A high-profile autopsy finding that has angered

a politically influential family also raises serious questions about the form and function of the state's medical examiner system, which forensics experts and former New Jersey MEs say is fundamentally flawed and needs to be changed

EDITOR'S NOTE

After "Postmortem" went to press in the July print edition of Inside Jersey, the state Attorney General's Office released related material that had been requested last year under the Open Public Records Act. A new story, based on the new information about why the Northern Regional Medical Examiner's office failed to attain reaccreditation, can be found here.

By KEVIN C. SHELLY | For INSIDE JERSEY magazine

THEY WERE DISCOVERED in the bedroom. She stabbed repeatedly; he pinned to the floor beneath a heavy armoire. The room set afire.

Six months later, authorities concluded that the deaths of John and Joyce Sheridan were a murder/suicide. They found that John Sheridan, CEO of Cooper Health System in Camden, and a longtime member of the state's Republican power elite, had killed his wife of 47 years, set fire to their bedroom and then took his own life.

The tragedy shook family, friends and community. But it was the formal determination of what happened in the Sheridans' Montgomery Township home in the early hours of Sept. 28, 2014, that ignited a war between their sons and officials, calling into question how the Office of the State Medical Examiner operates.

The Sheridans' sons, Mark, Matt, Tim and Dan, have challenged the official version of events. They believe their parents were killed by an intruder and have offered a $250,000 reward for the capture and conviction of an assailant. And they want an appellate court to order that a ruling on the cause of their father's death be changed from "suicide" to "undetermined."

MARK SHERIDAN

Mark Sheridan, on behalf of himself and his brothers, laid out the family's concerns in a lengthy May 7 letter to John Jay Hoffman, acting state attorney general, harshly criticizing the state's Medical Examiner's Office, which operates under the state Attorney General's Office through the Division of Criminal Justice.

Sheridan, a high-profile partner with the Squire Patton Boggs law firm in Newark, states in the letter that New Jersey's medical examiner system is rife with problems. He lists the grievances:

• The Northern Regional Medical Examiner's Office (NRMEO), in which John and Joyce Sheridan's autopsies were performed, failed to earn reaccreditation two years ago.

• New Jersey has not had a state medical examiner or acting medical examiner, which is required by law, for six years.

(UPDATE: After the July issue of Inside Jersey went to press, Gov. Chris Christie nominated Andrew L. Falzon for the post of state medical examiner. Falzon, whose name was submitted on June 8, is board certified in anatomic and clinical pathology, as well as forensic pathology. He has served as a medical examiner for Middlesex and Monmouth counties.)

• The assistant medical examiner who conducted the Sheridan autopsies is not board certified and, because of the chief medical examiner vacancy, was not "supervised" by a board-certified forensic pathologist.

• That same assistant medical examiner made a significant error in a prior autopsy ruling and, in the Sheridan case, findings were unduly influenced by the Somerset County Prosecutor's Office, which led the criminal investigation.

Not stated in the letter, but expressed during interviews, Mark Sheridan says, "The medical examiner's system in New Jersey is a disaster, an embarrassment. MEs should not be under the attorney general or law enforcement. They should not be agents of the state."

And while some might dismiss Sheridan's comments as legal wrangling, past New Jersey medical examiners interviewed for this story agree that the fundamental structure of the state's ME system is flawed in a way that can make it vulnerable to second-guessing and doubt, as the Sheridan case shows.

Faruk Presswalla, a retired former top New Jersey ME appointed by then-Gov. Christie Whitman in 1996, and one of the few state medical examiners to serve a full five-year term, plus another year as a carryover under then-Gov. Jim McGreevey, characterizes the state's system as "impossible."

"It should run either under the state's health department, or through a university medical system, not law enforcement," he says. "It's not the right thing to do because the bulk of the work of the ME is about health and unexpected deaths, not murder. Having law enforcement overseeing doctors and allied investigators and scientists is an inherent bias."

VICTOR WEEDN

Victor Weedn, a board-certified pathologist who served as acting state medical examiner from 2007 until 2009, says he quit in "frustration and protest" over staffing, support issues and the involvement of Division of Criminal Justice lawyers in what he believes should be an autonomous office.

In his letter of resignation to then-Gov. Jon S. Corzine, which Inside Jersey obtained through the state's Open Public Records Act, Weedn called his tenure "disappointing," said the office had been "poorly supported and overseen by the Office of the Attorney General and the Division of Criminal Justice" and that he was resigning "as have all my predecessors except the first two appointees more than a decade ago."

