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Photograph by Dave Lepori

Cold Comfort: The somber labs of the county coroner's office, which is located on the west side of the Valley Medical Center, have been the center of strife for the 20 employees who work there.

Skeletons in the Coroner's Office

A botched 9-year-old murder case continues to haunt the much-maligned Santa Clara medical examiner's office

By William Dean Hinton

ON THE MORNING of Sept. 18, 1995, 76-year-old Palo Altan Josephine Galbraith tied a red sash around her neck, double-knotted it under her chin as if she were tying a tie, then wrapped and double-knotted the sash twice more until she slowly suffocated to death. She left no suicide note, but apparently Galbraith had planned her death. On the bed, where she usually watched television alone, was spread an old blanket for the mess she was about to make. A white 5-gallon bucket was found nearby, ready to catch the blood from the wrist she'd nicked with a knife and another half-inch gash from a razor blade on the inside of her left elbow.

It is not uncommon for older women to use multiple methods to attempt suicide. And Galbraith, mother of six children, was showing severe signs of depression after being diagnosed with Parkinson's disease. Santa Clara County's coroner, however, determined Josephine was murdered. The key evidence was the red sash, a casual-dress accessory Galbraith used to hold her bathrobe together. It was almost 5 feet long and 2 inches wide, made of nylon and stained on one end.

At the time of Galbraith's death, the chief coroner was Dr. Angelo Ozoa, a Filipino-American who had performed 6,000 autopsies by the time Galbraith died. Ozoa was not the handpicked successor of John Hauser, the gruff coroner who presided over the office for a quarter of a century until his retirement in 1993. Hauser never bothered to prepare an heir apparent, so the county settled on Ozoa, who was one of Hauser's assistant medical examiners for 13 years but had no management experience.

The strangest thing about the sash, according to Ozoa, was how tightly it was wound around Galbraith's neck—so tight that Galbraith's daughter-in-law, who found her body, could not undo the knots. "My conclusion is that [Josephine] couldn't have tied it herself," Ozoa would later testify.

Ozoa's conclusion that Josephine Galbraith was murdered led to the arrest of her husband, Nelson Galbraith, 16 months after her death. Though the two had technically divorced years earlier, they still lived together as a married couple. He was watching television in a front room at the time Josephine's body was discovered.

Nelson Galbraith posted a half-million-dollar bond and spent $300,000 fighting the charges. It took a jury one day to acquit him. Galbraith subsequently filed a $10 million federal lawsuit against the county for arresting him without probable cause, thus violating his Fourth Amendment rights. He made Metro's cover and caught the attention of the national media when he exhumed his wife's body in 1999 to prove Ozoa botched her autopsy.

Nelson died in 2002 at the age of 83, but his court case has lived on, taking many twists and turns. The case was thrown out by now-retired Northern District federal Judge Spencer Williams, who worked for Santa Clara County in the 1960s as its chief attorney, but it was reinstated by the Ninth Circuit Appeals Court two years ago. Since then it has languished in San Francisco because three judges in San Jose recused themselves, presumably because of ties to the county.

The medical examiner's office has also undergone many changes. It hired a chief medical examiner who was supposed to be the anti-Ozoa, competent on the dissection table as well as in the boardroom. During Ozoa's five-year tenure, which ended in the fall of 1998 under an avalanche of criticism, a number of serious management problems arose, including the competency of assistant coroners who weren't certified by the American Board of Pathology and the legitimacy of some of the eight coroner investigators, who never had to undergo background checks to determine whether they had financial and legal problems.

"Investigators were the ones going out to the scenes of crimes," says Gregory Schmunk, the media-friendly coroner who replaced Ozoa in 1999. "We had no idea—we still don't—whether investigators were in $50,000 worth of debt. If they opened up a drawer with $1,000 in it, would they be tempted to take it?" Schmunk resigned last fall after allegations of petty infractions appeared in the Mercury News stemming from Schmunk's previous employment in Green Bay, Wis. Schmunk, now contracted to provide coroner services with Stanislaus County, says he left because county administrators failed to support him when the allegations surfaced.

Diana Hunter, a holdover administrator under Dr. Ozoa, was promoted to fill the chief medical examiner position. The county, unable to find a competent coroner-manager, is ready to cede control of the office to Sheriff Laurie Smith. Though 40 counties in California appoint the sheriff to be the coroner, many agencies in Santa Clara oppose the change, including the district attorney, the public defender, the three assistant medical examiners Schmunk hired last summer and some defense attorneys. Schmunk, on the other hand, supports the idea, saying Sheriff Smith would ensure background checks were completed and bring a level of professionalism the office lacks. "The only negative review I ever received was that I didn't attend enough department meetings," Schmunk says. "I was brought in to fix the Ozoa problem. The other medical examiners could not testify in cases because they were not competent. I told them that if I was at the scene of a major homicide or testifying at a child-abuse case, that was not something that should bother them." He says he presided over 70 autopsies his last year in office because he was tied up in bureaucracy. "I was called away to meetings and other crap I didn't like doing."

