the unclaimed cremated
remains that are stored at the MEO.
No matter how Broward County chooses to administrate this program, the program should
primarily be considered an "Unclaimed" body program. The goal is to efficiently and effectively
remove non-Medical Examiner cases from the place of death and store them in accordance with
the law. Law enforcement does not wait long at the scene of a natural death, bodies do not
remain at the hospital for extended periods, and unclaimed Medical Examiner cases do not
crowd the body cooler. If later claimed by a legally authorized person, the final disposition of
the remains will progress in a similar fashion as a decedent that was initially claimed. If the
body is not claimed, the disposition is handled at taxpayer expense only if the decedent is
confirmed to be indigent based upon the value of his/her assets at death. The decedent's
progression through the program should be systematic as well as timely.
Trauma Services: This portion of the operation is completely unrelated to the official duties of the MEO.
In speaking with the MEO and Trauma Services staff, it is abundantly clear that Trauma Services has an
efficient staff and virtually runs itself. Thus Trauma Services could be housed elsewhere within another
25
department of county government or as a stand alone division of Broward County without a negative
impact on trauma management, yet the positive impact upon the MEO should not be underestimated.
Recommendation:
We strongly recommend that Trauma Services be removed from the auspices of the Medical
Examiner as soon as feasible.
DUI program: The MEO performs drug and ethanol testing for local law enforcement agencies. This
includes DUI samples from live persons and other testing involving criminal activity including sexual
assaults. The MEO provides an invoice for the service, but the cost of the laboratory analysis is only paid
through investigative cost recovery through the Circuit Court as previously described. By all accounts,
the toxicology laboratory does a good job with the DUI program.
Death investigations suffer significant negative impact due to the DUI program. The testing of these
cases must be prompt and often supersedes testing of Medical Examiner cases. Also, court testimony
on these cases is frequent and sometimes multiple analysts are absent from the lab as they wait to
testify at the courthouse. The specimen storage, record retention, and preparation for DUI cases take a
significant portion of the toxicologists' time and energy. Ironically, the same individuals who praise the
DUI testing are critical of the time it takes to get toxicology results on Medical Examiner cases.
Recommendations:
We have made suggestions to the toxicology staff ways of mitigating these difficulties
particularly when dealing with specimen storage and the courts. DUI testing is very similar to
Medical Examiner testing and, if properly adjusted, this program can continue without
significant interference with death investigations.
If the laboratory can't make the suggested adjustments, the county should consider relocating
the DUI testing elsewhere or out sourcing the testing to FDLE or another laboratory.
26
Assessment of Broward County Medical Examiner Toxicology Laboratory
February 24, 2012
Executive Summary
This assessment was performed at the request of Dr. Jon Thogmartin as a part of a larger review,
requested by the Broward County Administrator, of the Broward County Medical Examiner Office. This
portion of that review was limited to the operations of the toxicology laboratory as it pertains to post
mortem and DUI analyses. The direction was to evaluate toxicology section and make
recommendations as to ways to improve, if warranted, the quality, efficiency and cost-effectiveness of
that operation.
Since this laboratory is not currently accredited by an external forensic science accrediting body, the
portion of this assessment that pertains to quality assurance and general operation was evaluated
against the 2006 SOFT/AAFS Forensic Toxicology Laboratory Guidelines. This document represents the
minimal recommended standard for forensic toxicology laboratory operations; the requirements of the
relevant accrediting bodies (ASLCD/LAB International, ABFT, etc) are much more stringent. It is highly
recommended that the laboratory pursue and obtain external accreditation, however, for the purpose
of this report, the SOFT/AAFS document was deemed sufficient.
The laboratory performs a very important function within the Medical Examiner Office and within the
law enforcement community. In the course of this investigation it was determined that the laboratory is
staffed with quality, professional, well-trained personnel. The analytical procedures used by the
laboratory are common to and generally accepted the forensic science community. The instrumentation
is state-of-the-art and well maintained. The case files are well constructed and complete.
New procedures are currently being evaluated by the staff to improve turn around time and increase
efficiencies. The laboratory staff interviewed was well- versed in the scientific principles and new
method development appears to be well planned.
Overall, it is my opinion that the toxicology unit has the staff, experience, technical knowledge, and
resources to be effective and efficient.
