Sequenom Fires Top Brass After Investigation
David Washburn
Voice of San Diego
September 28, 2009
San Diego-based Sequenom Inc. today forced out its CEO and three other executives,
including its research and development chief executive, after an in-house investigation into
the mishandling of test results for its potentially breakthrough blood test for Down syndrome,
the Associated Press is reporting.
The company, according to the AP story, fired CEO Harry Stylli, and Elizabeth Dragon,
senior vice president for research and development. Sequenom's chief financial officer Paul
Hawran and an unnamed executive resigned on Friday. Three lower-level employees were
also fired.
The news caused shares of the company to plunge 44 percent — from $5.69 to $3.21 — in
after hours trading Monday. Shares have been as high as $29.14 during the past year.
From the AP story:
"While each of these officers and employees has denied wrongdoing, the special
committee's investigation has raised serious concerns, resulting in a loss of confidence by
the independent members of the company's board of directors in the personnel involved,"
the company said in a statement.
The company did not say that any deliberate wrongdoing was discovered, but in a filing with
the Securities and Exchange Commission, it said it did not put adequate protocols and
controls in place. Some employees were not adequately supervised, it said.
Sequenom acknowledged on April 29 that employees had mishandled trial data on the test,
which, because it is far less invasive than amniocentesis, could revolutionize how pregnant
women are tested for the presence of Down syndrome in their babies.
As we chronicled in May, stock analysts and other industry watchers were shocked not only
with the news that data had been mishandled, but also with the way the company managed
the fallout. Since Sequenom's April admission, several class action lawsuits have been filed
against the company on behalf of shareholders.
— DAVID WASHBURN
David Washburn
Voice of San Diego
September 28, 2009
San Diego-based Sequenom Inc. today forced out its CEO and three other executives,
including its research and development chief executive, after an in-house investigation into
the mishandling of test results for its potentially breakthrough blood test for Down syndrome,
the Associated Press is reporting.
The company, according to the AP story, fired CEO Harry Stylli, and Elizabeth Dragon,
senior vice president for research and development. Sequenom's chief financial officer Paul
Hawran and an unnamed executive resigned on Friday. Three lower-level employees were
also fired.
The news caused shares of the company to plunge 44 percent — from $5.69 to $3.21 — in
after hours trading Monday. Shares have been as high as $29.14 during the past year.
From the AP story:
"While each of these officers and employees has denied wrongdoing, the special
committee's investigation has raised serious concerns, resulting in a loss of confidence by
the independent members of the company's board of directors in the personnel involved,"
the company said in a statement.
The company did not say that any deliberate wrongdoing was discovered, but in a filing with
the Securities and Exchange Commission, it said it did not put adequate protocols and
controls in place. Some employees were not adequately supervised, it said.
Sequenom acknowledged on April 29 that employees had mishandled trial data on the test,
which, because it is far less invasive than amniocentesis, could revolutionize how pregnant
women are tested for the presence of Down syndrome in their babies.
As we chronicled in May, stock analysts and other industry watchers were shocked not only
with the news that data had been mishandled, but also with the way the company managed
the fallout. Since Sequenom's April admission, several class action lawsuits have been filed
against the company on behalf of shareholders.
— DAVID WASHBURN
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Report: 2001 Anthrax Attacks Were Preventable
Scientist With Psychiatric Problems Given Access to Deadly Pathogen
By JASON RYAN
March 23, 2011
The Army scientist believed to have caused the 2001 anthrax attacks that left five dead and
paralyzed Capitol Hill and media organizations had severe psychological problems, was
obsessed with a sorority and should never have been given security clearance or access to
deadly pathogens, according to a newly released report.
An independent review of the psychiatric records of the alleged anthrax killer Dr. Bruce Ivins
has revealed that the Army scientist, who committed suicide in 2008, should never have
been given a security clearance or access to anthrax based on his psychological profile and
diagnosable mental illness.
The report also found that Ivins allegedly carried out the attacks for revenge and
redemption for questions about his work with the anthrax vaccine. The findings also delve
further into his troubled relationships with women and an obsession he developed for a
sorority that had a profound impact on his life.
"Information regarding his disqualifying behaviors was readily available in the medical record
and accessible to personnel had it been pursued," the report concluded in its key findings.
The records were obtained by the Justice Department when they sought a court order to
obtain Ivins' sealed psychiatric records. The findings were made by the Expert Behavioral
Analysis Panel, ordered by a federal judge to review Ivins' sealed psychological records to
determine if future acts of bioterrorism could be prevented.
Read the full report here.
Ivins worked at the U.S Army's Medical Research Institute of Infectious Diseases (USAMRIID)
and committed suicide as FBI investigators, in 2008, zeroed in on him as the main suspect in
the Fall 2001 anthrax attacks. The anthrax attacks left five people dead and sickened 17
others after mail containing the toxin arrived on Capitol Hill and at news organizations in
Florida and New York.
"Dr. Ivins had a significant and lengthy history of psychological disturbance and diagnosable
mental illness at the time he began working for USAMRIID in 1980 that would have
disqualified him from a Secret level security clearance had this been known." said panel
chairman Dr. Gregory Saathoff at a Tuesday press conference in Washington to announce
the panel's findings. Dr. Saathoff is the executive director of the University of Virginia Critical
Incident Analysis Group and associate professor of Research Psychiatry at the UVA medical
school. He also worked as an FBI consultant during the investigation...
Medical records point to doctor in anthrax attacks, report
says
Psychiatric panel says there's support for FBI's accusation against Army employee
NBC News NBC News
011-03-23
Medical records of Dr. Bruce Ivins, blamed by the FBI for the deadly 2001 anthrax mail
attacks, "support the Justice Department's determination that he was responsible," a panel
of behavioral experts and psychiatrists contended in a newly released report.
"Dr. Ivins was psychologically disposed to undertake the mailings, his behavioral history
demonstrated his potential for carrying them out, and he had the motivation and the means,"
they said in a report made public Wednesday.
Letters containing powdered anthrax were sent to news organizations and two US senators
in late 2001, infecting 22 people who received or handled them, five of whom died. Ivins, a
civilian researcher at the US Army's Medical Research Institute of Infectious Diseases in
Maryland, committed suicide in July 2008 as the FBI was preparing to accuse him of
preparing and mailing the letters. He was never charged.
Dr. Ivins displayed behavioral problems that should have led his Army employers to look
closer at his medical history, the report contended. Such an examination should have
prevented him from obtaining the security clearances needed to work with such a dangerous
material as anthrax, the panel members said.
Their report was requested in secret by a federal judge, Royce Lamberth of Washington
DC, who asked for an examination detailing "the mental health issues of Dr. Bruce Ivins and
what lessons can be learned from that analysis that may be useful in preventing future
bioterrorism attacks." The findings were filed last fall under seal.
Though many of his co-workers at the bioweapons lab in Maryland have disputed the FBI's
findings, the panel found that Ivins "cultivated a persona of benign eccentricity that masked
his obsessions and criminal thoughts."
Dr. Gregory Saathoff of the University of Virginia School of Medicine, the panel's chairman,
said the medical records "document behavior he claimed he undertook and provide an
indication of a strong component of revenge, including graphic plans to engage in violent
behavior."
But even though Ivins repeatedly waived confidentiality and gave Army background
investigators permission to obtain his medical records, such a step was never taken, panel
members said. "Had these records been obtained, they would have shown a longstanding
pattern of disturbed thinking in response to stress," the report said.
In one example, in 1987, Ivins placed question marks next to a check list of items on a
medical history report that included "memory change, trouble with decisions, hallucinations,
improbable beliefs, and anxiety."
A spokesman at the Army lab in Maryland declined to comment, citing privacy laws.
As for his motives, the report says he acted out of a desire for revenge against his critics, "a
desperate need for personal validation," and a hope that the response to the attacks would
revive the government's efforts to develop an anthrax vaccine — a program on which he
was a key researcher.
The scientists and doctors who studied the records emphasized what they said was an
obsession Ivins had with the Kappa Kappa Gamma sorority, which began when a member of
the sorority turned him down for a date while he was a graduate student. Shortly after the
first anthrax letters were mailed, but before they were discovered, he wrote an e-mail to
another KKG sister he had known as a student. In the e-mail, he referred to bio-warfare and
anxiety.
"The e-mail would soon cast him in her eyes, he appears to have hoped, as a prophet and
as a defender of the nation," the report said.
Briefing reporters on their findings, panel members also said they found no reason to
question the FBI's findings that Dr. Ivins acted alone in carrying out the anthrax attacks.
The FBI's findings, blaming Ivins for the attack, have been criticized by one of the US
senators who was sent an anthrax letter, Patrick Leahy of Vermont, and by the lawyer who
represented Ivins before his death.
In a written statement, the FBI said Wednesday that the panel's conclusions "provide
important insight that will further contribute to the public's understanding of the investigation
into the deadly anthrax mailings. The report also provides valuable perspectives that may be
useful in preventing future attacks."
Scientist With Psychiatric Problems Given Access to Deadly Pathogen
By JASON RYAN
March 23, 2011
The Army scientist believed to have caused the 2001 anthrax attacks that left five dead and
paralyzed Capitol Hill and media organizations had severe psychological problems, was
obsessed with a sorority and should never have been given security clearance or access to
deadly pathogens, according to a newly released report.
An independent review of the psychiatric records of the alleged anthrax killer Dr. Bruce Ivins
has revealed that the Army scientist, who committed suicide in 2008, should never have
been given a security clearance or access to anthrax based on his psychological profile and
diagnosable mental illness.
The report also found that Ivins allegedly carried out the attacks for revenge and
redemption for questions about his work with the anthrax vaccine. The findings also delve
further into his troubled relationships with women and an obsession he developed for a
sorority that had a profound impact on his life.
"Information regarding his disqualifying behaviors was readily available in the medical record
and accessible to personnel had it been pursued," the report concluded in its key findings.
The records were obtained by the Justice Department when they sought a court order to
obtain Ivins' sealed psychiatric records. The findings were made by the Expert Behavioral
Analysis Panel, ordered by a federal judge to review Ivins' sealed psychological records to
determine if future acts of bioterrorism could be prevented.
Read the full report here.
Ivins worked at the U.S Army's Medical Research Institute of Infectious Diseases (USAMRIID)
and committed suicide as FBI investigators, in 2008, zeroed in on him as the main suspect in
the Fall 2001 anthrax attacks. The anthrax attacks left five people dead and sickened 17
others after mail containing the toxin arrived on Capitol Hill and at news organizations in
Florida and New York.
