Key cases where death probes were complicated by harvesting of body parts

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The industry that trades in human tissue has said there has never been a case in which the harvesting of body parts complicated a death investigation by a medical examiner or coroner. The Times studied reports of autopsies performed by medical examiners in Los Angeles and San Diego, finding more than two dozen investigations that were upended or delayed by the procurement of tissues or organs.

Several deaths under investigation by detectives went unsolved, a death after a fight with police remains unsettled, and families have been left without answers to why their loved ones died.

Times reporters found similar problems, and more than 20 cases, across the country as medical examiners contended with new laws pushed through by the industry. The laws are aimed at forcing coroners to release more bodies from county morgues to the companies for procurement of parts.

Here is a sampling of key cases.

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A death after fight with police was left unsettled

David Walters, a 44-year-old homeless man, suffered a direct blow to his head in a scuffle with a Santa Monica police officer in September 2010. Eight days later, he was found lying on Wilshire Boulevard with severe brain damage. Doctors at UCLA Ronald Reagan Medical Center declared him brain-dead.

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The coroner couldn’t determine what role if any the police encounter had played in the death. A hospital administrator had used a state law to authorize OneLegacy to harvest his organs, which complicated the coroner’s investigation.

The 500 block of Santa Monica Boulevard
David Walters died eight days after getting into a fight with police near the 500 block of Santa Monica Boulevard.
(Christina House / Los Angeles Times)

By the time of the coroner’s autopsy, the brain had disintegrated to the point that the county’s neuropathologist couldn’t determine where the bleeding in his skull had started, according to the autopsy report. Had it begun near his right eyebrow where his head slammed the wall during the police encounter? The brain’s fragmentation happens naturally as bodies are kept on ventilators after brain death. It can occur in those who don’t donate organs, but donors are often kept on ventilators for days until transplant recipients are found.

In his final report, the deputy medical examiner said his autopsy had been “compromised” by the brain’s disintegration. He listed the cause of death as stroke from hypertension, relying on the hospital’s diagnosis, which included a CT scan. Walters’ past medical history included seizures, according to the autopsy report. It did not note a history of hypertension.

The medical examiner wrote that “the indirect effects of the preceding history of battery by police cannot be excluded” from contributing to Walters’ death. He said he could not say whether it had been a homicide, accident or natural death.

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Lt. Saul Rodriguez, a Santa Monica police spokesman, said the department looked into the incident, deciding it wasn’t the officer’s blow that led to Walters’ death more than a week later. “Who knows what happened in those eight days?” he said.

OneLegacy said it had alerted the coroner to the police encounter before procuring the organs. Coroner officials said they don’t believe the procurement harmed the investigation.

Cyril Wecht, a forensic pathologist from Pennsylvania who has consulted on many prominent death investigations, said he believed the harvesting of organs had “significantly compromised” the county’s autopsy because it may have destroyed evidence of internal injuries. “Police-related deaths require scrutiny with meticulous detail,” Wecht said.

April Walters, the man’s former wife, said a California official eventually informed their son of his death. The family did not know his organs had been donated until told by The Times.

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Body parts were taken before a coroner could look for abuse

In Long Beach in 2008, Stephen Beal allowed OneLegacy to take bones and skin from his wife’s body. Forty-eight-year-old Christine Beal had died three weeks after she allegedly tumbled down a staircase in their home with a heavy table landing on top of her, according to the autopsy report.

Her skin and bones were gone by the time a nurse called the coroner. After an autopsy of what remained, a county pathologist said he couldn’t determine whether trauma from the fall caused her death. Adding to the questions, investigators found she had toxic levels of lead, arsenic and mercury in her blood. The pathologist wrote it was a “mysterious case.” The hospital reported Beal had been “uncooperative, not wanting to ‘reveal’ information” about his wife.