Some concerns, however, do exist and should be addressed. It should be noted that many of these
underlying problems exist due to mismanagement of the laboratories activities outside of the authority
of toxicology staff. There is a crucial lack of a systematic mission-defined, mission-driven approach to
death investigation that greatly impacts the efficiency and operational costs of the laboratory.
Additionally, the purchasing and contract review processes outside of the medical examiner authority is
cumbersome and slow.
Broward County Toxicology Lab Review Page 1
Specifically, there is a serious lack of systematic policies, controls, and processes by the Medical
Examiner Office and the associated bureaucracy that directly impact the toxicology section's
operations.
Additionally, the toxicology laboratory seriously lacks sufficient quality assurance documentation. While
the procedures observed appear to be well within common practice within the field, the underlying
documentation which is necessary to ensure this is insufficient and/or non-existent.
Each of the major concerns will be detailed, with objective evidence, in the body of this report. A
summary is provided here:
1) The security of the facility, which is managed completely outside the Medical Examiner Office, is
not sufficient to ensure the integrity of evidence stored within the toxicology unit. The county
has the obligation to secure the facility to maintain an unquestionable chain of custody. That is
not the case, nor does it appear that the managers associated with or who should be associated
with the security process (Facilities Management staff, Medical Examiner Administrative staff)
understand the fundamentals of evidence security.
In order for evidence to be considered securely stored (and thus to maintain a chain of custody)
it must be stored in such a manner such that no unnecessary personnel (in the case of forensic
evidence that would be any person outside the direction of the ChiefToxicologist) can have or
perceive to have access. A number of county employees completely unassociated with the
Medical Examiner Office have access to all areas this facility.
This is a systematic problem that should be addressed immediately. Effective written
procedures for who can have or has electronic door access, alarm codes, and keys are needed
and they need to be enforced. As evidence associated with criminal investigations is stored in
this facility, documented procedures most include tight controls and routine audits. It is highly
recommended that an outside expert familiar with evidence security be involved in developing
these procedures.
2) It has been reported to the reviewer that the most common complaint about the toxicology unit
by their stake holders is the excessive turnaround time of laboratory analysis. Thus, that was
one of the primary focuses of this review.
Through interviews, case file reviews, and an assessment of the unit's procedure manual it is
apparent that the section has the tools to be efficient and certainly to maintain a reasonable
turnaround time, however, the operational management and lack of a systematic approach is
inefficient and burdensome. The Medical Examiner case management systems is fragmented,
inconsistent, cumbersome and contributes to a significant backlog and stress between the
laboratory and its stake holders (notably the ME pathologists, the law enforcement community,
and the State Attorney's Office). Some examples of issues impacting turn around time include:
Broward County Toxicology Lab Review Page 2
Purchasing needs are not fulfilled in a timely manner, thus decreasing efficiencies and
increasing backlogs.
The meeting-laden requirements of the Medical Examiner Office are a time drain that
unnecessarily takes away from laboratory activities.
The inconsistencies in management, interpretation, and directed testing by the Medical
Examiner staff is burdensome, inefficient and leads to significant follow-up by toxicology
personnel- reducing their laboratory time and increasing the work load. The lack of
mission driven operational policies and procedures is of special concern as it results in
timely, expensive and unnecessary testing.
An over interpretation of Administrative Code 11G; a lack of thorough scene and
situational investigations; and a lack of routine "meds found" inventories has resulted in
more expensive and unnecessary analyst and equipment-driven analyses. Based on
this review, as much as 30%, if not more, of the death investigation analyses done by
the toxicology staff is unnecessary. This contributes significantly to the overall turn
around time and cost of laboratory operations.
The operation of the toxicology unit (and the Medical Examiner Office) needs to be mission and
objective driven. That mission and those objectives need to be coupled with compliance with
Administrative Codes 11G (Medical Examiner) and 11D (Implied Consent- DUI). A triage system
of performing only necessary or appropriate analyses, as it pertains to each case should be
implemented. An example of such a process is provided in the body of the body of this report.
3) The Quality System in the laboratory is inadequately documented. There is a serious need for
detailed written policies and procedures that address the current minimum expectations of the
forensic science community. Over the past decade, the quality assurance standards for forensic
laboratories, especially in the arena of documentation, have drastically increased. The Quality
System of the toxicology unit has not evolved with those expectations.
Documented method validations for quantitative procedures are inadequate or non-existent.
