The medical team went straight to coding blue, pumping air into the baby’s lungs, trying to push an intravenous line into Emberly’s neck and scalp, pushing her with a rectal thermometer – but her vital signs were still failing. After four hours, they left. A state medical examiner concluded that the death was not due to a medical problem, but was homicide, the result of “blunt force injuries with signs of strangulation”. Mrs McLean, a 29-year-old black mother with two other young children, has been charged with murder. Mrs. McLean was surprised. The emergency doctor who had tried to save the baby was shocked. But Dr. Joey Carter, a medical examiner summoned by the defense to review the case, saw a well-known pattern: a medical examiner making a decision without talking to the doctor or even looking at the hospital records. Supervisors who signed his decision. A criminal justice system that very often sends blacks to jail with evidence they may not have convicted anyone else. In court, Ms. McLean and her lawyer recalled that Ms. McLean was called a “monster.” She spent more than a year in jail before Dr. Carter’s autopsy forced the state medical examiner and prosecutor to acknowledge that the baby’s injuries could be explained by desperate efforts to save her that night. “I am grateful that this woman did not kill her child,” said Steven Jumbera, the assistant prosecutor in Tallahatsi County, in an interview after the allegations were dropped. “But the other side of it is, ‘My God, I had a woman locked up.’ The nation’s death investigation system, a patchwork of medical examiners, independent experts and elected medical examiners who may not have medical education, is responsible for examining suspicious and unexplained deaths. Wrapped in a cloak of scientific power, its professionals translate the complexity of disease, decay, toxicology and physics into simple categories such as accident, homicide or death from natural causes, setting in motion the most serious cases of the legal system and exerting enormous influence. in the juries. However, these experts are far from infallible. As forensic science of all kinds faces scrutiny for its reliability, with blood splatter patterns, hair matching and even fingerprints that are no longer considered the undisputed proof they once were, the science of death has been rocked by questions over the past year. whether the work of medical examiners is influenced by racial prejudice, prejudiced expectations and the strong influence of law enforcement. A study published last year in the Journal of Forensic Sciences found evidence of cognitive bias when 133 medical examiners presented identical medical evidence in hypothetical cases involving infant deaths. Deaths were more likely to be considered an accident if the child was white and the caregiver was a grandmother. It was most often considered homicide when the child was black and was cared for by his mother’s friend. The study, the authors of which included Dr. Carter, touched on the very essence of the simmering debate about forensic pathology. It has shown, its authors said, that judgments that should be based on science can be clouded by prejudice when medical examiners allow their findings to be influenced by information that is not medically relevant. But many industry leaders insist medical examiners have to deal with the whole case before them – including statistics showing that friends are more likely than blood relatives to commit child abuse. The new research has met with an explosive reaction. The National Association of Medical Examiners complained that the study had been poorly designed and conducted inappropriately. A member of the union filed a moral complaint against Dr. Carter and the three other medical examiners who are listed as authors, claiming that the work would do “incalculable damage to our profession.” One of the authors suggested the dismissal of the work simply to end the controversy. “I can not even sleep at night because of all the hatred and vitriol I have received,” he wrote in an email to the Times. Disappointed, Dr. Carter, who had spent years trying to expand racial representation in the profession, resigned as head of the agency’s diversity committee. Recent events such as the death of George Floyd in Minneapolis – where some experts have argued that the prolonged police burden on Mr. Floyd was not the cause of his death – have sparked debate in the public arena. Dr. Andrew Baker, the chief medical examiner in Minneapolis, who would conduct the official autopsy in the Floyd case, acknowledged in a speech at the American Academy of Criminology in 2015 that “the system’s gross failures have led to tragic consequences for . But he attributed the failures to bad apples in the profession, not to the inability to enforce safeguards against mistakes. “Obvious failures – such as incompetence, dishonesty, fraud and corruption – are not cognitive bias,” he said. Dan Simon, a law and psychology professor who served for six years on the federal committee tasked with setting better forensic standards, said medical examiners were uniquely resilient to reform. “They stand out in their arrogance,” he said. “And it’s a serious problem.”

Wrong autopsies and wrong convictions

Critics say the reluctance to acknowledge the possibility of bias, combined with a lack of professional diversity and a traditionally friendly relationship with law enforcement, can increase the chances of racial differences when medical examiners make a mistake. A number of black and Latino defendants have been released in recent years, some from the death penalty, after the autopsy findings that helped them convict were refuted. In a California case, Vicente Benavides was sentenced to 25 years in prison for raping and sodomizing his girlfriend’s 21-month-old daughter so brutally that he killed her. Mr. Benavidis was released in 2018 after experts said that the cause of death presented at trial was anatomically impossible. Prior to her involvement in the Mississippi Mississippi death case, Dr. Carter had devoted much of her career to the issue of racial bias in the medical examiner profession. She attended medical school at Howard University, then the only historically black School of Pathology, and in 1992 became the first black woman to lead a medical examiner’s office in Washington. She realized that there was virtually no conduit to train and recruit non-whites into her profession, even though more than half of the country’s homicide victims are black. Later, she heard absurd allegations from fellow medical examiners, including that blacks were impervious to pain and that bruises could not be detected on dark skin. He came to believe that the lack of intercultural education caused mistakes with great consequences. Some of these extensions became apparent during her time in forensic pathology in the 1980s, when she was the only black physician in the medical examiner’s office in Miami. A number of poor black women appeared dead in gloomy environments – cheap hotels, abandoned buildings, open fields. Although the women were found in similar positions, the deputy medical examiner believed that their death was caused by a combination of cocaine use and voluntary sex. Almost all of them were classified as drug-related accidents. Dr. Carter pushed back. The victim he examined had a heavy crack habit, but Dr. Carter refused to call the death an accident. He was right – after a public outcry, the autopsies were examined. injuries that had been overlooked or rejected were found and all deaths were reclassified as homicides. A man with previous convictions for rape has become the prime suspect in 32 murders for nearly a decade. He died before being tried. Over the years, the most frequently cited source of bias in forensic pathology has been the influence of law enforcement, in part because in some places police detectives are usually present during autopsies. In the Mississippi case, it could have been the other way around: Prosecutor Jubera said there was no suspicion of obscene play in Emberly’s death until the doctor described it as homicide. That left, she said, only one suspect: her mother.

Emberly autopsy

For months after Emberly’s death, Jocelyn McLean called the county medical examiner and the state medical examiner’s office for an explanation as to why her daughter had died, worried that she had lost a warning sign or that the hospital had released the baby too much. . He did not get any answers. The medical examiner’s office had a huge delay that forced families, police and courts across the state to wait long periods for autopsy reports. But unlike many jurisdictions, Mississippi medical examiners were board-certified medical examiners working in a state-of-the-art laboratory. However, 15 months passed before the local prosecutor was notified by the physician about the case, Dr. J. Brent Davis, that death was homicide. Ms. McLean, who lived near Atlanta and was visiting Mississippi when she started giving birth, saw the first sign of trouble in December 2017 when she received a Facebook message from an employee of the Georgia Family and Child Services Department warning that if Mrs. McLean’s two living children did not see the agency within 48 hours, it would be …