Inspector General Robert P. Storch announced today that the Department of Defense Office of Inspector General released the “Audit of the Management of Organs Retained for Forensic Examination by the Armed Forces Medical Examiner.” The DoD OIG determined that DoD officials did not effectively manage the retention and disposition of organs that were the subject of forensic examinations by Armed Forces Medical Examiner System (AFMES).
For example, the DoD officials did not obtain next of kin disposition instructions for 109 of 208 decedents, or more than half the sample of cases that we reviewed. When disposition instructions were obtained, DoD officials did not follow those instructions for 41 of 99 decedents (41 percent). AFMES officials were unsure how to proceed with the disposition of the organs they had in their possession until the Under Secretary of Defense for Personnel and Readiness (USD[P&R]) made the decision in September 2022 to hold what they now refer to as “specimens” for 10 years unless the next of kin requests that the specimen be returned.
However, the DoD OIG found that implementation of the September 2022 decision may not honor next of kin wishes. The DoD OIG identified 11 cases in which the decision to hold retained organs for 10 years would not follow the next of kin’s disposition request. Furthermore, due to the time that has passed since the next of kin were first contacted, it is likely that the next of kin are not aware that AFMES officials have not dispositioned these organs. As of March 2023, AFMES had a total of 553 retained organs in its possession that needed disposition.
The DoD OIG also found that AFMES officials did not effectively track organs that medical examiners retained during autopsies. For instance, AFMES officials did not have complete or accurate records of retained organs stored at Medical Treatment Facilities and the Joint Pathology Center. This occurred because AFMES officials did not have clear policies or procedures in place to track retention, transportation, storage, or release of retained organs. As a result, DoD officials may not be able to effectively respond to next of kin requests for information on the retained organs, a deficiency that we found ultimately could cause emotional distress to the decedent’s family.
“Implementation of the DoD OIG’s recommendations to address these shortfalls will help the DoD ensure greater transparency and efficiency in its policies and procedures in this very important area,” said IG Storch.
The DoD OIG made several recommendations that addressed the findings in the report, including that the USD(P&R) either reconsider their September 2022 decision or take steps through targeted notifications or through a public awareness effort to ensure that the next of kin are aware of the decision and their options under it. This would include ensuring that the DoD has appropriately trained staff to explain to the next of kin the reason for the delay. We also recommended that the Director of the Defense Health Agency review all locations where retained organs may have been stored and ensure that all organs were sent to AFMES at Dover Air Force Base, Delaware.
The DoD OIG will continue to monitor the DoD’s progress toward full implementation of the recommendations in this report.
*If you were the person authorized to direct disposition (usually next of kin) for a decedent who had a forensic examination performed by AFMES and you believe that DoD may have retained your loved one’s organ, you may request additional information by contacting DHA.AFMES.Queries@health.mil with your contact information and the name of the deceased. Additional general information can found on DoD’s AFMES web page https://health.mil/Military-Health-Topics/Health-Readiness/AFMES.