"Dr. Ivins had a significant and lengthy history of psychological disturbance and diagnosable
mental illness at the time he began working for USAMRIID in 1980 that would have
disqualified him from a Secret level security clearance had this been known." said panel
chairman Dr. Gregory Saathoff at a Tuesday press conference in Washington to announce
the panel's findings. Dr. Saathoff is the executive director of the University of Virginia Critical
Incident Analysis Group and associate professor of Research Psychiatry at the UVA medical
school. He also worked as an FBI consultant during the investigation...
Medical records point to doctor in anthrax attacks, report
says
Psychiatric panel says there's support for FBI's accusation against Army employee
NBC News NBC News
011-03-23
Medical records of Dr. Bruce Ivins, blamed by the FBI for the deadly 2001 anthrax mail
attacks, "support the Justice Department's determination that he was responsible," a panel
of behavioral experts and psychiatrists contended in a newly released report.
"Dr. Ivins was psychologically disposed to undertake the mailings, his behavioral history
demonstrated his potential for carrying them out, and he had the motivation and the means,"
they said in a report made public Wednesday.
Letters containing powdered anthrax were sent to news organizations and two US senators
in late 2001, infecting 22 people who received or handled them, five of whom died. Ivins, a
civilian researcher at the US Army's Medical Research Institute of Infectious Diseases in
Maryland, committed suicide in July 2008 as the FBI was preparing to accuse him of
preparing and mailing the letters. He was never charged.
Dr. Ivins displayed behavioral problems that should have led his Army employers to look
closer at his medical history, the report contended. Such an examination should have
prevented him from obtaining the security clearances needed to work with such a dangerous
material as anthrax, the panel members said.
Their report was requested in secret by a federal judge, Royce Lamberth of Washington
DC, who asked for an examination detailing "the mental health issues of Dr. Bruce Ivins and
what lessons can be learned from that analysis that may be useful in preventing future
bioterrorism attacks." The findings were filed last fall under seal.
Though many of his co-workers at the bioweapons lab in Maryland have disputed the FBI's
findings, the panel found that Ivins "cultivated a persona of benign eccentricity that masked
his obsessions and criminal thoughts."
Dr. Gregory Saathoff of the University of Virginia School of Medicine, the panel's chairman,
said the medical records "document behavior he claimed he undertook and provide an
indication of a strong component of revenge, including graphic plans to engage in violent
behavior."
But even though Ivins repeatedly waived confidentiality and gave Army background
investigators permission to obtain his medical records, such a step was never taken, panel
members said. "Had these records been obtained, they would have shown a longstanding
pattern of disturbed thinking in response to stress," the report said.
In one example, in 1987, Ivins placed question marks next to a check list of items on a
medical history report that included "memory change, trouble with decisions, hallucinations,
improbable beliefs, and anxiety."
A spokesman at the Army lab in Maryland declined to comment, citing privacy laws.
As for his motives, the report says he acted out of a desire for revenge against his critics, "a
desperate need for personal validation," and a hope that the response to the attacks would
revive the government's efforts to develop an anthrax vaccine — a program on which he
was a key researcher.
The scientists and doctors who studied the records emphasized what they said was an
obsession Ivins had with the Kappa Kappa Gamma sorority, which began when a member of
the sorority turned him down for a date while he was a graduate student. Shortly after the
first anthrax letters were mailed, but before they were discovered, he wrote an e-mail to
another KKG sister he had known as a student. In the e-mail, he referred to bio-warfare and
anxiety.
"The e-mail would soon cast him in her eyes, he appears to have hoped, as a prophet and
as a defender of the nation," the report said.
Briefing reporters on their findings, panel members also said they found no reason to
question the FBI's findings that Dr. Ivins acted alone in carrying out the anthrax attacks.
The FBI's findings, blaming Ivins for the attack, have been criticized by one of the US
senators who was sent an anthrax letter, Patrick Leahy of Vermont, and by the lawyer who
represented Ivins before his death.
In a written statement, the FBI said Wednesday that the panel's conclusions "provide
important insight that will further contribute to the public's understanding of the investigation
into the deadly anthrax mailings. The report also provides valuable perspectives that may be
useful in preventing future attacks."
Incompetence
or, in some cases, apparent sabotage
or, in some cases, apparent sabotage
"...[I]f 14,000 votes can
just disappear because
someone forgot to push
a button, how many times
has that happened in the
past when we didn't learn
about it?"
--Eugene Kane
Skeptical voters
raise collective
brows after election
surprises
Eugene Kane
Milwaukee Wisconsin
Journal Sentinel
April 9, 2011
"What's most disconcerting
about the Waukesha County
election foul-up is the sense
that if 14,000 votes can just
disappear because
someone forgot to push a
button, how many times has
that happened in the past
when we didn't learn about
it?"
Wisconsin court race
won't be certified without
probe
By James B. Kelleher
Apr 8, 2011
Reuters
The agency overseeing
Wisconsin elections will not
certify results of Tuesday's
state Supreme Court race
until it concludes a probe
into how a county clerk
misplaced and then found
some 14,000 votes that
upended the contest.
Michael Haas, Government
Accountability Board staff
attorney, told Reuters on
Friday the watchdog agency
was looking into vote
tabulation errors in
Republican-leaning
Waukesha County which
gave the conservative
incumbent a net gain of
more than 7,000 votes -- a
lead his union-backed
challenger seems unlikely to
surmount.
"We're going to do a review
of the procedures and the
records in Waukesha before
we certify the statewide
results," Haas said.
"It's not that we necessarily
expect to find anything
criminal. But we want to
make sure the public has
confidence in the results,"
Unofficial returns in the
statewide race had given
the challenger, JoAnne
Kloppenburg, a narrow 204
vote statewide lead over
David Prosser, a former
Republican legislator.
But late Thursday, the top
vote counter in Waukesha
County said votes she had
failed to report in earlier
totals resulted in a net gain
of 7,582 votes for Prosser in
the county.
Wisconsin Leaves Out
14,000 Votes After Clerk
Forgets to Click 'Save'
By: Nick Carbone
Time
April 8, 2011
Computers are tricky
beasts. We've all had our
share of simple, avoidable
mishaps: accidentally
clicking “reply all” or saving
an essential file where you'll
never find it again. But a
Wisconsin clerk takes top
honors on avoidable errors.
While tallying votes,
Waukesha County Clerk
Kathy Nickolaus forgot to
click “save” – a mistake that
almost gave the state
Supreme Court election
away to the wrong
candidate. A windfall of
votes flowed into the camp
of David Prosser on
Thursday, after she finally
saved them in the tally
system.
A visibly-shaken Nickolaus
appeared at a press
conference Thursday to
claim responsibility. “This is
human error which I
apologize for," she said.
Once she correctly input the
data and clicked that elusive
“save” button, 14,315 votes
from the Milwaukee suburb
of Brookfield suddenly
became valid. And what was
a meager 204-vote lead for
Democrat JoAnne
Kloppenburg turned, in a
matter of minutes, into a
huge runaway for Prosser,
putting him ahead by more
than 7,500 votes. Looks like
Kloppenburg was a little
rash in declaring victory.
Tuesday's Wisconsin
Supreme Court election was
a hotly-contested race
between incumbent
Republican Justice Prosser
and current Wisconsin
Attorney General
Kloppenburg, a Democrat.
In what would typically be a
bland election,
Wisconsinites voters turned
out to the tune of 1.5 million
on Tuesday, because the
state's Supreme Court may
have final say on Governor
Scott Walker's controversial
anti-union law.
The original 200-vote
difference would most likely
have prompted a recount.
And now, given this issue of
user error, it's practically
inevitable. This race isn't
over, folks.
just disappear because
someone forgot to push
a button, how many times
has that happened in the
past when we didn't learn
about it?"
--Eugene Kane
Skeptical voters
raise collective
brows after election
surprises
Eugene Kane
Milwaukee Wisconsin
Journal Sentinel
April 9, 2011
"What's most disconcerting
about the Waukesha County
election foul-up is the sense
that if 14,000 votes can just
disappear because
someone forgot to push a
button, how many times has
that happened in the past
when we didn't learn about
it?"
Wisconsin court race
won't be certified without
probe
By James B. Kelleher
Apr 8, 2011
Reuters
The agency overseeing
Wisconsin elections will not
certify results of Tuesday's
state Supreme Court race
until it concludes a probe
into how a county clerk
misplaced and then found
some 14,000 votes that
upended the contest.
Michael Haas, Government
Accountability Board staff
attorney, told Reuters on
Friday the watchdog agency
was looking into vote
tabulation errors in
Republican-leaning
Waukesha County which
gave the conservative
incumbent a net gain of
more than 7,000 votes -- a
lead his union-backed
challenger seems unlikely to
surmount.
"We're going to do a review
of the procedures and the
records in Waukesha before
we certify the statewide
results," Haas said.
"It's not that we necessarily
expect to find anything
criminal. But we want to
make sure the public has
confidence in the results,"
Unofficial returns in the
statewide race had given
the challenger, JoAnne
Kloppenburg, a narrow 204
vote statewide lead over
David Prosser, a former
Republican legislator.
But late Thursday, the top
vote counter in Waukesha
County said votes she had
failed to report in earlier
totals resulted in a net gain
of 7,582 votes for Prosser in
the county.
Wisconsin Leaves Out
14,000 Votes After Clerk
Forgets to Click 'Save'
By: Nick Carbone
Time
April 8, 2011
Computers are tricky
beasts. We've all had our
share of simple, avoidable
mishaps: accidentally
clicking “reply all” or saving
an essential file where you'll
never find it again. But a
Wisconsin clerk takes top
honors on avoidable errors.
While tallying votes,
Waukesha County Clerk
Kathy Nickolaus forgot to
click “save” – a mistake that
almost gave the state
Supreme Court election
away to the wrong
candidate. A windfall of
votes flowed into the camp
of David Prosser on
Thursday, after she finally
saved them in the tally
system.
A visibly-shaken Nickolaus
appeared at a press
conference Thursday to
claim responsibility. “This is
human error which I
apologize for," she said.
