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In Texas, medical examiners are entrusted to investigate, through autopsy, all mysterious, strange and unexpected deaths, including homicides. At the Travis County morgue, that trust fell on Dr. Roberto Bayardo for nearly 30 years.

During his tenure as chief medical examiner, Bayardo conducted more than 18,000 examinations. Scribbled, handwritten notes uncovered by KXAN detail each of those procedures: the names of the dead, their ages, the manner of their deaths.

Through a line-by-line examination of hundreds of pages of the handwritten logs, county budgets and audits, court transcripts, autopsy reports and interviews with former county officials, it appears that behind the walls of the morgue, Bayardo oversaw a monumental workload fueled in part by a unique financial arrangement that netted him millions of dollars in extra pay and also, according to experts, may have contributed to critical missteps in high-profile murder cases.

Officials believe, and court records show, the impacts of those flawed autopsies were used in botched prosecutions that led to wrongful imprisonment, and the ripples are still being felt today.

In fact, authorities have called on Bayardo to testify in a murder case again this year, according to court records.

Body of work

A medical examiner’s findings can single out a killer; pivotal legal arguments often hang on autopsy.

An imperfect examination can devastate a homicide case and the lives of those involved.

The National Association of Medical Examiners (NAME)-the nation’s foremost association for accrediting medical examiner offices-sets guidelines for output, procedures and training.

NAME places a recommended limit on the number of autopsies a medical examiner performs: no more than 325 per year, according to association literature.

But the Travis County ME’s office was not NAME-accredited during Bayardo’s career, and he routinely performed more than twice the number of recommended autopsies, records show.

Bayardo told KXAN he was just doing his job, completing an important task and never had concerns about the high number of autopsies he was performing.

“Someone has to do the work, and there was nobody else to do it,” Bayardo said.

Recipe for a conviction

Bayardo examined two bodies Aug. 14, 1986. One was a man stabbed four times in the neck, head and back.

The other body was Christine Morton, 31, killed in neighboring Williamson County, one of numerous counties outside Travis that sent bodies to Bayardo for examination.

Christine Morton, murdered in 1986 at the age of 31, was found bludgeoned to death in her bed.

She arrived in a blood-stained nightgown, her skull distorted by a “massive crushing injury.” In her stomach, Bayardo found “semi-digested food material,” including mushrooms, tomatoes, olives and squash, the autopsy report states.

The food she ate that day would become a key ingredient in the prosecution’s case against Christine Morton’s husband, Michael.

Prosecutors used Bayardo’s determination, which he arrived at by examining the food in her stomach, to inaccurately state when she died, according to court records.

At trial, Bayardo said the use of stomach contents was not based in science; yet he used that very method to base his opinion on her time of death. He later walked back that testimony, saying it should not have been used and was misinterpreted by the prosecution. With the help of DNA evidence, the Innocence Project helped exonerate Michael Morton in 2011.

The flawed evidence helped secure the wrongful conviction and 25-year incarceration of Michael Morton, Christine’s husband.

In his 1997 book, “Crime in Texas, Your Complete Guide to the Criminal Justice System,” former Williamson County prosecutor Ken Anderson used Bayardo’s autopsy of Morton to show how important autopsy findings can be at trial.

“A critical part of the proof was the results of the autopsy,” Anderson wrote. “The medical examiner [Bayardo] fixed her time of death at around midnight but no later than 4 a.m.”

The year 1986, Bayardo conducted about 790 examinations, more than doubling NAME standards. It was one of his busier years, according to medical examiner logs.

The Morton case was not the first high-profile case, nor the last, in which Bayardo called into question his own findings.

Mounting workload

Speaking generally on medical examiner best practices, experts told KXAN such a workload would be “excessive.”

Such a high number of autopsies, according to Dr. Max Buja, professor of pathology at University of Texas Health Science Center in Houston and executive director of Texas Medical Center Library, could lead to a “significant error rate,” including “misinterpretation of the examinations, and the incompleteness of the examinations.”

“That is not a good practice of medicine, and it should be stopped as quickly as possible,” he said.

Marcus Nashelsky, former NAME president, echoed Buja’s sentiment.

“It is possible that performing too many autopsy examinations will lead to oversights, errors, fatigue and reduced effectiveness,” Nashelsky said.

The Travis County ME’s office was not NAME accredited during Bayardo’s career. If it had been, Bayardo’s workload would have vastly exceeded the association’s standards.

NAME has accredited medical examiner offices since the early 1980s, and the standards for autopsy limits per doctor have been in place since at least the late 1990s, according to current NAME President Dr. David Fowler.

Bayardo told KXAN he was just doing his job, completing an important task and never had concerns about the high number of autopsies he was performing.

KXAN’s autopsy numbers include a portion of visual examinations.

Execution on hold

April 23, 1996, Bastrop County authorities found the body of Stacey Stites, 19, discarded alongside a rural road. Stites had been strangled and sexually assaulted, Bayardo noted in his autopsy. The autopsy results provided prime evidence leading to the conviction of Rodney Reed, of Bastrop, for capital murder.

Stacey Stites was killed just weeks before her wedding, and Bayardo’s findings from her autopsy helped a jury convicting Rodney Reed for the murder.

