Welling's son James, who accompanied her, kicked in the locked front door. The pair entered to find Pacheco's limp body slumped in a chair with his legs and arms extended. The floor was littered with pill bottles. They called paramedics but it was too late. Pacheco, 51 years old, was declared dead at 11:30 p.m.
Two nights later, about 7:00, Welling walked into the Garcia Funeral Home in Miami to prepare for her brother's viewing. Teary-eyed relatives and friends were expected at 8:00 to pay their final respects. As is customary in such situations, the funeral director asked Welling to look into the casket to make sure everything was in order. To her horror it wasn't. Instead of her handsome, five-foot six-inch, brown-skinned brother, she found Robert Drummond, a white man five inches taller and seven years older than Pacheco.
"I never thought this could happen. The emotional aspect of it was so much, I am seeing a psychologist," says Welling, who declined to discuss the incident further on the advice of her attorney.
Pachecho and Drummond both died on April 4 within 30 minutes of each other in Miami Beach apartments located fifteen blocks apart. Their bodies then were taken to the Miami-Dade County Medical Examiner Department so a doctor could perform autopsies. After the corpses entered the morgue minutes apart about 4:00 a.m., a technician confused their names in the paperwork. That mistake sent Drummond's body to Pacheco's viewing. The department only learned about the mixup when the funeral home called to complain.
Three times this year, the morgue has sent the wrong body to a funeral home. In a highly publicized incident this past February, the corpses of Ralph and Rafael Rodriguez were switched because the men had similar names. (The two were unrelated.) The third mixup occurred in March when Esteban Madan and Dulce Abasalo were switched because of an error by county workers. That mistake was corrected before the families realized it.
Body mixups are but one of the myriad problems that have plagued the department during the three-year tenure of chief medical examiner Roger Mittleman. Employees complain that Mittleman has exhibited poor judgment in high-profile cases, inconsistently enforced department rules, and allowed lofty reporting standards to sag. Mittleman's critics say murder defendants and lawyers could use the screwups in court to impeach the department's credibility. They grumble that morale is at an all-time low.
Moreover several associate medical examiners have taken their complaints in recent months to the State Attorney's Office (SAO) and Assistant County Manager Paul Philip, the government's public-ethics tsar. A half-dozen employees contacted by New Times declined to discuss their complaints on the record, but privately blamed Mittleman for lowering the quality of work at the once-world-renowned office. They say the chief medical examiner is more interested in peering at slides than managing.
SAO sources and Philip downplay the problem, saying the doctors' concerns are hearsay and there has been no decline in the quality of the morgue's performance. The SAO sources, who asked to remain anonymous, attribute complaints to office politics. A recent report by the county personnel department recommends only minor changes.
Mittleman explains the switched bodies as "human errors." The department designed a computerized bar code system in 1995 to inventory incoming corpses, but it was shut down in October owing to computer problems. Over 3000 corpses pass through the morgue each year, making it one of the busiest in the nation.
Mittleman chalks up the other complaints to employees' stress caused by the leadership change. He acknowledges he has insufficiently communicated with his staff. The chief says he is trying to increase dialogue and more changes are in store. "I was not aware that there was this quote, unquote problem, if there ever was a major problem," says Mittleman. "I don't think there ever was because nobody has been complaining from the outside."
With 57 employees and a yearly budget of $6.2 million, the medical examiner department is a tiny part of Miami-Dade County's four-billion-dollar-per-year bureaucracy. But it serves a vital public-safety function. Roughly 85 percent of the corpses that enter the morgue are autopsied. After an external examination, doctors saw open the rib cage, and inspect each internal organ, noting size, weight, and any abnormalities. Blood and tissue samples are taken from the lifeless body and examined for foreign substances that may have contributed to the death. When the inspection is completed, the corpse is reassembled.
Doctors' conclusions aid police in solving homicides, inform public-health officials about the spread of disease, and notify families as to how their loved ones died.
