This week, The Charlotte Observer published the results of a two-year investigation into the way suspicious deaths are investigated in North Carolina. It revealed that the state’s death investigation system is fraught with serious problems–problems that have been known for a decade or more.
The Observer began its investigation in 2012 after several families sued the state for mishandling investigations of their loved ones. These problems gained national attention last summer when seven-year-old Jeffrey Williams died of carbon monoxide poisoning while staying at a hotel in the mountain town of Boone. It turned out that an elderly couple from Washington state, David and Shirley Jenkins, died while staying in the very same room two months earlier. However, Watauga County’s part-time medical examiner, Brent Hall, never visited the room after the Jenkinses died. He also didn’t ask the state to put a rush on the Jenkinses’ toxicology tests. Although the state says Hall got the results on June 3, which showed that the couple had ingested a lethal dose of CO, he never shared them with local authorities. As a result, the police didn’t know that the Jenkinses had died of CO until June 10. By then, it was too late–two days earlier, Jeffrey had died and his mother, Jeanie, had suffered permanent damage to her brain and heart after being without adequate oxygen for 14 hours. Read more about this ordeal here.
However, it turns out that the rot extends far deeper than that. In most of the state, death investigations are done on the cheap. The state’s two largest counties–Mecklenburg, home to Charlotte, and Wake, home to Raleigh–have full-time medical examiner offices funded mostly with tax dollars. The other 98 counties farm out death investigations to one or more state-appointed medical examiners who handle investigations part-time–mostly doctors, but also some nurses, physician assistants and paramedics. The state pays them $100 per case. All told, North Carolina spends roughly 84 cents per capita on death investigations, less than half the national average and far less than what conventional wisdom would suggest for a state with 10 or more congressmen. That system was implemented in 1971, when the state was still more than half rural. But to put it mildly, it simply doesn’t begin to be adequate for a state with 9.8 million people. The state doesn’t require these part-time examiners to get specialized training, and provides only bare-bones oversight. It also seems hard to believe that the state can’t find enough qualified pathologists even though it’s home to four medical schools–UNC, Duke, Wake Forest and East Carolina. Although the state recommended reforms after several of these shortcomings were pointed out by The Observer in 2001, few of them have been implemented.
All too often, medical examiners don’t even follow the short list of guidelines provided by the state. For instance, even though one of the guidelines states in bold letters that examiners must personally examine every corpse. But The Observer found that in 11.1 percent of the cases reviewed from 2001 to 2013, examiners didn’t do that, even though nearly every expert in the field considers that one of the most basic steps in an investigation–indeed, some consider failure to view the corpse to be a firing offense. When you break it down by county, it’s even more stark–and the usual stereotype of rural counties getting the shaft doesn’t apply. In Chatham County, a fast-growing exurb of the Triangle, examiners failed to view the body a whopping 59 percent of the time, the highest in the state. Almost as staggering, medical examiners only conducted autopsies in 40 percent of their cases.
With so many holes in the system, it should come as no surprise that there can be some ghastly mistakes. Here are some examples:
- When Tim Wilson died in a 2011 car accident, the nurse practitioner who doubled as Cherokee County’s medical examiner didn’t order an autopsy, and ruled Wilson had died of a heart attack after a cursory investigation. As a result, his widow, Cathy, nearly lost out on life insurance that only paid out in the event of an accidental death. Cathy Wilson had the body exhumed and sent to Raleigh for an autopsy, which revealed that he had died of injuries sustained in the accident. While Cathy managed to get the insurance companies to pay her $300,000, she’s still trying to get the state to pay back the money she spent fighting the original ruling.
- In 2008, the medical examiner in Guilford County, home to Greensboro, failed to conduct an autopsy on Lorraine Young after she died in a fiery car accident. Even worse, he mistakenly swapped Young’s body with the body of one of her two friends who also died in the crash. Young’s family only discovered the mistake when they went to a funeral home to view her body just before it was due to be cremated–and discovered it was the wrong body. Earlier this month, the state industrial commission awarded Young’s family $400,000 in damages, pending appeal.
- Last July, the medical examiner in Cumberland County, home to Fayetteville and Fort Bragg, initially ruled David Worley had died after being thrown from his car in an accident. The family didn’t buy it, since there was a lot of blood in the car. Worley’s relatives later told funeral home workers that one of Worley’s children had seen his mother, Toni Talley, stab Worley in the back. The funeral home found several wounds missed by the initial exam, and an autopsy found Worley had died from four stab wounds in the back. Talley is now facing charges of first-degree murder. However, because of the delay in determining the cause of death, Worley’s family still hasn’t gotten the death certificate–and thus can’t collect on his life insurance. The medical examiner has since said that she didn’t see the stab wounds because her knees were too weak for her to turn over the body for a full examination.
Deborah Radisch, the state’s chief medical examiner since 2010, has tried to make improvements to the system. She has rescinded the appointments of four examiners in her tenure–the only such dismissals in the last 20 years. She has also reprimanded examiners who make a habit of not examining bodies. She wants to do more, but claimed she didn’t have the money to do so. However, in response to The Observer’s findings, Governor Pat McCrory included several requests for reforms in his proposed 2015 budget, including a requirement for a training program and greater funding for regional autopsy centers. These changes are at least 20 years overdue–and it shouldn’t have taken a little boy dying in a hotel for them to be made.
Darrell Lucus is a radical lefty Jesus-lover who has been blogging for change for a decade. Follow him on Twitter @DarrellLucus or connect with him on Facebook.
edited by tw
