The missed homicide
A killer walks free. A victim is denied justice. Others may be harmed by the same hands. Failing to see what is there is a failure of medicine.
Every autopsy we perform may one day be read aloud in a courtroom, with a person’s liberty or a family’s peace hanging on every word. So we hold our work to one standard: it must be good enough to convict the guilty and free the innocent. Nothing less is forensic medicine.
Forensic pathology is not a paperwork exercise. It is not a technical service. It is not a step to be hurried through on the way to a charging decision. It is the medical foundation on which death investigation, criminal justice, civil justice and public health are built. When that foundation is weak, everything built on it fails.
A finding that cannot survive cross-examination is not a finding. An opinion that cannot be checked is not science. A report that bends to pressure is not medicine.
We do not ask whether our work is “good enough for this case.” We ask whether it would stand up to the hardest examination it could ever face: by an opposing expert, a skeptical jury, an appellate court, a grieving family, or the next generation of forensic pathologists reading it years from now.
A killer walks free. A victim is denied justice. Others may be harmed by the same hands. Failing to see what is there is a failure of medicine.
An innocent person loses their freedom, their family and their name. A grieving parent becomes a defendant. Seeing what is not there is a failure of medicine too.
Both failures are catastrophic. Both are preventable. We guard against both with equal ferocity, because the dead deserve the truth, and so do the living.
Our findings do not change depending on who calls. NAAG keeps an open door to prosecutors, law enforcement and defense counsel alike. Our Medical Director has testified more than 250 times in criminal matters, for the prosecution and for the defense, in California, across the United States, in federal and military courts, in Canada and overseas. The answer is the same no matter which side asks the question, because the evidence is the same.
Independence is not a slogan. It is the reason sheriff-coroners, prosecutors and defense attorneys can all rely on the same report.
Forensic pathology belongs at the top of the medical pyramid. It is the doctor’s doctor: the specialty that brings together anatomy, physiology, pathology, biomechanics, toxicology, imaging and law in the service of truth. We practice it that way, using the full power of modern medicine: postmortem CT and forensic radiology, ultra-high-resolution imaging, histology and special stains, forensic neuropathology, forensic anthropology and osteology, and toxicology.
Every examination is performed directly by a board-certified forensic pathologist, held to national and international standards. Our specialty services are directed by board-certified experts.
Photographs, imaging, slides and records thorough enough that another qualified pathologist can test every conclusion we reach. If we cannot show it, we do not claim it.
We say what we know, what we do not know, and how certain we are. “Undetermined” is an honest answer when the evidence demands it. Speculation dressed as certainty has no place in our reports.
Our death investigation services include formal peer review, so no single pair of eyes stands between the evidence and the truth.
When a child’s death raises questions of abuse, our Deep Dive puts the retained biological evidence through a full secondary laboratory investigation. We go looking for the answer, not for the convenient one.
Slides and blocks are kept indefinitely. Wet tissue is kept for five years, and indefinitely in criminal cases. Justice can take decades; our evidence will still be there.
Original blocks stay secure in our custody. Any party with legal standing and the authority to request them, usually counsel, may obtain recuts, stains or unstained slides at their own expense to test our work for themselves.
The current model of death investigation, with fragmented training, inconsistent standards, underinvestment and chronic recruitment failures, is no longer fit for purpose. Death investigation now sits amid advanced imaging, molecular diagnostics, digital evidence and global scrutiny. Our systems have not kept pace.
Recruit differently. Train more rigorously. Support more honestly. Measure quality relentlessly.
And we call on our national professional societies to stop looking inward and to start defining enforceable standards and demanding demonstrably high-quality work. Medicolegal death investigation is not ancillary to justice or medicine. It is foundational to both. Anything less is a disservice to the dead, and to the living.
Evan W. Matshes, MD
Medical Director & Chief Forensic Pathologist, NAAG Forensic PC
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