Of all the institutions subjected to the microscopic attention that the Simpson case brought with it, the Los Angeles County coroner’s office was among the most maligned.

Some public officials and forensic pathology experts say the double murder case exposed serious gaps in the credibility and competence of the 166-person, $12-million department, which is charged with the thankless job of investigating, classifying and clearing roughly 19,000 deaths a year.

At the very least, many observers came away from the trial believing that the coroner had bungled the autopsies of Nicole Brown Simpson and Ronald Lyle Goldman. To make matters worse, the pathologist who performed the procedures, Dr. Irwin Golden, came off so badly during Simpson’s preliminary hearing that prosecutors declined to allow him to testify in the trial.

“The O.J. case has vastly exposed the inadequacies of that department,” said Werner U. Spitz, a former Wayne County, Mich., medical examiner and author of one of the most widely read textbooks on forensic pathology.


“It’s just lucky--really lucky--that the coroner’s testimony eventually played no role in the case. . . . I don’t believe for a minute that the verdict would have been different if the coroner’s office had done everything by the book. And it bungled everything.”

Los Angeles County Supervisor Yvonne Brathwaite Burke called the coroner’s performance an “embarrassment” and said county officials must take steps to shore up the department. Problems with body storage moved supervisors recently to spare the coroner a planned $2.5-million budget cut.

“We have to really look at the coroner’s office to make sure they have the funding not to embarrass us in the world’s eyes,” Burke said. “We cannot have a coroner’s office that is sloppy and does not have the equipment it needs.

“Here you have worldwide exposure and still this happened. What happens in all the other murder cases that no one is watching?”


In fact, moments after Simpson was acquitted, chief defense counsel Johnnie L. Cochran Jr. said: “I hope the coroner’s office gets their act together. The public should demand that.”

Yet while they continue to acknowledge that mistakes were made during the autopsies, coroner’s officials said the goofs were minor, well within acceptable professional standards, and did not detract from the basic purpose of the procedures--determining the cause and approximate time of death. Their conclusions held up under scrutiny and cross-examination, they said.

But agency spokesmen agree that they did a disastrous job of presenting their conclusions in the early stages of the trial.

“That’s not why we hire pathologists,” said Anthony T. Hernandez, director of administration. He conceded that the pathologist who initially testified was not very articulate on the stand and that he was “crucified” by the former athlete’s lawyers during a preliminary hearing.


“We don’t hire them to be PR people,” he said. “We hire them to do autopsies.”

Having been singed by the Simpson spotlight, the coroner’s office wants to change. Hernandez said it has adopted a new policy dealing with high-profile cases, has instituted more extensive psychological background checks for autopsy personnel and even hired a jury consultant--at $150 an hour--for seminars on how to become better expert witnesses.

The new policy, adopted Jan. 1, codifies security and autopsy procedures for cases in which the victim or suspect is “so prominent that intense media or public interest is anticipated.”

It requires that wrapped remains be kept in a locked crypt, a change from the past. And it requires that every celebrity death be treated and examined as if it were a homicide, even if the obvious signs indicate that it is not.


The new policy also clamps tight controls on access and documents. Anyone allowed in for a high-profile autopsy must sign a log with their name, agency and times in and out of the dissection room. Duplicating coroner documents is forbidden unless approved by Hernandez or Chief Medical Examiner-Coroner Lakshmanan Sathyavagiswaran.

Meanwhile, Hernandez said he has expanded psychological background checks to include everyone--even the mortuary attendants who retrieve bodies--hired to work on the autopsy floor. The reason: To make sure they “have the ability to handle this level of stress and not be totally thrown over the edge” on high-profile cases.

For help in the courtroom, Hernandez has hired jury consultant David Tunno of Marina del Rey. Tunno has given three seminars advising coroner staffers about the language and nonverbal cues that help expert witnesses deflect attacks by attorneys or get their point across to jurors. More intensive workshops are being contemplated.