The section is in dire need of a Quality Manager position (which is the standard in most public
forensic laboratories in the United States) to bring the documentation up to the currently
accepted standards with the expressed intent of achieving external accreditation by a forensic
science accrediting body (e.g. ASCLD/LAB, ABFT). Failure to bring the section to accreditation
readiness will, ultimately, result in serious backlash within the criminal justice system. Future
admissibility of results and testimony has the potential to be limited or disallowed and, as the
organization does not indemnify Broward County, financial repercussion to the county may
result.
Broward County Toxicology Lab Review Page 3
Findings
Physical Plant
The toxicology section is housed in one of the buildings on the Medical Examiner site. There is more
than sufficient work and office area to accommodate the existing (and future) staff and equipment and
processes. The freezer/refrigeration system has a dialer alarm system that notifies toxicology staff in
the event of a failure. The laboratory is very clean and well maintained by the custodial and toxicology
staff. The environmental conditions of the laboratory, temperature, humidity, etc at the time of the
review were appropriate to the operations.
The building has good basic security features including restricted key card access to all evidence and
analytical processing areas and an intrusion alarm system. However, the management of that system is
inadequate, ultimately resulting in a non-secure operation.
The most specific area of concern is the management of the access and alarm systems. The systems are
not under the direct control of the laboratory director or the Medical Examiner. The electronic access
system is managed by Broward County Facilities Maintenance Division and the alarm system is managed
by an outside vendor via human resources department. There is no current audit system in place to
ensure that door access is truly limited to existing laboratory personnel or that intrusion alarm pass
codes are unique to existing personnel. A limited audit was conducted by another assessor on this team
(refer to the main body report), however, a summary is necessary here as DUI specimens are stored in
this area.
In the course of that audit it was determined that numerous county and past employees had access to
most areas of the facility. Alarm codes were also issued to a significant number of non-laboratory
employees including a "blanket" facility management code which would provide unlimited access to
unspecified (and un-specifiable) non-Medical Examiner and non-laboratory employees.
It was very evident that. currently, many people outside the laboratory director's (Chief Toxicologist)
authority have access to and the ability to grant access to the toxicology laboratory. The current system
does not provide the laboratory director the authority to control the laboratory's security.
Recommendations:
Broward County Toxicology Lab Review Page 4
1) Immediately change the procedure for who grants access to this facility. Require written
authorization from the Chief Toxicologist to allow anyone access, this applies to both key card
access as well as the issuance of alarm codes.
2) Implement and document an annual security audit (at least annual) of the facility.
a. This audit should include the following:
An audit trail from the door access computer system of all personnel (key cards)
that have access to each individual door in the toxicology section.
o Cross checks to ensure that only toxicology personnel have access
o Cross checks to ensure that all terminated personnel have been removed
from the system
An electronic audit trail of the intrusion alarm system of all personnel that have
assigned alarm codes to the intrusion alarm in the toxicology building.
o Cross checks to ensure that all existing personnel are assigned a code
o Cross checks to ensure that all terminated personnel have been removed
from the system
o Cross checks to insure that alarm codes are unique to the toxicology section.
This audit should be conducted annually and should, at a minimum, be extensively reviewed and
approved by the Chief Toxicologist.
Equipment and Instrumentation
For the most part, the section has quality state-of-the- art analytical instrumentation in the form of
four gas chromatograph-mass spectrometers (GC-MS), one gas chromatograph-flame ionization
detector (GC-FID), a co-oximeter/blood gas analyzer, and a robotic ELISA workstation. Four of the Ge
MS's are on line and in use for casework. The analytical equipment is well maintained by the staff and
maintenance contracts are in place with the instrument manufacturers.
The laboratory uses a LIMS system for generating reports. While not specifically designed by forensic
applications, it appears to meet the needs of the laboratory.
Drug screening is currently performed by dip stick (urine) or ELISA (blood). These processes are limited
in scope but sufficient for within the context of the current analytical scheme. The laboratory is in the
process of validating a more comprehensive immunoassay system (Randox) that should greatly increase
efficiencies.
Broward County Toxicology Lab Review Page 5
Recommendations:
Streamline a procesdor the purchase of instrument parts. The GC-MS-FID has never been used
in casework even though it has been installed for a significant period of time. The delay in
acquiring an EPC (electronic pressure controller) has resulted in months of in-operation of an
instrument that could significantly increase analytical throughput.
Obtain/implement GC-MS analysis protocols that utilize the AM DIS system. This is a system for
the rapid and semi-automated evaluation of qualitative GC-MS data. Such a system would
reduce the analyst's data interpretation time by at least half.
