The US air force has disciplined three senior officials at its largest mortuary after finding that they repeatedly lost the body parts of deceased servicemen and in one instance removed a fallen soldier's arm without seeking his family's permission.
An 18-month investigation into the Dover Air Force Base mortuary in Delaware uncovered "gross mismanagement" and a "pattern of negligence, misconduct, and neglect" in the way it handled the remains of some 6,000 American soldiers killed in Iraq and Afghanistan in the past decade.
When junior staff attempted to blow the whistle on wrongdoing, they were first ignored and then retaliated against. One was threatened with redundancy. Their superiors meanwhile "knowingly misrepresented" the affair to government inspectors attempting to establish what had gone wrong.
"They knew about these problems about two and a half years ago and only recently took action to correct them," said Carolyn Lerner, who heads the White House's Office of Special Counsel. "Those responsible have been treated with kid gloves. They haven't been fired. In fact a job was created for one of them in order to keep him employed."
Ms Lerner's report identified multiple examples of wrongdoing at the mortuary in recent years. In at least two instances, pieces of tissue belonging to soldiers killed in explosions simply vanished from plastic bags in which were stored. Their families were not informed. In a third example of "systematic" and "egregious" misconduct, mortuary staff removed the arm of a dead soldier with a hacksaw, without seeking permission from relatives. The man's family had asked for him to be dressed in uniform and placed in an open casket. But embalmers were unable to fit his corpse into the coffin in its original state because intense heat from the fatal explosion had fused the arm at 90 degrees to his body.
The report holds three members of senior staff responsible for the mishandling of remains. They are Robert H Edmondson, the mortuary's former commander; Trevor Dean, his former deputy; and Quinton R Keel, the former mortuary director. Mr Edmondson received a letter of reprimand. Mr Dean and Mr Keel were demoted. Ms Lerner said: "I question whether the Air Force has taken appropriate disciplinary action."
Though the trio are accused of incompetence rather than criminality, the report claims that Mr Keel deliberately misrepresented his actions to investigators. It adds that he attempted, unsuccessfully, to fire a whistle-blower.
General Norton Schwartz, the Air Force chief of staff, acknowledged "systematic failures" at Dover and ordered a review of the management of the entire mortuary to be completed in the next two months.