To give you an idea of how bad this report is, the words gross mismanagement are in the title of the report, and the terms flabbergasted and loosey goosey appear on page one.
The findings level crushing charges against former ME supervisor Linda Krivjanik and her boss, longtime Chief Medical Examiner Joshua Perper, who is made to look as if he was sitting around like a clueless stooge while Krivjanik allegedly robbed the office blind. Allegations also land on other medical examiners -- one investigator explained to OIG agents:
Some investigators never followed procedures, including never counting medications, much less logging them into the computer system. He also stated that one investigator merely kept a big black garbage bag in her office, where she stored medications without logging them.
The report also quotes a second medical investigator as saying he was "'flabbergasted' by the way in which the ME operated compared to other places he had worked... The manner in which investigators performed their duties was in 'total conflict' with the Manual."
Below is the story outlined in the report. It should be noted up-front that no one has been convicted of anything.
The unraveling of Krivjanik's alleged pill scheme starts early in October 2011, when a medical investigator (unnamed in the report) started noticing unsealed evidence bags and missing inventory forms. As time went on, he also started noticing Krivjanik bringing investigation boxes into her office but bringing black trash bags out. Soon, Krivjanik was doing this every Friday, and black trash bags began piling up in the file room.
This lax "filing system" wasn't out of the ordinary for this office -- before they landed in their current office, medical investigators were housed in a trailer in which one said they stored medications in a bathroom.
On October 28, the suspicious medical investigator watched Krivjanik bring medication boxes into her office. He said he saw her take a brown evidence bag out of the box, rip off the inventory form, and open the bag. A sandwich bag sat empty on her desk. She pulled out a plastic bottle and poured pills into her hand.
It's here, the investigator said, he believes she looked up and saw him.
Krivjanik placed the paper bag on the ground, walked out of her office, and shredded the inventory forms.
The Monday after that, the investigator decided to do some searching. It was Halloween night, and he went to the file room and opened a garbage bag. Inside, he found paper bags and containers of medication in "total disarray," with numerous oxycodone pills missing. He took his findings to the interim chief medical examiner, Darin Trelka, the next day, on Trelka's first day on the job after Perper's retirement.
Trelka walked into Krivjanik's office and opened a garbage bag laying inside. He found four bottles that should have been full of oxycodone; two were empty. He notified county officials, who called the Broward County Sheriff's Office.
BSO investigators arrived and found 46 investigations' worth of drug files in Krivjanik's office, stored in boxes and trash bags. All but 12 were missing their required inventory forms. When officials finished inventorying the stash, plus five black garbage bags on the floor in the file room, they found that more than 3,600 pills were missing, including 2,300 of "significant street value."
On December 1, Krivjanik was fired.
"Human Resources reported that among Ms. Krivjanik's professional failings, she was grossly negligent, displayed extremely poor judgment, and poorly performed her professional duties," the inspector general's report says. It also notes that investigators will never be able to figure out how many pills were taken.
Any meager attempts at stopping the behavior appear to have gone ignored -- a senior investigator told OIG agents that attempts to report issues to management went unanswered and that "everyone in the unit knew that when such issues were brought to Dr. Perper's attention, they would simply 'die.'"
Once, it seems Perper tried to bring up stricter medication controls at a meeting, which Krivjanik reportedly ignored. The investigator who turned in Krivjanik told OIG agents that Krivjanik didn't ever bother listening to Perper's direction because she said, "Perper will not remember what he wanted by next week."
The man who conducted Anna Nicole Smith's autopsy comes out looking pretty dumb here. In a summary of an interview with investigators: "Perper acknowledged that during his 17-year tenure as Chief Medical Examiner, neither he nor anyone on his staff ever conducted an inventory of the evidence room... Dr. Perper stated that it would be very surprising to him if there were several thousand missing pills from the evidence room."
Perper also said in a letter to investigators that "in retrospect, closer attention should have been paid to this issue in a more pro-active manner, however, looking back there were no 'red flags' regarding this issue."
The report is full of strange allegations, including a 2007 episode in which someone was using a room reserved for storing body tissues to house dolls they were selling on eBay. The full report is below. Grab a sandwich and have a look, but eat quick -- you won't be hungry for long.
