Sep 28 2006 10:59 PAGE @4/13 aa/2e/2886 1a:54 8584187691 FDLE O08 ' . STATE OF FLORIDA MEDICAL EXAMINERS COMMISSION MEDICAL EXAMINERS COMMISSION, Petitioner, vs. CASE NO. 06-1 CHARLES F. SIEBERT, JR., M.D. Respondent.. — — — — —— “ice ADMINISTRATIVE COMPLAINT The Medical Examiners Commission files this Administrative Complaint against the Respondent, Charles F, Siebert, Jr, M.D. The Commission seeks to impose discipline upon the Respondent based on the following allegations: 1. Petitioner is the entity charged with the responsibility for taking disciplinary action against a medical examiner Pursuant to Section 406.075, Flotida Statutes. : 2. Respondent. has been the Interim District Fourteen Medical Examiner and then the gubernatorially appointed District Fourteen Medical Examiner from August of 2002 until the present, | 3. On or between August, 2003 and the present date, tha Respondent, as the Interim ar gubernatorially appointed Medica! Examiner for District Fourteen, did complete autopsy reports containing mistakes, deficiencies, and/or errors, to wit: (a). ME 04-187-is the report of a vehicle occupant who was a traffic. fatality. Transcription of a blood alcohol concentration from a toxicology report to. the autopsy - feport was incorrectly recorded as 0.016% when it should have been recorded as 0.16%. : (p). ME 05-010 is the report of a natural death. ‘The race ofthe subject was incorrectly listed as white on the front sheet of the report,’ ‘The associated external examination, photographs, and other data indicate a black person. (c). ME 05-068 is the report of the homicide of an elderly person by gunshot injury. The front sheet lists “TAH & BSO [Total Abdominal Hysterectomy and Bilateral 4 Sep 28 2006 10:59 aog/2e/2886 1a:54 8584187691 — FDOLE OC PAGE 5/13 Salpingoophorectomy]" as one of the findings while the bedy of the report Includes a description of these organs as if they had not been removed. . (a). ME 08-129 is a report of a natural death. There is a conflict in the autopsy record. The serosal cavities are described as free of blood, while in another location there is a description of a ruptured aortic aneurysm with a 500 mi: hemoperitoneum, (2): ME 05-356 is the report of a motor vehicle driver who was a traffic fatality. . "The race of the subject is incorrectly noted in the report to ba 4 white, The photograph and provided information is that of a black person, , (f), ME 03-229 is the report of a drunk driver w vehicle crash. There was a post-crash fire and the autopsy report indicates the presence of soot in the airway. No earbon monoxide level is included in the report. No order for earbdn monoxide level is found on the orderform. =" (g). ME 03-233 is the report of accidental death due to multiple drug toxicity of a young adult. The subject was a person of small stature who'suffered from and under medical care for osteogenesis imperfecta, There is No mention of this genetic disease an the autopsy findings. ho died as a result of a single (h). ME 03-295 is the report of the death at home of a 2-week old baby, Death is attributed to congenital heart disease and ruled natural. _ The report déscribes a large heart. (70 gm.) with markedly dilated right atrium. However, a specific congenital anomaly is not described. No consult is obtained from a cardiac or pediatric pathologist. (i). ME 03-326 is the report of a prison inmate who died in the hospital. While hospitalized the diagnosis of Toxoplasmosis of the brain was suggested by a radiologist, | Death is attributed to Toxoplasmosis, Microscopic examination of the brain does not mention Toxoplasma. No Special stains are reported. No serologic tests far Toxoplasmosis are reported. No consultation from a neuropathologist is reported, : (). ME 03-338 is the report of a middle aged white female believed to have an acute cholecystitis that died in the hospital, Autopsy examination revealed acute _ peritonitis as a rasult of a ruptured sigmoid colon. No toxicology, microscopic exams or culture studies were processed. There is no mention of diverticula, neoplasia, inflammatory bowel disease, mechanical obstruction or interval since last colonoscopy. (kK). ME 04-039 is the report.of the autopsy findings of'a middle aged man whose death is attributed to coronary artery disease and classified. as natural, The investigative information indicates that the subject had ‘been drinking heavily but toxicology tests were not processed. The front sheet also lists a diagnosis o' emphysema which is not described in the report. : (). ME 04-180 is the report of a quadriplegic who died at home of alprazolam toxicity. The death is ruled accidental. There is no mention of quadriplegia on the front sheet nor of how the drug was administered within the autopsy report. The diagnosis of an Important disability should be among the findings. {t would also be helpful to list whether or not the paralysis was complete or partial, (mm), ME 04: 343 is the report of a homicidal stab wound to a middle aged man. This was a single s tab wound. The measurement of the surface injury does not specify . 