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Several hundred autopsy reports were never finished in Mesa County during the coroner’s administration of Dr. Robert Kurtzman from the late ‘90s through the mid-2000s, hindering the flow of information from the office and raising questions of medical ethics, The Daily Sentinel has learned.
While the lack of some written reports doesn’t appear to violate Colorado law, officials including current Mesa County Coroner Dr. Dean Havlik said it has hamstrung Mesa County’s ability to accurately track and report about death in our community. That includes reporting on Mesa County’s notoriously high rate of suicide, as the county claims to have accurate numbers only since 2007.
The shortcomings take on particular significance now because Kurtzman and Havlik — who have served both as the other’s boss and employee — are facing off this year in a rare contested election for the coroner’s office.
Kurtzman defends his record but says he’s “not proud” of certain parts of it.
“Yes, there are cases that I did not complete the written report of an autopsy,” said Kurtzman, who speaks of partaking in more than 5,000 autopsies and testifying as an expert witness in hundreds of criminal trials.
“I certainly completed a great majority of the written reports, but not all. Regardless, in every case, the investigation, autopsy and death certificates were completed and the results were made available to appropriate individuals.”
‘A POTENTIAL PROBLEM’
Former colleagues, Kurtzman and Havlik make odd political opponents.
Kurtzman was elected coroner in 1998 and performed the county’s autopsies through the company he founded that year, The Pathology Group. He hired Havlik in 2001 to assist him in the office. Kurtzman left office in 2006 because of term limits and sold his interest in the company to Havlik, who ran for coroner unopposed and took office the following year. Kurtzman continued to perform autopsies as an employee of Havlik’s.
Havlik switched parties from Democrat to Republican to challenge Kurtzman in the June 24 primary election. The Republican county assembly, during which delegates will decide whether one or both candidates make the primary ballot, is Saturday.
“He’s (Kurtzman) good at the autopsy part of it. I’ll leave it at that for now,” Havlik told the Sentinel in a Dec. 6 story announcing Kurtzman’s candidacy for coroner.
After the story was published, Havlik in December terminated a contract with Kurtzman to perform Mesa County autopsies.
Inconsistent completion of autopsy reports during Kurtzman’s leadership was a long recognized issue with the office, according to Havlik and multiple former coroner employees. Cases with no autopsy report total “several hundred,” Havlik and others said.
“We used to take a lot of calls from people wanting information about things we just didn’t have information on,” Havlik said. “Sometimes we found nothing, sometimes the file was missing and in other cases there’s a little bit of information.
“It’s all about having respect for people who have died and their family and friends. Completing reports in a timely manner and doing our work thoroughly ... that’s something you should take very seriously. That’s part of our job.”
Havlik said he first became aware of the issue some 13 years ago, saying, “after I first started here, I knew it was a potential problem.”
Why delay raising it?
“I don’t know,” Havlik said. “I’m a loyal person and I guess I can be loyal to a fault. Rob did bring me here and he hired me. I thought maybe I should have said something back then but it wasn’t my place at the time. When I became coroner (in 2007), I made sure it didn’t happen again.”
Havlik said Kurtzman’s employment contract, after 2007, specified autopsy reports must get done.
Judy Johnson, an office manager with The Pathology Group between 2001 and 2009, said Kurtzman’s penchant for unfinished reports during his coroner term was familiar to anybody who worked there.
“It was something that came up fairly often,” she said. “There were the high profile cases, accidents and murders, and others that weren’t (high profile). Those would kind of get toward the bottom of the pile.”
Two former coroner’s investigators, Steven Stogsdill and Kim Hollingshead, said they used to encourage Kurtzman, perhaps with a friendly reminder, to finish his reports over the years. Hollingshead said he was “floored” by the number of cases without finished autopsy reports in Mesa County.
“It wasn’t my position to say you have to have these done,” said Stogsdill, who worked in the office from 2001 to 2010.
State law doesn’t specifically address a coroner’s duty to complete a written autopsy report. Coroners must make “all proper inquiry” of deaths occurring under varying circumstances, including performing autopsies and determining cause and manner of death.
Dr. Patrick Allen, the elected Larimer County coroner and president of the Colorado Coroners Association, said autopsy reports in most cases should be done within three to four weeks. Standards for autopsies from the National Association of Medical Examiners say a forensic pathologist shall prepare a report that is “readable, descriptive of the findings and include interpretations and opinions to make them informative.”
Not completing an autopsy report is unacceptable, Allen said.
“There might be a rare case that for some reason we can’t get completed because we’re waiting for some additional piece of information,” Allen said. “Here, we’re only paid when we complete a case.”
For the past 16 years, Mesa County has paid a monthly fee for services to The Pathology Group, before and after Kurtzman’s years as coroner. Contracts have been approved annually by the Mesa County Commission. During Kurtzman’s leadership of the office between 1998 and 2006, contracts reviewed by the Sentinel show Mesa County paid anywhere from $90,000 to $181,000 per year. The contracts also specify scope of work to include “(providing) timely autopsy reports,” among other tasks.
Did Mesa County get full value for its money? Kurtzman responded this way:
“I guess I’d say the obligations of coroner are to investigate death, determine cause and manner. I did that, and to me that’s the most important issue. If you’re not investigating deaths that you should, if you’re not thorough in the process of investigation, bodies are stacking up and you don’t sign death certificates, to me that’s a different issue.”
Asked about the unfinished reports, he said, “I don’t have any excuses. I certainly was very busy. But I didn’t complete the paperwork on a portion of the cases. I should have. I recognized that. It’s something I recognized I had to correct and I corrected it.”
Havlik, too, believes Kurtzman’s righted some things.
“Now we can do things like annual reports, suicide reports ... information that helps the community,” he said. “We couldn’t before because we didn’t have the data.”