“They are seminars telling you how to get the truth out,” said Hernandez, who estimated the cost to date at $1,300.


All these changes are part of an internal re-examination that began while the Simpson trial was in progress.

The coroner got off to a bad start in the case when LAPD detectives, contrary to state law and police policy, failed to call the coroner or let its investigator onto the scene for more than 10 hours after the bodies were discovered. Forensic experts said this was a major disadvantage because it prevented the coroner from more accurately estimating the time of death, a key question in the case against Simpson.

Claus Speth, a forensic pathologist from New Jersey and past chairman of the National Assn. of Medical Examiners’ accreditation and inspection committees, said that if the police had called the coroner early on, the agency could have helped thwart charges of a conspiracy to frame Simpson.

“The medical examiner could very well have been witness to the fact that none of the evidence was planted,” said Speth, who himself is at the center of a controversy in New Jersey over his examination after a jail death. “As an independent fact-finder, non-advocate who is present from the beginning, he is witness to everything at the scene.”


Trial testimony revealed a number of alleged lapses. The coroner’s office did not perform a “rape kit” examination on either victim, something experts said should have been routine. The death scene investigator failed to notice drops of blood on Nicole Simpson’s back--blood the defense said could have come from the real killer.

But most of the testimony highlighted mistakes made by Golden, one of the department’s veteran pathologists, who performed the autopsies. He discarded the contents of Nicole Simpson’s stomach, then failed to identify all the items contained in Goldman’s, according to testimony.

He did not X-ray bone fragments to look for microscopic bits from the attacker’s knife, missed a bruise to Nicole Simpson’s brain and failed to note that part of Goldman’s Adam’s apple had been severed.

Golden mislabeled a vial containing bile from Nicole Simpson and issued a supplemental report when he noticed additional cuts in photographs that he did not mention in his original autopsy.


Golden declined comment. But Dr. Michael M. Baden, the former New York City pathologist who served as a defense expert witness in the Simpson case, defended Golden’s handling of the autopsies of Nicole Simpson and Ron Goldman.

“It was much better than the average autopsy, although he made some mistakes,” said Baden, who also worked for L.A. prosecutors in the drug death of comedian John Belushi. “If a perfect autopsy was a 10, this would have been a 7.”

Still, Deputy Dist. Atty. Brian R. Kelberg, who examined the coroner for the prosecution, said the magnifying power of the Simpson case made it look otherwise and illuminated the quality of work the public can expect from an overburdened office he likened to an assembly line.

“If people put that assembly-line process under the microscope expecting to see a Rolls-Royce, they’ll be disappointed,” said Kelberg, who guided the introduction of autopsy evidence in the trial. “What you produce in the end is going to be a satisfactory model, but it’s going to have flaws.”


Unfortunately, Kelberg said, the flaws in the Simpson case left no choice but to keep Golden off the stand. Instead, Kelberg called Golden’s boss, Sathyavagiswaran, who gave his opinions based on his reading of the autopsy and further tests. The coroner’s office believes the chief came off well and received many accolades for his honesty.

“What I had to face is the reality that [Golden] made a number of mistakes, and those mistakes, although not significant, would have had an impact on the jury,” Kelberg said.

The prosecutor added that he had to face another reality about Golden--that his courtroom demeanor turned jurors off. He said several jurors said they saw Golden testify about the autopsies during Simpson’s preliminary hearing and “there was something less than a favorable impression left.”

The jurors were not the only ones who didn’t like the owlish Golden’s style. Jury consultant Tunno observed him during the preliminary hearing and wrote: “He appeared not to care whether or not anyone understood him.”


Tunno, who has authored a book of testimony tips for expert witnesses, mailed his observations about Golden and other prosecution witnesses to the district attorney’s office unsolicited. A little while later, he said, the coroner’s office called and asked for his help.

He has given three seminars so far. Among those who attended: Irwin Golden.