to Florida Dept. of Health on May 2, 2003 by Francine Yurko
[Editor's note: the text of this Complaint has been copy-edited for publishing on the Yurko Project Website, and therefore reads differently from what was sent to the Dept of Health. However, it is identical to the original in terms of information and specifications.]
On 29 November, 1997 at 10:15 A.M., Shashi B. Gore, MD performed autopsy on Alan Ream Yurko, wherein he attributed the cause of death to subdural hematoma (SDH) due to Shaken Baby Syndrome (SBS), and the manner of death a homicide. This Complaint surrounds the autopsy report and procedure as well as Dr. Gore’s testimony and role in the connected criminal proceedings.
Attached to this Complaint in the form of a compact disc are copies of the autopsy report, hospital records, trial transcripts, and other relevant data. It is alleged that Dr. Gore performed a substandard autopsy, cross-contaminated data and tissue from another case, provided numerous erroneous facts and false testimony in a First-Degree Murder Trial, and altered evidence after trial to deflect attention from his errors.
Perusal of the autopsy report will verify the facts enumerated below.
1.) Page 1 and page 3 state decedent was two months old, whereas decedent was (10) weeks old.
2.) Page 2 states there were no hemorrhages at the thoracic, lumbar, or sacral spine, whereas page 7 states that there are hemorrhages in the lower thoracic, lumber, and sacral spine.
3.) Page 6 states that head circumference is 22 cm, whereas decedent was born with a 31.5 cm head, and just prior to autopsy, decedent is noted to have a 37.5 cm head.
4.) Page 9 has a description of microscopic examination of inner heart muscle tissue, whereas pages 2 & 5 state that the heart was surgically absent as a result of organ harvesting. Special Procedures on page 6 notes that blood was obtained at harvesting, but no heart tissue. TransLife records do not indicate tissue samples saved for the ME. Tissue blocks on file at Dr. Gore’s office do not contain a heart sample. The expert for the defense in the subsequent criminal trial noted in testimony that heart tissue slides were not included in the set. Tissue samples of myocardium are not logical for donor organs. The heart was successfully transplanted.
5.) Page 6 notes a normocephalic head, whereas hospital records note swelling, bulging fontanelle, and visible edemic/macrocephalic conditions prior to autopsy. As well, a 22 cm head circumference on a 9 lb. baby would indicate a microcephalic head.
6.) Page 4 notes a contusion of the left lateral surface of the chest, whereas page 8 states that the skin does not show any subcutaneous contusions of the buttocks, chest or abdomen. Yet, elsewhere on page 8, a chest contusion is noted.
7.) No toxicology, virology or bacteriology testing was ordered by Dr. Gore.
8.) Page 10 notes that decedent was a 2 month-old black male, whereas he was a 10 week-old white male.
9.) After the criminal trial, Dr. Gore altered his report to state the correct race without notice to the courts or involved parties, and thus altered evidence in criminal proceedings. Dr. Gore testified that the mistake was a typographical error; however, it should be noted that there are no letters in the word “black” that are in the word “white.” (TT Vol. III p.272; 24 thru p.273; 23)
10.) Dr. Gore testified that he did not seek or review medical history of the decedent, which would have revealed a 75-hour course of heparin overdose in an absolutely contraindicated setting (decedent had received iatrogenically 1095 IUs of heparin every five hours, whereas maximum dosage for this infant, according to the Physicians Desk Reference (2002 and 1997 editions), is only 125 IUs of heparin every five hours; and, as stated, heparin was absolutely contraindicated due to the high risk of hemorrhage. Furthermore, had Dr. Gore properly investigated, he would have seen that CT scans revealed only an antemortem intracranial hemorrhage, 10 hours post terminal hospital course admission. As well, the CT scans revealed only one “tiny” subdural hemorrhage occurring in hospital. Therefore, the bilaterality and inclusion of subarachnoid hemorrhages indicate that these hemorrhages occurred during the hospital course and could not have been SBS, but were a result of absolutely contraindicated over-heparinization, infused at 8.8 times maximum recommended allowances.