Bid out the instrument maintenance contracts, especially for the Agilent equipment. There are
several local vendors who possess the relevant credentials for the maintenance of this type of
equipment at a significant savings to the county.
The laboratory uses manual vacuum solid phase extraction (SPE) manifolds for the extraction of
drugs from biological samples. Consideration should be given to a small scale robotics system
(e.g. RapidTrace) that would free analysts to do other duties. Manual SPE techniques are half to
full day processes that require intensive analyst manipulation. Small scale robotic systems are
ideal in that they are cost effective and redundant. Their use results in increased productivity
without increasing personnel. The laboratory does have a large scale SPE robotics system;
however, the capacity of the system exceeds the needs of the laboratory and is very
cumbersome, ultimately resulting in a loss of productivity due to its extensive maintenance
needs. It is better suited for a much larger scale operation.
Invest in a medium to large capacity scanner and document preservation software. The
laboratory generates large amounts of data that is distributed on a regular basis. An example is
the validation data associated with blood ethanol analysis. This document is hundreds of pages
in length. For each request (public records or duces tecum subpoena) the laboratory staff
photocopies this document by hand. By scanning these large, often reproduced and distributed
documents, they could be electronic transferred in a matter of minutes resulting is significant
cost and time savings.
It is likely, however I was unable to confirm, that some operation within the county has an
electronic document management system (i.e Webextender, Documentum). The Medical
Examiner Office should look to implement such a system (to include toxicology data, QA/QC
records, and case files). Not only would such a document management system increase
efficiency. Currently, in the wake of a catastrophic event (fire, water, etc) there is a high
probability that irreplaceable documents will be lost.
Personnel
Broward County Toxicology Lab Review Page 6
The laboratory is currently staffed with a ChiefToxicologist (lab director), three Toxicologist II, two
Toxicologist I, one laboratory technician, and one administrative clerk. There is also an unfilled vacancy
for an additional toxicologist. The two Toxicologist I staff members are in the process of being
promoted to the Toxicologist II designation.
There is no Quality Manager position or designation for any staff member.
With the exception of the Chief Toxicologist, no members have received significant external toxicology
professional development (American Academy of Forensic Sciences, Society or Forensic Toxicologists,
etc). The explanation for which is lack of funding and excessive workloads.
Only one staff member, the Chief Toxicologist, is currently certified by an accepted forensic toxicology
certification program (American Board of Forensic Toxicologists).
An interview of a selection of staff members (NSO%) indicates that the analytical staff is well trained and
has a firm understanding of their duties and the underlying scientific principles associated with forensic
toxicology.
The salary range for the analytical positions is comparable to most other toxicology programs within the
state; but, significantly lower than neighboring Miami Dade. The lack of salary increases due the
economic conditions does have the potential to result in serious turn-over.
The laboratory occasionally utilizes forensic science interns (non-paid positions for students who require
semester long internships to complete their degree requirements). However, these interns have been
limited to clerical and administrative duties.
Recommendations:
Employ a Quality Manager. This is an essential designated position that is found in most
forensic laboratories. The Quality Manager position is typically aligned at the Assistant Lab
Director level on the organizational chart. The job duties for this position include managing the
quality system (in this case developing a quality system) aligned with the professional standards;
quality assurance guidelines; and, ultimately, accreditation requirements for forensic
laboratories. The position should be filled by someone with extensive QA/QC training.
Qualifications should include significant analytical experience as a forensic toxicologist (with an
emphasis on post-mortem toxicology); training and experience as a certified auditor or assessor
with a recognized accrediting body (i.e. ASCLD/LAB); experience with organizational
management and employee development; formal training in laboratory auditing; and in depth
knowledge and experience with a least one of the recognized laboratory standards (i.e. ISO
17025).
Ensure that each toxicologist is provided an opportunity to attend external professional
development/training at least once every two years. Without exposure to the newer more
efficient techniques and new drug developments, the efficiency of the laboratory has suffered.
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Use interns in a more effective manner. The QA documentation, notably but not exclusively in
the arena of method validation is seriously lacking. Unpaid interns are an excellent, cost
effective source to performing method validations and generating method validation reports.
Forensic Science interns are typically in their last year of study and are well suited to such task.
They have the basic analytical training and knowledge to complete a well planned project
(method validation).
