The accuracy of his reports have been questioned, he was arrested last year for driving drunk on the way to an autopsy, and the state is attempting to suspend or revoke his medical license.
But San Luis Obispo County’s embattled medical examiner is still on the job.
Since 2005, the county Coroner’s Office has contracted out its forensic examination services part-time to Dr. Gary Alan Walter, a Tulare-based forensic pathologist doing business as Microcorre Diagnostic Labratory. He performs autopsies in San Luis Obispo County once a week and testifies about his findings as the primary forensic expert for the county District Attorney’s Office in the prosecution of murder and other cases resulting in death.
But his findings have been criticized by attorneys in court and by the families of two inmates who died in San Luis Obispo and Kings county jails.
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Most recently, Walter ruled that the death of a Ventura woman at a Lake San Antonio music festival was caused by an overdose of the hallucinogenic drug LSD — a finding one pharmacology expert told The Tribune “defies logic.”
Walter’s contract expired June 30, but he remains on a month-to-month basis because the county says it hasn’t been able to find a suitable replacement. The Sheriff’s Office received approval in December to hire a full-time staff coroner to take over after his contract expired. The position will pay up to $248,000 a year.
“We have been actively trying to hire a full-time pathologist. However, there is a shortage nationwide, and we have already lost candidates in the process because of not being able to compete with pay,” sheriff’s spokesman Tony Cipolla said in an email.
He said the county is in the final stages of hiring someone and plans to make an announcement in about two weeks.
Cipolla said Thursday there are “simply no alternatives” to employing Walter for now, and noted that a coroner’s sergeant or a coroner investigator is always with Walter during autopsies to supervise his work performance.
Walter was arrested at about 8 a.m. on March 9, 2016, after a San Luis Obispo police officer saw him speeding in an SUV southbound on Broad Street toward the sheriff’s coroner’s examination facility on Aerovista Place, according to a Medical Board filing by the state Attorney General’s Office.
The car had a blown front tire and front-end damage, the report says, and Walter told the arresting officer that he was on his way to work. A blood test showed he had a blood-alcohol content of 0.19, well over the legal limit of 0.08, according to the filing.
Walter pleaded no contest to misdemeanor DUI in May 2016, was given three years of probation and attended a standard DUI first offender program. Emails provided in a public records request show the Sheriff’s Office offered Walter a last-chance agreement on March 29 to finish out his contract.
A spokesman for the Attorney General’s Office said Walter’s disciplinary hearing is set for Nov. 6-8 in Sacramento.
Contradictions, disputed findings
Walter’s work has been challenged in recent years.
In October 2016, he served as an expert witness for the prosecution in the murder trial of Nipomo resident James Lypps, whose wife was found dead in the couple’s bathtub in 2009. The criminal case against Lypps was based in part on Walter’s finding that Sherre Neal-Lypps was strangled and drowned, and that her death was not a suicide or accidental, as Lypps had maintained.
Walter’s accuracy was called into question by defense attorney Matthew Guerrero, who pointed out that Walter had written in his autopsy report that he examined Neal-Lypps’ gallbladder, a claim Walter repeated on the stand. During cross-examination, Guerrero provided proof that Neal-Lypps had her gallbladder removed nine years before her death.
Walter was caught in another inconsistency when Guerrero proved he grossly misstated the amount of contents in Neal-Lypps’ stomach at time of death, important in judging whether a drowning is accidental or homicide.
Guerrero presented a photograph of the whiteboard Walter used during the autopsy, which showed a measurement eight times higher than what Walter listed in his report and testified about on the stand. Defense investigators remeasured the stomach contents and found them eight times larger than Walter’s testimony and report, supporting a defense argument that Neal-Lypps’ drowning may have been accidental or the result of a medical emergency.
Jurors ultimately acquitted Lypps.
Walter has also performed autopsies or written final reports on inmates who died while in custody at the San Luis Obispo County Jail. Among them: nine of the 11 inmates who died in the last five years, according to a review of autopsy reports provided by the county.
In January, Walter performed the autopsy on Andrew Holland, a 36-year-old Atascadero man who Walter said died of an embolism in his lung caused by a blood clot that formed in his leg. Holland died after being released from a plastic restraint chair he had been strapped to for 46 hours.
Walter listed Holland’s death as natural and did not state what caused the blood clot. An intrapulmonary embolism usually begins as a blood clot in a leg vein and can be caused by extended time sitting or lying down, according to the National Institutes of Health.
In defending the jail and county staff’s actions, Sheriff Ian Parkinson told The Tribune that Walter told him Holland’s “prolonged seated position is ‘possibly contributory’ to clot formation,” but that “the (restraint) chair itself does not cause clots to form.”
Holland family’s attorney, Paula Canny, says Walter’s reports can’t be trusted and that his last-chance agreement with the county constitutes a conflict. The county reached a $5 million settlement with Holland’s family last month.
Walter is also linked to a wrongful death claim in Kings County, where a County Jail inmate died after vomiting with a spit hood over his face, according to The Fresno Bee.
The family of inmate Donald “Donnie” Hill, 30, disputes Walter’s autopsy report in that case, which said Hill died of cardiac dysrhythmia with an unknown cause and listed the manner of death as undetermined, according to a news release from the Kings County Sheriff’s Office.
Walter did not conduct the autopsy of the last inmate to die in the SLO County Jail. On April 13, Parkinson asked the Santa Cruz County Coroner’s Office to do so; Cipolla said Parkinson wanted to be transparent and that Santa Cruz could perform the autopsy more quickly.
In late May, Walter ruled that the death of 20-year-old Ventura resident Baylee Gatlin at the Lightning in a Bottle music festival in Lake San Antonio was caused by acute LSD toxicity. That report was released in August.
The finding — which would make Gatlin’s cause of death one of the few recorded in history as an LSD overdose — was criticized by a nationally renowned professor of pharmacology and chemistry who reviewed the autopsy report at The Tribune’s request.
Dr. David E. Nichols, a pharmacologist and medicinal chemist considered a global expert on hallucinogens, told The Tribune that Walter failed to test for substances that were more likely to have killed Gatlin and used an arbitrary standard for fatal LSD toxicity.
“It’s totally bogus, and they need it to wipe it from their books,” Nichols said.
Walter’s report contains no physical cause of death.
The Sheriff’s Office said Friday that Walter and the county’s coroner’s investigators stand by their findings.
Tribune staff writer Monica Vaughan contributed to this article.