Three senior officials at the base were disciplined following the 18-month investigation. The three disciplined officials were then-Port Mortuary Director Quinton Keel, former Deputy Director Trevor Dean and the former Air Force Mortuary Affairs Operations commander, Col. Robert Edmondson.
The investigation was conducted after allegations were raised by three whistle-blowers at the base's mortuary affairs office -- James Parsons, Mary Ellen Spera and William Zwicharowski -- regarding improper handling, processing and transport of human remains of deceased personnel and military dependents.
The whistle-blowers had expressed concern about the improper preparation of remains of a deceased Marine; improper handling and transport of possibly contagious remains; improper transport and cremation of fetal remains of military dependents; and the failure to resolve cases of missing portions of remains.
"The report presents disturbing findings and conclusions that AFMAO leadership failed to adequately address the loss of accountability, even after a second incident occurred within months of the first," special counsel Carolyn Lerner wrote in a letter to Air Force Secretary Michael Donley. "More concerning, however, are the findings that these managers ignored evidence given to them, presented baseless explanations that were 'simply not credible' and took affirmative steps to conceal the problem.
"The Air Force concluded that the loss of accountability of these portions resulted in 'a negligent failure' to meet the requisite standard of care for handling remains and several violations of agency rules and regulations.
"I do note with concern, however, the conclusion that, because there is no law, rule, or regulation specifically requiring notification to the family when a portion is lost, there was no finding of any wrongdoing by failing to provide such notification. The fact that there is no specific provision for a scenario that, until these cases, was largely unanticipated does not remove the question of whether a duty was owed to inform the families when Port Mortuary personnel determined they could not guarantee that disposition of the remains had been carried out in accordance with their instructions.
"I further note that the Air Force has taken significant corrective action to address these issues and improve the accountability of remains. However, given the pattern of negligence, misconduct, and dishonesty by ... Keel and ... Dean, and the 'failure of leadership' by ... Edmondson, I question whether the Air Force has taken appropriate disciplinary action."