H for Homicide

County administrators will discuss this week whether to turn over the coroner's office to the sheriff. If that issue is settled in the weeks and months ahead, it will leave only the Galbraith case as the last piece of unfinished business from the Ozoa era, given that the county quietly settled the Victor Duran case for $207,500 in 2000. (Duran was a 360-pound parolee who fled from San Jose police on a bicycle, was beaten and died a day later in county jail. The medical examiner's office ruled Duran had been strangled to death, leaving the county in the thorny position of having to disprove its own coroner.) The Galbraith case displays all the elements of what led to Ozoa's dismissal—including lost files, counterintuitive decisions, overlooked evidence, haphazard investigations and possibly a coverup.

Among the things that won't be reconciled until the Galbraiths finally make it to trial is the red sash found around Josephine's neck. Dr. Ozoa estimated the noose that the sash formed was only 2 1/2 inches in diameter, which had to be a miscalculation. In fact, Josephine did not have the corresponding neck wounds to match such a small enclosure. Ozoa also said he only suspected murder when he inspected the sash days after the Sept. 20 autopsy. But the sash is listed on the autopsy with a bloody 8-inch kitchen knife and razor blade. Other seemingly incongruous comments include Ozoa's handwritten notes that say Josephine was "strangled by [an] assailant." Over this observation is circled an "H," for homicide, which looks as if somebody tried to erase it with a pencil.

Contrary to the way Hollywood portrays forensic science, coroners rely more on families to provide information about a death than the body left behind. "We pride ourselves on openness with families," says Judy Melinek, one of three assistant Santa Clara County medical examiners Schmunk hired last summer. "My communication is not with the dead body; it's with the family." Yet Ozoa contacted only one Galbraith family member—the oldest son, Bill, who happened to be at the house the day Josephine died but has been estranged from his siblings since 1970. For reasons not yet clear, Bill Galbraith told Dr. Ozoa that Nelson Galbraith had reasons to murder Josephine. The allegation, however, was so noncredible that prosecutors failed to provide it to the jury at trial.

Ozoa mishandled the Galbraith case so badly the state's medical examiner board tried to sanction him last summer. No action was taken, but he might eventually have to answer why he testified during the hearing that he had never performed a ligature strangulation autopsy. (Ligature strangulation, as opposed to manual strangulation, is suffocation with a rope, cord or other instrument, like a sash.) In fact, Ozoa performed at least five ligature strangulation procedures from 1989 to 1991. All of the victims—Olivia Exum, Lucille Boomer, Irene Singh, Su Chieh Hung and Jit Brar—were listed as ligature strangulation victims, or a cord or other device was listed in Ozoa's reports, each of which he'd signed.

Neck Dissection

There is also a strange incident that occurred while Dr. Schmunk was testifying during Dr. Ozoa's competency hearing. Schmunk was called on to corroborate testimony that Ozoa had competently performed parts of the autopsy relating to Josephine's neck. By his own admission, Schmunk did not want to be part of the proceedings but felt pressured by County Attorney Ann Ravel's office as well as by James Towery, who was hired to defend Ozoa and the county against the Galbraith family.

Nonetheless, Schmunk testified at the inquest he had not "substantially" spoken to anyone about the case: "I had not had any discussions to the best of my knowledge with anyone outside of the office."

In fact, Schmunk had conducted an autopsy in June 2000 so that Towery and several county employees would know what a layered neck dissection looks like—the exact type of procedure at issue in Josephine's autopsy. Confounding matters was the fact no witnesses were listed in the autopsy report.

County Executive Pete Kutras says he was made aware after the fact that Towery and others were present during the autopsy but that by then Schmunk had already resigned. "I did review the information, which did indicate there were other people present," Kutras says. "People have asked me what I'm going to do about it. Dr. Schmunk is no longer here. This doesn't relate to the medical findings, so I don't see any follow-up at this juncture."

But Schmunk says everything about the autopsy was legitimate. He says it is routine for spectators to view autopsies without their names appearing in the report. "The only people who are listed are people specifically involved in that case," Schmunk says. "Police officers often observe autopsies but only log into the building."

Whether any of the discrepancies will help the Galbraiths win their case is uncertain. The family still has to prove Ozoa acted maliciously, which could be difficult if not impossible. It nothing else, James Towery will likely argue Ozoa, who is approaching his 80th birthday, was nothing more than senile. The Galbraiths will try to show the county knew about problems with the office but failed for years to rectify problems.

To prove their case, the Galbraiths will likely have the red sash pulled from storage at the coroner's office—if it's still available. Palo Alto police already lost the 5-gallon bucket found with Josephine's body. The coroner, meanwhile, can't find the entire Josephine Galbraith autopsy folder, including Ozoa's handwritten notes. Though far from over, her case grows colder by the day.

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From the June 16-22, 2004 issue of Metro, Silicon Valley's Weekly Newspaper.

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