2018 The University of Florida Award for Investigative Data Journalism, Large Newsroom finalist

Death & Dysfunction

About the Project

Fourteen hours and 36 minutes.

That’s how long it took New Jersey Gov.-elect Phil Murphy to promise “wholesale reform” of the state medical examiner system in response to NJ Advance Media’s investigation, “Death & Dysfunction.”

Over the course of the past 40 years, one of the most fundamental duties of the state — determining how and why someone died — deteriorated into disarray and became a national disgrace. All the while, families across New Jersey suffered the tragic consequences of a failing system.

Ask Valentino Ianetti or James Andros, who both lost years of their lives because medical examiners wrongly implicated them in their wives’ murders. Ask the children of Susan Pfost, who found their mother’s amputated hand on the side of the road two days after her fatal car accident because her remains weren’t properly collected. Or ask Stephen Valiante, who might never find closure in his daughter’s death because a flawed investigation by a medical examiner left too many questions unanswered.

In 2015, while covering the spike in overdose deaths, data reporter Stephen Stirling heard complaints about widespread dysfunction at medical examiner offices. He filed a public records request with the state Attorney General’s Office, which oversees the Office of the State Medical Examiner, seeking a database of deaths to corroborate those complaints. The attorney general denied the request, but released the records after months of negotiations with NJ Advance Media attorneys.

The database — a massive repository of 420,000 sudden or suspicious deaths dating to 1996 — and NJ Advance Media’s subsequent analysis formed the basis of the investigation.

Over 18 months, Stirling and reporter S.P. Sullivan obtained hundreds of internal and investigatory records, and interviewed pathologists, police, prosecutors, public defenders, attorneys, funeral directors, academics, industry leaders and families affected by the system’s failures. The story was complemented online by case files and videos, an illustration of how the system should work, a timeline of how it fell apart and a tool for readers to see which office would investigate their death and how badly it performs.

Top officials in Gov. Chris Christie’s administration for months declined to discuss the problems and denied access inside a medical examiner’s office. Weeks before publication, State Medical Examiner Andrew Falzon granted an interview and disclosed officials had been quietly working to improve two of the largest offices in the state, including rehabbing buildings and increasing salaries.

Once published, the investigation prompted more results. Murphy called it “shocking and appalling” and pledged reform. Top lawmakers held a standing-room-only oversight hearing, wrote a scathing op-ed that ran on and introduced legislation to overhaul the system. That bill has since passed both houses and awaits Murphy’s expected signature. Among the changes, the Office of the State Medical Examiner will be removed from the purview of the state attorney general and placed under the Department of Health, eliminating serious conflicts of interest.

All of that because of relentless investigative reporting that punched until its final line.