Amid an uptick in homicides and a spike in drug overdose fatalities, the Maine medical examiner’s staff is slowly ramping up the number of autopsies it conducts after years of lagging behind national averages.
Annual autopsy rates in the state consistently hovered at well under 20 percent of death investigations for the past five years, an analysis of the Maine Office of Chief Medical Examiner annual reports shows.
State medical examiner offices nationwide, on average, perform autopsies in 38 percent of the deaths that were investigated, according to a 2018 U.S. Department of Justice report, the most recent available data.
“I would say that’s unusual compared to the nation,” Denver Chief Medical Examiner Dr. James Caruso, the secretary of the American Academy of Forensic Sciences, said of Maine’s autopsy numbers.
“All of us have many more cases than we’ve had, mostly due to drug overdoses,” Caruso said. “The real driver of the workload is not COVID. And it’s not really even [the] increasing homicide rate. It’s drugs. Specifically, it’s fentanyl.”
In 2021, the Maine medical examiner’s office performed 277 autopsies out of the 2,391 cases it took jurisdiction over — an 11 percent rate, according to its 2021 annual report. In 2022, the office performed 403 autopsies on the 2,526 deaths it took jurisdiction on, said Lindsey Chasteen, the Maine examiner’s office administrator — or a 15 percent autopsy rate.
In contrast, the medical examiner’s office in New Hampshire, which is similar to Maine in staff size and population, in 2021 performed 607 autopsies in 1,794 deaths it investigated, or a 33 percent rate. In 2022, the New Hampshire medical examiner performed 605 autopsies in 2,037 deaths it investigated, or a 29 percent rate, state records show.
Similarly, the Rhode Island medical examiner’s office has had significantly higher autopsy rates than Maine. In Rhode Island in 2022, there were 888 autopsies done in 1,598 cases the medical examiner’s office investigated, and in 2021, there were 887 in 1,653 deaths investigated — or a rate of 55 percent and 53 percent, respectively, state records show.
Maine’s chief medical examiner, Dr. Mark Flomenbaum, did not dispute the state autopsy rates.
“I agree fully that the number of autopsies is small compared nationally. That is OK,” Flomembaum said. “The numbers are what they are.”
He said Maine’s numbers may be lower because his office is selective about which deaths to autopsy.
“If a person commits suicide with a gunshot wound to the head, most jurisdictions will automatically do an autopsy. In Maine, if the circumstances are not at all questionable, we don’t always autopsy those cases,” Flomenbaum said.
Flomenbaum also said Maine’s aging population can be a factor in lower numbers.
“We have our elderly folks who fall and break a hip. We don’t need a full autopsy to know they died of that fracture,” Flomenbaum said.
Limited resources for staffing and funding also force the agency to make choices.
“There are jurisdictions that can autopsy every motor vehicle accident,” which Maine cannot do, Flomenbaum said.
In Maine, the medical examiner’s office is mandated by law to investigate all violent or drug-related deaths and unexpected natural deaths. But last year, the office said in its annual report: “While most cases should be autopsied, constraints at the office only allow for full autopsies to be performed when they are necessary for criminal prosecution, for unexpected deaths in individuals under 55 years old or for deaths suspected of being due to a threat to the public health.”
The National Association of Medical Examiners, an organization of death investigators that accredits offices, recommends the Maine medical examiner perform at least 625 autopsies annually based on the number of potential death investigations in the state, according to the Maine medical examiner’s 2021 annual report.
But Chasteen said despite the lower-than-average rates, “Maine is not lagging behind. We are being more discerning” about which cases to autopsy.
Still, the number of autopsies in Maine has left some families with unanswered questions.
Elizabeth Lafortune, 35, was found dead last Sept. 27 at Oakwood Inn Town Motel in Sanford. The police reported her death to be drug-related, but her family believes it is suspicious because Lafortune did not use drugs, according to her sister, Michelle Medevielle. The medical examiner’s office did not perform an autopsy, Medevielle said.
“We think it’s pretty messed up,” Medevielle said.
Medevielle said her family was told that “there wasn’t any foul play that they noticed” — and because of that, there was no need for an autopsy. In her view, the medical examiner’s office wanted to “take the easy way out, so they don’t have to do the work.”
Flomenbaum said he couldn’t comment on a specific case due to the privacy of the deceased and the family.