Ten years later, Beal was arrested on suspicion of killing his former girlfriend. Ildiko Krajnyak died in a May 2018 explosion when she opened a package bomb in the Orange County spa the two operated together. He has pleaded not guilty. His public defender did not return repeated calls.

OneLegacy said it had no records on Christine Beal. After the arrest, detectives looked into her death, said Jennifer De Prez, a Long Beach police spokeswoman, “but could not find any substantial evidence of foul play.”

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Failing to report suspicious or unexpected deaths

Jose De La Rosa, ​31, of Pacoima was confused and disoriented when admitted to the hospital in November 2004. A CT scan revealed blood collecting between his brain and skull, a sign of a severe head injury. Doctors at Henry Mayo Newhall Memorial Hospital declared him brain-dead Dec. 1. OneLegacy asked his family to donate his kidneys. The coroner’s office didn’t learn of his mysterious death until the funeral home called seven days later. The coroner’s office attempted an investigation that left many questions unanswered. A county pathologist wrote he died from “a presumed fall.” The report said it was not known where, when or how his head was injured.

OneLegacy said the hospital had told its employees he died of a stroke, making its staff believe his death wasn’t a coroner’s case. Henry Mayo said it had no information on the death because records are destroyed after 10 years.

OneLegacy didn’t call the coroner after Brent Shapiro, 24, died of a possible overdose in October 2005, according to an L.A. County coroner’s report. The company told the hospital his death wouldn’t be a coroner’s case, the report said. Under state law, all suspected overdose deaths fall under the coroner’s jurisdiction. The coroner found out about the USC student’s death from his father, Robert Shapiro, the lawyer who has represented celebrities including O.J. Simpson.

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A coroner’s investigator asked a OneLegacy employee why he hadn’t reported the death. “He told me, ‘OneLegacy doesn’t call except during daylight hours,’” the investigator wrote. Later, a county pathologist determined the young man died after taking a small, non-lethal amount of ecstasy at a party. A preexisting heart murmur may have contributed to his death, the pathologist said.

OneLegacy said it has no information on the case, but that it “does not tell any hospital what deaths should be reported.” It said its staff calls the coroner “regularly at all hours.”

County officials blacked out the details about OneLegacy in the autopsy report they gave to The Times. An unredacted copy of the report was obtained by a reporter for the LA Weekly, who wrote about it in 2005.

Keck Hospital of USC didn’t call the coroner when Christy Hinton​, 41, died Sept. 17, 2017. Instead her body was sent to Research for Life, a company that asks for donations of whole bodies used in research and education. The day before Hinton died, doctors had said her liver was injured. They also found high levels of Tylenol in her blood. She had accidentally taken too much or tried to commit suicide, according to the autopsy report. Either possibility made her death a coroner’s case. The coroner didn’t learn of her death until nine days later. An autopsy couldn’t determine how she had died. The pathologist wrote he found “no evidence of trauma.” Yet bones and skin were gone at the time of his exam.

Keck Hospital and Garland Shreves, chief executive of Research for Life, said they couldn’t speak about Hinton’s case because of privacy laws. Shreves said his staff has repeatedly found suspicious deaths that hospitals or others had not reported. “The law applies to us,” he said. “It applies to anyone.”

In 2007, ​Marcia Neiswander​, 57, suddenly collapsed and fell out of her chair at work. Doctors at Hollywood Presbyterian Medical Center declared she was brain-dead. OneLegacy quickly gained approval from the family to make her a donor, but neither the hospital nor the company called the coroner. “OneLegacy harvested kidneys and liver on 9/19/07 and bone, skin and corneas on 9/20/07 without reporting this case or getting approval from our doctors,” an official later wrote in her record.

OneLegacy told The Times that the hospital had informed the company she died of natural causes. Later a doctor refused to sign the death certificate, the company said, which under state law made her death a case for the coroner.

