N.C. Medical Examiners

Fatally Flawed: Broken death investigation system leaves families in pain

Across North Carolina, medical examiners fail to follow crucial investigative steps, raising questions about the accuracy of thousands of death rulings.

The living face the consequences.

Widows can be cheated out of insurance money. Families may never learn why their loved ones died. Killers can go free.

Because of a medical examiner’s mistake, Cathy Wilson had her husband’s body dug up to show what killed him. Shannon Santimore had to fight for three days in court to prove that her husband did not commit suicide.

After a medical examiner concluded David Worley died in a car wreck, a funeral home discovered what the examiner missed: four stab wounds in his back. His widow is now charged with killing him.

“People can get away with murder if the medical examiners don’t do the job,” said Worley’s mother, Ella Grant. “Their job is to check bodies from top to bottom. That did not happen.”

A Charlotte Observer investigation, entailing the most comprehensive analysis of state death rulings ever conducted, found that examiners regularly close cases without following recommended practices.

Medical examiners are called in to investigate when the stakes are highest: suspicious, violent, accidental and unattended deaths. Those account for about 10,000 of the roughly 75,000 deaths in North Carolina each year.

But the state doesn’t require examiners to get training and rarely disciplines them when they break the rules.

Dr. Deborah Radisch, the state’s chief medical examiner, acknowledged shortcomings in death investigations, and blamed them on a lack of money.

“ We’re trying to do the best we can with what we have,” she said.

Last year, the state’s failings – and sloppy paperwork – proved deadly.

After an elderly couple died the same night in a Boone hotel room, the local medical examiner, Dr. Brent Hall, did not go to the scene. Hall also didn’t alert the state toxicology lab in Raleigh about the mysterious circumstances – or ask that tests be rushed.

At the time, the state didn’t require that examiners include a description of death circumstances with blood samples sent to the lab.

It took the state nearly six weeks to determine that carbon monoxide killed the couple. Even then, no one warned the public. The next weekend, the poisonous gas leaked into the hotel room again and killed 11-year-old Jeffrey Williams.

Hall, who has declined interviews, resigned as medical examiner. The state denied wrongdoing, but three days after Jeffrey’s death, it changed its policy: Pathologists must now include descriptions of each death with any specimen submitted to the lab.

Little training, low pay

Unlike television crime dramas, where death investigators swarm the scene and take microscopic samples, North Carolina’s medical examiner system operates much the way it did 40 years ago, when the population was about half as large.

Here’s how it works:

If a person dies in mysterious circumstances, one of the state’s roughly 350 medical examiners is called to investigate.

The state recruits medical examiners for each county by canvassing hospitals or placing ads in newspapers. The state’s chief medical examiner can appoint nurses, coroners, physician assistants and paramedics.

But most medical examiners are full-time doctors who perform death investigations on the side. The state requires no investigative training, provides little equipment or guidance and pays just $100 per case. It pays them no mileage.

By comparison, North Carolina pays transporters $90 – plus additional money for trips longer than 40 miles – simply to move the body.

Still, the state gives medical examiners a big responsibility: determining whether suspicious deaths in their counties result from homicide, suicide, accidents or natural causes.

They’re required to take blood samples and send them to toxicologists in Raleigh. They also decide which cases should be sent to pathologists for autopsies.

Radisch oversees all the state’s medical examiners, pathologists and toxicologists. Her Raleigh office has the final say on every ruling – and every death certificate in cases it accepts.

‘Messing with people’s lives’

When a medical examiner gets it wrong, challenging the ruling can take years and cost families thousands of dollars.

Cathy Wilson is still fighting.

On a rainy morning in 2011, her husband, Jim, was driving near home in the mountain town of Andrews when his pickup ran off the road and crashed into a tree.

Jane Barwick, a nurse practitioner who is medical examiner in Cherokee County, did not go to the scene. She did not order an autopsy despite guidelines requiring an exam in “any death where there is a reasonable suspicion that trauma (external force) may have been the cause or a contributing cause.”

From 2001 to mid-2013, the period for which the Observer obtained state data, Barwick went to a death scene just once in about 200 cases she handled; she did not view bodies in 41 percent of cases, though she did examine Wilson’s body. She noted bruising on his abdomen and a laceration of his left eyelid, but concluded he died of a heart attack. Barwick did not respond to interview requests.

It was only when Cathy Wilson tried to collect on her husband’s life insurance policies that she realized the consequences of Barwick’s ruling. Two of his three policies paid only if his death resulted from an accident.

Wilson had her husband’s body exhumed and sent to Raleigh, where Radisch performed an autopsy. It showed he died of injuries caused by the crash.

The insurance companies paid up – around $300,000, Wilson said. Now, three years later, she is trying to get back the money she spent fighting the state.

“When the medical examiner does something like that she’s just messing with people’s lives,” she said. “It causes a lot of pain.”

Rules routinely broken

The state rarely holds local medical examiners accountable.

Examiners are supposed to follow a short list of guidelines, including one that requires them to view each corpse. But they have failed to view more than 13,000 bodies since 2001. They usually collect their fee whether they examine corpses or not.