Once she correctly input the
data and clicked that elusive
“save” button, 14,315 votes
from the Milwaukee suburb
of Brookfield suddenly
became valid. And what was
a meager 204-vote lead for
Democrat JoAnne
Kloppenburg turned, in a
matter of minutes, into a
huge runaway for Prosser,
putting him ahead by more
than 7,500 votes. Looks like
Kloppenburg was a little
rash in declaring victory.
Tuesday's Wisconsin
Supreme Court election was
a hotly-contested race
between incumbent
Republican Justice Prosser
and current Wisconsin
Attorney General
Kloppenburg, a Democrat.
In what would typically be a
bland election,
Wisconsinites voters turned
out to the tune of 1.5 million
on Tuesday, because the
state's Supreme Court may
have final say on Governor
Scott Walker's controversial
anti-union law.
The original 200-vote
difference would most likely
have prompted a recount.
And now, given this issue of
user error, it's practically
inevitable. This race isn't
over, folks.
04/14/2011
FAA head of air traffic resigns
By Ashley Halsey III
Washington Post
The head of the Air Traffic Organization at the Federal Aviation Administration resigned
Thursday morning amid recent reports of several controllers sleeping on the job.
Hank Krakowski submitted his resignation Thursday morning to FAA Administrator Randy
Babbitt, who said he accepted it, federal officials said.
Krawkoski joined the FAA in 2007. Prior to that he spent about 30 years at United Air Lines in
senior management positions, including as vice president of flight operations.
“Hank is a dedicated aviation professional and I thank him for his service,” Babbitt said in a
statement. “Starting today, I have asked David Grizzle, FAA's chief counsel, to assume the
role of acting ATO chief operating officer while we conduct a nationwide search to
permanently fill the position.”
Babbitt said recent reports of “unprofessional conduct on the part of a few individuals have
rightly caused the traveling public to question our ability to ensure their safety.”
On Wednesday federal officials ended the practice of leaving one controller on duty in airport
towers during overnight shifts.
The FAA also revealed that a Nevada air traffic controller allegedly fell asleep Wednesday
morning as a medical flight carrying a patient tried to land.The plane landed safely at Reno-
Tahoe International Airport with the help of a radar controller based in California, the FAA
said. The controller was suspended and the incident is under investigation.
However, the incident Wednesday was the fifth time this year that a controller apparently slept
while on duty, including at Reagan National Airport, where a controller supervisor was
suspended last month after he admitted to napping in the tower .
The FAA plans to conduct a “top to bottom review” of the nation’s air traffic control system,
Babbitt said.
FAA head of air traffic resigns
By Ashley Halsey III
Washington Post
The head of the Air Traffic Organization at the Federal Aviation Administration resigned
Thursday morning amid recent reports of several controllers sleeping on the job.
Hank Krakowski submitted his resignation Thursday morning to FAA Administrator Randy
Babbitt, who said he accepted it, federal officials said.
Krawkoski joined the FAA in 2007. Prior to that he spent about 30 years at United Air Lines in
senior management positions, including as vice president of flight operations.
“Hank is a dedicated aviation professional and I thank him for his service,” Babbitt said in a
statement. “Starting today, I have asked David Grizzle, FAA's chief counsel, to assume the
role of acting ATO chief operating officer while we conduct a nationwide search to
permanently fill the position.”
Babbitt said recent reports of “unprofessional conduct on the part of a few individuals have
rightly caused the traveling public to question our ability to ensure their safety.”
On Wednesday federal officials ended the practice of leaving one controller on duty in airport
towers during overnight shifts.
The FAA also revealed that a Nevada air traffic controller allegedly fell asleep Wednesday
morning as a medical flight carrying a patient tried to land.The plane landed safely at Reno-
Tahoe International Airport with the help of a radar controller based in California, the FAA
said. The controller was suspended and the incident is under investigation.
However, the incident Wednesday was the fifth time this year that a controller apparently slept
while on duty, including at Reagan National Airport, where a controller supervisor was
suspended last month after he admitted to napping in the tower .
The FAA plans to conduct a “top to bottom review” of the nation’s air traffic control system,
Babbitt said.
Norway police
slammed for slow
response to
rampage
By SHAWN POGATCHNIK,
Associated Press
July 26, 2011
OSLO, Norway (AP) —
When Anders Behring
Breivik launched his
assault on the youth
campers of Utoya Island,
he expected Norway's
special forces to swoop
down and stop him at any
minute.
Instead, Delta Force police
officers made the 25-mile
journey by car — they
have no helicopter — then
had to be rescued by a
civilian craft when their
boat broke down as it tried
to navigate a one-minute
hop to the island.
It took police more than 90
minutes to reach the
gunman, who by then had
mortally wounded 68
people. Breivik immediately
dropped his guns and
surrendered, having
exceeded his wildest
murderous expectations.
As Oslo's police force
sounds an increasingly
defensive note,
international experts said
Tuesday that Norway's
government and security
forces must learn stark
lessons from a massacre
made worse by a
lackadaisical approach to
planning for terror.
"Children were being
slaughtered for an hour
and a half and the police
should have stopped it
much sooner," said Mads
Andenas, a law professor
at the University of Oslo
whose niece was on the
island and survived by
hiding in the bushes. One
of his students was killed.
"Even taking all the
extenuating circumstances
into account, it is
unforgivable," he said.
These include the fact that
Breivik preceded his one-
man assault on the island
with a car bomb in the
heart of Oslo's government
center. Authorities were
focused on helping
survivors from that blast as
the first frantic calls came
in from campers hiding
from the gunman on Utoya,
northwest of Oslo.
Survivors said they
struggled to get their
panicked pleas heard
because operators on
emergency lines were
rejecting calls not
connected to the Oslo
bomb. When police finally
realized a gunman was
shooting teens and 20-
somethings attending a
youth retreat on the island,
Breivik had already been
hunting them down for half
an hour...
Police spokesman Johan
Fredriksen rebuffed
criticism Tuesday of the
planning and equipment
failures, calling such
comments "unworthy."
"We can take a lot, we're
professional, but we are
also human beings," he
said...
[Maura Larkins comment:
Wait a minute. Did you
just say you were a human
being? Everybody involved
is, or was, a human being.
The question is, "Is your
police force incompetent?"
We don't need to discuss
whether or not you're
human beings.]
slammed for slow
response to
rampage
By SHAWN POGATCHNIK,
Associated Press
July 26, 2011
OSLO, Norway (AP) —
When Anders Behring
Breivik launched his
assault on the youth
campers of Utoya Island,
he expected Norway's
special forces to swoop
down and stop him at any
minute.
Instead, Delta Force police
officers made the 25-mile
journey by car — they
have no helicopter — then
had to be rescued by a
civilian craft when their
boat broke down as it tried
to navigate a one-minute
hop to the island.
It took police more than 90
minutes to reach the
gunman, who by then had
mortally wounded 68
people. Breivik immediately
dropped his guns and
surrendered, having
exceeded his wildest
murderous expectations.
As Oslo's police force
sounds an increasingly
defensive note,
international experts said
Tuesday that Norway's
government and security
forces must learn stark
lessons from a massacre
made worse by a
lackadaisical approach to
planning for terror.
"Children were being
slaughtered for an hour
and a half and the police
should have stopped it
much sooner," said Mads
Andenas, a law professor
at the University of Oslo
whose niece was on the
island and survived by
hiding in the bushes. One
of his students was killed.
"Even taking all the
extenuating circumstances
into account, it is
unforgivable," he said.
These include the fact that
Breivik preceded his one-
man assault on the island
with a car bomb in the
heart of Oslo's government
center. Authorities were
focused on helping
survivors from that blast as
the first frantic calls came
in from campers hiding
from the gunman on Utoya,
northwest of Oslo.
Survivors said they
struggled to get their
panicked pleas heard
because operators on
emergency lines were
rejecting calls not
connected to the Oslo
bomb. When police finally
realized a gunman was
shooting teens and 20-
somethings attending a
youth retreat on the island,
Breivik had already been
hunting them down for half
an hour...
Police spokesman Johan
Fredriksen rebuffed
criticism Tuesday of the
planning and equipment
failures, calling such
comments "unworthy."
"We can take a lot, we're
professional, but we are
also human beings," he
said...
[Maura Larkins comment:
Wait a minute. Did you
just say you were a human
being? Everybody involved
is, or was, a human being.
The question is, "Is your
police force incompetent?"
We don't need to discuss
whether or not you're
human beings.]
Second chances underscore flaws in death
investigations
January 31, 2011
Ryan Gabrielson
Pro Publica
Chris Reynolds vividly remembers his first encounter with the work of forensic pathologist Dr.
Thomas Gill.
It was 2001. Reynolds, a Santa Rosa private investigator, was hired by a Sonoma County man
accused of killing his wife. Gill, who conducted the wife’s autopsy, was the prosecution’s key witness,
having determined the death was a “textbook” case of suffocation.
Reynolds’ client’s prospects looked grim. But when Reynolds dug into Gill’s background, he
unspooled a history in which Gill landed post after post despite a lengthening trail of errors and, in
one instance, drinking on the job.
Gill had been forced out of a teaching position at an Oregon university, and then fired for inaccurate
findings and alcohol abuse by the coroner in Indianapolis, Reynolds discovered. Demoted for poor
performance as a fellow for the Los Angeles County Coroner, he resurfaced at a private autopsy
company in Northern California.
Reynolds learned that Gill had missed key evidence in the Sonoma County case and that he had
been coached by prosecutors to downplay his past, prompting the dismissal of the murder charge.
Yet, in the decade since, Gill has continued to do thousands of autopsies and to serve as an expert
witness in criminal cases. He landed a job as the No. 2 forensic pathologist in Kansas City, Mo.,
where his work again drew fire, and then returned to Forensic Medical Group Inc., the Fairfield firm
that handled the case investigated by Reynolds.
The private forensics firm has held contracts with 16 Northern California counties to perform
autopsies for local agencies. Besides Sonoma County, Gill has conducted death investigations or
testified in court cases in Contra Costa, Solano, Marin, Napa, Sutter, Lake and Humboldt counties as
a doctor for Forensic Medical Group. He had done more than 800 autopsies during a three-year
period in Yolo, Napa and Solano counties alone.
Forensic Medical Group cut its ties with Gill in December after Yolo County Sheriff-Coroner’s officials
learned of the doctor’s history from reporters and barred him from performing its autopsies. In a
written response to questions, Forensic Medical Group said that after Yolo County’s decision, it no
longer had enough cases to justify employing Gill.