Encourage certification for each member of the analytical staff. A key recommendation of the
National Academy of Sciences review of the forensic science was that ALL analysts be externally
certified by an accredited certifying body. Two such accrediting bodies currently exist for
forensic toxicologists: ABFT (American Board of Forensic Toxicologist) and FTCB (Forensic
Toxicology Certification Board). There is a high likelihood that individual analyst certification
will be necessary to provide expert testimony in the courts system within the next 5-10 years.
Provide funding to send at least two members of the senior toxicology staff to a comprehensive
quality assurance training program specially designed for forensic science practitioners.
Provide funding to send at least a two of members of the analytical staff to tour/visit accredited
forensic laboratories that conduct post-mortem toxicology.
Analytical Procedures
The laboratory has a procedure manual that provides direction for analytical procedures. However, this
manual has not been updated since 2005, with some methods dating back to 1997 without proper
approval or revision documentation. The manual includes handwritten changes to procedures.
None of the analytical procedures, with the exception of ethanol, have comprehensive documented
method validations. This is a minimum standard in the forensic science community. As a result most of
the documented procedures do not include criteria for acceptance, i.e. minimal QC requirements for
accepting the data as determining that is an element of method validation.
It should be noted, that most of the procedures that are used are within the norm of the forensic
toxicology community. However, the use of controls in quantitative methods (except Ethanol) is outside
the accepted practice.
Recommendations:
Employ a Quality Manager (as described above) to manage the process of bringing
documentation and validation up to current standards.
Broward County Toxicology Lab Review Page 8
Use interns and existing staff to validate/re-validate all quantitative and qualitative analytical
methods using current method validation criteria. Alternatively, contract an outside entity to
perform or manage validation of existing methods.
Immediately change the current practice of reassigning calibrator points as controls as this is
not acceptable analytical practice. Add appropriate independently prepared and tested
controls to all quantitative methods. Bracket at least every 10 samples by an appropriate
positive control.
Generate comprehensive validation reports that address all pertinent aspects of validation
including accuracy, precision, specificity, limit of detection, limit of quantitation, and robustness.
A good reference for proper method validation can be found in
Bertholf, R.L., and R.E. Winecker, ed. Chromatographic Methods in Clinical Chemistry and
Toxicology. John Wiley & Sons, Ltd, 2007.
Case management
While some policies for the management of post mortem toxicology cases exist, for the most part, it
appears that the analytical process is at the whim of the individual forensic pathologist. This is the
primary basis for the excessive turn around time in the toxicology section.
Cases are currently classified as fast, faster, fastest as defined by the status of the case after autopsy
(initial cause of death determination) and the case process is to essentially abandon cases based upon
that criteria. As a result the "easiest" cases are not analyzed or closed for months after the autopsy.
The processing of DUI cases, while delayed by much of the post mortem case inefficiency, is appropriate.
The analytical scheme for law enforcement toxicology cases does not need significant changes; it simply
needs appropriate redirected resources.
Recommendations:
Develop a mission driven analytical scheme. In the simplest terms the mission is the
determination of cause and manner of death. Currently, a significant number of analyses are
conducted that greatly exceeds the needs of cause and manner determination. There clearly is
no systematic approach, the impression is that that Medical Examiner staff relies on the
toxicology laboratory to test for everything and then determine the significance based upon the
investigation. This is the most inefficient approach to death investigation. The laboratory
services are the most expensive and most time consuming elements of the death investigation
process. The investigative process should fuel the toxicological process and not vice versa.
Broward County Toxicology Lab Review Page 9
o Examples: Case 1: Decedent was a passenger in a motor vehicle accident. The cause
and manner of death was easily determined at autopsy as blunt trauma/accident. In
this situation the toxicology is all but irrelevant for cause and manner. To comply with
Administrative code llG, ethanol and appropriate- chemical and drug concentrations
are all that are required to be done. Since chemical and drug concentrations generally
have no bearing on the cause and manner of death in these types of cases, the
"appropriate" quantitations are dependent on the needs of the pathologists and,
depending on the circumstances of the crash, no quantitations may be deemed
necessary. Ethanol (volatiles) analysis and a routine drug screen (targeting those drugs
specified by the Medical Examiner Commission Drug Report) with appropriate
confirmations may be all that is needed. However, in this case, a drug screen,
confirmations, and several drug quantitations were conducted.