Similar to Medevielle, Sally Blais of Sturbridge, Massachusetts, said the Maine medical examiner’s office did not conduct an autopsy for her son, David Blais, after his death from a gunshot wound in late 2018, even though she believes he was entitled to one under the state law.
Blais said police ruled her son’s death a suicide. He was found dead in a gravel pit during a gun target practice in Maine, and had been accompanied on the trip by two others, Sally Blais said. His mother thinks the case should have been investigated further and an autopsy performed to confirm it was not a homicide.
Instead, the medical examiner conducted an external examination of the body and toxicology testing, according to Sally Blais, who has been left with years of unanswered questions.
“I should have insisted [that an autopsy be conducted],” she said.
The medical examiner’s case report for investigations into Blais’ death also mentions David Blais’ history with mental illnesses, including major depressive disorder, anxiety and ADHD.
But Sally Blais said her son’s mental health had stabilized by June 2018.
“Some people will commit suicide without giving any hint that they were intending to do that,” Sally Blais said. “But I never thought, and anybody who knew David never thought, he was that hopeless that he would kill himself.”
Blais said it was not until 2022 that she began to come to terms with her son’s death and is now raising questions about the lack of an autopsy.
“I was just trying to cope with the fact that he was gone,” she said. “That’s all I had the capacity to even mentally handle at that time — nothing about an investigation.”
Maine’s autopsy numbers come as there were 32 homicides in 2022, according to the Maine attorney general’s office, the most in recent years. In 2021, there were 18 and in 2020 there were 20.
Also rising in recent years are confirmed and suspected drug overdose deaths, state data shows. A February report from the Maine attorney general’s office shows there were 10,110 overdoses reported in Maine in 2022, with 716 suspected or confirmed deaths. In 2021, there were 631 suspected or confirmed overdose deaths out of 9,678 overdoses reported.
Flomenbaum’s tenure has been punctuated by controversy. He was originally appointed to his seven-year term in 2014 by then-Gov. Paul LePage. In 2021, he said he would not seek reappointment after being privately reprimanded by Gov. Janet Mills for his office giving an inappropriate gift to a departing worker, and for questioning a second worker’s approved sick and medical leave, according to news reports.
Flomenbaum is remaining as medical examiner until his replacement is hired.
Flomenbaum was fired as chief medical examiner in Massachusetts in 2007 after a consultant’s report revealed rampant mismanagement and the misplacement of the body of a Cape Cod man.
In 2016, a Connecticut prosecutor sent Mills, who was then the Maine attorney general, a warning letter about Flomenbaum’s credibility after Flomenbaum served as a defense expert in a child manslaughter case in Connecticut. The letter said the judge in that case found Flomenbaum’s testimony not credible.
Flomenbaum said his office’s inadequate budget, staffing and facilities have contributed to its ability to perform autopsies.
In 2021, the agency’s budget was approximately 55 percent of the recommended national standard, according to the medical examiner’s annual reports.
The average budget for state medical examiner offices was $5.8 million in 2018, according to a U.S. Department of Justice report. In contrast, Maine’s budget was $2.2 million for 2018 and $2.5 million for 2021, according to the medical examiner’s annual reports.
The medical examiner’s facility, built about 30 years ago in Augusta, has two autopsy tables and shelving units to store 15 bodies, according to Chasteen. The facility also lacks proper ventilation and is unable to keep up with current health codes, Flomenbaum said.
“We are the final point for people who do not get identified, so we have to hold them in our facility, do the DNA testing, find out who they are … It’s a huge burden,” Flomenbaum said. “This building was not designed for that.”
It also lacks the capacity for multiple autopsies to be conducted simultaneously or the ability to perform autopsies on infectious cases, Flomenbaum said.
“The building itself can only house a certain number of bodies. The secretarial staff can only pick up a certain number of phone calls,” Flomenbaum said. “We are working within the budget.”
In 2020, legislation for a new medical examiner’s facility was approved and construction is expected to begin this year. The building will be equipped with six autopsy tables and can store closer to 30 bodies, Chasteen said.
An ongoing shortage of forensic pathologists is creating a problem nationally. In Maine, there are only two full-time forensic pathologists and Flomenbaum has asked the Legislature to increase the agency’s budget to hire more.
“There’s not enough people to hire and competition for hiring is bringing salaries out of scope for jurisdictions like Maine that can’t really afford to keep up,” Flomenbaum said.
Dr. James R. Gill, Connecticut’s chief medical examiner, said the national shortage can cause some medical examiner offices to not conduct autopsies on deaths they would normally autopsy.
