The Commission found the Office of the Medical Examiner to be unprofessional in its conduct, claiming the office had failed to conduct a proper investigation, had not stored the bodies at the proper temperature to prevent deterioration, had incorrectly identified a body, and had co-mingled some evidence. The author notes that these findings relied on outside expert evidence because there are no standardized guidelines in pathological practice. In addition to the paucity of nationalized practices, there is a parochial lack of regulatory and legislative oversight of forensic laboratories and medical examiners. Finally, the Commission seemed to hold the medical examiner's office responsible for failure to coordinate and control the search for evidence, crime scene diagrams, location stakes, and sequential photography, functions which should have been carried out by the city's police and fire departments. 21 references