o Case 2: Decedent was a passenger in a motor vehicle accident. The cause and manner
or death was blunt trauma/accident. The initial drug testing was negative. The
pathologist order an additional test of consisting of a quantitation of epinephrine in the
urine. There was no documentation for the purpose of this test and neither the
toxicologist nor the interim District Medical Examiner had any explanation for why such
testing was conducted. All agreed that such testing had no value.
o Case 3: An obese man with significant heart history was examined. The findings at
autopsy lead to the determination that the decedent died from heart disease. The
death certificate was issued and the manner was determined to be natural. A full
toxicology analysis was preformed at the direction of the pathologist. There is no
requirement for any toxicology under llG for natural deaths. It was reported by the
toxicology staff that most natural deaths receive full analysis.
o Case 4: An elderly man was examined by a pathologist. No autopsy was performed.
The cause and manner of death were determined to be natural causes at the time ofthe
external examine. A full toxicological analysis was ordered and performed.
o Case 5: An elderly man of extreme age has extensive medical history but no Florida
licensed physician to certify the death. The MEO accepts jurisdiction and examines the
body. The pathologist certifies the cause of death as heart disease and the manner as
natural. The office draws and runs toxicology. Drugs are found in the urine and blood.
Interpretation of the results in the absence the anatomical findings of an autopsy are
difficult even when the drug concentrations appear significant. Neither toxicology
testing nor sampling of is required or, in many cases, interpretable on these cases.
An example of a mission driven analytical scheme:
o Obvious natural cases and non-autopsy: "Hold" toxicology.
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o Non-natural deaths with obvious causes of death. Limit toxicology to screens and
confirmations. Screens should be semi-quantitative so that in that abnormal readings
filter to drug quantitations, but results within expected ranges are reports with
qualitative findings only. Note: at percentage (estimate 20%) of these cases will convert
to full quantitative analysis. However, the reduction in analytical procedures preformed
on the other 80% will result in significant cost and time savings. An example of an
appropriate analytical scheme would include a comprehensive (10+ drug classes) blood
immunoassay coupled with a qualitative urine drug screen that includes mass
spectrometry.
o Non-natural causes or unknown causes of death- full comprehensive quantitative
toxicology.
Other cost and time saving measures:
o Minimize or eliminate gastric quantitation procedures. There is disagreement in the
forensic science community as to the value, accuracy and interpretation of these results.
Furthermore, the procedure used for gastric quantitation is not sufficiently validated. In
drug overdoses, suicide vs. accident is, for the most part, a circumstantial
determination. Highly elevated blood drug levels support the conclusion. Gastric
quantitations in most situations are unnecessary. Qualitative (as opposed to
quantitative) gastric analysis is highly valuable for identifying non-routinely found drugs
to target for additional analysis. Taxi-lab is a rapid non-quantitative method that can be
used for gastric analysis as opposed to the much more time consuming quantitative
methods currently employed.
o In (at least) all suspected overdose cases: collect, inventory and report on the
medications found at the scene. The current (revamped) policy for handling
medications found at the scene is completely inadequate. Medication inventories and
identifications are invaluable to the toxicologist for determine target (non-routine)
analytes and to pathologists in assessing potential suicides.
For security purposes, access to medication should be strictly limited to two
personnel. One clerk and one manager. Routine audits should be conducted to
ensure security.
Create an inventory for each case that includes the prescription information
(when known), the count, and the dosage prescribed, and a calculation to
determine the number of pills "missing" (i.e. likely taken faster than prescribed).
Toxicologists can use this to determine target analysis (beyond drug normally
detected by routine analyses).
Broward County Toxicology Lab Review Page 11
Toxicologists use pill identification and counts as the tools to determine non
routine quantitations. For example, a drug (not routinely quantitated) is
detected in the urine. The toxicologist must determine quantitation of that
drug is necessary (a significant cost if it must be sent to a reference lab). If the
medications found report shows that 15 pills were prescribed and 14 remain,
thus it is probably not necessary to quantitate. The reverse, however, is that
only 1 pill is remaining. Quantitation then is likely needed. The cost of a clerk
position to inventory and secure medications is significantly less than that of
additional analytical testing .
. The laboratory currently has a backlog that dates to April, 2011. Many of these cases are from natural
death or cases with known causes of death. In September, 2011 the laboratory was award a grant (2011
Paul Coverdell Forensic Science Improvement Grant), which was effective October 1, 2011. The purpose
of this grant is to out-source the backlogged cases to an accredited reference laboratory in an effort to
alleviate the backlog.