Weedn was the last to serve as the state's top medical examiner. Now a professor and chairman of the Department of Forensic Sciences at George Washington University, Weedn also noted in his resignation letter that New Jersey "should have a true state medical examiner system and it should be independent of law enforcement."

Pathologist Zhongxue Hua, who worked as an assistant medical examiner in New Jersey from 2001 to 2011, believes the fairest system for restructuring would be to make the Office of the State Medical Examiner autonomous, either as a commission or a university hospital-based system.

"It is a medical business. You don't need someone meddling," says Hua, pointing out that MEs under a law enforcement system are not permitted to testify for the defense, only for the prosecution, opening the door to "too much manipulation" by authorities.

While Weedn expressed the problems he saw privately in his resignation letter, it is the office's handling of the Sheridans' deaths last fall that has suddenly propelled the inner workings of the system into public view.

THE AUTOPSIES of John and Joyce Sheridan were performed at the state's Northern Regional Medical Examiner's Office in Newark. Eddy J. Lilavois, an assistant medical examiner, completed John Sheridan's autopsy on Sept. 29. Joyce Sheridan's postmortem examination was done the next day.

Joyce Sheridan's death was labeled a homicide. The 69-year-old woman died of a stab wound to her chest that tore her aorta. She also had several cuts and stab wounds on her face and hands. She was dead before the fire was started.

As for John Sheridan, Lilavois concluded that the 72-year-old's death was a suicide, caused by a combination of smoke inhalation and a self-inflicted cut that nicked his jugular vein on the right side of his neck. He also had several stab wounds on the left side of his body, as well as broken ribs, which were attributed to the heavy piece of furniture falling on him. Both had sustained burns.

However, Lilavois did not sign off on his pathology findings until six months later.

Mark Sheridan notes in his May 7 letter to Hoffman that Lilavois had three meetings with the Somerset County Prosecutor's Office prior to county Prosecutor Geoffrey Soriano issuing the final summary and closing the case. Sheridan writes that during this time the prosecutor's office attempted "to convince Dr. Lilavois to adopt their murder-suicide conclusion."

Sheridan also asserts that "by not being actively involved in the investigation from day one, Dr. Lilavois allowed the Somerset County Prosecutor's Office to perform an inadequate investigation that tainted his conclusions."

Just days after the state autopsies, the Sheridan family hired prominent private pathologist Michael Baden to do an independent autopsy of John Sheridan and a visual autopsy on Joyce Sheridan.

However, significant questions remain involving one of the most important aspects of John Sheridan's autopsies -- the fatal jugular wound. It still is not known whether Lilavois or Baden was the first to discover the mortal cut, and the fact that it clearly came from a weapon not in the possession of investigators. Lilavois isn't talking. Soriano says the Attorney General's Office is responsible for overseeing Lilavois' work. The Attorney General's Office has refused to comment. And Mark Sheridan has declined to let Baden speak until the appellate court hearing.

What Sheridan does say, however, is that Lilavois should have been supervised during the autopsies and that the final report included errors, such as misstating John Sheridan's age, and getting his weight and height wrong.

Such inconsistencies underline the Sheridan family's issues with New Jersey's medical examiner system, in general, and with Lilavois, in particular.

EDDY LILAVOIS

Lilavois worked at the Northern Region Medical Examiner's Office from 1996 to 2007 as a pathologist in charge of death investigations and where he also conducted autopsies, according to a statement from the Attorney General's Office. In 2007, Lilavois, who is not board certified, began serving as an assistant medical examiner, but the AG's statement does not explain the reason for the change. In his new position, Lilavois' duties expanded to include performing autopsies in homicide cases.

Lilavois came to New Jersey following a controversial finding in a case in New York City where he was working as a pathologist. The case involved the death of a 3-year-old boy. Lilavois initially classified it as a homicide, the result of "blunt injuries." Law enforcement then began an investigation that focused on the child's father, Edward Lauer.

Weeks later, however, Lilavois and another doctor reviewed the case and determined that the child died from a ruptured brain aneurysm. However, Lilavois failed to correct the autopsy report and death certificate and failed to notify law enforcement. The corrected information was not released until 18 months later after a series of stories about the case was published in the New York Daily News.

Lilavois resigned as a result. But in the meantime, according to Lauer's attorney, the father lost his job, his wife divorced him and neighbors shunned him.

Zhongxue Hua, who oversaw the Newark ME office from 2005 to 2007 where he also served as Lilavois' supervisor, reviewed the autopsy reports for the Sheridans, as well as the March statement from the Somerset County Prosecutor's Office, at the request of Inside Jersey. Hua says he believes there are "deficiencies" in the autopsies, as well as misinterpretations in the prosecutor's presentation of the examinations' findings.

