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THE SIMPSON LEGACY / LOS ANGELES TIMES SPECIAL REPORT : Trial & Error: FOCUS SHIFTS TO A JUSTICE SYSTEM AND ITS FLAWS : Weighing the Necessity of Change : How One Case May Reshape Criminal Justice in America : The Coroner / "It's just lucky that the coroner's testimony eventually played no role in the case. . . . It bungled everything."

October 08, 1995

The coroner got off to a bad start in the case when LAPD detectives, contrary to state law and police policy, failed to call the coroner or let its investigator onto the scene for more than 10 hours after the bodies were discovered. Forensic experts said this was a major disadvantage because it prevented the coroner from more accurately estimating the time of death, a key question in the case against Simpson.

Claus Speth, a forensic pathologist from New Jersey and past chairman of the National Assn. of Medical Examiners' accreditation and inspection committees, said that if the police had called the coroner early on, the agency could have helped thwart charges of a conspiracy to frame Simpson.

"The medical examiner could very well have been witness to the fact that none of the evidence was planted," said Speth, who himself is at the center of a controversy in New Jersey over his examination after a jail death. "As an independent fact-finder, non-advocate who is present from the beginning, he is witness to everything at the scene."

Trial testimony revealed a number of alleged lapses. The coroner's office did not perform a "rape kit" examination on either victim, something experts said should have been routine. The death scene investigator failed to notice drops of blood on Nicole Simpson's back--blood the defense said could have come from the real killer.

But most of the testimony highlighted mistakes made by Golden, one of the department's veteran pathologists, who performed the autopsies. He discarded the contents of Nicole Simpson's stomach, then failed to identify all the items contained in Goldman's, according to testimony.

He did not X-ray bone fragments to look for microscopic bits from the attacker's knife, missed a bruise to Nicole Simpson's brain and failed to note that part of Goldman's Adam's apple had been severed.

Golden mislabeled a vial containing bile from Nicole Simpson and issued a supplemental report when he noticed additional cuts in photographs that he did not mention in his original autopsy.

Golden declined comment. But Dr. Michael M. Baden, the former New York City pathologist who served as a defense expert witness in the Simpson case, defended Golden's handling of the autopsies of Nicole Simpson and Ron Goldman.

"It was much better than the average autopsy, although he made some mistakes," said Baden, who also worked for L.A. prosecutors in the drug death of comedian John Belushi. "If a perfect autopsy was a 10, this would have been a 7."

Still, Deputy Dist. Atty. Brian R. Kelberg, who examined the coroner for the prosecution, said the magnifying power of the Simpson case made it look otherwise and illuminated the quality of work the public can expect from an overburdened office he likened to an assembly line.

"If people put that assembly-line process under the microscope expecting to see a Rolls-Royce, they'll be disappointed," said Kelberg, who guided the introduction of autopsy evidence in the trial. "What you produce in the end is going to be a satisfactory model, but it's going to have flaws."

Unfortunately, Kelberg said, the flaws in the Simpson case left no choice but to keep Golden off the stand. Instead, Kelberg called Golden's boss, Sathyavagiswaran, who gave his opinions based on his reading of the autopsy and further tests. The coroner's office believes the chief came off well and received many accolades for his honesty.

"What I had to face is the reality that [Golden] made a number of mistakes, and those mistakes, although not significant, would have had an impact on the jury," Kelberg said.

The prosecutor added that he had to face another reality about Golden--that his courtroom demeanor turned jurors off. He said several jurors said they saw Golden testify about the autopsies during Simpson's preliminary hearing and "there was something less than a favorable impression left."

The jurors were not the only ones who didn't like the owlish Golden's style. Jury consultant Tunno observed him during the preliminary hearing and wrote: "He appeared not to care whether or not anyone understood him."

Tunno, who has authored a book of testimony tips for expert witnesses, mailed his observations about Golden and other prosecution witnesses to the district attorney's office unsolicited. A little while later, he said, the coroner's office called and asked for his help.

He has given three seminars so far. Among those who attended: Irwin Golden.

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