Gill’s ability to resurrect his career time and again reflects a profound weakness at the center of the U.
S. system of death investigation.
A chronic shortage of qualified forensic pathologists allows even questionably competent
practitioners to remain employable. The absence of trained practitioners is so acute that many
jurisdictions don't look closely at the doctors they employ. Some of the officials who hired Gill
acknowledged they knew about his problems but said they had no other viable options.
With no national oversight of forensic pathologists or standards that dictate who can do autopsy work,
there is nothing to prevent Gill from resuming his career.
In some cases, officials in charge of death investigation are more concerned with costs than with
competent autopsies, said Dr. John Pless, a director of the National Association of Medical
Examiners and retired forensic pathology professor at Indiana University.
“What the problem is all over and why Tom Gill is accepted is there are people running the system
who don’t understand the complexity of the medical determinations,” Pless said.
Although the California State Bar deemed him incompetent in a 2006 report on the Sonoma case, Gill
ruled on more than 1,000 death investigations in eight California counties from 2007 to 2010.
Gill, 67, initially declined requests for interviews for this story. Approached by a reporter at his Fairfield
home in December, he would not address specific cases or criticism of his work.
“I am a qualified forensic pathologist, and I have testified on numerous occasions,” Gill said.
Later, in a written statement, Gill acknowledged that when he joined the Indianapolis coroner’s office,
“I had no formal training in forensic pathology and therefore made mistakes, particularly in pediatric
cases where findings tend to be more subtle and complex.”
Gill pointed out that his autopsy findings have not been contested or reversed since 2007.
Dr. Arnold Josselson, Forensic Medical Group’s vice president, said he had seen Gill’s work
firsthand and trusted him. “I've observed him doing autopsies, and I think he's competent,” Josselson
said.
A troubling history
When Gill started work at the Marion County Coroner’s Office in Indiana on New Year’s Day in 1993,
he had performed only about 20 forensic autopsies since graduating from medical school 24 years
earlier.
Certified specialists in forensic pathology, the science of unexplained deaths, have completed
medical school and a four-year residency in pathology, plus an additional year of intensive training
and autopsy work. According to the National Academy of Sciences, there are roughly 500 such
practitioners nationwide, less than half the number needed to properly investigate suspicious or
unattended deaths.
Gill, a neuropathologist by specialty, had spent the first two decades of his career teaching medical
students at the Oregon Health & Science University and analyzing brain tissue for a nearby Veterans
Affairs hospital.
But Gill has acknowledged during preparation for court testimony that he was stripped of his teaching
duties in 1992, possibly due to a drinking problem that dated back to the mid-‘80s. Gill gave written
answers to nearly 200 questions that prosecutors anticipated defense attorneys would ask during a
2001 homicide trial. One inquired whether his drinking had affected his work in Oregon. “Probably,”
Gill wrote in response, “but no documentation.”
Gill was willing to shift from brain study to death investigation if that meant better job prospects.
At the time, the Marion County coroner, who serves the Indianapolis metropolitan area was desperate
for help. Left without autopsy services after a contract dispute, the office had bodies stacked up in its
refrigeration units.
Gill worked seven days a week during his first several months in Indianapolis, examining four to eight
bodies per shift, court and county records show. Signed to a four-year contract that paid $100,000
annually, he performed about 650 autopsies in 1993 alone, more than twice the maximum workload
recommended by the National Association of Medical Examiners.
It didn’t take long for problems to surface with the accuracy and precision of his work.
In early 1993, Gill ruled that Dylan Petroff, a 17-month-old boy, had died from a blood infection. A
second autopsy conducted by a leading specialist hired by Petroff’s parents, however, came to a
different conclusion.
Petroff had strangled, the specialist determined, caught in the slats of a defective crib at the
uncertified day care center run by his babysitter.
Pam Faught, Dylan’s grandmother, said she was shocked that Gill continued to be entrusted with
death investigations.
“They don’t tell the next person that’s going to hire him how unqualified this individual really is,” she
said. “And he’s got ‘doctor’ in front of his name.”
A year later, 6-month-old Julian Dorsey ended up on Gill’s table. The doctor ruled the infant was a
homicide victim, shaken to death by his father. But Gill’s finding was reversed by his boss. There was
no physical evidence that the child had sustained a brain injury.
Gill’s drinking also became an issue over the course of his tenure in Indianapolis.
Soon after he started in Marion County, another coroner’s office employee found him passed out
drunk in a loading dock after the end of a shift, Gill acknowledged in written answers during
preparation for a 2001 trial.
On March 31, 1994, Gill arrived at a law office for a deposition in a homicide case. The prosecutor and
court reporter later stated they smelled alcohol on his breath. Gill denied being drunk, but his sworn
testimony on the shooting death of Cheryl Angleton repeatedly contradicted his autopsy findings. At
one point, Gill speculated that his conclusion – that Angleton had been murdered – might have been
wrong and that Angleton could have committed suicide.
“Whatever credibility he may have had no longer exists,” the prosecutor wrote in a report afterward,
calling Gill’s testimony “inaccurate, contradictory and absurd.”
Although an internal investigation officially cleared him of testifying drunk, Gill was told in July 1994
that his contract would end after just 19 months.
“Your well documented inability to provide services at a reasonably necessary level has prevented
you from establishing and maintaining credibility with the law enforcement community,” Marion
County Coroner Karl Manders wrote in his termination letter.
Gill was given 30 days’ notice but was unable to complete his final month. He was arrested on the
charge of drunken driving on his way to the morgue one morning and barred from further work. He
was convicted of the charge and Indiana’s medical board suspended his license until he received
substance abuse treatment.
Fresh start in California
Gill moved to California and spent months undergoing treatment for alcohol abuse, records show.
Then, in early 1995, he landed a dream job: a one-year fellowship with the Los Angeles County
Coroner, an ideal place to hone his training in forensic autopsies and death investigation.
Gill did not disclose on his resume or application that he had been fired in Indianapolis. Los Angeles
officials first caught wind of his troubles when a reporter from The Indianapolis Star called.
“We were not knowledgeable, nor was this information voluntarily given to us,” a coroner’s office
personnel administrator told the newspaper regarding Gill’s mistakes in Marion County.
Gill kept his post, even after his omissions were exposed, but struggled to meet the program’s
requirements. Nine months into his training, personnel records show, the coroner’s office deemed
his work deficient, cut his pay in half and demoted him to the equivalent of a medical student.
In a written evaluation, Gill’s superiors wrote “there are significant technical problems in some of your
autopsies resulting in the need for continued supervision.”
Gill also was unable to complete the number of cases needed to finish the fellowship in a year, said
Dr. James Ribe, a Los Angeles County deputy coroner and one of Gill’s supervisors. The coroner’s
office gave Gill an additional six months to catch up.
In 1997, with his fellowship completed, Gill was eligible to take the American Board of Pathology’s
certification exam for forensic pathology, the field’s most universally recognized measure of
competence.
Gill failed the test on his first try. And his second. He passed the third time, in 1999.
Nevertheless, Gill was hired in April 1998 by Forensic Medical Group, the for-profit autopsy company
with contracts to handle cases for more than a dozen Northern California counties, including Sonoma
County in the heart of one of the state’s most renowned wine-producing regions.
It was there that Reynolds, the private investigator, began to unravel Gill’s past.
Private investigator Chris Reynolds outside the Sonoma County Coroner’s Office.Deanne
FitzmauricePrivate investigator Chris Reynolds outside the Sonoma County Coroner’s Office.
Errors surface in Sonoma case
Late on the evening of Nov. 7, 1999, a prominent local physician in Petaluma, Calif., called 911. His
wife was dead, Dr. Louis Pelfini told the emergency operator, adding that he feared she had
committed suicide.
The Sonoma County Sheriff’s Office investigators who responded to the call did not initially treat
Pelfini’s home as a crime scene, police records show, but they ultimately came to suspect Pelfini had
killed his wife, Janet.
Gill started his examination of her body two days later. After a month, he ruled that Janet Pelfini had
died from asphyxiation. His notes showed abrasions circling her mouth and a bruise on her
forehead. Based on his findings, the sheriff’s office classified her death as a homicide, and
prosecutors filed murder charges against Louis Pelfini.
Gill’s certainty about what caused Janet Pelfini to suffocate prompted her husband’s defense team
to worry, said Reynolds, the private investigator hired by Louis Pelfini’s attorney.
But Gill’s work on the case had some holes.
Gill did not take pictures of Janet Pelfini’s injuries as he autopsied her. He made drawings, but
photographs from the scene taken by sheriff’s deputies showed they were inaccurate. He failed to
note a bruise on the back of her head on the drawings. In his written report, the injury was included,
but on the wrong side of her head.
Gill also overlooked mucus plugs in her lungs. Another pathologist, hired by the prosecution, later
argued the plugs were evidence that Janet Pelfini had suffered a severe asthma attack shortly before
her death, indicating she may have died from natural causes.
Another limitation: The body had been cremated after Gill's autopsy, leaving other experts to argue
over how to interpret his notes.
With Pelfini’s case resting primarily on Gill’s conclusions, Reynolds began running the doctor’s
name through news archives and calling his former colleagues.
When the defense team reported its findings about Gill to prosecutors, however, the state did not re-
examine the charges. Instead, they secretly began coaching Gill, arranging for him to meet with a
speech therapist to help craft his trial testimony.
In the videotaped sessions, Gill acknowledged he would have to sidestep flaws in his casework.
“There are deficiencies in the autopsy,” he acknowledged. “You know we have kind of alluded to that.”
The tapes also showed Gill and his coach, Jeffrey Harris, trying to downplay his past problems.
Practicing an answer to the question of why Marion County fired him, Gill said the termination was
due to “errors in autopsies and inability to testify in trials.”
“OK, timeout,” Harris interrupted. “Don’t say … I would not say, ‘My inability to testify in trials.’ I would
say, ‘My difficulty in testifying effectively,’ or ‘my inability to effectively communicate the results of my
autopsies.’ Something to that effect.”
Gill is shown on the tape taking down Harris’ instructions on a yellow notepad.
“We always want to be thinking about, how do we counter these allegations, these innuendos that
there’s something wrong with you,” Harris told Gill during one of the sessions.
The strategy failed when Pelfini’s attorney learned of the coaching sessions and the trial judge
ordered the tapes released to the defense. Days later, the district attorney’s office dropped all
charges.
