Philadelphia is struggling to properly investigate all of its sudden and unexplained deaths, a new report has found, citing the city’s opioid crisis, COVID-19, and a record-high homicide rate for exacerbating problems in an understaffed Medical Examiner’s Office.

An independent report on medical examiners’ mishandling of remains from the Philadelphia Police Department’s bombing of the MOVE complex in West Philadelphia in 1985 also criticized the office for wide-ranging problems — many associated having too few investigators and pathologists to keep pace with the city’s deaths.

Among America’s 10 most populated cities, Philadelphia is one of three that isn’t accredited by a national professional organization, a process that ensures certain quality standards are being met. Right now, even the office’s toxicology department isn’t accredited, something a national expert in the field called unusual.

“That’s very fundamental — that a toxicology lab is to be accredited,” said John Fudenberg, a retired Las Vegas coroner and executive director of International Association of Coroners and Medical Examiners.

The report also criticized its lack of written policies. Establishing a policy manual will be one of the first tasks for a soon-to-be hired city medical examiner, said Cheryl Bettigole, the city health commissioner who oversees the medical examiners office, in an interview on Monday.

She said the MOVE controversy itself highlights one of those policies needing crafting: how much families should be told about the specimens and remains taken from victims in an investigation, and what input they should have about what happens to them.

» READ MORE: Philly health commissioner resigns over cremating MOVE victims without telling family; Kenney apologizes

Staffing shortages are contributing to the problems in the office, which has just 58 staffers and was asked to consider investigating 6,921 deaths in 2021, Bettigole said.

“We are very, very stretched,” she said.

The staffing shortages keep the office from effectively acting as an independent investigator — essentially another set of eyes, separate from law enforcement or prosecutors — on cases involving police killings or deaths in custody, according to the report prepared by the law firms Dechert and Montgomery, McCracken, Walker, and Rhoad.

The report included 16 recommendations for the medical examiner’s office, including a call for more independence from other branches of city government, cultural sensitivity training, and a push to gain national accreditation, which the health department has said could take years.

Bettigole said she is near the end of a search for a new chief medical examiner, a more-than $200,000-a-year position that has been vacant since the office’s previous director resigned in 2021 the handling of the MOVE victims’ remains.

Staff at the medical’s examiner’s office described feeling “overwhelmed and suffering burnout,” investigators found. It’s a complaint that resonates throughout the profession. Nationwide, there are just 400 to 500 full-time forensic pathologists working — half the number needed to fill vacancies at medical examiners’ offices across the country.

“It’s a common problem across the nation that medical examiners and coroners offices are underfunded and understaffed,” said Fudenberg. “The crux of that problem is the counties don’t fund the offices.”

An overwhelming caseload

One of the office’s primary goals is to ensure investigators are present when a police officer shoots someone or a person dies in government custody, like in a jail or prison, Bettigole said. Currently, the medical examiner’s office isn’t able to guarantee an investigator always responds those calls.

As of March 2022, the office had a $7.2 million annual budget, eight staff investigators and five unfilled investigator positions. Whenever a death is called in — and there were 6,921 in 2021 — an investigator determines whether the medical examiner’s office has jurisdiction, which typically involves cases with sudden, unnatural, or unexpected deaths.

In the 40% of cases where the office does get involved, an investigator must gather records, interview witnesses and relatives, and in some cases investigate scenes.

The report noted an independent review is particularly important in those cases to boost public trust. ”These deaths have the potential to be highly politicized, drawing heavy media interest and scrutiny,” the report stated.

» READ MORE: Questions persist over Philly’s mishandling of MOVE remains

Instead, staffers are swamped by a tide of death investigations that have only become worse during the pandemic. In 2021, the office performed 1,721 autopsies. That’s more than 240 autopsies per pathologist, the report stated. Even that is likely an underestimate, since it counts the current acting medical examiner as a pathologist, and his administrative work keeps him from doing a full slate of autopsies.

It’s questionable whether the office’s caseload would warrant accreditation, which requires no more than 250 autopsies per year for each forensic pathologist.

Reaching accreditation also requires that training, equipment, and an office’s physical location meet professional standards.

Medical examiners aren’t regulated by the federal government, and there are no national standards for the profession. About 4% of the nation’s 2,500 offices were accredited as of 2016, according to the report, although it is more common in big cities.

The lack of accreditation could result in criminal prosecutors losing cases to defense attorneys, who could home in on the medical examiner’s lack of professional certification, Fudenberg said.

Philadelphia’s health commissioner said the immediate goal is to address the toxicology department’s accreditation, a step needed before the office as a whole can obtain accreditation. And the report noted that toxicology was the only department within the office that has a policy manual.

Bettigole said she also is lobbying the city’s office of human resources to boost the median pay for some jobs in the hopes of attracting new workers and retaining current ones. The office added three new positions in 2022, but it loses people as quickly as it can hire them.

Difficult decisions

The report, released Thursday, was the result of a yearlong independent investigation commissioned by Philadelphia officials over the handling of a box of victims’ bones from the MOVE bombing that languished in the city medical examiner’s office for decades.

In 2017, the box was discovered in a storage room, and then-health commissioner Thomas Farley ordered them cremated without notifying the victims’ families. The decision outraged victims’ relatives when it came to light and led to his resignation. For reasons that remain murky, the remains were never destroyed, and are still held by the medical examiner’s office.

Daniel Hartstein, a lawyer for Lionel Dotson, whose sisters, Katricia and Zanetta, were killed in the bombing, said city officials showed him and Dotson what is believed to be bones of his sisters on a Zoom call last fall. Hartstein hopes to get them returned to his client soon.

The office’s treatment of the MOVE remains has caused Dotson “tremendous pain,” he said Monday.

“They were literally forgotten, just sitting in a box. The family thought they were buried and given a proper funeral,” he said. “How much disrespect can there be?”

The city has not had contact with the families of the bombing’s victims since the report was released Thursday. Health commissioner Bettigole said officials are in the process of reaching out to them. It isn’t clear who some of the bones belonged to, Bettigole said. The next step could be doing additional forensic investigation to confirm identifies, or creating a joint memorial for the remains.

The report described shoddy record keeping and storage policies that played a role in the misplacement of the remains. The office has introduced a digital record keeping system for specimens that should keep that from happening again, Bettigole said.

In February, the medical examiner’s facilities moved to a new location on North Broad Street, a big improvement over their older offices in West Philadelphia.

The staffing issues, though, are harder to resolve.

“I want this office accredited,” Bettigole said. “Unfortunately with the continued rise in the homicides and overdose deaths, it’s a moving target.”