Mittleman took over the office in 1996 following the retirement of Dr. Joseph Davis, a legend in the pathology field. During Davis's 40-year tenure, the county morgue earned a reputation as a first-class facility for the study of death. During Dade's cocaine-cowboy days in the 1980s, nearly a quarter of the bodies entered the morgue with drugs in their bloodstreams. County medical examiners were among the first to document how small amounts of the drug increase heart rate, blood pressure, and expose users to heart-attack risk.
Part of Davis's legacy is the $12 million ultramodern morgue, which he designed and which bears his name: the Dr. Joseph H. Davis Center for Forensic Pathology. The compact campus of three brown, angular, brick buildings opened in 1988 and is situated across the street from the Ryder Trauma Center at Jackson Memorial Hospital. It can store up to 350 bodies in four double-car-garage-size coolers and contains both an onsite laboratory and electronic air scrubbers that rid the building of unpleasant odors. Security cameras, tall fences, and doors with electronic locks guard the premises.
Mittleman runs the operation from a third-floor corner office decorated in natural wood. Dressed in a white, short-sleeve shirt with a bland tie and khaki slacks, the 51-year-old has receding salt-and-pepper hair and a mustache. Behind bifocals, he often squints as he leans forward to talk with the accent of his native Brooklyn. Shelves filled with medical books line the walls and his long, rectangular desk is covered with neatly stacked papers. Pictures of his wife dressed in a ballerina outfit, his three-year-old son, and his infant daughter flank his computer monitor.
To Mittleman pathology is the science of finding solutions to medical puzzles. "It's an intriguing aspect of medicine ... using science to figure out what happened to an individual," he comments. "It's the type of field where one works alone to a considerable degree."
Despite Mittleman's shy and professorial mien, controversy over his leadership arose soon after he took the post. When ValuJet Flight 592 crashed in the Everglades in 1996, just four months after Davis's retirement, the morgue was flooded with unrecognizable body parts that had been culled from the wreckage. Doctors worked round-the-clock, but results and details of their work were slow to reach the public, which was starving for information. Eventually the department identified 70 of the 110 passengers. Mittleman shied from the television cameras and the details of the coroner's work weren't divulged. "I felt it was most important I be in the morgue," he says. "This department did a terrific job. I think it was this office's shining hour."
Mittleman moved to Coral Gables as a ten-year-old boy with his family in 1958. When Roger wasn't helping run the family business, Jahn's Ice Cream on Miracle Mile, he was playing with an Erector set. He remembers watching his father Jonas serve malts and chat with University of Miami students, who made the soda shop their hangout. So after graduating from Miami High and Miami-Dade Community College, he enrolled in the University of Miami in 1968. After earning his bachelor's degree, he studied at UM's medical school and graduated in 1974 with a medical degree and specialization in pathology.
In 1975 Mittleman completed a one-year internship at a Boston hospital, then finished a three-year residency at Jackson Memorial Hospital in 1978 before landing his first job as the general pathologist at the Coral Reef General Hospital (now Deering Hospital) in South Miami-Dade. He held similar positions at three other South Florida hospitals before arriving at the medical examiner department in 1979.
Mittleman's curriculum vitae is twelve pages long. It lists eleven memberships in local and national pathology associations, his post as a clinical associate professor of pathology at UM's school of medicine, and 67 articles and books he has written. Titles range from the dramatic, "Homicide by Heart Attack," to the clinical, "Pulmonary Teflon Granulomas Following Periurethral Teflon Injection for Urinary Incontinence."
"I'm a visual person. I like to see things, I like to discover things. I like to put things together," says Mittleman, whose hands have been inside nearly 6000 corpses.
With such impressive credentials, it is easy to see why Mittleman was selected to replace Davis on February 1, 1996.
Elinor "Bunny" Lieberman is Mittleman's most outspoken critic. The tall redhead worked with Davis for a decade, gained his trust, and rose to a top administrative position that paid $67,589.86 per year. Then, she says, her tendency to speak her mind caused her to clash with Mittleman, whom she describes as an unethical liar. Lieberman claims the medical examiner harassed her in an attempt to force her to resign, then used budget cuts as an excuse to get rid of her. Presently she is an administrator at the county parks and recreation department. Her annual salary is $49,664.94.