The laboratory is to be commended for pursuing such an innovative and cost effective solution.
However, as of February 1, 2012 no samples have been sent. The delay has been attributed to
bureaucratic delays on the part ofthe County purchasing process. With an anticipated send-out rate of
40 cases per week, had the grant been executed within 60 days of the award, the backlog would be
more than halved by this time.
Summary
The National Academy of Science (NAS) produced a comprehensive review of the state of forensic
science in the United States. Several legislative actions at both the national and state levels are in the
process of addressing the concerns identified in that report. The main recommendations of the NAS to
improve the quality of forensic science were:
1) All forensic laboratories should be accredited by external accrediting bodies and to the
international standard ISO 17025.
2) All forensic science practitioners should be externally certified by an accredited
certifying body.
3) All analytical methods used in forensic science should be thoroughly vetted and
completely validated prior to use in cases work.
These should be the immediate and long term goals of this laboratory.
The Chief Toxicologist currently lacks the autonomy and authority to manage laboratory operations in
an efficient manner. A redefinition of his role and authority is necessary to increase productivity and
Broward County Toxicology Lab Review Page 12
reduce costs. The Broward County Medical Examiner Office toxicology laboratory has the tools,
knowledge and personnel to achieve all of the recommendations.
The Medical Examiner Office needs to move to mission-based operations with more consistency among
pathologists on testing needs and processes. With a budget-minded and mission-minded systematic
approach concerns regarding turnaround time and cost effectiveness will be eliminated. The current
ineffective case management is the result of requests and random practice from the forensic
pathologists and not the fault of the toxicology section. A minimal estimate of 30% of the laboratory
work performed by the toxicology staff as part of death investigations is unnecessary. As a result, the
public is bearing the financial burden of costly, unnecessary expenses and the backlog of the unit is
increasing.
The actual work currently produced by the laboratory appears to be of the highest quality, once the
contemporary method validations and reasonable case management practices are in place; this
laboratory has the staff and knowledge to be a hallmark laboratory. In summary:
1) Create a systematic approach to toxicology within the ME organization.
a. Generate binding policies and procedures for pathologists. It is recognized that every
case has specific nuances that may require additional testing. However, the current
policy is that every case is treated as non-routine.
b. Classify toxicology cases based on needs for cause/manner determination and
requirements of 11G.
i. Do not perform toxicology on external examinations unless otherwise required
by Florida Administrative Code 11G or warranted by the specific circumstances
of the case.
ii. Do not perform toxicology on clear natural deaths (i.e. cases where the
pathologist issued a death certificate upon examination or autopsy without
toxicological results) unless warranted by the specific circumstances of the case.
iii. Minimize (triage) toxicology of cases with a known cause of death (i.e. trauma
from auto accidents, hanging, etc) to coincide with the investigative needs of
the case.
iv. Do not routinely perform toxicology on trauma cases with a time of death in
excess of 12 hours from the injury.
v. Perform analyses on all case types (known cause, unknown cause, etc)
concurrently based upon submission dates. Limit the testing, not the start date
of testing.
Broward County Toxicology Lab Review Page 13
2) Inventory and identify all decedent medications that appear pertinent to cause and/or manner
of death. The newly proposed decedent medication policy is without meaning. Having clerk
level staff inventory medications provides for additional security, auditing documentation and
greatly minimizes additional expensive and time consuming testing.
3) Reassign as many investigative and administrative activities away from toxicologists as possible.
4) Establish a contemporary document management system.
5) Create, update policies and procedures. Generate organized validation reports for all
procedures.
6) Hire a Quality Manager.
7) Achieve, at a minimum, external accreditation.
8) Develop a system within the county to expedite purchasing and contract review processes for
time critical supplies and resources.
Broward County Toxicology Lab Review Page 14
References:
"Forensic Toxicology Laboratory Guidelines." Society of Forensic Toxicologists. 2006.2 Feb. 2012
<www.soft-tox.org/filesjGuidelines_2006_Final.pdf>.
Laws: Florida Administrative Code llg." Florida Association of Medical Examiners Web Site. 2 Feb.
2012 <http:/jwww.fameonline.orgflaws>.
Strengthening Forensic Science in the United States: A Path Forward. Washington, DC: The National
Academies, 2009. Aug. 2009. The National Academy of Science. 3 Feb. 2012
<www.nap.edu>.
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