The California State Bar investigated the handling of the Pelfini case and suspended the prosecutor
from practicing law for four years for his role in suppressing evidence about Gill’s coaching sessions.
The bar report devoted several pages to Gill’s errors.
“Unfortunately,” it concluded, “Dr. Gill was not a competent pathologist.”
Mistakes in Missouri
The Pelfini case left Gill’s reputation in Northern California tarnished. Sonoma County officials barred
him from conducting autopsies there. As he had before, Gill sought a new start in a new state.
In late 2002, the Jackson County Medical Examiner’s Office, which handles autopsies for Kansas
City, Mo., advertised for a deputy. The pickings were slim.
“There were two applicants,” said Dr. Thomas Young, then the office’s sole forensic pathologist. “And
the other one had already gotten into some ethical trouble back east, so he was just completely out.”
Young said he knew about the Pelfini case and about Gill’s drunken driving conviction. But Young
said he trusted what Gill told him: that the doctor had recovered from alcohol abuse and that the
Sonoma County murder case collapsed due to prosecutorial misconduct, not poor autopsy work.
Gill started work in Kansas City in November 2002, earning $140,000 a year. Young said he watched
his colleague closely.
“In terms of his conscientiousness, being thorough, he was good,” Young said. “He did make some
mistakes, but I caught them.”
Not all of them.
In September 2003, Gill autopsied 23-year-old Robert Patterson, who had died a day after being
injured in a car accident. Based on toxicology tests that showed painkillers in Patterson’s blood, Gill
ruled the death a suicide.
But a second autopsy commissioned by Patterson’s mother revealed an artery in Patterson’s neck
that showed signs of damage so severe it would have blocked blood flow to his brain. The injury
almost certainly occurred in the car accident, the second pathologist concluded.
Presented with the results, Gill reversed his finding, ruling the death an accident.
The following year, several Missouri prosecutors learned of Gill’s problems in California and
Indianapolis and threatened to boycott the Jackson County Medical Examiner’s Office unless it fired
Gill.
Young refused. Asked why, he said the shortage of practitioners made the move impractical and that
even the field’s best sometimes misdiagnose causes of death.
Gill stayed another two years, quitting at the end of 2006 after one of the prosecutors became the
county’s chief executive and after Young retired.
Another new beginning
Again, it didn’t take long for him to find another job. In early 2007, Forensic Medical Group rehired Gill.
Click on the image to enlarge the graphic.Brian Cragin/California Watch
p>Dr. Brian Peterson, who was the firm’s president for 15 years before becoming Milwaukee’s chief
medical examiner, defended the decision.
“To my mind, he was always a victim,” Peterson said. “Gill’s a great guy, and he’s a fine pathologist.”
But the group didn’t advertise Gill’s background. On its website, it gave resumes and educational
histories for all its doctors – except Gill.
In his written statement, Gill said his work since returning to Forensic Medical Group in 2007 had
been above reproach. In addition, the doctor said that county officials in the jurisdictions he served
were aware of his background.
“In court and during application for jobs, since 2001 much of the background information has been
made available to prospective employers, defense lawyers and ultimately, if the latter deemed it
relevant to the jurors in court cases involving one of my postmortem examinations,” Gill wrote.
Several Forensic Medical Group clients say they did not receive this information, however.
Presented with records detailing Gill’s professional history in late November, officials with the Yolo
County Sheriff-Coroner’s Office expressed surprise.
“This is an eye-opener for us, to admit humbly,” said Yolo County Chief Deputy Coroner Robert
LaBrash.
Yolo County subsequently joined Sonoma in demanding that Gill not be used on its cases.
Jana McClung*, a Sutter County prosecutor, said neither she nor the sheriff-coroner’s office were
aware of Gill’s background before being contacted by a reporter in December. Gill is scheduled to
testify in a death penalty case being prosecuted by the district attorney’s office. McClung said she had
alerted the sheriff and the defendant’s attorneys.
“Obviously, what we’re going to have to do is have another forensic pathologist look at our case as a
follow up to him,” she said.
Until December, when Forensic Medical Group says it stopped employing Gill, the doctor remained
active. Last summer he gave testimony in a homicide case, a stabbing.
Asked if he intended to continue working as a forensic pathologist and if he was seeking
employment, Gill e-mailed back.
“Yes and yes,” he said.
investigations
January 31, 2011
Ryan Gabrielson
Pro Publica
Chris Reynolds vividly remembers his first encounter with the work of forensic pathologist Dr.
Thomas Gill.
It was 2001. Reynolds, a Santa Rosa private investigator, was hired by a Sonoma County man
accused of killing his wife. Gill, who conducted the wife’s autopsy, was the prosecution’s key witness,
having determined the death was a “textbook” case of suffocation.
Reynolds’ client’s prospects looked grim. But when Reynolds dug into Gill’s background, he
unspooled a history in which Gill landed post after post despite a lengthening trail of errors and, in
one instance, drinking on the job.
Gill had been forced out of a teaching position at an Oregon university, and then fired for inaccurate
findings and alcohol abuse by the coroner in Indianapolis, Reynolds discovered. Demoted for poor
performance as a fellow for the Los Angeles County Coroner, he resurfaced at a private autopsy
company in Northern California.
Reynolds learned that Gill had missed key evidence in the Sonoma County case and that he had
been coached by prosecutors to downplay his past, prompting the dismissal of the murder charge.
Yet, in the decade since, Gill has continued to do thousands of autopsies and to serve as an expert
witness in criminal cases. He landed a job as the No. 2 forensic pathologist in Kansas City, Mo.,
where his work again drew fire, and then returned to Forensic Medical Group Inc., the Fairfield firm
that handled the case investigated by Reynolds.
The private forensics firm has held contracts with 16 Northern California counties to perform
autopsies for local agencies. Besides Sonoma County, Gill has conducted death investigations or
testified in court cases in Contra Costa, Solano, Marin, Napa, Sutter, Lake and Humboldt counties as
a doctor for Forensic Medical Group. He had done more than 800 autopsies during a three-year
period in Yolo, Napa and Solano counties alone.
Forensic Medical Group cut its ties with Gill in December after Yolo County Sheriff-Coroner’s officials
learned of the doctor’s history from reporters and barred him from performing its autopsies. In a
written response to questions, Forensic Medical Group said that after Yolo County’s decision, it no
longer had enough cases to justify employing Gill.
Gill’s ability to resurrect his career time and again reflects a profound weakness at the center of the U.
S. system of death investigation.
A chronic shortage of qualified forensic pathologists allows even questionably competent
practitioners to remain employable. The absence of trained practitioners is so acute that many
jurisdictions don't look closely at the doctors they employ. Some of the officials who hired Gill
acknowledged they knew about his problems but said they had no other viable options.
With no national oversight of forensic pathologists or standards that dictate who can do autopsy work,
there is nothing to prevent Gill from resuming his career.
In some cases, officials in charge of death investigation are more concerned with costs than with
competent autopsies, said Dr. John Pless, a director of the National Association of Medical
Examiners and retired forensic pathology professor at Indiana University.
“What the problem is all over and why Tom Gill is accepted is there are people running the system
who don’t understand the complexity of the medical determinations,” Pless said.
Although the California State Bar deemed him incompetent in a 2006 report on the Sonoma case, Gill
ruled on more than 1,000 death investigations in eight California counties from 2007 to 2010.
Gill, 67, initially declined requests for interviews for this story. Approached by a reporter at his Fairfield
home in December, he would not address specific cases or criticism of his work.
“I am a qualified forensic pathologist, and I have testified on numerous occasions,” Gill said.
Later, in a written statement, Gill acknowledged that when he joined the Indianapolis coroner’s office,
“I had no formal training in forensic pathology and therefore made mistakes, particularly in pediatric
cases where findings tend to be more subtle and complex.”
Gill pointed out that his autopsy findings have not been contested or reversed since 2007.
Dr. Arnold Josselson, Forensic Medical Group’s vice president, said he had seen Gill’s work
firsthand and trusted him. “I've observed him doing autopsies, and I think he's competent,” Josselson
said.
A troubling history
When Gill started work at the Marion County Coroner’s Office in Indiana on New Year’s Day in 1993,
he had performed only about 20 forensic autopsies since graduating from medical school 24 years
earlier.
Certified specialists in forensic pathology, the science of unexplained deaths, have completed
medical school and a four-year residency in pathology, plus an additional year of intensive training
and autopsy work. According to the National Academy of Sciences, there are roughly 500 such
practitioners nationwide, less than half the number needed to properly investigate suspicious or
unattended deaths.
Gill, a neuropathologist by specialty, had spent the first two decades of his career teaching medical
students at the Oregon Health & Science University and analyzing brain tissue for a nearby Veterans
Affairs hospital.
But Gill has acknowledged during preparation for court testimony that he was stripped of his teaching
duties in 1992, possibly due to a drinking problem that dated back to the mid-‘80s. Gill gave written
answers to nearly 200 questions that prosecutors anticipated defense attorneys would ask during a
2001 homicide trial. One inquired whether his drinking had affected his work in Oregon. “Probably,”
Gill wrote in response, “but no documentation.”
Gill was willing to shift from brain study to death investigation if that meant better job prospects.
At the time, the Marion County coroner, who serves the Indianapolis metropolitan area was desperate
for help. Left without autopsy services after a contract dispute, the office had bodies stacked up in its
refrigeration units.
Gill worked seven days a week during his first several months in Indianapolis, examining four to eight
bodies per shift, court and county records show. Signed to a four-year contract that paid $100,000
annually, he performed about 650 autopsies in 1993 alone, more than twice the maximum workload
recommended by the National Association of Medical Examiners.
It didn’t take long for problems to surface with the accuracy and precision of his work.
In early 1993, Gill ruled that Dylan Petroff, a 17-month-old boy, had died from a blood infection. A
second autopsy conducted by a leading specialist hired by Petroff’s parents, however, came to a
different conclusion.
Petroff had strangled, the specialist determined, caught in the slats of a defective crib at the
uncertified day care center run by his babysitter.
Pam Faught, Dylan’s grandmother, said she was shocked that Gill continued to be entrusted with
death investigations.
“They don’t tell the next person that’s going to hire him how unqualified this individual really is,” she
said. “And he’s got ‘doctor’ in front of his name.”
A year later, 6-month-old Julian Dorsey ended up on Gill’s table. The doctor ruled the infant was a
homicide victim, shaken to death by his father. But Gill’s finding was reversed by his boss. There was
no physical evidence that the child had sustained a brain injury.
