Coroner Leaves Cloud Of Questions Disputed Rulings Haunt Relatives, Hinder The Health-Care System

The Spokane County coroner is leaving a trail of questionable and incomplete death records that could frustrate families and mislead experts for years.

He says people die of alcoholic disorders of the liver without doing autopsies. He doesn’t always ask for autopsies when children die. He snubs police who request autopsies to rule out murder. Sometimes, what appears on death certificates doesn’t jibe with what Dr. Dexter Amend tells families.

These and other decisions run against practices followed by pathologists nationwide. Some even contradict Spokane County’s own policy, as cited by Amend.

Concerned about complaints, county commissioners asked Amend last week to clear his death certificates with his lawyer before filing them.

Over the past two months, The Spokesman-Review analyzed thousands of state death records filed since 1980. Amend has been coroner for four of those years.

A computer study shows:

In a three-year term in the 1980s, Amend was the only coroner or medical examiner to list “alcoholic fatty liver” as the cause of death without an autopsy. Experts say the diagnosis is difficult to make without an autopsy.

He made that diagnosis so often that those cases account for more than 75 percent of the state’s “alcoholic fatty liver” deaths that did not get autopsies from 1980 to 1994.

Spokane County’s autopsy rate dropped when Amend took office again in 1995. In the 15 previous years, it climbed from 11 percent to 65 percent of deaths investigated by the coroner. Between January and September last year, Amend’s rate was 43 percent.

Amend calls for autopsies on far fewer suicides than many other professionals statewide. He orders fewer autopsies for accident victims and people under 40.

Amend, 76, a retired urologist, refused repeated requests for an interview for this story.

He defended his decisions by responding in writing to general questions from The Spokesman-Review but would not meet to discuss details.

As coroner, Amend has a top cop’s power, a doctor’s authority and a judge’s captive audience. He makes $48,658 a year. He orders autopsies but doesn’t perform them himself.

Last year, his office investigated 383 of the 3,937 deaths in the county.

His actions have far-reaching effects. Spokane County death statistics may be skewed. Lawsuits and legal claims are piling up. Families live with questions and deal with insurance nightmares.

Bereaved families often complain that Amend is insensitive. They say he scolds, asks inappropriate sexual questions and makes other callous comments.

He asked a mourning man to help carry his uncle’s rigid body. Another woman said he tried to comfort her by crooning a Johnny Cash song.

He has his supporters.

One mother applauded him for his attitude when her son, Randy Johnson, died Aug. 8 from an addiction to solvent fumes.

“Because Dr. Amend is a man of morals, I believe he has every right to call sin, sin,” Leone Johnson said. “We need to stand behind men that don’t compromise truth.”

Truth, experts say, is what the whole Amend controversy is about.

“The public needs to know why people are dying, whether it’s from heart problems or gunshot wounds, so we can best allocate our dollars toward health care and prevention,” said Ross Zumwalt. He is president of the National Association of Medical Examiners and New Mexico’s chief medical examiner.

Drinking to death?

James Henry always said he couldn’t live without his wife, Lelia. Married 46 years, they died three days apart.

As Henry stepped into the shower hours before his wife’s March 9 memorial service last year, the 70-year-old man collapsed. His son Jerry Henry performed cardiopulmonary resuscitation.

“My dad drank, yes he did,” said Jerry Henry, who once investigated deaths and responded to medical calls as an Alaska state trooper. “He drank a lot. But he died of a broken heart.”

There was no autopsy. The death certificate says Henry died because of fatty metamorphosis of the liver due to alcohol abuse, also known as an alcoholic fatty liver.

The diagnosis is one of Amend’s most common.

It’s rarely used in the rest of the state - and almost never without an autopsy.

Critics say he’s on a mission: To ferret out people who drink regularly and mark them by emblazoning it on their death certificates - even if it’s not what killed them.

“It’s kind of like an ostrich. All you see is what you want to see, and in this case, it’s dirt,” said Dr. George Lindholm, who does more than 90 percent of the autopsies ordered by Amend.

“This is second-class treatment. If this was a county commissioner’s relative, would it be handled this way?”

Alcoholics can develop fat deposits in their livers, which can kill them. But many drink their whole lives without developing these deposits. Several medical examiners and pathologists said making that liver diagnosis with no autopsy is impossible, or at best, sloppy.

“Without looking at the tissue, I don’t know how you’d make that diagnosis,” said Dr. Donald Reay, King County’s chief medical examiner.

Two medical examiners, including one from Oregon, said the diagnosis can occasionally be made with no autopsy, but only if medical records show a history of liver problems or alcoholism.

James Henry was never treated for liver problems - only a broken knee and skin cancer, said his daughter Sandy Billings. She unsuccessfully pressed Amend to change Henry’s death certificate.

“I’m very angry about it and there’s nothing I can do,” Billings said. “I don’t have the financial means to fight it.”