Reed has maintained his innocence, saying he was in a casual and secret sexual relationship with Stites, who was just weeks from her wedding day at the time of her death. Reed’s defense has pointed to Stites’ fiance, Jimmy Fennell, as the possible killer. Fennell, a former police officer, is currently in prison on an unrelated conviction for engaging in a sex act with a woman in his custody. The woman claimed she was raped, according to court records.

15 years after Reed’s conviction, which was based in part on Bayardo’s time-of-death estimation, the medical examiner reversed his original opinion.

Reed’s defense team presented Bayardo with the expert opinions of other renown pathologists, who said the time estimate used at trial was likely incorrect. The experts cited the tinted color of Stites’ body, called lividity, as scientific evidence to back their claim.

After being presented with those pathologists’ opinions, Bayardo signed a sworn affidavit stating he could not accurately determine when Stites died.

Rodney Reed’s death sentence is currently on hold pending a review by the Texas Court of Criminal Appeals.

Bayardo examined 656 bodies in 1996.

KXAN has reported extensively on Rodney Reed’s case.

Unique financial arrangement

“It took years and examples and other professionals to make it clear that there were serious problems,” said former Travis County Judge Bill Aleshire. “It may have been related to [Bayardo] trying to do way too many autopsies, for which he had a financial incentive to do at the time, before it was stopped.”

Bayardo’s “incentive” originated from the autopsies Travis County conducted for other counties. The number has fluctuated, but Travis County has taken bodies from up to 45 other counties.

In return for these out-of-county autopsies, Travis County receives a fee. During Bayardo’s tenure, a portion of that payment went straight to him.

On top of his salary, Bayardo earned at least $2.6 million through these autopsy fees during his career, according to a KXAN analysis of autopsy records.

Former County Judge Sam Biscoe, Aleshire’s successor, said the fee arrangement helped supplement Bayardo’s income and the county’s coffers without burdening Travis County taxpayers, and, all the while, helping other counties with necessary work.

The ME’s office had the appearance of functioning well, Biscoe said, until county officials decided to accredit the office, then deficiencies surfaced. As Biscoe learned about NAME standards and compared them to the Travis County ME’s office, he described the revelation as “mind-blowing.”

Bayardo said he never felt overworked, nor did he feel the workload would impact the quality of the autopsies. He enjoyed the job and preferred to stay busy, he said.

“I did everything to the best of my abilities, to the best of my knowledge,” Bayardo said. “I don’t have no remorse, no problems.”

Biscoe said Bayardo rarely asked for help in the form of budget increases.

“In fairness, he was a good team player, and looking back he probably leaned over too far backwards to, quote, save us money,” Biscoe told KXAN.

Intentional or accidental?

Feb. 8, 1994, 3-month-old Brandon Baugh.

Bayardo concluded Baugh died after being smashed on the ground, severely fracturing his skull. The autopsy was central to the conviction of Cathy Lynn Henderson, the boy’s babysitter. Henderson said she accidently dropped the baby before fleeing the state.

Police believe Henderson hid the baby in her trunk before burying him in a shallow grave. In the midst of a nationwide hunt, Henderson took steps to evade authorities and change her identity. Authorities found her in Missouri.

A Travis County jury sentenced Henderson to death in the killing. She maintained that she dropped the infant. More than two decades after her conviction, her attorneys obtained a sworn affidavit signed by Bayardo, in which the medical examiner casts doubt on his own findings.

The year of Baugh’s autopsy, Bayardo conducted about 665 examinations, according to records reviewed by KXAN.

Terry Keel, Travis County Sheriff at the time of Baugh’s death, said Bayardo’s affidavit triggered a trial review, appellate review and ultimately a plea deal.

In June 2015, the former death-row inmate pleaded guilty to murder, but was going to be able to walk free in four years, having already served 22 years in prison. Henderson died a prisoner shortly after the plea deal was struck at the age of 58.

“The whole issue was the medical examiner’s testimony about the cause of death,” Keel told KXAN at Travis County District Court following the plea deal.

Cutting ties

The logbooks show days in which Bayardo conducted up to five autopsies in a single day.

And those duties were “in addition to the others, going to court and doing several types of testing… and getting together with lawyers and doctors and medical students,” Bayardo said.

The county put an end to Bayardo’s high-output office in 2006.

Biscoe said he and a majority of the Travis County commissioners decided it was time to move forward with accreditation, without Bayardo and his profitable financial arrangement.

“It hurt me to the core to accept Dr. Bayardo’s resignation,” Biscoe said. “But I think it was clear, at that point that realistically we had no choice.”

Travis County brought on a new medical examiner and deputies, and made improvements to the facility and record keeping.

In 2009, the Travis County Medical Examiner’s Office received full accreditation from NAME.

It does not appear Bayardo is in any danger of legal or regulatory backlash resulting from his time and work as medical examiner.

Often in the past, physician-regulating entities have not disciplined medical examiners because autopsies were not considered a practice of medicine. In fact, an analysis of data from the Texas Medical Board reveals just five disciplinary actions taken against Texas medical examiners in the past two decades statewide.

Furthermore, criminal cases against medical examiners in Texas are rare – there must be proof of deliberate wrongdoing, like a former Lubbock-area medical examiner sentenced to prison in the 90s for falsifying autopsies for financial gain.

Now back in Austin, prosecutors may again look to Bayardo for answers, despite being in retirement and past issues with his testimony.