The burns to the bodies make it impossible to say that John Sheridan did not have defensive wounds, says Hua. He also says that the prosecutor mischaracterizes and overstates the DNA findings regarding John Sheridan. That's because the marker examined is far too broad -- present in about half of all white males -- offering no conclusive link to John Sheridan.

Hua adds that the absence of a definitive weapon matching the wound to John Sheridan's nicked jugular is reason enough to have classified the case as "undecided," rather than murder/suicide.

ZHONGXUE HUA

"Based on the available (information)," says Hua, "the possibility of (John Sheridan's) suicide/homicide can neither be ruled out nor ruled in. The autopsies and their associated investigations were superficially correct and wrong," meaning the findings are too simplistic.

"The key question of 'weapon' is far from certain," he says. "An 'undetermined' manner of death is more reasonable if no further investigation will be pursued."

Weedn, who was the state's top ME when Lilavois resumed doing autopsies in homicide cases, also reviewed the autopsy reports for the Sheridans at the request of Inside Jersey.

He says it is likely Lilavois got the murder/suicide call right.

"This is just speculative. My guess is it probably was a murder/suicide. It is probably likely. Could it be a double homicide? Maybe, but it doesn't sound right."

He finds it odd that a weapon could not be matched to John Sheridan's fatal wound. And Weedn says the DNA found is not a meaningful match to John Sheridan.

The Sheridan sons are particularly critical of the failure to identify the weapon used to inflict John Sheridan's wounds. The report by the Somerset County Prosecutor's Office discusses a piece of melted, but resolidified, metal "two inches wide by six and one-half inches long," whose shape and purpose could not be identified. It was found embedded in the bedroom floor near John Sheridan's body.

There is also no mention of a fireplace poker, discovered a month later in the bedroom (which has no fireplace), nor that at least one of John Sheridan's teeth was chipped, or that a missed bag of Joyce Sheridan's jewels was found in a closet by insurance investigators three months later.

The report also does not detail that there is a back entrance from a dressing room in the bedroom to stairs leading to a locked door into the garage, as well as the main entrance to the room from the upper hallway.

GEOFFREY SORIANO

The report also implies that a possible motive might have been John Sheridan's concerns over a pending state health report he believed would be critical of Cooper Hospital's performance in cardiac surgery. The hospital dismissed the implication and Mark Sheridan said the issue had been addressed and his father had moved on to other concerns.

So angered by the findings -- or lack thereof -- by Soriano's office, Mark Sheridan recently stepped down from his post as counsel to the Republican State Committee to take the lead in his family's fight to clear his father's name. Sheridan also has vowed to block Soriano's reappointment when the prosecutor's term expires this fall. Soriano has declined comment.

Calls to Lilavois' cell phone, home phone and office phone seeking comment were not returned. Nor could he be reached at his home in New York.

EVERY PATHOLOGIST interviewed for this story believes the key to reforming New Jersey's Office of the State Medical Examiner is to make it a true medical system.

Weedn says his preference would be an independent office supervised by a largely medical-oriented commission.

Faruk Presswalla agrees. He calls the state's system "a waste as it is now. And it should run either under the state's health department, or through a university medical system, not law enforcement. It needs to be changed."

Hua believes New Jersey should create a commission or align the ME office with a university hospital-based system.

Several states use teaching hospitals to oversee their ME systems, which means medical students are recruited to learn and work in the system, he says. This would help create better-trained professionals.

All say that getting the state out from under law enforcement is essential.

As the old, commonly rural, coroner systems have transformed into more advanced medical examiner structures over the years, law enforcement oversight has declined.

Now there are just 10 states, in addition to New Jersey, in which an attorney general or some other law enforcement agency oversees the medical examiner system, according to the latest data from the National Association of Medical Examiners. Most systems across the country operate under state health departments, independent commissions, university medical collectives and a number of hybrids, the 2014 data show.

Lawrence Kobilinsky, a professor and chairman of the science department at John Jay College of Criminal Justice in New York, says there is no reason a medical examiner's system -- and supporting labs -- should be under the control of law enforcement, prosecutors or attorneys general.

"There is too much bias, too much pressure. People get rewarded for convictions, they get raises and promotions. There is an essential bias," says Kobilinsky, who also is chairman of the Northeastern Association of Forensic Scientists and studies criminal justice systems around the world.

Kobilinsky says the better model is a system that falls under a state's health department because it guards against those biases.

