Overview
The Office of the Chief Medical Examiner (OCME) did not meet the policy target of completing 90% of autopsy reports within 90 days of an autopsy. Out of the 60 cases reviewed, we found that nine autopsy reports (15%) were not completed within 90 days of the autopsy exam. Those reports that took longer than 90 days to complete ranged from 92 to 807 days. Of the 60 cases sampled, we found 1 case for which an autopsy report had not yet been completed. We projected the test results for the completion of autopsy reports from our sample of 60 cases to the population of 3,842 cases during the audit period. 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.
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.
Authoritative Guidance
The Medical Examiners section (3.05[E][4]) of the Office of the Chief Medical Examiner: Policy Manual states, “Autopsy Reports— . . . the medical examiner . . . is responsible for finalizing 90% of cases (with . . . an autopsy report if the case was an autopsy) within 90 days of the examination.”
Reasons for Issue
OCME communicated that one reason for the delay in reporting was because of several underperforming medical examiners.
According to OCME, it currently follows a 94-day reporting time frame that allows for a 4-day administrative buffer. This is inconsistent with the policy, which states that the requirement is 90 days. Additionally, only one of the nine exceptions identified was completed in under 94 days. Therefore, OCME only completed 87% of our sample cases within the time frame using 94 days as the criterion.
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.
Auditee’s Response
The Office of the Chief Medical Examiner (OCME) would like to thank the Office of the State Auditor (OSA) for its thoughtful and meticulous review of our Agency. During the audit process we strived to be transparent and thorough in our responses, allowing for a broad and deep look into the identified systems. We are pleased with the results of the OSA’s analysis of our work.
Although we of course always have more work to do, we are encouraged that this audit has shown compliance with four of the five stated objectives. 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. 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. The OCME has been working hard to improve the turnaround times for the past couple of years and has seen marked improvement in efficiency. We intend to continue this work so that we bridge the gap in achieving this metric.
It is worth pointing out specifically that the OSA found that the OCME completed death certificates consistent with the requirements of the policy. Highlighting this is important because death certificates, more than autopsy reports, are heavily relied upon for resolving end-of-life administrative issues such as obtaining life insurance benefits. By completing more than 90% of death certificates in 90 days or less, the OCME has made great strides in ensuring this end-of-life documentation is completed in a timely manner.
Overall, these audit results demonstrate the OCME’s commitment to excellence under its current leadership and executive team, especially when benchmarked against the preceding audit results.
Auditor’s Reply
We acknowledge that OCME has taken steps to improve its percentage of completed cases of autopsy reports within 90 days. 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. We encourage OCME to prioritize engagement with the Executive Office of Public Safety and Security and the Legislature to ensure that resources and oversight are adequate to complete this work.
Date published: | December 19, 2024 |
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