Pathologist Jeffrey Terrel started the autopsy the day after Jerry died.
Linda and Jordan Carswell expected a “complete” autopsy to be exhaustive, including whatever it took to determine the cause of death. They said they insisted to hospital officials that they test Jerry’s urine for drugs to see if they contributed to his death. But Terrel performed no toxicology tests on Jerry’s blood or urine, later testifying that Jerry’s medical records suggested that drugs could not have contributed to his death, based on dosage and the time of administration.
According to experts, Terrel’s approach was standard for a clinical autopsy. Even though the Institute of Medicine has reported that medication errors affect an estimated 1.5 million patients per year, it is not typical to conduct toxicology tests as part of clinical autopsies, though they are routine in forensic autopsies.
Terrel testified he had performed more than 1,000 autopsies during his career and had never determined that an overdose caused a patient’s death. Further, he testified that he had never classified a death as “accidental” because those cases would be referred to the medical examiner.
In his preliminary report, Terrel said he suspected a heart attack was the cause of death, but his final report said there was no evidence of a heart attack. In court, Terrel said he still thinks a heart attack is the most medically probable explanation. Terrel also testified that the cause of death was natural, ruling out medical error.
As Terrel performed Jerry Carswell’s postmortem exam, Linda came across some discomfiting information. St. Joseph Medical Center was owned by the same company that owned Christus St. Catherine, where Jerry died. The pathology group that employed Terrel worked for both facilities.
If Carswell had known that the hospitals were linked, she would have paid for a private autopsy elsewhere. Eight days after her husband’s death, she and Jordan delivered a letter to the pathology lab at St. Joseph Medical Center, requesting the preservation of tissue and fluid samples “following any diagnosis that may be made.”
Terrel later testified that he interpreted Carswell’s letter as a legal threat. He stopped working on the case immediately, putting Jerry Carswell’s tissue samples and specimen slides into a cabinet.
Jerry Carswell’s admitting physician, urologist Paul Cook, filled out and signed the death certificate. Cook listed several findings from Terrel’s final autopsy report as causes of death: inflammation and infection of the abdomen and stomach, as well as the cancerous kidney tumor. He checked off “natural” for the manner of death.
Yet, during the trial, he testified that Jerry Carswell hadn’t needed treatment for the stomach or abdominal problems and that the prognosis for the kidney cancer was good. Cook did not respond to a request to speak to ProPublica.
Not knowing how her husband died ate away at Linda Carswell’s psyche. Hospital officials’ refusal to discuss the matter fanned her grief into anger.
On June 7, 2005, Carswell sued the hospital, alleging negligence and fraud. “It was strictly for us to know what exactly had happened,” she said.
In October 2006, her attorney, Carl Shaw, took a deposition from Terrel, attempting to determine what evidence he had retained, that led to a ghastly revelation. “Is there anything more than the slides?” Shaw asked.
“Yes. The heart,” Terrel replied.
Shaw was taken aback. “You have Mr. Carswell’s heart,” he repeated.
Terrel went on to say that he had not informed anyone of what he had done, including Linda Carswell.
When Shaw told Linda, she collapsed into a chair in her kitchen and wept.
Later, in trial testimony, Terrel said he had misspoken in the deposition and that he had not retained the entire heart.
Pathologists told ProPublica that organs are typically returned or disposed of once tests performed as part of an autopsy are complete. It’s inappropriate to retain them for an extended period without the consent of the next of kin, said Victor Weedn, MD, JD, professor and chair, department of forensic sciences, George Washington University.
In March 2008, a judge hit Christus Health, the company that owns Christus St. Catherine, with a $250,000 fine for improperly keeping Jerry Carswell’s heart tissue and running tests on it without his family’s permission, as well as mishandling his blood serum. “They were using Jerry’s heart against him,” Linda said. “I was just furious.”
The lawsuit finally went to trial in August 2010. After 22 days, a jury cleared hospital nurses of negligence but determined that hospital officials had committed fraud when obtaining Linda Carswell’s consent for the autopsy. The jury awarded her $2 million, including $1 million in punitive damages.
The hospital has appealed (as of press time, the case is ongoing), arguing there is insufficient evidence that administrators misled Linda Carswell or knowingly made false statements about the autopsy.
Despite the jury’s multimillion-dollar affirmation, Linda Carswell remains angry that the negligence claim failed. The case was difficult to argue without an autopsy yielding a confirmed cause of death, said Mike O’Brien, the Carswells’ trial attorney. “Without the autopsy, you’re hamstrung,” he said.
When Jerry died, Linda Carswell was not aware of the differences between forensic and hospital autopsies. She has since learned that the medical examiner’s office was required to consider cases like Jerry’s. The realization that she could have pushed for a forensic autopsy by the medical examiner caused her to roam the house at night, wondering how she could’ve been so ignorant.
Carswell was determined to ensure that other families knew their rights. She urged a family friend, Texas Rep. Bill Callegari, to introduce legislation requiring doctors to use standardized forms to simplify the complex system.
He could identify with Carswell’s distress. Decades earlier, his brother, a 26-year-old Air Force B-52 navigator, had been killed during a training mission in Wisconsin under mysterious circumstances. Callegari finally learned the cause of the accident after he was elected in 2000. A stranger, recognizing his name, explained that the plane had malfunctioned while testing some high-tech equipment.
The Carswell family would never have a similar reprieve from the pain of not knowing. “What happened in this case was atrocious,” Callegari said of Jerry Carswell’s death. “You can feel the anguish … you have a right to know what happened.”
In September 2011, the Jerry Carswell Memorial Act, which Linda worked with Callegari to draft, went into effect. It requires Texas hospitals to use a standardized autopsy consent form that spells out families’ rights when a loved one dies in a medical facility, including: the circumstances under which a medical examiner is required to conduct an investigation; that, in cases not taken by a medical examiner, survivors have a right to have an independent pathologist conduct a clinical autopsy; that the family has a right to place special limitations on the examination; and that the person giving consent for the autopsy controls the release of the remains.
Had the law existed when Jerry died, Linda is certain she would have the answers she needs. “And most likely Jerry’s heart would not still be in a plastic bucket at St. Joseph’s.”