In 1997, with his fellowship completed, Gill was eligible to take the American Board of Pathology's certification exam for forensic pathology, the field's most universally recognized measure of competence.
Gill failed the test on his first try. And his second. He passed the third time, in 1999.
Nevertheless, Gill was hired in April 1998 by Forensic Medical Group, the for-profit autopsy company with contracts to handle cases for more than a dozen Northern California counties, including Sonoma County in the heart of one of the state's most renowned wine-producing regions.
It was there that Reynolds, the private investigator, began to unravel Gill's past.
Errors Surface in Sonoma Case
Late on the evening of Nov. 7, 1999, a prominent local physician in Petaluma, Calif., called 911. His wife was dead, Dr. Louis Pelfini told the emergency operator, adding that he feared she had committed suicide.
The Sonoma County Sheriff's Office investigators who responded to the call did not initially treat Pelfini's home as a crime scene, police records show, but they ultimately came to suspect Pelfini had killed his wife, Janet.
Gill started his examination of her body two days later. After a month, he ruled that Janet Pelfini had died from asphyxiation. His notes showed abrasions circling her mouth and a bruise on her forehead. Based on his findings, the sheriff's office classified her death as a homicide, and prosecutors filed murder charges against Louis Pelfini.
Gill's certainty about what caused Janet Pelfini to suffocate prompted her husband's defense team to worry, said Reynolds, the private investigator hired by Louis Pelfini's attorney.
But Gill's work on the case had some holes.
Gill did not take pictures of Janet Pelfini's injuries as he autopsied her. He made drawings, but photographs from the scene taken by sheriff's deputies showed they were inaccurate. He failed to note a bruise on the back of her head on the drawings. In his written report, the injury was included, but on the wrong side of her head.
Gill also overlooked mucus plugs in her lungs. Another pathologist, hired by the prosecution, later argued the plugs were evidence that Janet Pelfini had suffered a severe asthma attack shortly before her death, indicating she may have died from natural causes.
Another limitation: The body had been cremated after Gill's autopsy, leaving other experts to argue over how to interpret his notes.
With Pelfini's case resting primarily on Gill's conclusions, Reynolds began running the doctor's name through news archives and calling his former colleagues.
When the defense team reported its findings about Gill to prosecutors, however, the state did not re-examine the charges. Instead, they secretly began coaching Gill, arranging for him to meet with a speech therapist to help craft his trial testimony.
In the videotaped sessions, Gill acknowledged he would have to sidestep flaws in his casework. "There are deficiencies in the autopsy," he acknowledged. "You know we have kind of alluded to that."
The tapes also showed Gill and his coach, Jeffrey Harris, trying to downplay his past problems.
Practicing an answer to the question of why Marion County fired him, Gill said the termination was due to "errors in autopsies and inability to testify in trials."
"OK, timeout," Harris interrupted. "Don't say ... I would not say, 'My inability to testify in trials.' I would say, 'My difficulty in testifying effectively,' or 'my inability to effectively communicate the results of my autopsies.' Something to that effect."
Gill is shown on the tape taking down Harris' instructions on a yellow notepad.
"We always want to be thinking about, how do we counter these allegations, these innuendos that there's something wrong with you," Harris told Gill during one of the sessions.
The strategy failed when Pelfini's attorney learned of the coaching sessions and the trial judge ordered the tapes released to the defense. Days later, the district attorney's office dropped all charges.
The California State Bar investigated the handling of the Pelfini case and suspended the prosecutor from practicing law for four years for his role in suppressing evidence about Gill's coaching sessions. The bar report devoted several pages to Gill's errors.
"Unfortunately," it concluded, "Dr. Gill was not a competent pathologist."
Mistakes in Missouri
The Pelfini case left Gill's reputation in Northern California tarnished. Sonoma County officials barred him from conducting autopsies there. As he had before, Gill sought a new start in a new state.
In late 2002, the Jackson County Medical Examiner's Office, which handles autopsies for Kansas City, Mo., advertised for a deputy. The pickings were slim.
"There were two applicants," said Dr. Thomas Young, then the office's sole forensic pathologist. "And the other one had already gotten into some ethical trouble back east, so he was just completely out."
Young said he knew about the Pelfini case and about Gill's drunken driving conviction. But Young said he trusted what Gill told him: that the doctor had recovered from alcohol abuse and that the Sonoma County murder case collapsed due to prosecutorial misconduct, not poor autopsy work.
Gill started work in Kansas City in November 2002, earning $140,000 a year. Young said he watched his colleague closely.
"In terms of his conscientiousness, being thorough, he was good," Young said. "He did make some mistakes, but I caught them."
Not all of them.
In September 2003, Gill autopsied 23-year-old Robert Patterson, who had died a day after being injured in a car accident. Based on toxicology tests that showed painkillers in Patterson's blood, Gill ruled the death a suicide.
But a second autopsy commissioned by Patterson's mother revealed an artery in Patterson's neck that showed signs of damage so severe it would have blocked blood flow to his brain. The injury almost certainly occurred in the car accident, the second pathologist concluded.
Presented with the results, Gill reversed his finding, ruling the death an accident.
The following year, several Missouri prosecutors learned of Gill's problems in California and Indianapolis and threatened to boycott the Jackson County Medical Examiner's Office unless it fired Gill.
Young refused. Asked why, he said the shortage of practitioners made the move impractical and that even the field's best sometimes misdiagnose causes of death.
Gill stayed another two years, quitting at the end of 2006 after one of the prosecutors became the county's chief executive and after Young retired.
Another New Beginning
Again, it didn't take long for him to find another job. In early 2007, Forensic Medical Group rehired Gill.
Dr. Brian Peterson, who was the firm's president for 15 years before becoming Milwaukee's chief medical examiner, defended the decision.
"To my mind, he was always a victim," Peterson said. "Gill's a great guy, and he's a fine pathologist."
But the group didn't advertise Gill's background. On its website, it gave resumes and educational histories for all its doctors — except Gill.
In his written statement, Gill said his work since returning to Forensic Medical Group in 2007 had been above reproach. In addition, the doctor said that county officials in the jurisdictions he served were aware of his background.
"In court and during application for jobs, since 2001 much of the background information has been made available to prospective employers, defense lawyers and ultimately, if the latter deemed it relevant to the jurors in court cases involving one of my postmortem examinations," Gill wrote.
Several Forensic Medical Group clients say they did not receive this information, however.
Presented with records detailing Gill's professional history in late November, officials with the Yolo County Sheriff-Coroner's Office expressed surprise.
"This is an eye-opener for us, to admit humbly," said Yolo County Chief Deputy Coroner Robert LaBrash.
Yolo County subsequently joined Sonoma in demanding that Gill not be used on its cases.
Janna McClung, a Sutter County prosecutor, said neither she nor the sheriff-coroner's office were aware of Gill's background before being contacted by a reporter in December. Gill is scheduled to testify in a death penalty case being prosecuted by the district attorney's office. McClung said she had alerted the sheriff and the defendant's attorneys.
"Obviously, what we're going to have to do is have another forensic pathologist look at our case as a follow up to him," she said.
Until December, when Forensic Medical Group says it stopped employing Gill, the doctor remained active. Last summer he gave testimony in a homicide case, a stabbing.
Asked if he intended to continue working as a forensic pathologist and if he was seeking employment, Gill e-mailed back.
"Yes and yes," he said.
This investigation was reported and produced by staff at ProPublica, Frontline, NPR, the Investigative Reporting Program at UC Berkeley, and California Watch [8]. Reporters Lowell Bergman, Andres Cediel and Carrie Lozano contributed reporting to this story.
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