“The goal is to conduct a maximum of 250 autopsies per full-time forensic pathologist a year,” Gill said. “If you only have one or two medical examiners and your office is getting 700 or 800 deaths in need of autopsies, at some point you have to decide what you are going to do.”
Despite the lack of qualified forensic pathologists, Flomenbaum maintains his office is fulfilling its duties.
“We have always done every autopsy that was necessary,” he said.
He also said the pandemic hampered the agency’s ability to move quickly because people were working remotely, deaths were not reported or bodies were not transported as quickly as usual. Some deaths were not reported until a body was cremated, preventing the medical examiner’s office from conducting examinations or autopsies, Flomenbaum said.
“What slows us down is stuff beyond our control. If we have to wait for toxicology samples to come back from the labs, we can’t do anything but wait,” he said.
The number of autopsies in Maine has increased slightly this year partly because a slowdown in COVID deaths has given the office more capacity to focus on other cases, Flomenbaum said.
“As the drug epidemic continues, we, as a state, decided we are going to autopsy all individuals under the age of 30, even if it is a suspected drug overdose,” he said.
Other internal changes are increasing the autopsy numbers, he said, including the medical examiner’s office taking jurisdiction in the deaths of individuals who are homeless, incarcerated or under guardianship.
“We are doing at least an examination of those individuals,” he said. “We did have some policy changes in 2021 that, I think, have increased our autopsy numbers from the previous year.”
Flomenbaum said the medical examiner’s office operates seven days a week to keep up with demand.
“A lot of the jurisdictions, to save money, they shut down on the weekends,” Flomenbaum said. “We can’t afford that because then we’d be backed up Monday, Tuesday.”
Chasteen said the medical examiner’s office asked for four additional staff for this budget cycle but the request was cut from the budget before it reached the Legislature. A request for $330,405 in funding is pending, Chasteen said.
“We are always doing the best we can,” he said. “The numbers are going up. There’s more reason to investigate traumatic deaths because there are more traumatic deaths. There’s more reason to autopsy drug deaths because there are more drug deaths.”
Autopsies still aren’t conducted on suspected fatal overdose victims who are over age 30, Chasteen said. Instead, the office examines those deaths through toxicology testing with external inspections and blood draws.
“Unless it’s recorded by someone in video recording or you’ve got multiple witnesses with all the same story, whether we did a full autopsy or not, we’re not going to know how that individual came to have those drugs in their system,” Chasteen said. “We rely on law enforcement for that type of investigative piece of information.”
While it’s common practice for some medical examiner offices, there is debate among experts whether drug-related deaths should be examined without autopsies.
“It varies on the study, but without doing autopsies in suspected drug intoxication deaths, you’re likely to misdiagnose some deaths,” Gill said. “And so the risk is missing a homicide.”
Besides families who cannot get an autopsy, others remain critical of the medical examiner’s performance.
Recently retired state Rep. Jeffrey Evangelos, an independent from Friendship and longtime critic of the medical examiner’s office, cites Flomenbaum’s credibility as the office’s main issue.
Evangelos has filed a number of complaints during Flomenbaum’s tenure, including whether Flomenbaum was handling private business on state time. The state attorney general, in a 2019 letter, found Flomembaum was not performing private business on state time. The attorney general did, in the letter, fault Flomenbaum for a posted job advertisement for a deputy chief medical examiner that contained macabre language seemingly poking fun at Maine corpses.
Evangelos said Maine needs to hire credible forensic pathologists to improve autopsy rates and the quality of investigations. He added that a new building will not be enough to improve the office’s performance, comparing it to a newly constructed school that still employed poor teachers.
“Building that fancy new school is not going to change what goes on inside,” Evangelos said. “It’s the character and empathy of our teachers that we’re looking for.”
Flomenbaum said he hopes increased budgeting and the new building will ease the burden on the medical examiner’s staff and help Mainers.
“Our goal is to save lives,” Flomenbaum said. “Everything we do within the budget has to be directed at that.”
He said the agency’s core work is to determine cause of death to prevent similar deaths — like those caused by overdoses — from recurring.
“We try to find out why people die, so other people stay alive,” he said.
This story was produced in Boston University Professor Maggie Mulvihill’s Data Journalism class as part of an ongoing collaboration with The Maine Monitor, a nonprofit and nonpartisan news organization. To get regular coverage from the Monitor, sign up for a free Monitor newsletter here.