(KMSP) - A sudden death and search for answers soon revealed a deeper concern for one Minnesota woman.
"I'm questioning is that really what he died from?," said Yvonne Perez. "Do I have confidence in his report? Absolutely not."
Can an office that's responsible for death investigations across the state be trusted to do the job right?
"When there's mistakes like that made, I mean where does it end?,” Yvonne said.
The work of the Ramsey County Medical Examiner's office can play a crucial role in sending someone to prison or simply help console a grieving family by explaining the cause of a death.
"You know, you wonder, did they even do an autopsy?," she said. "It was wrong, they stated it wrong."
Yvonne has serious doubts about the quality of the office's work and little confidence that it's being held accountable when mistakes happen.
Death do over
As evidence, she points to the sudden death of her brother Leroy Ladoucer in 2015.
Yvonne and her husband were outside his apartment when they heard him stumble inside.
"He was laying on the bed and I felt for a pulse and I couldn't find one so I started CPR and told the caretaker to call 911," Ladoucer's brother in law, Ramon Perez, said.
An autopsy was done by Dr. Butch Huston, an assistant Ramsey County Medical Examiner.
He determined the cause of death was "complications of chronic ethanol use."
"We truly felt like he had a heart attack," Yvonne said.
She acknowledges her brother had liver disease from being a drinker, but questioned if that would cause him to suddenly collapse on to his bed and die.
When she took a closer look at his autopsy report, she had even more doubts.
"I mean those are blatant mistakes," Yvonne said.
The report showed Ladoucer's gallbladder was unremarkable, medical jargon for normal.
But in fact, his gallbladder had previously been removed in a surgery,
"Ok, well that is a huge discrepancy,” Yvonne said.
She spoke with the chief investigator at the medical examiner's office, and set up a meeting in person with Dr. Huston, who did the autopsy.
She secretly recorded all of her conversations.
"I don't believe he died from that," Yvonne can be heard saying on the recording.
As she shared her concerns with Huston, he suddenly offered to change the official death certificate.
"What if we classify his death as natural and attributed to cardiomegaly, which just means slight enlargement of the heart," he said.
Was there a real medical reason for making the change? Alcoholics can have enlarged hearts, but was the medical examiner just making the change to make her happy?
“At that point he lost all credibility with me because I thought anybody that will change something that quick, especially a death certificate, he's not credible to me," Yvonne said.
She became even more suspicious of the autopsy results when Dr. Huston discussed the condition of Ladoucer’s prostate.
"He didn't have enlargement of the prostate. What prostate was there just seemed smaller than what I would expect,” said Huston.
“Ok, but he didn't have a prostate,” Yvonne said.
“Well, then that would be a reason for that I guess," Hutson replied.
Besides the missing prostate, the autopsy report also failed to mention that part of Ladoucer’s right kidney had been removed previously.
Yvonne was well aware of her brother’s medical history because she went with him to his doctor appointments.
"I started questioning whether anything was ever really done," Yvoonne said.
Neither Huston, nor his boss, Chief Medical Examiner Dr. Michael McGee, would do an interview with the Fox 9 Investigators.
They have also not responded to a list of questions Fox 9 delivered to their office.
Outside expert reviews case
The Fox 9 Investigators asked a certified forensic pathologist not affiliated with this case, Dr. Judy Melinek to review the official records.
She wrote a book about forensic training called "Working Stiff."
"It's incredibly concerning when there is an autopsy report that describes organs being present that have previously been taken in surgery," Melinek said. "It indicates to me that either the pathologist didn't do a complete autopsy or did a sloppy, incomplete job."
The expert also questions why there was no screening for medications or other drugs which also might have contributed to Ladoucer’s death.
"Generally, when we start to see a lot of mistakes in an individual pathologists report, it tends to be the result of many factors but the most common factor is overwork,” Melinek said.
The Ramsey County Medical Examiner's office has plenty of work.
It is a privately owned business which contracts with 16 Minnesota counties, plus a couple dozen more in surrounding states.
A report given to the Ramsey County Board, obtained by the Fox 9 Investigators, shows each pathologist in the office averaged 271 autopsies in 2014 and 287 last year.
That is beyond the limit of 250 recommended by the National Association of Medical Examiners.