From 1980 to 1994, Spokane County coroners said 27 people died of an alcoholic fatty liver; 24 were during Amend’s first term, and at least 22 of those were not autopsied.

From 1984 to 1986, Amend diagnosed almost half the state’s alcoholic fatty liver cases. Autopsies were performed in all the state’s other fatty liver cases.

After Amend became coroner last year, the diagnosis began popping up again. From January to September, death records show eight Spokane residents died of alcoholic fatty livers.

Relatives of six of the eight people questioned Amend’s diagnoses. The other families couldn’t be found for comment.

Those who talked admitted that their relatives were heavy drinkers. Some said they believed the deaths were heart attacks. Most questioned why autopsies weren’t done and why they weren’t asked for more background information.

In one case, the death certificate contradicted what Amend told the family.

Ronald Swensen, 61, collapsed last April 14 while at his job, working on a swimming pool. His daughter, Lynn Buchheit, said Amend didn’t get any background from the family.

“My dad died of a heart attack,” Buchheit said. “Amend said, ‘Heart attack is not a cause of death.’ He said, ‘You don’t just have a heart attack. There has to be a reason.”’ That reason was alcoholic cirrhosis of the liver, Amend told her. But the death certificate says alcoholic fatty liver - a different diagnosis.

Buchheit was incredulous about her father’s death certificate and Amend’s treatment.

“He was very rude and uncaring and determined to say he died of alcoholism,” said Buchheit, who has attended autopsies in her job at Pathology Associates Medical Laboratories. “It hasn’t sat right to this day.”

It doesn’t sit well with medical professionals either. Dr. Lone Thanning, a forensic pathologist outside of New York City, said she would order autopsies in cases such as Swensen’s and Henry’s.

“That is an unorthodox way to handle these cases,” said Thanning, recommended as an expert by the American College of Forensic Examiners in Missouri. “They should have both had autopsies - especially the one who was at work. There’s a workman’s compensation issue.”

In his written response to the newspaper, Amend said alcoholic fatty liver is a valid diagnosis without an autopsy.

“When a long history of alcohol abuse is clearly identified together with repeated falls while inebriated, this diagnosis is a valid cause of death,” he wrote.

Even an autopsy didn’t stop a dispute over LaDonne Krause’s death.

Her daughter Tahnya Ader opened her mother’s bedroom door on Easter Sunday, when she stopped by with a homemade basket. An almost empty half-gallon bottle of vodka sat next to her mother’s body.

Lindholm, who did the autopsy, said Krause’s death was probably an accident, possibly caused by mixing alcohol and anti-depressants.

Amend wrote on the death certificate that the 42-year-old died naturally - of an alcoholic fatty liver.

“He said that her liver blew up,” Ader said.

Lindholm scoffed. “There was fatty metamorphosis,” he said. “But it’s an obtuse sort of silly thing to put on the death certificate. It’s in the ballpark, but it’s only hitting a corner.”

Removing the ‘cloud of doubt’

Judy Armstrong rarely used her asthma inhaler. That’s why her husband doesn’t believe it killed her.

Amend does. He ruled that Judy Armstrong overdosed on Beclovent, an asthma inhalant, in January 1995. There was no autopsy.

More than a year later, Chuck Armstrong questions how his wife, a 50-year-old child-care worker, really died.

Two medical examiners and a toxicologist called Amend’s Beclovent diagnosis unlikely and impossible with no autopsy.

“My suspicion is you could not inhale enough of it to be the direct cause of death,” said Gary Kunsman, deputy chief at the Armed Forces Institute of Pathology’s toxicology lab in Washington, D.C.

“You don’t even know if she took it. Who knows? She could have had a blood clot, a bleeding aneurysm.”

No real standards exist for when to perform an autopsy - only guidelines. Most children who die should have autopsies. People who drown, hang or die under questionable circumstances should be autopsied. So should people who die alone, in accidents or at work, experts say.

“The autopsy results often remove the cloud of doubt,” said Thomas Bennett, Iowa’s state medical examiner. Coroners and medical examiners across the state order autopsies at a steadily growing rate.

In 1980, autopsies were performed in almost four of 10 deaths investigated by a coroner or medical examiner. By 1994, the number rose to almost six of 10.

Until Amend took office, Spokane County followed the trend, jumping from one autopsy in 10 investigated deaths in 1980, to more than six in 10 in 1994.

From January to September last year, the autopsy rate dropped to about four in 10 of all investigated deaths.

Marvel Jackson, 45, was one of those who wasn’t autopsied. The gospel singer sat down with her family after dinner last June to watch “The X Files” and had a seizure, said her sister, Glenda Muse.

Paramedics took Jackson to Sacred Heart Medical Center.

“I waited two hours for the coroner to come,” Muse said. “I was told he was coming. Then they told me he thought an autopsy wasn’t necessary. I didn’t know what to think.” Jackson had no history of seizures, Muse said.

