N.C. medical examiners are supposed to investigate suspicious and violent deaths, but the state’s former chief medical examiner for years was aware of careless work that raised the risk of faulty death rulings.
Now, Dr. John Butts, who oversaw death investigations for 23 years, is expected to testify this week in an unprecedented attempt to hold the state’s medical examiners accountable for their mistakes.
At issue in the hearing before the N.C. Industrial Commission is whether the state should pay damages to grieving families for egregious errors by medical examiners.
During his tenure, Butts told the Observer last week, some medical examiners closed cases without viewing bodies or failed to follow other guidelines. Experts contend that visually inspecting corpses is considered a crucial first step in determining how a person died.
Butts, who retired in 2010, said he could not discipline medical examiners for flawed investigations because they are not state employees. Medical examiners are appointees, paid $100 per case.
“I can’t demote them,” Butts said. “I can’t fine them.”
Despite some problems, Butts believes the system is still effective.
Four families have sued, seeking damages for emotional, mental and physical distress after investigative errors.
In one case, a Franklin County medical examiner declared a living man dead and sent his unconscious body to the morgue, zipped inside a body bag. The man’s family says the mistake has left him bedridden and unable to speak.
In three other cases, families were confronted with faulty investigations that they say deepened their pain or cost them life insurance payouts. They allege medical examiners did not follow generally accepted practices, including failing to order needed autopsies or view the bodies of the deceased.
Attorneys and state officials say they believe it is the first time in North Carolina that families have tried to make the state liable for the actions of medical examiners.
North Carolina law grants broad protections to public officials who make mistakes in the line of duty.
The N.C. attorney general’s office has said the law shields the government from liability because medical examiners work for the public and have no duty to individual families.
“There is not a single mention of the next of kin,” in the state law that sets the duties of medical examiners, state attorney Olga Vysotskaya said last year.
History of problems
Families, law enforcement, insurance companies and researchers depend on medical examiners to find the cause of death in shootings, suicides, and other sudden or suspicious deaths.
They inspect corpses, interview witnesses and seek other evidence to determine the manner of death, which includes five broad categories: natural, accidental, homicide, suicide or undetermined. They issue rulings on the probable cause of death.
A good investigation can help solve crimes, determine insurance payouts, identify public health threats and ensure nothing is overlooked in a suspicious death.
In 1967, North Carolina became a national leader by replacing county coroners who had little or no medical expertise with state-appointed medical examiners. But the system was designed for a small, rural state where doctors had time to investigate cases in their spare time. In recent years, the state has had trouble recruiting enough doctors. Paramedics, nurses and others perform the work.
A 2001 Observer investigation found medical examiners failed to detect at least five homicides over a five-year period. Errors and oversights jeopardized hundreds of other investigations. The report found as many as 4,400 apparent suicides, drownings and fire deaths were not autopsied.
Unlike states and counties with leading death investigation systems, North Carolina has no mandatory training for medical examiners.
Butts said he would sometimes travel from his agency’s former headquarters in Chapel Hill to different counties to help medical examiners. A limited budget and short staffing prevented the state from offering extensive training, he said.
When medical examiners made errors, Butts said he would offer advice on how to improve their performance instead of rescinding their appointments.
“We would use it as an educational episode,” Butts said.
Despite the issues, Butts said the vast majority of cases are properly handled.
Current Chief Medical Examiner Dr. Deborah Radisch said she first noticed some medical examiners were not viewing bodies – which is recommended to check for evidence of violence, trauma or other signs of unnatural death – while she was in training in 1983.
In some instances, she said, bodies have been buried or cremated before a medical examiner can see them because they are not initially reported as suspicious deaths.
But in a December 2011 memo to the state’s medical examiners, Radisch criticized them for failing to inspect corpses.
“Many medical examiners have fallen into the bad habit of not viewing bodies over which they have assumed jurisdiction, and this behavior defeats a main purpose of the medical examiner system,” Radisch wrote.
Since she became chief medical examiner, Radisch said she has taken the unusual step of rescinding the appointments of two medical examiners for failing to follow state guidelines on death investigations.
Forensic pathologists inspect medical examiners’ investigative reports to ensure investigations are thorough and accurate, Radisch said.
Car wreck, then questions
In a Hillsborough courtroom this week, Butts will testify about the state’s investigation into the 2008 death of Lorraine Young, 40, of Baltimore.
Her family filed a suit in 2010 against the N.C. Department of Health and Human Services, which oversees the death investigation system, and the N.C. Department of Crime Control and Public Safety.
The suit alleges that after Young and two friends died in an auto wreck near Greensboro, a Guilford County medical examiner failed to independently verify her identity and shipped the wrong corpse to a New Jersey funeral home.
Edward Young, her brother, opened a box at the funeral home expecting to see Lorraine’s body. Instead, he saw another woman.
The shocking discovery set off a frantic three-day search for Young’s body that ended only hours before a Greensboro funeral home – unaware it had her body and not one of her friends’ – was scheduled to cremate the remains.
Butts told the Observer that the state handled Lorraine Young’s death properly. Butts defended the medical examiner’s decision not to conduct autopsies or other identification tests. He said the state performs autopsies in relatively few traffic deaths.
Given that medical examiners investigate more than 10,000 deaths a year on a tight budget, “you have to be reasonable,” Butts said.
But documents show that Guilford County Medical Examiner Ronald Key did not follow state guidelines governing death investigations.
Key failed to order an autopsy or other tests to determine the crash victims’ identities, even though fire disfigured Young’s face and upper body.
State guidelines dictate that medical examiners order an autopsy when bodies are badly burned.
“One of the primary duties is to accurately identify the body,” said Chet Rabon, a Charlotte attorney who represents the Young family. “Everybody has the expectation medical examiners will perform their duties. He didn’t make an attempt.”
Key declined comment.
But testifying in a 2011 deposition for the lawsuit, he acknowledged making mistakes.
“I’ve learned from this particular case,” Key said. “It has not happened and hopefully will not happen again.”