Gill’s drinking also became an issue over the course of his tenure in Indianapolis.
Soon after he started in Marion County, another coroner’s office employee found him passed out
drunk in a loading dock after the end of a shift, Gill acknowledged in written answers during
preparation for a 2001 trial.
On March 31, 1994, Gill arrived at a law office for a deposition in a homicide case. The prosecutor and
court reporter later stated they smelled alcohol on his breath. Gill denied being drunk, but his sworn
testimony on the shooting death of Cheryl Angleton repeatedly contradicted his autopsy findings. At
one point, Gill speculated that his conclusion – that Angleton had been murdered – might have been
wrong and that Angleton could have committed suicide.
“Whatever credibility he may have had no longer exists,” the prosecutor wrote in a report afterward,
calling Gill’s testimony “inaccurate, contradictory and absurd.”
Although an internal investigation officially cleared him of testifying drunk, Gill was told in July 1994
that his contract would end after just 19 months.
“Your well documented inability to provide services at a reasonably necessary level has prevented
you from establishing and maintaining credibility with the law enforcement community,” Marion
County Coroner Karl Manders wrote in his termination letter.
Gill was given 30 days’ notice but was unable to complete his final month. He was arrested on the
charge of drunken driving on his way to the morgue one morning and barred from further work. He
was convicted of the charge and Indiana’s medical board suspended his license until he received
substance abuse treatment.
Fresh start in California
Gill moved to California and spent months undergoing treatment for alcohol abuse, records show.
Then, in early 1995, he landed a dream job: a one-year fellowship with the Los Angeles County
Coroner, an ideal place to hone his training in forensic autopsies and death investigation.
Gill did not disclose on his resume or application that he had been fired in Indianapolis. Los Angeles
officials first caught wind of his troubles when a reporter from The Indianapolis Star called.
“We were not knowledgeable, nor was this information voluntarily given to us,” a coroner’s office
personnel administrator told the newspaper regarding Gill’s mistakes in Marion County.
Gill kept his post, even after his omissions were exposed, but struggled to meet the program’s
requirements. Nine months into his training, personnel records show, the coroner’s office deemed
his work deficient, cut his pay in half and demoted him to the equivalent of a medical student.
In a written evaluation, Gill’s superiors wrote “there are significant technical problems in some of your
autopsies resulting in the need for continued supervision.”
Gill also was unable to complete the number of cases needed to finish the fellowship in a year, said
Dr. James Ribe, a Los Angeles County deputy coroner and one of Gill’s supervisors. The coroner’s
office gave Gill an additional six months to catch up.
In 1997, with his fellowship completed, Gill was eligible to take the American Board of Pathology’s
certification exam for forensic pathology, the field’s most universally recognized measure of
competence.
Gill failed the test on his first try. And his second. He passed the third time, in 1999.
Nevertheless, Gill was hired in April 1998 by Forensic Medical Group, the for-profit autopsy company
with contracts to handle cases for more than a dozen Northern California counties, including Sonoma
County in the heart of one of the state’s most renowned wine-producing regions.
It was there that Reynolds, the private investigator, began to unravel Gill’s past.
Private investigator Chris Reynolds outside the Sonoma County Coroner’s Office.Deanne
FitzmauricePrivate investigator Chris Reynolds outside the Sonoma County Coroner’s Office.
Errors surface in Sonoma case
Late on the evening of Nov. 7, 1999, a prominent local physician in Petaluma, Calif., called 911. His
wife was dead, Dr. Louis Pelfini told the emergency operator, adding that he feared she had
committed suicide.
The Sonoma County Sheriff’s Office investigators who responded to the call did not initially treat
Pelfini’s home as a crime scene, police records show, but they ultimately came to suspect Pelfini had
killed his wife, Janet.
Gill started his examination of her body two days later. After a month, he ruled that Janet Pelfini had
died from asphyxiation. His notes showed abrasions circling her mouth and a bruise on her
forehead. Based on his findings, the sheriff’s office classified her death as a homicide, and
prosecutors filed murder charges against Louis Pelfini.
Gill’s certainty about what caused Janet Pelfini to suffocate prompted her husband’s defense team
to worry, said Reynolds, the private investigator hired by Louis Pelfini’s attorney.
But Gill’s work on the case had some holes.
Gill did not take pictures of Janet Pelfini’s injuries as he autopsied her. He made drawings, but
photographs from the scene taken by sheriff’s deputies showed they were inaccurate. He failed to
note a bruise on the back of her head on the drawings. In his written report, the injury was included,
but on the wrong side of her head.
Gill also overlooked mucus plugs in her lungs. Another pathologist, hired by the prosecution, later
argued the plugs were evidence that Janet Pelfini had suffered a severe asthma attack shortly before
her death, indicating she may have died from natural causes.
Another limitation: The body had been cremated after Gill's autopsy, leaving other experts to argue
over how to interpret his notes.
With Pelfini’s case resting primarily on Gill’s conclusions, Reynolds began running the doctor’s
name through news archives and calling his former colleagues.
When the defense team reported its findings about Gill to prosecutors, however, the state did not re-
examine the charges. Instead, they secretly began coaching Gill, arranging for him to meet with a
speech therapist to help craft his trial testimony.
In the videotaped sessions, Gill acknowledged he would have to sidestep flaws in his casework.
“There are deficiencies in the autopsy,” he acknowledged. “You know we have kind of alluded to that.”
The tapes also showed Gill and his coach, Jeffrey Harris, trying to downplay his past problems.
Practicing an answer to the question of why Marion County fired him, Gill said the termination was
due to “errors in autopsies and inability to testify in trials.”
“OK, timeout,” Harris interrupted. “Don’t say … I would not say, ‘My inability to testify in trials.’ I would
say, ‘My difficulty in testifying effectively,’ or ‘my inability to effectively communicate the results of my
autopsies.’ Something to that effect.”
Gill is shown on the tape taking down Harris’ instructions on a yellow notepad.
“We always want to be thinking about, how do we counter these allegations, these innuendos that
there’s something wrong with you,” Harris told Gill during one of the sessions.
The strategy failed when Pelfini’s attorney learned of the coaching sessions and the trial judge
ordered the tapes released to the defense. Days later, the district attorney’s office dropped all
charges.
The California State Bar investigated the handling of the Pelfini case and suspended the prosecutor
from practicing law for four years for his role in suppressing evidence about Gill’s coaching sessions.
The bar report devoted several pages to Gill’s errors.
“Unfortunately,” it concluded, “Dr. Gill was not a competent pathologist.”
Mistakes in Missouri
The Pelfini case left Gill’s reputation in Northern California tarnished. Sonoma County officials barred
him from conducting autopsies there. As he had before, Gill sought a new start in a new state.
In late 2002, the Jackson County Medical Examiner’s Office, which handles autopsies for Kansas
City, Mo., advertised for a deputy. The pickings were slim.
“There were two applicants,” said Dr. Thomas Young, then the office’s sole forensic pathologist. “And
the other one had already gotten into some ethical trouble back east, so he was just completely out.”
Young said he knew about the Pelfini case and about Gill’s drunken driving conviction. But Young
said he trusted what Gill told him: that the doctor had recovered from alcohol abuse and that the
Sonoma County murder case collapsed due to prosecutorial misconduct, not poor autopsy work.
Gill started work in Kansas City in November 2002, earning $140,000 a year. Young said he watched
his colleague closely.
“In terms of his conscientiousness, being thorough, he was good,” Young said. “He did make some
mistakes, but I caught them.”
Not all of them.
In September 2003, Gill autopsied 23-year-old Robert Patterson, who had died a day after being
injured in a car accident. Based on toxicology tests that showed painkillers in Patterson’s blood, Gill
ruled the death a suicide.
But a second autopsy commissioned by Patterson’s mother revealed an artery in Patterson’s neck
that showed signs of damage so severe it would have blocked blood flow to his brain. The injury
almost certainly occurred in the car accident, the second pathologist concluded.
Presented with the results, Gill reversed his finding, ruling the death an accident.
The following year, several Missouri prosecutors learned of Gill’s problems in California and
Indianapolis and threatened to boycott the Jackson County Medical Examiner’s Office unless it fired
Gill.
Young refused. Asked why, he said the shortage of practitioners made the move impractical and that
even the field’s best sometimes misdiagnose causes of death.
Gill stayed another two years, quitting at the end of 2006 after one of the prosecutors became the
county’s chief executive and after Young retired.
Another new beginning
Again, it didn’t take long for him to find another job. In early 2007, Forensic Medical Group rehired Gill.
Click on the image to enlarge the graphic.Brian Cragin/California Watch
p>Dr. Brian Peterson, who was the firm’s president for 15 years before becoming Milwaukee’s chief
medical examiner, defended the decision.
“To my mind, he was always a victim,” Peterson said. “Gill’s a great guy, and he’s a fine pathologist.”
But the group didn’t advertise Gill’s background. On its website, it gave resumes and educational
histories for all its doctors – except Gill.
In his written statement, Gill said his work since returning to Forensic Medical Group in 2007 had
been above reproach. In addition, the doctor said that county officials in the jurisdictions he served
were aware of his background.
“In court and during application for jobs, since 2001 much of the background information has been
made available to prospective employers, defense lawyers and ultimately, if the latter deemed it
relevant to the jurors in court cases involving one of my postmortem examinations,” Gill wrote.
Several Forensic Medical Group clients say they did not receive this information, however.
Presented with records detailing Gill’s professional history in late November, officials with the Yolo
County Sheriff-Coroner’s Office expressed surprise.
“This is an eye-opener for us, to admit humbly,” said Yolo County Chief Deputy Coroner Robert
LaBrash.
Yolo County subsequently joined Sonoma in demanding that Gill not be used on its cases.
Jana McClung*, a Sutter County prosecutor, said neither she nor the sheriff-coroner’s office were
aware of Gill’s background before being contacted by a reporter in December. Gill is scheduled to
testify in a death penalty case being prosecuted by the district attorney’s office. McClung said she had
alerted the sheriff and the defendant’s attorneys.
“Obviously, what we’re going to have to do is have another forensic pathologist look at our case as a
follow up to him,” she said.
Until December, when Forensic Medical Group says it stopped employing Gill, the doctor remained
active. Last summer he gave testimony in a homicide case, a stabbing.