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Bones, skin were taken before a coroner checked for trauma

When someone dies unexpectedly, responsibility for determining the cause falls to the coroner, according to California law. At a minimum, the coroner must view the body to ensure there’s no sign of trauma or foul play, according to rules on the L.A. County coroner’s website. When some young and middle-aged adults died suddenly, however, companies harvested bone and skin even before the coroner could view the body. OneLegacy, which procured the tissue in some of these cases, told The Times the coroner often allowed it to procure tissues if a death was believed to be from natural causes. The coroner’s office said as a safeguard in those cases it had instructed OneLegacy not to remove fractured bones.

Jesse Meza​ was just 33 when his mother couldn’t wake him in the early morning of June 23, 2009. Paramedics pronounced him dead at their South Gate home. A coroner’s investigator viewed his body at the funeral home a week later, finding that bones and patches of skin were already gone. “No obvious signs of trauma were observed, however previous harvesting prevented any meaningful examination,” the investigator wrote.

Diane Smith​, 49, was in cardiac arrest when she arrived at Lakewood Regional Medical Center on March 27, 2009. About a week later, an investigator from the coroner’s office examined the body of the Inglewood resident, finding that skin and bones had been procured. “Body was viewed at the [mortuary] after harvesting therefore, preventing any meaningful examination,” the investigator wrote.

An investigator from the L.A. County coroner’s office arrived at a Long Beach mortuary in December 2007 to find the body of ​Edita Pickel​, 66, in “poor condition,” according to a coroner’s

report. “The body appeared to have been harvested for skin and is therefore not possible to check for any obvious signs of trauma,” the investigator wrote.

An excerpt from Edita Pickel​'s autopsy report.
An excerpt from Edita Pickel​'s autopsy report.
(Los Angeles County Department of Coroner)

An emergency crew pronounced ​Heidi Ann Nelson, 62,​ dead when they arrived at her Long Beach home in November 2008. She had not been breathing when her husband found her. A week later, an investigator from the coroner’s office examined Nelson’s body at the funeral home. “Obvious signs of harvesting … prevented observation of any signs of trauma,” the investigator wrote.

Raymon Clary, ​65, of Anaheim passed away in 2009 in the emergency room of Glendale Adventist Medical Center. A coroner’s investigator examined his body at the funeral home, finding incisions down the length of both arms and legs. Another surgical cut crossed his abdomen. “Further examination of the body was not practical as harvesting had occurred,” the investigator wrote.

Oscar Ashford, 52,of Torrance was found in bed not breathing. A doctor at Little Company of Mary Hospital pronounced him dead in the early morning of May 26, 2009. His unexpected death was a mystery. He had no known history of drugs or alcohol. A coroner’s investigator viewed his body at the funeral home a couple of days later. “Body was … in poor condition due to harvesting on both the back and front of the body,” the investigator wrote.

Kenneth Flynn, 56,of Azusa was vomiting and having trouble breathing when he arrived at Foothill Presbyterian Hospital on July 6, 2009. A coroner’s investigator viewed his body at the funeral home, finding surgical incisions down his arms and legs. Patches of skin were gone from his legs, arms and back. “The decedent has been harvested prior to being examined by our office,” she wrote.

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Procurement firms’ actions complicate death investigations

The San Diego County medical examiner decided not to investigate the 2008 death of Jennifer Marshall​ after Lifesharing gave officials wrong information about what happened at Sharp Chula Vista Medical Center. Lifesharing reported Marshall, 34, had hemorrhaged while giving birth. The company gave officials incomplete information, not reporting that doctors had performed an emergency caesarean section, according to the autopsy report.

By the time the medical examiner learned of the C-section and decided to investigate, Lifesharing had harvested Marshall’s kidneys.

A medical examiner’s spokeswoman said officials don’t believe the procurement hampered their investigation, which found Marshall died a “natural” death from bleeding caused by a “spontaneous uterine laceration.”

Lifesharing and Sharp Chula Vista said they couldn’t comment because of patient privacy regulations.