"There is a need for a nexus between law enforcement and an ME office because both agencies handle evidence and both will appear in courts to testify about their findings in criminal cases. However, that does not imply that law enforcement should have oversight or control of the ME. It is essential that these organizations remain independent of each other."

New Jersey's medical examiner system stands out, Kobilinsky continues, as "understaffed and underfunded. This is a shame. It is a very key office. It needs to be protected from politics, and the way it is operated is not the way a system should work."

He says the state's failure to achieve reaccreditation at the NRMEO facility is "pretty bad. The standards are minimal."

In Kobilinsky's view, New Jersey should require every medical examiner be board-certified. The system needs financial support, a consistent budget and updated facilities. And all critical autopsies should require a second view.

Kobilinsky says New Jersey comes up short in all those areas.

New Jersey's ME system has 12 local offices that, by law, are required to be coordinated by a chief medical examiner.

In a May statement responding to the state medical examiner vacancy and questions about how the office operates, the Attorney General's Office said that "the Office of the State Medical Examiner is run by senior professionals, including those with decades of experience in medical, legal and administrative disciplines. To be clear, our doctors make all the medical decisions without exception.

"The doctors performing death investigations in both full-time and per diem capacities in our system are among the most accomplished and credentialed in their profession. Because of the institutional expertise of our staff and the fact that the per diem doctors work throughout multiple medical examiner's offices in New Jersey, a constancy of policy and procedure is maintained.

"All 14 doctors working in our system, which covers seven counties, including Dr. Eddy Lilavois, meet the strict qualification requirements set forth by our statute.

"New Jersey's requirements for medical examiners are some of the most stringent in the nation. Our law mandates medical examiners to be both a medical doctor and a forensic pathologist. There are only approximately 450 individuals in the country that meet these rigorous qualification standards."

ONE STEP the agency can take right now to assure public confidence is to have all of its regional offices seek accreditation through the National Association of Medical Examiners, which offers guidelines for the profession.

The Newark facility, in which the Sheridan autopsies were completed, failed to earn its reaccreditation in 2013. And though some medical examiner offices in New Jersey have been accredited in the past, none presently has this distinction.

While NAME accreditation is not mandatory, it shows a facility meets "an average accurate bar that validates and protects them," says David Fowler, chief medical examiner for the state of Maryland, who helps sets NAME's accreditation guidelines.

Zach Hosseini, a public information officer with the state Attorney General's Office, notes that medical examiner offices in large cities such as New York City, Philadelphia and Washington, D.C., are not accredited.

However, Hosseini concedes that New Jersey does not have enough doctors to assure that fewer than 250 autopsies per year per doctor are done, which is the cap permitted under NAME guidelines.

Fowler says that exceeding the autopsy cap "is the surest way to produce more errors. If you fail (accreditation), something is wrong."

Explaining why NRMEO failed to secure reaccreditation from NAME in 2013, the Attorney General's Office said in a statement that it "did not meet the organization's preferred staffing ratio. However, the Department of Law and Public Safety has for several months been making personnel improvements." The office declined to elaborate.

One place to find a well-run medical examiner system is Maryland. The state's consolidated structure is considered a national model -- and for many reasons.

The Maryland system is largely autonomous, though it is tied to the state's health department and cooperates with six medical universities. Its enacting law was written by doctors, not politicians and lawyers.

"We are not beholden to political interference," says Fowler.

Turnover is low -- there have been just four chief MEs in the office's 76-year history. Funding is consistent. Every autopsy for the entire state is performed in the same central well-equipped and modern facility in Baltimore.

"We have buy-in and resources," says Fowler.

Every pathologist with the Maryland ME's office is board-certified.

"The NAS (National Academies of Sciences) recommended that all practitioners be certified in their field. This proves you have the training and passed a barrier exam to verify it," Fowler says.

And Maryland's entire system is accredited.

"Would you take your family to an unaccredited hospital?" Fowler asks.

Every complicated case statewide has two pathologists assigned. Every homicide autopsy and cases involving the unexpected deaths of children are reviewed by Fowler -- about 800 a year.

"We treat our office like it was a hospital, not a part of law enforcement. Our findings are medical decisions," Fowler says. "Doing otherwise creates substantial risk for the justice system -- and that starts costing cases."

Or, as former New Jersey ME Presswalla says: "Justice must not just be done, but be seen to be done."

MORE FROM INSIDE JERSEY MAGAZINE

Follow Inside Jersey on Twitter. Find Inside Jersey on Facebook and Google+