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Doctor’s conviction for dispensing narcotics without a valid medical purpose reversed because autopsy reports of former patients were admitted in violation of the Confrontation Clause

The Defendant in U.S. v Ignasiak was a medical doctor convicted of dispensing controlled substances in violation of the Controlled Substances Act and for committing health care fraud. The prosecution’s theory was that Ignasiak prescribed unnecessary or excessive quantities of controlled substances (pain killers) without a legitimate medical purpose and outside the usual course of professional practice. Ignasiak ran a busy medical practice out of a medical clinic as the only medical doctor in a rural Florida panhandle town, seeing up to 32 patients each day. Evidence showed he was always available for people who became sick and needed to see a doctor right away. Most patients came in to renew their prescriptions, but he always interviewed and examined his patients before they got a prescription.

At some point his practice drew the attention of the federal Agency for Health Care Administration due to concerns that as a family practice doctor he was billing for higher than normal levels of service. The auditor reviewed 30 of the Defendant’s patients’ charts that he selected out of more than 3,700 patients and found the charts did not justify the charges he was submitting to Medicaid. He concluded that Ignasiak had a practice of prescribing certain narcotic pain-killers in significant quantities. A doctor who took over the practice found patient files appeared to show Ignasiak had been operating a pain management clinic rather than a family practice. Patients who wanted the new doctor to write pain medication became angry when he did not. The government presented testimony from individuals who worked in his office to support the government’s theory the Ignasiak’s practice was to mainly prescribe pain killers for patients that were not really sick. The government also presented patients and patient’s family members to further support this theory by testifying about how these patients became addicted.

Seven of Ignasiak’s patients died from what the autopsy reports concluded were pharmaceutical drug overdoses. The government called as a witness the medical examiner who conducted two of these autopsy reports. The district court allowed this medical examiner to testify about the five autopsies conducted by the non-testifying medical examiners, which included the conclusions that the cause of death was accidental drug overdose for each patient. The testifying medical examiner said she agreed with these conclusions.

Ignasiak raised a number of issues but the 11th Circuit focused on the sufficiency of the evidence and the introduction of the autopsy reports in violation of the Confrontation Clause. The 11th Circuit concluded that the evidence when viewed in a light most favorable to the government was sufficient was sufficient to support the conviction. Based on the evidence, along with the government expert’s testimony, “we cannot say the jury could not have found the defendant guilty under any reasonable construction of the evidence.”

But the 11th Circuit reversed because the admission of the autopsy reports of five former patients, through the medical examiner who did not prepare the reports, was a violation of the Confrontation Clause. All of these reports admitted in evidence concluded the cause of death to be intoxication from controlled substances and the testifying doctor was allowed to testify as to this aspect of the reports.

The 11th Circuit rejected the government’s argument that the autopsy reports were admitted as business records. The court determined that the autopsy reports are testimonial evidence and must be subject to the requirements of the Confrontation Clause. Relying on the following Supreme Court decisions: Crawford v. Washington, (prosecution may not introduce testimonial hearsay against the defendant), Melendez-Diaz v. Massachusetts (a laboratory report stating an unknown substance was cocaine was testimonial evidence), and Bullcoming v. New Mexico, (6th Amendment requires the government to present the witness that prepared the testimonial forensic report.)

The 11th Circuit found that Ignasiak’s 6th Amendment rights were violated because the autopsy reports were testimonial, they could not be offered and discussed by the medical examiner that did not prepare them. The Court further decided that based on the evidence presented the admission of the five autopsy reports did contribute to the guilty verdict because the government presented an overarching theory of prosecution that Ignasiak has prescribed unnecessary or excessive quantities of controlled substances without legitimate medical purpose and outside the usual course of professional practice. Moreover, the 11th Circuit found the evidence was not overwhelming. Though the evidence was sufficient for a guilty verdict, “we must be less tolerant of the idea that errors committed during the trial of this case are acceptable because they are harmless.”

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