In February 2007, Kathryn Gardia, 18, of Lakewood was riding in a car with her boyfriend on the 605 Freeway when he suddenly swung onto the ramp to the 5 Freeway. The car, traveling at an estimated 80 mph, went out of control and crashed into a tree.

Paramedics found that the Cal State Long Beach student had suffered devastating trauma. Doctors gave her blood transfusions and tried to repair her lacerated liver. Yet the outgoing young woman, who dreamed of being a nurse, was pronounced dead the next day.

Even though manslaughter charges were pending against the driver, OneLegacy asked the coroner for permission to procure her tissues. Dr. Pedro Ortiz agreed as long as the company took nothing injured in the crash, according to the autopsy report.

“Liver was apparently recovered despite Dr. Ortiz’s notation not to ‘procure over areas of trauma,’” the coroner’s investigator wrote in the county report.

OneLegacy said a coroner official had allowed it to take the liver as long as it documented the injury’s location and size.

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A death at a work site not reported

There wasn’t much left of the body of John Doe No. 92 by the time an L.A. County coroner’s investigator examined it. Most of his organs were gone. Also missing was skin from his legs and back, as well as bones from his arms and legs. Even his spine had been removed.

An ambulance crew had found the unidentified Latino man unconscious in a chair at a work site May 12, 2006, according to the coroner’s report. He had a lump on his head, which officials said was from an accident or violence. Doctors at California Hospital Medical Center said they couldn’t help the man, whom they determined was brain-dead. They left him on a ventilator while officials tried to identify him and find his family.

The hospital reported his death to the coroner as a natural death. Its staff didn’t mention a 5 1/2-inch fracture in his skull.

Eventually officials determined he was Julio Axochco Amatitlan, 42. They also found his wife, who refused when OneLegacy asked her to donate his organs and tissues. She told officials that people at the work site had given her conflicting information on how her husband was injured.

amatitlan1.jpg
In Amatitlan’s autopsy report, the medical examiner drew on the body where the organs and tissues were removed. Lines represent surgical incisions where organs or bones were removed while the circles are patches of skin that were removed.
(Los Angeles County Department of Coroner)

A few hours later, OneLegacy pressed her again to donate her husband’s parts, according to a county report. This time, she said yes.

After an autopsy, a medical examiner ruled Amatitlan had died from the head wound but said he did not know how the injury occurred. He said he found no trauma other than the head injury on what was left of the body to examine. His observations, he wrote, had been “limited to findings other than those caused by postmortem organ procurement.”

Coroner officials told The Times they don’t believe the autopsy was harmed by the loss of organs, bone, skin and the spine.

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Harvesting drug confuses investigators
Joseph Loudon died in May 2009.
Joseph Loudon, 16, who was on the Miramonte High School track team in Orinda, Calif., died in May 2009 from apparent alcohol poisoning.
(Mike Lucia / Bay Area News Group)

For months after he died, the family of a 16-year-old boy from Orinda, Calif., wondered why he had taken a drug called papaverine, sometimes used for erectile dysfunction. The Contra Costa County coroner had ruled after an autopsy that Joseph Loudon had died at a May 2009 party when he choked on vomit after drinking a small amount of alcohol and taking a high dose of the drug. For weeks, investigators questioned partygoers and relatives about why the teen had taken a medicine so rarely used that few pharmacies stocked it.

Stunned by the finding of the strange drug in her son’s body, his mother asked prosecutors to investigate his death as a murder. Four months after he died, the Northern California Transplant Bank wrote to his family, saying the teen hadn’t ingested the drug at the party. Instead a procurement team had injected his body with it as part of the tissue harvesting process, the company wrote.

Northern California Transplant Bank was part of a company called Tissue Banks International. The company changed its name to Keralink International and recently sold most of its operations. An employee told The Times it has no information about the case.


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Melody Petersen is an investigative reporter covering healthcare and business for the Los Angeles Times. Send her tips securely on Signal at (213) 327-8634.