State rules call for autopsies on any charred, skeletonized or decomposed body – a step that helps ensure murders aren’t overlooked or covered up. But medical examiners don’t always order autopsies in those cases. From 2001 until mid-2013, the remains of about 350 people weren’t autopsied, the Observer found.

In one 2008 case, Ronald Key, a Guilford County medical examiner, failed to order an autopsy on a corpse burned in a car crash.

The wreck killed three women, two of whom Key mistakenly swapped and sent to the wrong funeral homes. The brother of Lorraine Young, one of the victims, discovered the mistake when he went to a New Jersey funeral home to see her remains. It wasn’t his sister.

The state was recently ordered to pay nearly $400,000 to Young’s relatives.

N.C. guidelines also call for autopsies in deaths that are suspected to be drug-related as well as apparently natural deaths of known alcoholics and drug abusers. Such guidelines help identify drug-related fatalities and give communities insight needed to fight public health threats. But in more than 4,000 cases since 2001, the state allowed such corpses to be buried without autopsies.

Dr. Gregory Davis, a Kentucky forensic pathologist and former N.C. medical examiner, said it is difficult to hold medical examiners accountable because the state doesn’t require training or visits to death scenes.

When he complained about the relative lack of training and accountability of medical examiners in the 1990s, state officials told him “not to put too much pressure on these guys. They are volunteers and they will quit,” Davis said.

The state has rescinded the appointments of just four of the hundreds of examiners who have served over the past 20 years. All were dismissed since 2010 when Radisch took office.

One of those medical examiners – Kathy Rogers from Iredell County – failed to properly investigate numerous cases, including homicides, Radisch said. Two of the other medical examiners, in Gaston and Iredell counties, were cited for delays and failing to file investigative reports.

‘Operating on the cheap’

The average state medical examiner system spends $1.76 per capita on its death investigation system, according to a 2007 survey by the National Association of Medical Examiners (NAME).

Last year, North Carolina spent less than half that – about 84 cents per capita.

Told how much the state spends, Dr. Vincent DiMaio laughed. Bexar County, Texas, where he once served as chief medical examiner, spends more than $2.30 per capita.

“You get what you pay for,” said DiMaio, a nationally recognized pathologist who heads the Texas Forensic Science Commission. “ You're operating on the cheap.”

Some states rely on trained, full-time death investigators to visit scenes and gather evidence.

Not North Carolina. Only Mecklenburg County and the chief medical examiner’s office in Raleigh have full-time death investigators.

The $100 fee paid to N.C. medical examiners provides little incentive to get up at night or travel to death scenes, experts say.

“The entire system is completely underfunded and has been since its inception,” said Dr. Patrick Lantz, a longtime forensic pathologist at Wake Forest Baptist Medical Center in Winston-Salem. “It’s like having a volunteer fire department in Charlotte.”

Radisch acknowledged that the office needs additional funding. The state and its counties spent $8.3 million on the system last year.

“The system has been neglected at a variety of levels over the years,” she said. “Its importance has not been recognized.”

In years past, North Carolina has offered annual training, but examiners had to pay their own way to attend. The training was suspended last year because the state lacked money.

Dr. Luis Munoz, a pathologist who specializes in natural disease at MedWest Hospital in Haywood County, quit his medical examiner post about 10 years ago. Munoz said he was “uncomfortable at times and not totally informed. I have never fired a gun yet I am describing gun wounds and gun calibers on shooting victims.”

A mother’s questions

Last July, state troopers told David Worley’s mother

(Family photos)

her son died in a car crash.

But why was there so much blood on the seat if he was thrown from the car?

Later, one of Worley’s children told family members he saw his mother stab his father, according to a search warrant affidavit. Tipped off by the family, a funeral home worker found strange wounds on Worley’s body that the medical examiner did not see.

Only then was an autopsy ordered. A pathologist found four stab wounds in Worley’s back, one deep enough to kill him. The weapon appeared to be an 8-inch butcher knife.

Worley’s widow, Toni Marsha Talley, was moving out of her home in Spring Lake, near Fort Bragg, when authorities arrived. She is now charged with first-degree murder.

The local medical examiner – a 65-year-old family doctor named Dr. Linda Robinson – said she viewed Worley’s body at the morgue but didn’t see the stab wounds because she didn’t turn over the 218-pound corpse.

“Even if I wanted to turn it over, I couldn’t have,” she said, explaining that she has had knee and ankle surgeries in recent years and walks with a cane.

In failing to view the back of the body, Robinson violated a state guideline: “The body should be critically inspected, including the back, both before and after removal of clothing.”

Robinson said injuries on the front of Worley’s body seemed severe enough to kill him.

Had the child not spoken up, the suspect “could have gotten away with murder,” Robinson acknowledged. “There’s no doubt about it.”

Robinson, who did not go to the crash site, visited death scenes in only 2 percent of the cases she investigated since 2001.

Ten months after Worley’s death, the state completed its investigation and ruled the case a homicide. But the family is still waiting for the death certificate. Until they receive it, they cannot collect the life insurance.

Worley’s mother said she simply wants justice for her son.

“Medical examiners, they need to be examining a little more,” Ella Grant said. “Because I’m sure this has not only happened to my son. It’s probably happened to many people. But it’s time for them to get it right.”

Researcher Maria David contributed.