Experts warned North Carolina in 2001 that it needed to change its medical examiner system.
But 13 years later, the state’s own data show that problems remain and in some important ways may have gotten worse.
An Observer analysis of state records shows local medical examiners seldom visit death scenes. In some cases, they don’t view bodies before closing cases. With little or no training, they have made egregious errors while investigating sudden and unexplained deaths.
“It’s a public policy failure,” said former State Sen. Eleanor Kinnaird, a Chapel Hill Democrat who was in office in 2001. “The blame lies directly with the legislature.”
A 2001 state study group made nearly two dozen recommendations. They included mandatory training, hiring professional investigators and seeking accreditation from the National Association of Medical Examiners, which sets minimum standards.
The General Assembly, controlled by Democrats at the time, failed to implement most of the major proposals.
The mishandling of three deaths at a Boone hotel last year has put the state medical examiner’s office, and its supervisors in the state Department of Health and Human Services, under scrutiny again.
Aides say that Secretary Aldona Wos, who has declined interview requests from the Observer for 11 months, is now prepared to act on the 2001 report’s recommendations. They say Wos wants national accreditation for the chief medical examiner’s office in Raleigh, better training and other changes.
“We’ve got tremendous support from our administration to do more,” said Dr. Robin Cummings, acting state health director. “Yes, there is more we can do.”
In his May 13 budget proposal, Gov. Pat McCrory asked lawmakers for $1 million to fix some of the problems, including:
‘Change starts at the top’
North Carolina’s medical examiner system is one of the most poorly funded in the nation. Convincing lawmakers to spend more won’t be easy.
In 2010, Republicans swept into power in the General Assembly by promising lower taxes and less government regulation. A $20 billion state budget passed last year cut some state programs.
Changes to the medical examiner’s office would have to win approval from lawmakers such as State Sen. Louis Pate, a Mount Olive Republican. Pate is co-chairman of the Appropriations on Health and Human Services standing committee, giving him major discretion on budgets.
Pate questions whether spending more money would produce stronger death investigations.
Dr. Robert Farnham, a Charlotte pathologist who chaired the 2001 study group, said the medical examiner’s office lacks high-ranking allies in the General Assembly. He said he was not surprised lawmakers largely ignored the 2001 report, because they have other priorities.
“Change starts at the top,” said Farnham. “It doesn’t start with a committee. Virginia built a first-class system because some big shot said, ‘We gotta do this.’ ”
To change the medical examiner system, Farnham said, “You need a zealot with some power.”
Uncovering serious flaws
An Observer investigation spurred the 2001 commission. Those stories uncovered serious problems, including the failure to autopsy thousands of fire, drowning and suicide deaths.
As a result, state lawmakers raised medical examiners’ pay from $75 to $100 per case. They also approved funding for a $52 million building – unveiled in 2012 – that the chief medical examiner’s office shares with another agency. The facility in Raleigh triples the agency’s capacity for autopsies.
But other major recommendations were ignored.
Last year, the system’s flaws proved fatal.
When an elderly couple died in a Boone hotel room, the local medical examiner, Dr. Brent Hall, did not go the scene. Hall did not warn the state toxicology lab in Raleigh about the suspicious circumstances and did not ask that tests be given a priority.
At that time, the state did not require medical examiners to provide descriptions of the circumstances about deaths with blood samples sent to the lab.
The state took nearly six weeks to determine that carbon monoxide killed the couple. Even then, no one acted. The next weekend, carbon monoxide leaked into the hotel room and killed 11-year-old Jeffrey Williams.
In response, Wos of DHHS said that Jeffrey Williams’ death “should have never happened” and that she instructed staff to identify remedies to prevent future tragedies.
State Chief Medical Examiner Dr. Deborah Radisch said money and staffing shortages persist, but she believes state officials are more committed than their predecessors to producing strong death investigations.
No constituency for dead
Pate, the Senate committee chairman who represents parts of Wayne, Pitt and Lenoir counties, said he didn’t know about the current troubles in the medical examiner's system. He said he was surprised there are cases where local medical examiners do not view bodies.
“There may be medical malpractice, neglect or a nefarious scheme,” that goes undetected, Pate said. “Those things need to be ruled out. We don’t want there to be a crime and it is overlooked.”
But told that North Carolina receives significantly less money than many systems across the country, Pate said he does not agree that more money is needed. A 2007 national survey found the average state medical examiner’s office spends $1.76 per capita, but N.C. spends less than half that – about 84 cents per capita.
Kinnaird, the former state senator who served 17 years in the legislature before leaving in 2013, said other agencies receive more money from lawmakers because “there is no constituency” for the dead.
“They have only their families to speak for them,” Kinnaird said. “Compare that to the farm lobby. You’ve got the pork lobby. Look at the bank lobby. The insurance lobby. If you don’t have a constituency asking the legislature to fund this, it goes nowhere.”
Reporter Ames Alexander contributed to this report.