2 ; _. Sep 28 2006 11:00 PAGE 46/13 aoa 2e/2886 1a:54 8584187691 FDLE O08 , Suicide note was found. The estimating time of death, ‘described as having an whether or not the edges of the wound are, opposed or relaxed, There is no note of whether there is a sharp edge, dull edge, or hilt abrasion associated with the injury. There is no written estimate for the depth of the wound. ._ (n), ME 05-009 is the report of the sudden death of an elderly person due to cardiovascular disease. Investig ative information includes a report that this person was drinking and fell shortly before death. A brain only autopsy was performed. No toxicology was processed. , mo, (0). ME 05-015 is the report of the gunshot suicide of a young teenager, A > subject had been-missing for several days. There is no postmortem condition of the body which might assist in In one place the report ‘describes gunshot trauma to the head and later indicates that the cranial cavity is free of blood. : . (p). ME. 05- suicide note is foun There does hot appear to be an indication of hand \dedness ih the report. In one place the report describes gunshot trauma to the head and later indicates that the cranial cavity is free of blood. The subject had been missing for several days. There is no adequate description of the postmortem condition of the body which might assist time of death. . . adequate description. of the 016 is the report of the gunshot suicide of a young teenager. A (q). ME 05-049 is the report of the s person had not been seen for 3 da postmortem condition of the body death. The changes typically assoc’ uicidal hanging of a young adult. This ys prior to his death, There is no description of the which might assist in the determination of time of iated with hanging are not mentioned, (rf). ME 05 due to inhalation of products of combustion, An inciden the discovery of a markedly enlarged spleen (1360 grams) which is not otherwise y other abnormal characteristics. No microscopic or culture studies were processed. , (8). ME 05 The death is certifi the etiology of th communicable dis: ; (t). ME 05-087 is the report of a young adult female who died as a result of gunshot injury. ' She was one of 4 victims of a multiple homicide. The other 3 victims were her children, This was a very complicated case and much work was done. Thera is one issue which one might consider unresolved. That would be bruising on the back of the hands which is ‘noted on the ‘Teport and body diagram. Pale blue discoloration is noted on photographs. ‘ -076 is the report.of an adult male who died of illness complications. ed as natural. The subject had Pneumonia. As a public health issue, @ ‘pneumonia is-an important factor in the classification ‘of some eases. No microscopic or culture studies were processed, (u). ME 08-090 is companion to ME 05-087, This is the report of the homicide of the 3 week old child of the youn 9 adult female above. Much of the autopsy report reads like tha description of an adult rather than @ small infant. (v). ME 05-091 is the re cardiovascular disease and certified as natural. Investigative information indicates an 3 d, A gunshot entrance is described on the left side of the head, in estimating | -026 is. the report of a cocaine abuser who died in a residential fire” tal finding during the autopsy is, port of an elderly person whose death was attributed to Sep 28 2006 11:00 aog/2e/2886 1a:54 8584187691 FDLE 066 PAGE 7/13 issue of possible positiosal asphyxia. diagnosis of “brain tumor’ is listed on the . on the gross autopsy re has injuries noted which No toxicology samples were processed. A front sheet but is not mentioned or described port, No microscopic studies are processed, Also the patient are not explained in the autopsy report. (w). ME 05 094 is the report of a natural death of a middle aged man attributed to COPD and pneu monia. No microscopic examination or culture of the. cangolidated lung were processed. Such studies might have helped in the exclusion of aspiration or other drug related mechanism. This individual did Have a history of drug abuse and a low concentration of opiates was reported on the toxicology report. (x). , ME 05-102 is the report of the death of an adult in a bath tub. This person -wais found with the face under water. Methadone in potentially lethal concentration was found on toxicology. The death is attributed to methadone toxicity. The issue of possible drowriing is not addressed. a : (y). ME 05-119 is the report of a suicide by self-inflicted gunshot wound with a 30-06 rifle. The autopsy report records the fecovery of a “lead projectile." Most forensic pathologists would consider the recovery of a bullet in circumstances like this unusual. A more thorough description of the recovered bullet in this case might assist in deciding if the projectile is fragmented, or whether it is the result