On the day in 2012 that 4-month-old James “Bo” Phillips died in coastal Brunswick County, the local medical examiner didn’t visit the scene or question the infant’s parents. But he ruled the death an accident.
Bo’s mother told hospital staff she’d been sleeping with the baby – and might have rolled over on him.
A year and a half later, it happened again. Bo’s 8-month-old brother, Luke, died under nearly identical circumstances. The medical examiner again called it an accident without visiting the scene.
“If there had been any serious investigation after Bo died, I feel like Luke’s death wouldn’t have happened,” said Seth Phillips, the father of the two babies.
While the deaths in Oak Island were unusual, the investigations were not.
North Carolina medical examiners almost never go to infant death scenes and sometimes flout a state requirement to look at the baby’s body – two steps that national experts say are vital to competent inquiries.
A recent Observer series revealed that the state’s medical examiners often fail to follow crucial investigative steps, raising questions about the accuracy of thousands of death rulings.
By some measures, medical examiners investigate infant deaths even less rigorously than those of adults – and less thoroughly than they did a decade ago.
Medical examiners visited death scenes in just 2 percent of infant death cases last year, compared with 7 percent in 2003, a new Observer analysis found. When investigating adult deaths, medical examiners went to the scene 9 percent of the time last year.
“That’s pretty dismal,” Dr. Gregory Schmunk, chairman of the National Association of Medical Examiners board of directors, said of North Carolina’s low rate of visiting infant death scenes. The numbers, he said, suggest that the state is falling far short of best practices.
Experts say infant deaths deserve special attention because children are vulnerable to abuse and neglect. Thorough infant death investigations, they say, help educate parents and identify dangerous caregivers. And they reveal patterns that help communities reduce infant sleep deaths, violence against youths and other threats to children.
Although the number of infant deaths has declined in recent years, the mortality rate in North Carolina – about 7 infant deaths for every 1,000 live births – remains above average, according to the National Vital Statistics Reports.
“We ought to be horrified about someone totally vulnerable being abused or killed,” said Dr. Brian Peterson, chief medical examiner for Milwaukee County, Wis., whose office is nationally accredited. “How do we protect those kids? By careful study.”
If someone dies under mysterious circumstances, one of the state’s roughly 350 medical examiners helps determine whether the death resulted from homicide, suicide, an accident or a natural cause. They decide which cases should be sent to pathologists for autopsies.
But North Carolina depends on untrained medical examiners and performs fewer autopsies than the nation’s top systems.
Officials with the North Carolina medical examiner’s office defend their practices, saying they’ve significantly improved infant death investigations.
They note that even when medical examiners don’t view the bodies of infants, trained pathologists usually do. Medical examiners failed to view bodies in 16 percent of infant death cases last year, state data show. Pathologists autopsied 93 percent of infant cases.
While medical examiners usually don’t go to infant death scenes, police officers almost always do, state officials say.
The state offers a voluntary two-day training session on child-death investigations, providing tips on how to identify signs of homicide, sudden infant death syndrome and other causes of death. Police are among the more than 3,000 emergency workers, medical professionals and others who have attended the training. That represents a fraction of the roughly 20,000 law enforcement officers who work in North Carolina.
“Our child death investigations in North Carolina, I’d put them up against pretty much anybody around us,” said Lisa Mayhew, the medical examiner office’s child death investigator and trainer.
But national experts fault the state’s approach. Police must focus primarily on solving crimes, the experts say, not on determining how people died.
What’s more, they say medical examiners in top systems get far more training in death investigations. In some places, new hires must shadow seasoned investigators for weeks before being assigned cases.
Chris Morgan, a former Raleigh homicide detective who retired in 2004, said two days of training isn’t enough to turn police officers into top-notch infant death investigators. Besides, he said, police officers have other responsibilities.
“I probably should have gone further on some of the ones I had questions about,” Morgan said of the infant cases he investigated. “But I had X number of hours in the day and four homicides that I knew were homicides.”
‘The eternal question’
Medical examiners are responsible for investigating high-stakes cases: suspicious, violent and accidental deaths. Their rulings help determine whether killers get charged, safety hazards get addressed and families get the life insurance payments they deserve.
But North Carolina has one of the nation’s most poorly funded medical examiner systems. It relies on doctors and nurses to perform death investigations in their off-hours, and pays them just $100 per case – regardless of whether they visit scenes or view bodies.
Some medical examiners consider themselves volunteers. The state doesn’t require them to get training, and rarely punishes them when they break the rules.
As a result, many infant deaths get little scrutiny. Consider:
According to notes taken by a state official, the baby’s mother came home drunk with the infant around 1:30 a.m. and fought with the father. The notes also state that the mother later snatched the baby out of his crib, took him to her room and went to bed. Later, the boyfriend found the baby cold and unresponsive.
The cause of death was labeled “undetermined,” and the Moore County district attorney’s office declined to prosecute.
The medical examiner, a registered nurse named Max Muse, said authorities in his county work well together to investigate infant deaths. He said he prefers to visit death scenes when he can because “you can learn so much more from viewing all your information firsthand.” But he could not recall why he didn’t view the body or visit the scene in the Za’hiem Ocean case.