A half-dozen medical examiners and coroners said Jackson would have been autopsied in their jurisdictions.

Her death certificate says she died of anoxia, which means no oxygen, due to a seizure phenomenon.

“If she doesn’t have any history of it (seizures), that doesn’t sound very accurate,” said Larry Lewman, chief medical examiner in Oregon.

“Seizures may be seen in people during the dying phase,” Lindholm explained. “It’s kind of like during the course of dying, somebody might turn blue. You wouldn’t see ‘blue skin’ on the death certificate.”

In his written response to the newspaper, Amend said autopsies generally are performed “if there is evidence of violence … or evidence of suspected unnatural death or a death which needs explanation.”

In the past, he has said he saves taxpayers money by ordering fewer autopsies. An autopsy costs about $1,000; the state reimburses the county up to 40 percent.

Amend wrote that Spokane County’s policy calls for autopsies whenever people die from accidents, homicides or sudden infant death syndrome. Autopsies are done on people under 40 when there isn’t a medical reason for their deaths, he wrote.

But Amend doesn’t always follow the policy.

Death records show he didn’t call for autopsies in 26 percent of the 59 accidents he investigated through September. That is up from 9 percent of the 86 accidental deaths the year before he took office.

He didn’t order autopsies in about 28 percent of the 98 investigated deaths of people younger than 40, up from 4 percent of 143 a year earlier.

Clashing with other experts

Grieving families aren’t the only people Amend frustrates.

He angers doctors by not ordering autopsies for all children. His lax notification on SIDS cases infuriates public health nurses. He confounds police.

Experts say autopsies of children can rule out abuse and identify genetic defects that parents could pass on to other children.

Autopsies also can give parents the peace of knowing they did nothing wrong, said Mary Case, a St. Louis child death expert.

“Basically, children that do not have a disease you anticipate they’re going to die from - like some malignant tumor - need to be autopsied if they die,” Case said.

Children like the 2-year-old Elk boy who died in a bucket of water, or the 7-year-old Spokane boy whose death certificate says he died of an epileptic seizure, experts say. Autopsies weren’t done on either.

Or Cole O’Neill, a 1-year-old Spokane boy who died a year ago after a heart catheterization at the Heart Institute. Despite pleas from the boy’s doctor and parents, Amend refused an autopsy.

Dr. Hrair Garabedian bypassed Amend and offered to pay for it himself. Lindholm did the autopsy for free.

“The family wanted to have some explanation,” Garabedian said. The family learned the boy had multiple heart abnormalities.

Public health nurses have battled Amend for a year, asking to be promptly notified of SIDS deaths.

Amend didn’t tell public health nurses when parents found their 6-month-old baby dead in his crib from sudden infant death syndrome last April, said Judy Rose, who runs the county SIDS program.

The couple spent a week blaming themselves and wondering if they could have prevented the death.

The father, who didn’t want his name used, said he asked himself, “‘Why? What did I do? Maybe I should’ve been awake.’ You feel guilty for sleeping. It’s rotten.”

Public health nurses learned of the baby’s death eight days later when someone from the county’s vital statistics office mentioned it. They immediately went to console the family. Amend notified nurses of only four of 12 SIDS deaths last year, Rose said.

Amend blamed faulty communications. “We always try to notify the public health nurse assigned to SIDS death counseling,” he wrote in his letter.

Police and sheriff’s deputies have their own problems.

Detectives concerned about Amend’s decisions say they’ve started asking for autopsies in writing, so if they’re turned down, they’ll have evidence they asked.

They also say Amend jumps to conclusions when filling out death certificates, sometimes calling deaths suicides without enough evidence.

“This is pretty much a regular occurrence,” said sheriff’s Detective Mike Massong.

Amend said he talks with police and deputies to decide on autopsies. He said he refused autopsies requested by law enforcement only once, maybe twice.

Amend said he doesn’t believe in ordering autopsies for suicides “when there is absolutely no possible criminal relationship associated with the death according to all law enforcement agencies. …”

Massong argued with Amend over the death of Kelly Fletcher, 17, whose body was found in the Spokane River in April.

The death certificate says he jumped into the river.

“There’s no evidence to support that whatsoever,” Massong said. “For me, that’s a gross misconduct of office.”

Relatives and Massong said they don’t know if Fletcher jumped or fell in the river. He may have been beaten and thrown in the water.

Detectives called Amend six times to try to change the cause to undetermined. Fletcher’s fiancee has also tried unsuccessfully to get the death certificate changed.

Annaliese Hopkins worries her daughter, born just before Fletcher died, will someday have an inaccurate image of him.

“She’d think her father didn’t even care about her,” Hopkins said. “She’d think, ‘My father jumped off a bridge when I was only 18 days old.”’

, DataTimes ILLUSTRATION: 3 Photos (2 Color) 3 Graphics: Fewer autopsies; Was it suicide?; Death by drinking?