of old or improperly reloaded ammunition. ' ; . (z). ME 05-121 is the report of thé death of an elderly person who died of carbon’. monoxide intoxication. The death is certified as accidental, Typical findings for carbon monoxide intoxication are not noted one way or the other in the autopsy report, Theré is a diagnosis of “TAH’ & BSO [Total Abdominal Hysterectomy and: Bilateral Salpingoophorectomyy)’ is listed on the front sheet and is noted on the body diagram. However, there is a description of normal reproductive organs included in.the autopsy report. Medical records indicate treatment for depression which'is not listed as a finding. ‘ - (aa). ME 05-132 is the report of a middie aged male who died as a result of acetaminophen toxicity. The death is certified as accidental, As expected the liver was grossly abnormal... No microscopic studies were processed. The patient had left the hospital prior to. his death against: medical advice. The subject was an alcoholic and was being: treated for depression. . Frontal contusion was noted in the autopsy report. Additional injuries described by the police were not noted. None. of these additional factors were addressed in the opinion. The subject was 5-9 and weighed 115 pounds. He is characterized as “well nourished.” There is no mention of the patient appearing cachectic, debilitated or chronically ill. (bb). ME 05-133 is the report of a suicide by inhaling automobile exhaust fumes. _A lethal level of carbon monoxide is demonstrated on toxicology. However, the typical features of carbon monoxide intoxication are nat included in the autopsy report. The subject had a history of Huntington's chorea. Rélated abnormalities are noted in the gross examination of the brain. This disease js not listed as a finding on the frant sheet. (oc). ME 05-151 is the teport of a 4 day old newborn that died when mother and child both fell asteep while nursing. Cause of death was listed as probable asphyxia. The manner of death is listed as accidental. The police noted bruises on the héad and reported the death to Florida Children and Families, Mother reported ‘that the injuries 4 Sep 28 2006 11:01 PAGE 8/13 aoa 2e/2886 1a:54 8584187691 FDLE O08 were the results of a force ps delivery, Medical records in the file confirm the latter. There does not appear to b é any mention of bruises on the head in the autopsy report, (dd). ME 05-152 is the report of a middle aged pedestrian who was killed when struck by a vehicle, The death is certified as accidental. The description of the injuries described in the autopsy report lacks sufficient detail to determine whether or not the victim. was standing or lying in’ the toadway when struck by the motor vehicle. The. ‘Florida Highway Patrol investigator eventually found 4 witriess who described the subject.as waiking casually in the roadway apparently unconcemed about the vehicular traffic. This person had a history of mental illness. (ee), ME 05-183 is the rdport. of an accidental death attributed to fentanyl toxicity. The list of findings on the front sheet. includes cholelithiasis but omits other significant findings including a 780 gm. heart or the Presence of detected cocaine, (ff), ME 05-282 is the report of the accidental death of an elderly person who suffered a head injury. The autopsy Teport contains the statement “Internal examination reveals a right frontal and parietal subdural hematoma but no fractures.” There is no " indication of severity such as thickness or estimated volume. There is no indication of the age of the lesion such as color of the hematoma or whether there is an indication of _ Membrane formation or organization. ‘ (gg).. ME 05-295 is the report of the natural death of a middle aged man. He was brought to the emergency room after having had a’ seizure. Death is attributed to cardiovascular disease which is documented in the report. However, the history of seizure disorder or a subtherapeutic dilantin level are not listed as findings. (hh). ME 06-066 ‘is the re port of the natural death of an elderly person due to cardiovascular disease. An additional significant finding was the presence of a dermatosis described as “bullous lesions and rash” regionalized to the left lower extremity. A microscopic section was Processed but a report of the findings was not located. No culture was processed. Family members had expressed concern about “Vibrio infection’ might perceive this as an unresolved issue, (i). ME'08-089 is the report of the death of a middle-aged person attributed to morphine toxicity. The death is certified as accidental. Findings include a diagnosis of marked bilateral nephrosclerosis both on the front sheet and noted as well on the body diagram. In the internal examination of the report the kidneys are described as normal. ‘Omitted from the findings on the front sheet is a medical history for other significant diseases including Buergers disease, PVD [Peripheral Vascular Disease], and lupus. (ji). ME 04-016 