The Pentagon's internal watchdog has found that the Armed Forces Medical Examiner mismanaged the collection and handling of organs from at least 184 deceased troops -- and hundreds of others -- that were collected as samples as part of the autopsy process.
According to a report released Monday, officials with the medical examiner's office failed to set up "consistent processes or policies for organ retention and disposition" that led to families either not knowing that organs had been taken or not having their wishes for those remains honored.
The report by the Department of Defense Office of Inspector General also noted the military's medical examiner was not effectively tracking the organs that it kept and that administrative errors led to uncertainty and confusion for officials within the medical examiner's office.
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Defense Department officials who briefed reporters Monday following the release of the report said that some deaths require organs to be taken in order to conduct detailed analysis or testing to determine a cause of death. According to the inspector general investigation, the Defense Department was required to notify the next of kin if that needed to occur.
The medical examiner's office currently has specimens for 433 individuals -- including those of 184 service members, according to the officials. The office handles not only unnatural deaths of service members but also anyone who dies “under federal jurisdiction," according to the report.
However, the inspector general report also noted that the "policy on notifying next of kin of retained organs has changed multiple times between 2006 and 2022."
The patchwork of policies meant that, in 83% of the cases reviewed by investigators, next of kin were not notified that organs had been kept by the medical examiner. Another 17% were never asked what they wanted to happen to the organs once they were no longer needed.
Finally, officials in the office failed to follow those instructions in 41% of the cases reviewed.
The report includes several examples, such as a 2012 case in which several organs needed to be taken and officials told the family that they would be notified when the analysis was done and they would have a chance to decide what to do with the remains.
"However, there was no documentation ... that the next of kin was notified after examination, disposition instructions were not obtained, and as of March 2023, the retained organs remained in the AFMES inventory," the report reads.
In another 2008 case, the next of kin filled out a form saying they wanted to be notified when the examination was complete and provided the address of a funeral home to handle the organs. However, the forms never made it to the Defense Department and no one followed up with the family after the examination was complete.
"As of March 2023, more than 14 years later, the retained organ remained in the AFMES inventory," the report notes.
The news is the second time in recent years that the military mortuary has come under fire for the way it handles remains. In 2011, a massive investigation revealed gross mismanagement at the institution that led to missing remains, among other failures.
The military official who spoke with reporters Monday on the condition of anonymity, however, stressed that this issue is "completely separate" from that scandal.
The official explained that "2011 was probably best categorized as reassociation of portions or disassociated remains from service members who died from blast injury," adding that the new inspector general investigation was "all about specimens retained for determining cause and manner of death."
Another defense official said that, in determining a path forward for the mismanaged organs, they did a medical literature review and "found that there's a body of literature that says that retraumatization is something that should be avoided; that most people when they have come to peace and buried their loved one, they're ready to move on."
So, in that spirit, the official said that the plan is to leave it up to the families.
"We're going to post a public notification and a website where they can start the process of asking about what to do next -- to see whether they're impacted and what disposition they want to do," the official said.
Both the report and the military official who spoke with reporters said that families will simply not be told if organs are being retained for analysis. This move, according to the report, would "align AFMES policies and procedures with national medical standards."
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