By Simon A. Cole Maurice Possley Ken Otterbourg Jessica Weinstock Paredes , Barbara O’Brien, Meghan Cousino, & Samuel R. Gross,
EXECUTIVE SUMMARY
A. THE CASES
This report analyzes 151 cases in which defendants were exonerated between 1989 and 2023 in the United States and medicolegal death investigation (“death investigation” for short) contributed to the false conviction.
The 151 exonerees lost a total of 1,837 years in prison, an average of 12.2 years per exoneree. That is less than the average of 14.6 years for exonerees convicted of comparable crimes but for whom death investigation did not contribute to the false conviction.
B. CASE CHARACTERISTICS
Not surprisingly, 140 (93%) of the 151 cases in which death investigation contributed to the false conviction were homicides. However, death investigators did contribute to eleven non-homicide cases, all involving abuse of vulnerable people: children or dependent adults. Eight of these eleven were cases involving the Shaken Baby Syndrome (SBS) diagnosis, in which the top charge was child abuse.
In more than one-third of the cases, the death investigation evidence consisted of a claim that the medical evidence was consistent with the prosecution’s theory of the crime, e.g., that the victim’s wounds were consistent with a weapon linked to the defendant.
In another third of the cases the death investigation evidence concerned the cause of death.
Manner of death and time of death evidence contributed to fewer cases.
C. DEMOGRAPHICS
Women were overrepresented among the defendants for whom the death investigation contributed to their false conviction. Thirty-nine (26%) of the defendants in the 151 cases were female, more than three times the 8% of all exonerees who were female. Only around 5% of exonerees convicted of comparable crimes were female.-
Relatedly, cases involving child victims were particularly vulnerable to contributions by death investigation. Nearly half (47%) of the 151 cases involved child victims. That compares to only 19% of all non-death-investigation exonerations and 34% of non-death-investigation exonerations for comparable crimes.
Although concerns have been raised about racial bias in death investigation, the exonerees in death investigation exoneration cases were whiter than exonerees in general. One third of death investigation exonerees were Black compared to 53% of all exonerees. Similarly, 8% of death investigation exonerees were Hispanic, compared to 12% of all exonerees. The higher representation of whites diminishes somewhat if women are removed from the analysis.
D. DEATH INVESTIGATION SYSTEMS
The United States has a patchwork death investigation system with variations among and within states. The two primary types are medical examiner and coroner systems. Most, but not all, experts perceive medical examiner systems to be superior and call for them to replace coroner systems. We did not find that more false convictions occurred under coroner systems. Instead, false convictions generally occurred in proportion to where more people live: their occurrence correlated with those counties’ and states’ proportions of the US population.
Nor did we find that more false convictions occurred in systems with elected (rather than appointed) coroners and death investigators.
In 22% of cases, the death investigation office that contributed to the false conviction was accredited by the National Association of Medical Examiners (NAME). Only 17% of US death investigation facilities are accredited.
E. QUALIFICATIONS OF DEATH INVESTIGATORS
The highest qualification for death investigators in the US is generally considered to be board certification in the subspecialty of forensic pathology by the American Board of Pathology. However, for decades there have not been enough board-certified pathologists in the US to meet the need for death investigation services and autopsies. Therefore, many death investigations and autopsies are performed by less qualified personnel, such as pathologists without board certification, physicians with specialties other than pathology, and even, in some cases, non-physicians such as funeral directors. We did not find that most false convictions occurred in cases with underqualified death investigators. In fact, board-certified forensic pathologists contributed to 61% (92) of the 151 cases in this study.
National Registry of Exonerations (2024), 90p