is. the report of a middle-aged male [Claburn Wright] who committed suicide by a self-inflicted intraoral through and through gunshot injury to the head. The original autopsy report contained a description of the presence of a normal gall bladder in contradiction of the known fact that he had a previous cholecystectomy. On review there was no standard cholecystectomy sear or laparoscopic scars noted on the body diagram. . No standard cholecystectomy scar is evident on the photographs. — No bile was included among the toxicology samples. Dr. Siebert stated that his review of the audiotape he made while conducting the autopsy correctly noted that the decedent did not have a gall bladder. However, as previously noted, the original issued autopsy report was incorrect which leads to the conclusion that’ Dr. Siebert ‘did not 5 Sep 28 2006 11:01 PAGE 89/13 aoa 2e/2886 1a:54 8584187691 FDLE O08 ' reconcile the autopsy report with his actual findin 1 gs. This necessitated a later revision after the discrepancy was noted by the decedent’ . 's family, , (kk). ME 04-296 is a case involving a female [Donna Reed] who died of multiple blunt tratima as a result of her mobile home b eing struck by a tornado spawned by severe weather from Hurricane Ivan. The original autopsy report noted the presence of a normal gall bladder as well as male reproductive organs. The decedent's mother knew that the decedent had previously had a cholecystectomy [gall bladder removal] and a hysterectomy and informed Dr. Siebert about the operations. An amended autopsy report was filed that deleted the references to the presence of the gall bladder and male reproductive organs. However, this second. autopsy report listed the decedent as having a uterus, leading to the conclusion that the second report was not complete | ‘and accurate. : . (ll). ME 04-295 involves the death of a male (James Terry] from blunt force ~ trauma in the same incident as case ME 04- 298. The original autopsy report failed to contain any referencés to the presence of scars on the back of the decedent. The decedent's wife knew that the decedent had previously undergone back surgery and had scars on his back.and reported this discrepancy to Dr. Siebert who then issued an amended autopsy report. The amended report reads that “The back has .no Injuries ‘of tattoos, A wall-healed scar is in the midline of the lower back.” The body sketching on the first autopsy did not depict a scar on the back. ‘There was no amended version of the body sketching accompanying the amended report. (mm). ME 05-237 is the case of a suicide of a male [Larry Spires] by a self- . inflicted gunshot wound to the head. The original autopsy report failed to contain any references to the prasence of scars on the decedent. .The decadent’s sister knew that the decedent had scars on his back from lumbar Surgery and reported this discrepancy to Dr. Siebert who then issued an amended autopsy report. .A review of the autopsy photographs revealed that there was a visible scar on the decedent's lumbar region and ‘its presence should have been noted in the original autopsy report, 4. The actions of the Respondent, taken in whole or in part, did violate Section -406.075(1)(i), Florida Statutes, ‘which subjects medical examiners to professional discipline for Negligence or the failure to ‘perform the duties required of a. medical examiner with that level of care or skill Which. is recognized by reasonably prudent medical examiners ‘as being acceptable under similar conditions or circumstances. 5. This Administrative Complaint is issued pursuant to Sections 120.569, 120.57, 406.02(4)(c), and 406.075; Florida Statutes. : Any proceedings concerning this Complaint shall be conducted pursuant to Sectlons 120.569 and 120.57, Florida Statutes, and Chapters 28-106 and 28-107, Florida Administrative Code, Sep 28 2006 11:02 aoa 2e/2886 1a:54 8584187691 FDLE O08 PAGE 18/13 WHEREFORE it is alleged that the Respondent, Charles F. Siebert, Jr., M.D., is guily of violating Section 406.075(1)(), Florida Statutes. . NOW, THEREFORE, the Medical Examiners Commission hereby complains against and alleges that disciplinary action should be taken against Charles F. Siebert, dr., M.D., a8 provided in Sections 406.02(4)(c), and 406.075(1), Florida Statutes, for the reasons set forth above and in accordance with the Election of Rights Form and Explanation of Rights Form attached hereto and incorporated herein. BY ORDER OF THE MEDICAL EXAMINERS COMMISSION THIS 25 pay - OF AUGUST, 2006. . . STEPHEN J. NELSON, M.A, M.D. Chairman Medical Examiners Commission ', CERTIFICATE OF SERVICE {HEREBY CERTIFY that a true and correct copy of the foregoing has been sent by express mail this ie day of August, 2006, to Charles F. Siebert, Jr., M.D., at the District Fourteen Medical Examiner Office, 3737 Frankford Avenue, Panama Gity, Florida 32405. VICTORIA G. MARSEY Bureau Chief, Bureau of Standards Medical Examiners Commission

Docket for Case No: 06-003700PL