"Once a pathologist exceeds those limits in terms of autopsies per year, the error rate goes up and you start to see mistakes like this," Melinek said.
Other cases from the Ramsey County Medical Examiner's office
Yvonne Perez is not the first person to challenge the work of the Ramsey County Medical Examiner's office.
Michael Hansen was imprisoned for nearly seven years because McGee, who owns the Ramsey County Medical Examiner’s office, concluded Hansen had killed his infant daughter with a blow to the head.
“I’m dumb-founded, how can it still be happening,” Hansen said. "Allowing Michael McGee to still have his job is a slap in the face to me and my family. It’s a slap in the face to my daughter who he got to touch and do an autopsy on."
A judge later reversed the conviction when the Innocence Project presented evidence from six other experts who said the child accidentally suffocated while sleeping.
Earlier this year, Minnesota lawmakers set aside nearly one million dollars to compensate Hansen for his wrongful conviction.
"I don't even think Mike would've been charged without that report from the medical examiner's office," Julie Jonas of the Innocence Project said.
Then there is the case of Thomas Rhodes, who is serving a life sentence for murder..
McGee's autopsy report said Rhodes had fatally beaten his wife while they were boating on a Minnesota lake.
"Nothing like that happened, there was no contact between myself and my wife that night," Rhodes said in a 2010 interview with the Fox 9 Investigators.
Nine other experts have come forward since the conviction to say McGee was wrong, that the death was a tragic accidental drowning.
"Our experts have looked at those injuries and said that they are typical injuries that you see in drowning cases and that they occurred postmortem, after she died of drowning," said Jonas.
Damien Marsden was charged with murder after Dr. Victor Froloff, another assistant with the Ramsey County Medical Examiner's office determined Marsden’s infant son died from traumatic head injuries caused by an assault.
An outside expert looked at Froloff's autopsy results and said at best the death could be labeled "undetermined".
Marsden was acquitted at trial.
His defense attorneys challenged Froloff's competency because he's not a board certified pathologist.
Dr. Huston, who did the autopsy on Leroy Ladoucer, also is not board certified.
"Board certification in forensic pathology is the minimum qualification that indicates competency in this field, so, it’s incredibly important," Melinek said.
Minnesota does not require medical examiners to be board certified.
Ramsey County response
Yvonne Perez took her concerns to Ramsey County officials. It is the county that has a contract with McGee's company to conduct death investigations.
Yvonne told Ramsey County Manager Julie Kleinschmidt about the problems with her brother's autopsy and wanted to know what they were going to do about it.
"I would have the same kinds of concerns had I experienced what you experienced,” Kleinschmidt told her.
Yvonne followed up with Deputy Manager, Scott Williams who deals directly with the medical examiner's office.
"They put people in prison, and that were found innocent. To me its concerning. And it should be for you, for the county,” Yvonne told Williams.
“Sure. I understand what you're saying. I get where you're coming from," Williams said.
The Fox 9 Investigators approached the chairperson of the Ramsey County Board at the end of a meeting to ask some questions.
"Actually, we've got a workshop that's going on right now,” Victoria Reinhardt said as she left the room.
The county manager also declined an interview.
In a prepared statement the county says it does regular administrative and legal reviews of its contract with Mcgee and is confident his office consistently provides services of "high professional quality and value." and that the office is nationally and internationally accredited.
Oversight at the medical examiner's office
There is no agency in Minnesota that has responsibility to consistently monitor the work of the state's medical examiners.
They are, for the most part, accountable to themselves unless challenged in court.
"There really is nobody that people can complain to because it doesn't do any good," said Yvonne.
She did file a complaint with the Minnesota Board of Medical Practice, which licenses all physicians.
The board investigated her case and said it found no basis to take any action against Huston or McGee.
Some other states, like Maryland, have special boards that specifically oversee the work of medical examiners.
"This board has the ability to hire and fire the medical examiners, this board has the right to set rules and regulations. They approve all of our procedures and our policies,” said Dr. David Fowler, Maryland’s Chief Medical Examiner.
Yvonne would like to see Minnesota take a similar approach. She is already calling state lawmakers and pushing for change.
"I don't think its morally right to sit back and not do something when you know there's something wrong with what's being done," Yvonne said.