11.) Dr. Gore testified that he did not, nor did his office, interview the caretakers or get the medical history/records of the infant—necessary procedures in diagnosing SBS. Dr. Gore admitted that this was necessary to make the diagnosis, yet made the diagnosis despite it. (TT Vol. III pp. 246; 20 thru 254; 2)
12.) Dr. Gore testified that he removed the heart, lungs and all the organs, whereas TransLife removed the heart, liver, pancreas, spleen and other organs. (TT Vol. III p.218; 14-17, p.246; 2-5 & p.277; 20-23)
13.) Dr. Gore testified that he observed Diffuse Axonal Injury (DAI) in the decedent; however, the autopsy report makes no mention of DAI. (TT Vol. III p.280; 2-25, p.281; 1-6)
14.) Dr. Gore testified that DAI is very minute pinpoint hemorrhages in the brain, thereby providing the court with erroneous definition: DAI involves no blood or hemorrhage, but rather, injury to brain axons. (TT Vol. III p.226; 15-25, p.227; 1-4)
15.) Dr. Gore’s attention to the medical history would have shown that egregiously excessive administration of bicarbonate occurred also. Bicarbonate was continuously infused, despite pH levels of 7.6 and 7.7, accounting for the hypoxic, edematous and other changes seen intracranially and in the CNS.
16.) Dr. Gore did not decribe the microscopic appearance of the meninges or the presence of DAI in the brain or spinal cord.
17.) Dr. Gore presented no description of his x-ray findings of the rib changes.
18.) Dr. Gore presented slides and testified about the old callous of the 5th, 6th & 10th ribs, unrelated to the present condition, as there was no new callous; yet he notes the 7th as well in his report. (TT Vol. III p.221; 1-17)
19.) Dr. Gore’s description of the bleeding in the subdural spaces indicates a 3-5 day process, yet he testified that the bleeding occurred in a few minutes or seconds. (TT Vol. III pp. 256; 15-20, p.275; 9-25, p.276; 1-3, p.279; 16-25 & p.280; 1-11)
20.) The presence of bleeding in the lungs and lower spinal cord is not indicative of SBS, yet Dr. Gore maintains his diagnosis of SBS.
21.) Dr. Gore testified that he did not test the cerebrospinal fluid (CSF) because it was mixed with blood, whereas his autopsy report notes on page 7 that the CSF was clear. (TT Vol. III p. 238; 20-25, p.239; 1-22, p.242; 23-25 & p.243; 1-6)
22.) Dr. Gore testified decedent did not have meningitis; however, his autopsy report indicates that there was meningitis. Tissue samples of the meninges revealed prominent and acute meningitis. (TT Vol. III p.278; 9-14)
23.) Dr. Gore presented photos of decedent in trial and remarked about two bruises on the head, thereby presenting evidence not related to the cause of death: he later admitted that these bruises occurred in the hospital as a result of handling. (TT Vol. III p.215; 21-25, p.216; 1-18, p.254; 12-25 & p.255; 1-8)
24.) Neither Dr. Gore, nor his office, performed a crime-scene investigation, per protocol.
25.) Numerous other discrepancies are revealed when Dr. Gore’s autopsy report and his testimony are scrutinized and compared by independent analysts.
Dr. Gore’s neglect, errors, false testimony, and malfeasant performance led to a wrongful conviction, placing an innocent man in prison for life without parole. Moreover, he caused severe mental, emotional, and financial harm to an already grieving and traumatized family.
Appendix A is contact information for experts who have reviewed the materials and assert Dr. Gore’s negligence, as well as the serious and grave questions surrounding the integrity of Dr. Gore’s autopsy and testimony.
Also attached is an article which reports on an internal investigation which reveals that, among other things, hundreds of cases in the Medical Examiner's office were cross-contaminated as early as 1994. This article also points out that Dr. Gore is not a board certified forensic pathologist. Another attached article indicates ethical misgivings surrounding Dr. Gore.
Based on the above information, it is clear that an exhaustive and extensive independent review of Dr. Gore’s role in this case be examined and proper disciplinary action be taken. Dr. Gore’s incompetence is a liability to Orange/Osceola County and a threat not only to his profession and the courts, but to the families and citizens he serves. It is also noted that the two Orlando newspapers and three Orlando TV-news stations are reporting the case, as are dozens of other media sources here and abroad. This elevates the need for exhaustive review to the level of great public importance. Dr. Gore’s long history of incompetence and unethical practice calls for swift and thorough resolution.
Loren Rhoton, Esq.
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