Audit of the Office of the Chief Medical Examiner (December 19, 2024)
December 19, 2024 · Office of the Chief Medical Examiner · Read the full official report on mass.gov ↗
Published December 19, 2024 Audit covers July 1, 2021 – June 30, 2023 Under Diana DiZoglio · 2023–present
source
“OCME did not complete autopsy reports within policy time frames.”
Read the plain-English breakdown
This is a Massachusetts State Auditor performance audit of the Office of the Chief Medical Examiner, covering July 1, 2021 through June 30, 2023.
“In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of the Office of the Chief Medical Examiner (OCME) for the period July 1, 2021 through June 30, 2023.”
Auditors checked whether the office followed rules for autopsy reports, death certificates, family notifications, release of bodies, and COVID-19 fund accounting.
“The purpose of our audit was to determine whether OCME did the following:”
Late autopsy reports can affect court cases and delay families who are trying to settle estates or receive insurance money.
“Delays in autopsy reporting could delay court cases and prevent family members from receiving insurance proceeds and proceeding with other matters, such as estate settlement.”
If your family is involved in a death investigation, this audit is about whether key documents and communications are handled on time and according to policy.
“We work with families and funeral homes to provide information to those affected by sudden or traumatic loss.”
The office passed four of the five audit objectives, but it fell short on completing autopsy reports within the required time frame.
“We are pleased with the results of the OSA’s analysis of our work.”
The auditor recommends that the office follow the 90-day rule and address medical examiners who are not meeting reporting deadlines.
“OCME should work with underperforming medical examiners to ensure that they are meeting reporting time frames.”
Auditors estimate that at least 275 autopsy reports during the audit period were not completed within the required 90 days.
“Based on this, we are 95% confident that at least 275 cases during the audit period did not have autopsy reports completed within the required 90 days.”
An autopsy report is the written result of a medical examination of a body that explains the cause and manner of death.
“This examination results in a final autopsy report that documents the cause and manner of death.”
What the Auditor checked
- Did not comply Did OCME ensure that it completed 90% of autopsy reports within 90 calendar days after the date of the autopsy, in accordance with the Medical Examiners section (3.05[E][4]) of the Office of the Chief Medical Examiner: Policy Manual?
- Complied Did OCME ensure that death certificates were completed, in accordance the Medical Examiners section (3.05[E][3–4]) of the Office of the Chief Medical Examiner: Policy Manual, that were in effect during the audit period?
- Complied Did OCME confirm that the legal next of kin was notified of the decedent’s death and that communication was established with investigating agencies in accordance with the Medicolegal Investigators section (3.01[B][1–2]) of the Office of the Chief Medical Examiner: Policy Manual?
- Complied Did OCME ensure that it released decedents’ bodies to the people with the proper legal authority to receive them in accordance with Section 13 of Chapter 38 of the General Laws?
- Complied Did OCME account for COVID-19 funds received in accordance with the Office of the Comptroller of the Commonwealth’s “COVID-19 Revenue and Grants” directive that was effective April 1, 2020?
What the Auditor found
Why it matters: Delays could affect court cases and delay families from receiving insurance proceeds or resolving estate matters.
Standard: The Medical Examiners section (3.05[E][4]) of the Office of the Chief Medical Examiner: Policy Manual requires medical examiners to finalize 90% of autopsy cases within 90 days of the examination. ( Section 12 of Chapter 11 of the Massachusetts General Laws; Medical Examiners section (3.05[E][4]) of the Office of the Chief Medical Examiner: Policy Manual )
2 recommendations
- OCME should follow the 90-day time frame as stipulated in its medical examiner policy.
- OCME should work with underperforming medical examiners to ensure that they are meeting reporting time frames.
Agency response & Auditor reply
Agency: "While the OSA did find noncompliance with the 90-calendar day deadline for completing autopsy reports established in the Office of the chief Medical Examiner: Policy Manual, we are proud to have achieved an autopsy report turnaround time that falls to within five percentage points or less of the 90% in 90 days completion metric we strive to achieve."
Auditor: "Moving forward, we encourage OCME to continue to improve this percentage to bring OCME into full compliance with regulations, as families are relying on OCME to conduct autopsies in a timely manner."
Prior findings revisited
"This improvement is particularly striking when contrasted against the prior audit of the OCME by the OSA (released in 2017), which found that only 42% of autopsy reports had been completed within 90 days."
More audits of this entity
Other Office of the State Auditor reports on Office of the Chief Medical Examiner , including the prior audits referenced above.
- Office of the Chief Medical ExaminerState Agency / Office · August 11, 2017