Asked if he intended to continue working as a forensic pathologist and if he was seeking
employment, Gill e-mailed back.
“Yes and yes,” he said.
Negligently putting innocent people in prison
Serious problems among expert witnesses and doctors
at criminal trials
Serious problems among expert witnesses and doctors
at criminal trials
by Radley Balko
Leigh Stubbs,
Mississippi Woman,
Serving 44-Year
Sentence Despite
Discredited
Testimony
8/9/11
Leigh Stubbs, Mississippi Dept.
of Corrections photo.
Prosecutors in the U.S. often
decry what is sometimes called
the "CSI Effect." Movies and
TV crime dramas like the
popular "CSI" franchise on
CBS can fill jurors' heads with
unrealistic expectations about
forensic science. But there's
also a flip side to the CSI
Effect: Because jurors are
ready to believe the fantastical
feats preformed by the
wondrous forensics computers
they see on screen, an
unscrupulous prosecutor
armed with an expert willing to
offer otherwise dubious
forensics on the witness stand
can cause a lot of damage.
Witness Michael West. In the
early 1990s, West, a dentist in
Hattiesburg, Miss., was one of
country's most prolific forensic
odontologists, or bite mark
specialists. West claimed to
have perfected a new method
of identifying bite marks on
human skin, saying he could
then match them to the teeth of
a criminal suspect.
Conveniently, West often
testified that only he could
perform this new analysis,
which he called the "West
Phenomenon."
Over the years, West
broadened his areas of
claimed expertise, testifying in
at least 10 states as a wound
pattern expert, a trace metals
expert, a gun shot residue
expert, a gunshot
reconstruction expert, a crime
scene investigator, a blood
spatter expert, a "tool mark"
expert, a fingernail scratch
expert and an expert in "liquid
splash patterns." He also got
himself elected coroner of
Forrest County, Miss. Though
West was discredited in a
number of national media
reports beginning in the
mid-1990s, he continued to
testify in Mississippi
courtrooms until just a few
years ago.
Mississippi prosecutors no
longer use West as a witness,
but state Attorney General Jim
Hood continues to defend
convictions won because of his
testimony. And Mississippi's
appeals courts continue to
uphold them. There are still
dozens of people still in prison
thanks either to West's
testimony or his forensics
reports, and Mississippi
officials don't seem particularly
concerned about them. One of
those people is Leigh Stubbs,
now 10 years into a 44-year
prison sentence.
LEIGH STUBBS
Stubbs may not be the most
sympathetic of West's victims.
She's a former drug addict,
who on the night of her alleged
crimes wasn't in the best of
company. But witness accounts
say Stubbs remained sober
that night (she passed a drug
test), and the evidence
suggests she was the group's
caretaker.
Stubbs' story begins in March
2000, just after she
successfully completed
treatment at a rehab center in
Columbus, Miss. Stubbs
checked out with Tammy
Vance, a friend she met in
rehab, and Kim Williams, the
woman Vance and Stubbs
would later be accused of
assaulting.
After checking out, the three
women drove to the home of
Dickie Ervin, whom Williams
had been dating. Vance and
Stubbs then left Ervin's house.
They were joined later by
Williams, who had stolen some
of Ervin's Oxycontin. Vance
and Williams began drinking
and taking the Oxycontin, while
Stubbs drove and remained
sober. The three eventually
ended up at a Comfort Inn in
Brookhaven, Miss. By that
time, Vance and Williams had
passed out. Stubbs checked
the three of them in to the
hotel. According to the clerk's
testimony, Stubbs didn't
appear drunk or high, only
tired.
By Stubbs' account, she then
helped the other two women
into the room, and the three
went to sleep. The next day,
Stubbs and Vance went to get
some food, leaving Williams in
the room, still sleeping. Later
the same afternoon, Stubbs
and Vance noticed that
Williams still hadn't woken up,
and was having trouble
breathing. They called an
ambulance, and Williams was
admitted and treated for a drug
overdose. She fell into a coma.
At the hospital, doctors found a
number of injuries on Williams,
including swollen breasts, a
swollen and bruised vagina,
and marks across her
buttocks. The attending
physician believed the injuries
appeared to be two to four
days old. A rape kit was
inconclusive. Another doctor
later also found an injury to
Williams' head. A few days
later, the office of then-District
Attorney Dunn Lampton called
in Michael West to examine
Williams' injuries. (Williams,
who has since recovered, says
she doesn't remember who
attacked her.)
Lampton chose to bring in
Michael West as a witness
even though West's credibility
problems were already
well-known. West had
previously claimed to be able
to trace the bite marks in the
bread of a half-eaten bologna
sandwich to the prosecution's
chief suspect; he had
compared his own genius to
the musical genius of Itzhak
Perlman; and he once testified
in court that his own error rate
was merely "something less
than my savior, Jesus Christ."
West had been exposed in
articles in both the American
Bar Association Law Journal
and the National Law Review,
and he was suspended and
later resigned from the
American Board of Forensic
Odontologists. But Lampton
ignored West's history and
called in his expertise in yet
another criminal case.
In a routine he had by then
repeated dozens of times with
law enforcement officials
across Mississippi and
Louisiana, West claimed to find
human bite marks on Williams
that other doctors had
overlooked. He then ordered
dental impressions taken from
Stubbs, Vance and two other
suspects. But by the time the
plaster impressions arrived,
Williams' alleged wounds had
faded. So West performed his
analysis based on
photographs he had taken of
his findings days earlier. He
would later testify that it was a
"probability" that a bite mark he
claimed to have found on
William's thigh was made by
Stubbs. (In a rare display of
humility, West did concede that
he wasn't "100 percent" certain
of the match -- only that it was
likely.)
MICHAEL WEST, 'VIDEO
ENHANCEMENT EXPERT'
From there, the case against
Leigh Stubbs only grew more
bizarre. On the night of the
alleged attack, the Comfort Inn
had a security camera camera
trained on its parking lot.
Lampton sent the grainy VHS
tape, which was taken after
nightfall, to the FBI for
analysis. The agency's report
found nothing incriminating in
the footage. It repeatedly
points out that the quality of
the recording is insufficient to
tell for certain how many
people are depicted in the
video, much less determine
their identities or what sort of
clothing they're wearing. The
report also makes no mention
of anyone moving a "body."
Though he was obligated by
law to do so, Lampton never
turned that FBI report over to
Stubbs' defense attorney. But
he sent the video to Michael
West, who, now donning his
"video enhancement expert"
cap, claimed he was able to
enhance the video and capture
still photos from those
enhancements incriminating
Stubbs and Vance for Williams'
injuries.
The ability to "enhance"
security camera footage
beyond its resolution is a
Hollywood-perpetuated myth
so common that mocking it has
become a running pop culture
meme. Yet West testified in
court that he could do exactly
that. West and Lampton both
knew that the FBI itself was
unable to glean anything
useful from the video,
according to this
correspondence, in which West
references the FBI's
examination of the tape. They
kept that correspondence from
the defense and the jury.
Leigh Stubbs,
Mississippi Woman,
Serving 44-Year
Sentence Despite
Discredited
Testimony
8/9/11
Leigh Stubbs, Mississippi Dept.
of Corrections photo.
Prosecutors in the U.S. often
decry what is sometimes called
the "CSI Effect." Movies and
TV crime dramas like the
popular "CSI" franchise on
CBS can fill jurors' heads with
unrealistic expectations about
forensic science. But there's
also a flip side to the CSI
Effect: Because jurors are
ready to believe the fantastical
feats preformed by the
wondrous forensics computers
they see on screen, an
unscrupulous prosecutor
armed with an expert willing to
offer otherwise dubious
forensics on the witness stand
can cause a lot of damage.
Witness Michael West. In the
early 1990s, West, a dentist in
Hattiesburg, Miss., was one of
country's most prolific forensic
odontologists, or bite mark
specialists. West claimed to
have perfected a new method
of identifying bite marks on
human skin, saying he could
then match them to the teeth of
a criminal suspect.
Conveniently, West often
testified that only he could
perform this new analysis,
which he called the "West
Phenomenon."
Over the years, West
broadened his areas of
claimed expertise, testifying in
at least 10 states as a wound
pattern expert, a trace metals
expert, a gun shot residue
expert, a gunshot
reconstruction expert, a crime
scene investigator, a blood
spatter expert, a "tool mark"
expert, a fingernail scratch
expert and an expert in "liquid
splash patterns." He also got
himself elected coroner of
Forrest County, Miss. Though
West was discredited in a
number of national media
reports beginning in the
mid-1990s, he continued to
testify in Mississippi
courtrooms until just a few
years ago.
Mississippi prosecutors no
longer use West as a witness,
but state Attorney General Jim
Hood continues to defend
convictions won because of his
testimony. And Mississippi's
appeals courts continue to
uphold them. There are still
dozens of people still in prison
thanks either to West's
testimony or his forensics
reports, and Mississippi
officials don't seem particularly
concerned about them. One of
those people is Leigh Stubbs,
now 10 years into a 44-year
prison sentence.
LEIGH STUBBS
Stubbs may not be the most
sympathetic of West's victims.
She's a former drug addict,
who on the night of her alleged
crimes wasn't in the best of
company. But witness accounts
say Stubbs remained sober
that night (she passed a drug
test), and the evidence
suggests she was the group's
caretaker.
Stubbs' story begins in March
2000, just after she
successfully completed
treatment at a rehab center in
Columbus, Miss. Stubbs
checked out with Tammy
Vance, a friend she met in
rehab, and Kim Williams, the
woman Vance and Stubbs
would later be accused of
assaulting.
After checking out, the three
women drove to the home of
Dickie Ervin, whom Williams
had been dating. Vance and
Stubbs then left Ervin's house.
They were joined later by
Williams, who had stolen some
of Ervin's Oxycontin. Vance
and Williams began drinking
and taking the Oxycontin, while
Stubbs drove and remained
sober. The three eventually
ended up at a Comfort Inn in
Brookhaven, Miss. By that
time, Vance and Williams had
passed out. Stubbs checked
the three of them in to the
hotel. According to the clerk's
testimony, Stubbs didn't
appear drunk or high, only
tired.
By Stubbs' account, she then
helped the other two women
into the room, and the three
went to sleep. The next day,
Stubbs and Vance went to get
some food, leaving Williams in
the room, still sleeping. Later
the same afternoon, Stubbs
and Vance noticed that
Williams still hadn't woken up,
and was having trouble
breathing. They called an
ambulance, and Williams was
admitted and treated for a drug
overdose. She fell into a coma.