Muse, 57, has worked as a medical examiner since 2001. Since then, state data show he has visited death scenes in about a third of all of his cases – significantly more than most North Carolina examiners. But Muse also failed to view bodies in about 23 percent of all of his cases, twice the state average.
Dr. Ljubisa Dragovic, chief medical examiner for the nationally accredited Oakland County, Mich., office, said he finds it “unbelievable and unacceptable” that the manner of death in Joseph’s case was changed from accidental to natural without an autopsy.
An autopsy, he said, could have helped to determine whether mistakes during surgery – or any infection that might have developed afterward – played a role in the baby’s death.
“We should give the family the information they want and need,” he said.
“They want to know. They want to understand. They have the eternal question, ‘Why?’ ”
What police may not see
Top medical examiner offices order trained police investigators to interview caretakers and parents, fill out a checklist of questions and document details from the scene, such as the presence of drugs or alcohol.
The Observer interviewed nearly a dozen national experts. Best practices, they said, call for trained medical examiners to visit every scene and ask caretakers to use dolls to re-enact what happened.
Dr. John Howard, chief medical examiner for the nationally accredited office in Spokane County, Wash., said relying on police for interviews and scene information increases the likelihood that medical examiners will misdiagnose infant deaths.
“A medical investigator has seen many more deaths,” he said. “They may see something a patrol officer in a hurry to get back on patrol may not see.”
North Carolina’s system, which is not accredited, doesn’t require examiners to attend death scenes. Instead, the state medical examiner’s office relies on police to interview witnesses, take photographs and gather other evidence.
Since 2011, new police officers have received about 30 minutes of instruction on infant death investigations as part of their four-month training.
North Carolina officials insist it’s not necessary for examiners to visit scenes because they can get detailed information from police. Mayhew, the state investigator and trainer, said improved police work has enhanced the understanding of infant sleep deaths.
“It’s getting done quite well,” Mayhew said. “ It’s just that law enforcement is responsible for it.”
But Dr. Victor Weedn, a nationally recognized forensic pathologist, questions why North Carolina would rely on officers with little training and experience handling infant death cases.
A detective may investigate one child death in a year, Weedn said.
“There are people who devote their entire careers to just that,” Weedn said. “They (police) are not trained medically, and we can sometimes catch things they don’t.”
‘Twice in the same house’
On the night of June 25, 2012, Seth Phillips was stationed on a Coast Guard ship docked at Oak Island when he talked to his wife by phone. He could tell from Katherine Jennings’ voice that she’d been drinking, he said. The next morning, Phillips got the news: His son Bo was dead.
“If anyone had even talked to Katherine, I think they would have discovered that she’d been drinking too heavily,” he said.
Records show Jennings had a history of legal problems involving alcohol. She has been charged at least four times with driving under the influence in Georgia.
When Bo died, Jennings said she had been sleeping with her son and must have “rolled over on him,” though she wasn’t sure, according to a report by staff at Dosher Memorial Hospital in Southport. She woke to find the baby unresponsive.
The medical examiner, an internist named Dr. Douglas Hiltz, was responsible for investigating. But he never visited the home or talked to the baby’s parents.
Hiltz concluded that the baby died as a result of accidental suffocation. The state medical examiner’s office later changed the cause of death to “undetermined.” It’s unclear why. Officials with the medical examiner’s office did not respond to questions about individual cases.
In early 2013, Jennings gave birth to another baby – Luke Phillips.
On Dec. 13 of that year, Seth Phillips was on his ship when he got an early-morning phone call. Luke, too, had died.
Hiltz again did not visit the home or talk to the parents. He concluded the baby accidentally suffocated. The state medical examiner’s office agreed and said that “co-sleeping” – when parents sleep with infants – was a contributing factor.
David Crocker, a deputy coroner who said he collaborated with Hiltz on the investigation, said he did go to the house after the second death and initially agreed with the medical examiner’s findings. Now, however, he questions whether Luke’s death should be called an accident.
“Twice in the same house? That has to be investigated,” Crocker said. “You have got to stop and take a second look.”
Hiltz noted that he works as a hospital emergency room doctor and generally cannot leave to attend death scenes. He said it is unfair to expect medical examiners to visit most death scenes.
“It’s a volunteer job,” said Hiltz, who has worked as a medical examiner for more than 20 years. “It’s done for community service.”
Hiltz said he does not believe police pay much attention to medical examiners unless they can identify signs of trauma on the corpse. “The police are not expecting much from me. Basically what they want from me is the time of the autopsy.”
For North Carolina to follow national best practices, such as sending medical examiners to each scene, it “would have to have a different system,” Hiltz said.
In August, after the Observer began asking questions about the deaths, Brunswick County prosecutors charged Jennings with involuntary manslaughter in the second baby’s death. She was released from jail after posting a $50,000 bond. Her lawyer, Dustin Sullivan, won’t allow her to talk to the press.
Sullivan said it’s too soon to say how Jennings would plead and whether the state was justified in filing the involuntary manslaughter charge.
“No matter what happens, everybody loses,” he said.
Staff writer Gavin Off contributed.