SALT LAKE CITY — After 16-year-old Arianna Duenez was found dead in her bed at a “troubled teen” facility in St. George last year, her parents — desperate to figure out what had happened to their daughter — anxiously awaited the results of her autopsy report.
But as weeks turned to months with no answers, they began to feel frustrated with the Utah Medical Examiner’s Office.
“It just wasn’t a priority,” Daniel Bisinger, Duenez’s stepfather, said of the message their grieving family took from the office’s slow response.
Delays have long plagued Utah’s Medical Examiner, which investigates all deaths statewide that are deemed suspicious, sudden or unexpected. In 2016, the office had a caseload that was considered “twice the recommended maximum.”
Today, the office says it doesn’t “consider itself to have a backlog of autopsies, as was a significant concern in past years." But data shows the office is still falling short of national standards for autopsy completion.
The National Association of Medical Examiners (NAME) recommends that offices complete 90% of their reports within 60 days. In Utah, about 74% of all autopsy reports were finalized in that two-month timeframe, according to data provided by the Utah Medical Examiner from October 2023 to February 2024.
While some autopsies are finalized more quickly (the state office recently received national NAME accreditation after meeting a different requirement that 90% of autopsy reports are completed within 90 days), others take much longer.
Duenez, for example, died July 2, 2023. A copy of her autopsy, which her family shared with FOX 13 News, shows the report was finalized nearly five months later – 142 days after her initial examination.
“It’s been a struggle,” Deirdre Amaro, Utah’s new state medical examiner, said of the delays in a recent interview. “But we are in a much better place now.”
Amaro – who came to Utah recently from Missouri and replaces longtime medical examiner Erik Christensen – said offices across the country are facing similar delays as they grapple with government underfunding and a nationwide shortage of forensic pathologists.
“When offices are understaffed and under-resourced, it's hard to get dedicated time to think through a complicated case,” she said. “Because you're constantly interrupted; you're being pulled in so many different directions."
The Utah Governor’s Office of Planning and Budget and the Office of the Legislative Fiscal Analyst reviewed the Utah Medical Examiner’s processes in late 2022 as part of an efficiency improvement project. It found the “primary problem” within the office was that it was failing to meet “national standards for timeliness.”
“Not meeting these standards delays justice and prevention of future harm, and negatively impacts families who benefit from the final report,” the review said. Delays can also slow homicide investigations and insurance payouts.
At the time of the review, 69% of autopsy reports were completed within 60 days. Dozens took more than 200 days.
The state recommended several changes within the office, including:
- Improvements of its information collection processes
- Delegation of administrative tasks to staff other than forensic pathologists
- Protection of pathologists from interruptions
- Data collection to manage operations and performance
The Medical Examiner’s Office said in a statement that it has worked to increase staffing for both forensic pathologists and other staff who assist with autopsies and has also improved processes and procedures within the office in recent years.
“We've really focused on increasing efficiency in the office,” Amaro said. “And I think that has really shown some very tangible results.”
Knowing the cause and manner of death often provides some closure for families. But Duenez’s parents say her autopsy report – which ruled her cause and manner of death as undetermined – left them with as many questions as answers. They’re now seeking a second opinion on the autopsy.
On what would have been Duenez’s 17th birthday, her family held a celebration of her life and released doves in her honor. Duenez’s mother, Maggie Montelongo, said they “felt her spirit” there that day.
As the family continues to fight for answers in her death, she says they’re also “trying to find some peace,” knowing that their daughter is “in bliss and she’s in heaven.”