She asserts that disgruntled employees, fearful of publicly expressing their discontent, have called her in recent months. They have requested that she air their complaints of malfeasance. Several morgue personnel contacted by New Times confirm that claim.
The Chicago native came to Miami at age five; she says her parents wanted a better climate to alleviate her chronic bronchitis. Her father, a social studies teacher in Chicago, worked in the personnel department of the U.S. Postal Service. Her mother was a housewife. After graduating from Miami High in 1961, she attended the University of Miami for a year and transferred to the University of Illinois, then dropped out. She was married in 1963, cared for two children including an adopted son, was divorced and remarried, then completed her bachelor's degree at Florida International University in 1984.
Lieberman started her career with Dade County in the manager's office in 1977. She transferred to the medical examiner department in 1986, gained Davis's confidence, and rose through the ranks to become the only female manager. As head of administrative services, she was responsible for formulating the budget and handling personnel issues. According to several employees questioned by New Times, Lieberman earned a solid reputation: Approach her with a problem and chances were she could solve it.
Lieberman says the stress of losing her job has resulted in insomnia. As she sits in the living room of her modest Kendall home, her high-pitched voice, laced with anger, echoes from the white tile and the black entertainment center. She worked beside Mittleman for ten years before he was named chief. Although she believed another doctor, Bruce Hyma, was more qualified for the top spot, she figured the transition would be smooth.
Lieberman contends Mittleman sometimes lied and employed unethical practices. When he wanted a new clerk to type autopsy reports, he asked Lieberman to bypass bureaucratic hiring practices, she says; he even urged her to file false documents. Her refusal drew Mittleman's ire. "I did not allow him to break the rules," Lieberman says. (Mittleman declines to comment on the specifics of Lieberman's claims.)
Soon after Mittleman took over, he hired Robert Lengel, a former Miami-Dade Police Department lieutenant with no medical training, as assistant director. Lieberman says the pair began micromanaging her work, cutting her responsibility, and banning her from talking to certain subordinates.
In 1997 Mittleman eliminated Lieberman's position and shifted most of her job responsibilities to Lengel, who received a salary of $85,020, according to county personnel records. The department's top brass, including deputy director Michael Bell, now consists of three white males. "[Lengel] would constantly tell supervisors to treat their employees like children," Lieberman says.
In a 1998 complaint to the federal Equal Employment Opportunity Commission (EEOC), Lieberman accused Mittleman of harassment, gender discrimination, and creating a hostile work environment. She argued there was $200,000 in the budget to fund her position, but Mittleman improperly squeezed her out to reward Lengel. After a preliminary inquiry, the agency failed to substantiate her claims and sided with the county. Lieberman's only other option is to file a lawsuit.
"Mittleman was told I supported Dr. Hyma and had people encouraging him to push me out. Lengel wanted more power and more money and was jealous of a woman being more [powerful] than him," Lieberman asserts. "I don't intend on taking this lying down."
Lengel declined to comment for this story. Mittleman responds that Lieberman is a "nice" person and her dismissal was not personal. "We had to make a managerial decision at that time based on the budget cuts that had to be done in accordance with Mayor [Alex] Penelas's wishes.... Unfortunately she was a casualty of that," the chief says. "That's about all I can say. I don't think it's fair to talk about this in the media."
Mittleman defends Lengel as an efficient manager, but admits his personality may have grated on some staff members. "[The staff] was just not used to a more direct way of doing things," he says. "[Lengel] was just trying to get people to improve."
Numerous renegade staffers are so frustrated with problems at the department that they see only one solution: removal of Mittleman and Lengel. They outline their complaints in a nine-page memo that was delivered to Philip. The ethics tsar declined to accept it because he feared it would become a public record and reflect badly on the department, two morgue staffers say. (Philip acknowledges refusing the document, but offers a different rationale: It was useless.)