At the hospital, doctors found a
number of injuries on Williams,
including swollen breasts, a
swollen and bruised vagina,
and marks across her
buttocks. The attending
physician believed the injuries
appeared to be two to four
days old. A rape kit was
inconclusive. Another doctor
later also found an injury to
Williams' head. A few days
later, the office of then-District
Attorney Dunn Lampton called
in Michael West to examine
Williams' injuries. (Williams,
who has since recovered, says
she doesn't remember who
attacked her.)
Lampton chose to bring in
Michael West as a witness
even though West's credibility
problems were already
well-known. West had
previously claimed to be able
to trace the bite marks in the
bread of a half-eaten bologna
sandwich to the prosecution's
chief suspect; he had
compared his own genius to
the musical genius of Itzhak
Perlman; and he once testified
in court that his own error rate
was merely "something less
than my savior, Jesus Christ."
West had been exposed in
articles in both the American
Bar Association Law Journal
and the National Law Review,
and he was suspended and
later resigned from the
American Board of Forensic
Odontologists. But Lampton
ignored West's history and
called in his expertise in yet
another criminal case.
In a routine he had by then
repeated dozens of times with
law enforcement officials
across Mississippi and
Louisiana, West claimed to find
human bite marks on Williams
that other doctors had
overlooked. He then ordered
dental impressions taken from
Stubbs, Vance and two other
suspects. But by the time the
plaster impressions arrived,
Williams' alleged wounds had
faded. So West performed his
analysis based on
photographs he had taken of
his findings days earlier. He
would later testify that it was a
"probability" that a bite mark he
claimed to have found on
William's thigh was made by
Stubbs. (In a rare display of
humility, West did concede that
he wasn't "100 percent" certain
of the match -- only that it was
likely.)
MICHAEL WEST, 'VIDEO
ENHANCEMENT EXPERT'
From there, the case against
Leigh Stubbs only grew more
bizarre. On the night of the
alleged attack, the Comfort Inn
had a security camera camera
trained on its parking lot.
Lampton sent the grainy VHS
tape, which was taken after
nightfall, to the FBI for
analysis. The agency's report
found nothing incriminating in
the footage. It repeatedly
points out that the quality of
the recording is insufficient to
tell for certain how many
people are depicted in the
video, much less determine
their identities or what sort of
clothing they're wearing. The
report also makes no mention
of anyone moving a "body."
Though he was obligated by
law to do so, Lampton never
turned that FBI report over to
Stubbs' defense attorney. But
he sent the video to Michael
West, who, now donning his
"video enhancement expert"
cap, claimed he was able to
enhance the video and capture
still photos from those
enhancements incriminating
Stubbs and Vance for Williams'
injuries.
The ability to "enhance"
security camera footage
beyond its resolution is a
Hollywood-perpetuated myth
so common that mocking it has
become a running pop culture
meme. Yet West testified in
court that he could do exactly
that. West and Lampton both
knew that the FBI itself was
unable to glean anything
useful from the video,
according to this
correspondence, in which West
references the FBI's
examination of the tape. They
kept that correspondence from
the defense and the jury.
San Diego
Education Report
Education Report
What happened at NASA?
How did such a
successful agency
develop such a
dysfunctional
management?
How did such a
successful agency
develop such a
dysfunctional
management?
Aug. 31, 2011
Panel: Widespread waste and fraud in war spending
By RICHARD LARDNER
Associated Press
WASHINGTON (AP) - An independent panel that concluded as much as $60 billion in U.S.
funds has been lost to waste and fraud in Iraq and Afghanistan over the past decade will
release results Wednesday of its three-year investigation into wartime spending.
In its final report to Congress, the Commission on Wartime Contracting blamed the losses on
lax oversight of contractors, poor planning and widespread corruption, especially during the
early stages of the wars when few controls were in place to monitor the heavy flow of money.
The Associated Press obtained a copy of the commission's 240-page report in advance of its
public release on Capitol Hill. The commission was created by Congress in 2008 and ceases
operating at the end of September.
Panel: Widespread waste and fraud in war spending
By RICHARD LARDNER
Associated Press
WASHINGTON (AP) - An independent panel that concluded as much as $60 billion in U.S.
funds has been lost to waste and fraud in Iraq and Afghanistan over the past decade will
release results Wednesday of its three-year investigation into wartime spending.
In its final report to Congress, the Commission on Wartime Contracting blamed the losses on
lax oversight of contractors, poor planning and widespread corruption, especially during the
early stages of the wars when few controls were in place to monitor the heavy flow of money.
The Associated Press obtained a copy of the commission's 240-page report in advance of its
public release on Capitol Hill. The commission was created by Congress in 2008 and ceases
operating at the end of September.
Stranded JetBlue
pilot pleaded for
help from Conn.
airport
By Rebecca Ruiz, Senior editor,
msnbc.com
2011/10/31
A recording of transmissions
between a JetBlue pilot and
Bradley International Airport
near Hartford, Conn., captured
the pilot's frustration at being
stuck on the runway during a
snowstorm for more than seven
hours on Saturday.
Story: At least 4 jets strand
Conn. passengers for hours
The pilot continues to request
towing assistance so that
passengers can deplane at a
gate. "We can't seem to get any
help from our own company,"
says the unidentified pilot. "I
apologize for this, but is there
any way you can get a tug and a
towbar out here to us and get us
towed somewhere to a gate or
something? I don't care -- take
us anywhere."
The seven-minute recording
was posted to the air traffic
website LiveATC.net.
Flight 504, as it's identified in
the recording, was one of at
least three JetBlue planes that
reportedly sat on the tarmac for
several hours after being
diverted from New York-area
airports during a snowstorm.
According to JetBlue's website,
flight 504 is a daily flight from Ft.
Lauderdale to Newark.
The Department of
Transportation is investigating
the JetBlue tarmac delay and
others that lasted more than
three hours. Airlines that keep
passengers stranded for more
than three hours face fines of up
to $27,500 per flier.
A JetBlue spokeswoman,
Victoria Lucia, confirmed in an e-
mailed statement to the
Associated Press that six of its
planes, carrying a total of about
700 passengers, were diverted
to Hartford as a result of a
"confluence of events" including
equipment failures at Newark
and New York's John F.
Kennedy International Airport
that prevented planes from
landing in low visibility.
Andrew Carter, a passenger on
the plane, told the AP that the
crew ran out of snacks and
bottled water for the last few
hours of the delay. "The toilets
were backed up. When you
flushed, nothing would happen,"
he said.
The recording begins with the
pilot warning the airport not to let
a trooper board the plane. It is
unclear at what point during the
ordeal the airport considered
sending police to the plane.
"If you try to come on the jetway
now and flash a trooper's
uniform on this plane, it's not
going to be good, it's not going
to be pretty," the pilot said to the
airport. "They've calmed down a
little bit. We've told them we're
waiting for the gate, we're just
waiting for a tug and a tow bar ...
I appreciate your efforts, but it'll
be worse if you try to put a
trooper on here right now."
The pilot later mentioned that a
diabetic and paraplegic were
among the passengers who
urgently needed to deplane. The
airport eventually towed the
plane to a gate.
"Thank you very much ... for
helping us out," said the pilot. "I
think we got more help from you
guys than our own people."
JetBlue spokesperson Sharon
Jones told msnbc.com that the
airline was looking into the
incident. "We don’t have any
information regarding that
audiotape," she said. "We’re
conducting our own
investigation. Right now we don’
t have anything to share."
Information from the Associated
Press was included in this
report.
pilot pleaded for
help from Conn.
airport
By Rebecca Ruiz, Senior editor,
msnbc.com
2011/10/31
A recording of transmissions
between a JetBlue pilot and
Bradley International Airport
near Hartford, Conn., captured
the pilot's frustration at being
stuck on the runway during a
snowstorm for more than seven
hours on Saturday.
Story: At least 4 jets strand
Conn. passengers for hours
The pilot continues to request
towing assistance so that
passengers can deplane at a
gate. "We can't seem to get any
help from our own company,"
says the unidentified pilot. "I
apologize for this, but is there
any way you can get a tug and a
towbar out here to us and get us
towed somewhere to a gate or
something? I don't care -- take
us anywhere."
The seven-minute recording
was posted to the air traffic
website LiveATC.net.
Flight 504, as it's identified in
the recording, was one of at
least three JetBlue planes that
reportedly sat on the tarmac for
several hours after being
diverted from New York-area
airports during a snowstorm.
According to JetBlue's website,
flight 504 is a daily flight from Ft.
Lauderdale to Newark.
The Department of
Transportation is investigating
the JetBlue tarmac delay and
others that lasted more than
three hours. Airlines that keep
passengers stranded for more
than three hours face fines of up
to $27,500 per flier.
A JetBlue spokeswoman,
Victoria Lucia, confirmed in an e-
mailed statement to the
Associated Press that six of its
planes, carrying a total of about
700 passengers, were diverted
to Hartford as a result of a
"confluence of events" including
equipment failures at Newark
and New York's John F.
Kennedy International Airport
that prevented planes from
landing in low visibility.
Andrew Carter, a passenger on
the plane, told the AP that the
crew ran out of snacks and
bottled water for the last few
hours of the delay. "The toilets
were backed up. When you
flushed, nothing would happen,"
he said.
The recording begins with the
pilot warning the airport not to let
a trooper board the plane. It is
unclear at what point during the
ordeal the airport considered
sending police to the plane.
"If you try to come on the jetway
now and flash a trooper's
uniform on this plane, it's not
going to be good, it's not going
to be pretty," the pilot said to the
airport. "They've calmed down a
little bit. We've told them we're
waiting for the gate, we're just
waiting for a tug and a tow bar ...
I appreciate your efforts, but it'll
be worse if you try to put a
trooper on here right now."
The pilot later mentioned that a
diabetic and paraplegic were
among the passengers who
urgently needed to deplane. The
airport eventually towed the
plane to a gate.
"Thank you very much ... for
helping us out," said the pilot. "I
think we got more help from you
guys than our own people."
JetBlue spokesperson Sharon
Jones told msnbc.com that the
airline was looking into the
incident. "We don’t have any
information regarding that
audiotape," she said. "We’re
conducting our own
investigation. Right now we don’
t have anything to share."
Information from the Associated
Press was included in this
report.