"The staff of this department unanimously believes that the information presented in this document is indicative of malfeasance, misfeasance, and nonfeasance, and is deliberate in nature," the unsigned memo states. "The staff is recommending removal of Dr. Mittleman and Robert D. Lengel for violation of county personnel rules involving incompetence, antagonistic behavior towards fellow employees, and conduct unbecoming to county employees. By drafting this memorandum the staff of the medical examiner department is not interested in any personal or professional gain but we are imploring you to restore the morale and confidence in the fine professionalism and world renowned reputation previously enjoyed by this department."
Lieberman did not write the memo, but agrees with the content. Several anonymous morgue employees told New Times they authored it. "[Mittleman] has a pattern of nothing but lying," Lieberman says. "That's what you have to do when you're incompetent."
As evidence of Mittleman's failure, the memo points to his behavior in two high-profile cases: the 1997 death of Patricia Mishcon, the wife of North Miami Beach Mayor Jeffrey Mishcon; and that of Tayveis Smith, an eight-month-old boy found dead in a North Miami-Dade apartment on July 13, 1998. A third case, the murder of Denise Tyree, is outlined in department documents and highlights lax enforcement of the rules, say several anonymous staffers.
Patricia Mishcon died of heart failure after taking the now-banned diet-drug combination Phen-Fen. Doctors at Columbia Aventura Hospital and Medical Center found traces of marijuana in her system. They delivered their results to the coroner's office, but Mittleman removed the marijuana reference. He later told SAO investigators he deleted it after determining the drug was not a factor in Mishcon's death. Mittleman also says he sought to spare her family unnecessary public embarrassment.
An SAO investigation determined the public-records law was not violated because the marijuana reference remained in medical documents attached to the report. Assistant State Attorney Howard Rosen did criticize Mittleman's judgment in the case, noting that the department must "maintain accurate and complete public records."
Complaints stemming from the episode were also filed with the state Medical Examiners Commission in Pinellas County, which regulates medical examiners across the state, and the Florida Department of Professional Regulation in Tallahassee, which licenses medical examiners. Neither agency took action.
Mittleman apologized for the deletion. He says he had never done such a thing before and vowed never to do it again. "Some of the doctors may have not liked that issue," Mittleman admits.
In Smith's case Mittleman performed the autopsy and concluded the boy's death was caused by Sudden Infant Death Syndrome (SIDS). Doctors use the term to explain a baby's demise when there are no signs of foul play or illness. But weeks after the autopsy, blood test results contradicted Mittleman's conclusion. The medical examiner's laboratory found that little Tayveis had twenty milligrams of cocaine in every liter of blood, more than three times the lethal dose for adults.
In the unsigned memo, staffers criticize Mittleman for mistakenly labeling the case as SIDS before all of the test results were known. The switch caused the child's family additional anguish and damaged the department's credibility in the law-enforcement community. "Dr. Mittleman initially and inappropriately ruled the cause SIDS due to the lack of an explanation for the cause of death," staffers wrote.
Mittleman explains that an autopsy is subject to change if new information is found, which happened in the Smith case. "On the day of the autopsy, I believed there was enough information to go ahead and classify it as SIDS," says Mittleman. "To my surprise, my shock, I was informed that toxicology showed one of the highest levels of cocaine that you see."
The chief says he was trained by Dr. Davis to classify SIDS cases as quickly as possible so the family can reach closure over the loss of a young child. The average wait for test results is four to eight weeks. Mittleman says he now waits until all test results are available before classifying a death.
Staffers also point to the case of Tyree, a 34-year-old single mother who died in a barrage of bullets in Opa-locka. Two days before Thanksgiving 1998, a hooded gunman drove up to a crowd of people in a light-color car and fired an AK-47 assault rifle. Bystanders scrambled for cover, glass shattered, and Tyree was struck in the neck and chest. She later died and her corpse was sent to the medical examiner department.
Dr. Joann Habermann, a recent medical school graduate serving a yearlong residency at the department, performed the autopsy. She concluded Tyree died from a gunshot wound to the chest, but failed to follow the department's policy of chronicling her findings immediately after the autopsy. Instead Habermann boarded a plane and spent Thanksgiving weekend in New York, according to medical examiner personnel. She dictated the autopsy when she returned on November 30. (Habermann could not be reached for comment.)
This and similar incidents alarmed three associate medical examiners, Valerie Rao, Emma Lew, and Bruce Hyma, who have a combined 35 years of experience in the department. They expressed their concerns in an April 1 memo addressed to Mittleman. "The Pathologist should not leave the office for the day without dictating all the protocols for that day's work. Even though one may take voluminous notes for each case, it is impossible to recall minutiae after a day or two have elapsed," the doctors wrote. "The final reason is that the report may be challenged by the courts based on the premise that the protocol was not dictated on the day of the examination.... Given our current state of technology, we have no legitimate reason or excuse for not dictating the protocol on the day of the examination."
A New Times review of medical examiner records found two other instances where reports were completed several days after autopsies.
Rao, Lew, and Hyma also complained that autopsy reports were being changed after they were finished. Some personnel were pulling pages from autopsy reports and replacing them with new ones. Once again the three doctors believed the practice could discredit reports in a trial. They also feared such an activity would violate Florida's public-records law. "If something needs to be added or changed, an addendum must be written to the protocol, signed and dated, and provided as part of the autopsy protocol," Rao, Lew, and Hyma wrote. "Changing a protocol after it has been signed by the doctor can be construed as spoilage of or altering evidence."
Mittleman responds that he was unaware of these practices. The chief says he strictly enforces the department's policy and has ordered that changes in reports be made through addenda. He also told the staff to alert him when his order is violated.
In addition employees complain about assistant director Lengel's authoritative management style. When he took over, overtime pay was eliminated. Employees would receive a tardy slip if they were just a minute late. And, the employees add, Lengel frequently displayed a revolver he wore on his ankle to employees.
Mittleman acknowledges a few minor problems. "I believe there were some blips here and there," the chief admits.
In upcoming months Mittleman may have even more to worry about. The investigation ordered by Assistant County Manager Paul Philip is expected by the end of the month. A draft report written by Marcia Saunders, director of the Office of Fair Employment Practices, highlights thirteen areas where the department could improve.
Among the draft report's recommendations: "Caution [Lengel] not to use offensive language; assign senior staff to review styles and requirements for [autopsy reports] for uniformity and accuracy; continue collective dialogue on policy matters."
Saunders downplayed the problem of low morale. "At entry-level the employees expressed a great deal of pride in their work and its importance to the community. Without exception they expressed a strong commitment and dedication to the department. They take pride in the department's reputation for providing accurate autopsy reports and serving the affected families during very difficult circumstances," Saunders wrote. "Some members of the staff did, however, express concern regarding management and particularly the need to be involved in the decision-making and policy changes."
The staffers interviewed by New Times say Saunders underestimates the problems and point to a dozen employees who have left the department in the past year. Some worry that the stellar reputation they worked hard to build is being tarnished.
Lieberman describes the staff's overwhelming reaction to Saunder's report thus: "Nothing but a whitewash."
Mittleman says he has already instituted many of the report's recommendations. He is also open to further changes suggested by the staff.
One outstanding issue is a claim by forensic photographer Andre Santos that Lengel slapped him in the face this past November. Santos says he refused to follow Lengel's order to change his time card. Santos says the ex-cop grabbed him by the arm, pulled him into an elevator, and slapped him three times in the face. "I felt his hand fifteen minutes afterwards," Santos told a county investigator. Lengel denies touching Santos. The investigation by the Office of Fair Employment practices continues.
Lieberman and several staffers say a 1996 handout by Dr. Davis titled "Management Skills in Forensic Pathology" may provide the answer to their complaints. Written shortly after his retirement, it lists general problems in training, communication, budgetary issues, and provides recommended responses. It reads: "PROBLEM: A medical examiner may be able to quote from management texts but may fail to be a good manager," Dr. Davis wrote. "SOLUTION: Usually this involves a basic personality defect which has no solution except to get rid of the medical examiner.