N.C. Medical Examiners

It depends on where you die

How North Carolina investigates suspicious deaths depends largely on the county in which the person dies, a pattern that national experts say cheats families and distorts key statistics used to protect the public’s health.

Sloppy investigations mean killers could go free and grieving families could be denied the life insurance they deserve.

Take Johnston County. From 2001 to mid-2013, a period studied by the Observer, medical examiners there attributed more than 40 percent of the deaths they investigated to chronic ischemic heart disease – compared with a statewide average of 10 percent.

It’s probably not because of an epidemic of heart disease in the fast-growing county southeast of Raleigh, national experts say, but rather because medical examiners have not been thorough in doing their jobs.

When 80-year-old James “Tom” Cooper was found in a pool of blood in his kitchen in 2010, a Johnston medical examiner concluded the retired trucker died from heart disease. If not for pressure from Cooper’s family and sheriff’s deputies, the ruling might have stood and Cooper’s killer might still be free.

“It upsets me to know it could have ended right then and there,” said Stacey Franks, Cooper’s youngest daughter.

It didn’t. After detectives found that Cooper’s wallet and onyx ring were missing, they insisted on an autopsy. The exam showed that the back of Cooper’s skull had been bashed with what appeared to be the blunt end of a hatchet.

Their investigation soon focused on the real culprit: a woman with a history of larceny and drug violations, who is now serving time for manslaughter.

A Charlotte Observer investigation, entailing the most extensive analysis of state medical examiner data ever conducted, found wide variations from county to county in the way the state probes suspicious deaths. Consider:

Dr. David Fowler, chief medical examiner for the nationally accredited Maryland office, says the disparities in North Carolina’s numbers appear to be “symptomatic of a significant problem.”

“If people are not being consistent in the way they’re investigating and certifying deaths, the most important document in assessing your community’s health becomes a mockery,” he said.

Since 2001, medical examiners in Johnston attributed 44 percent of the suspicious deaths they investigated to chronic ischemic heart disease, the nation’s No. 1 cause of heart attacks.

No other North Carolina county had a higher percentage. And some of Johnston’s neighbors had rates below 4 percent, the Observer found.

“That is not something I would expect,” said Dr. Marilyn Pearson, Johnston’s health director, after being told of the newspaper’s findings.

Pearson said she wants to meet with the state’s chief medical examiner to find out how the office collected its information and to make sure it’s accurate.

Pearson said her office uses North Carolina death statistics to help identify the most pressing health concerns.

Her office’s top priority for 2010 through 2014: fighting heart disease.

‘It’s a crapshoot’

To understand why death investigations vary so much, it helps to know who’s doing them.

The state’s chief medical examiner appoints at least one medical examiner for each county; some counties have more than one.

Most of the state’s roughly 350 medical examiners are full-time doctors and nurses who investigate suspicious deaths in their off hours. They’re paid $100 a case to make initial cause-of-death rulings and decide whether corpses should be autopsied. They investigate roughly 10,000 cases a year.

But the state does not require them to undergo training and provides little guidance or supervision. That leaves local medical examiners to act largely on their own, with only a short list of guidelines to direct them.

As a result, says Dr. Todd Grey, Utah’s chief medical examiner, “you have a very disparate system with various parts of it functioning at different levels of competency. It’s a crapshoot.”

Utah operates a statewide system similar to North Carolina’s but requires training for its death investigators.

Dr. Gregory Hess, chief medical examiner for the nationally accredited Pima County, Ariz. office, said the variation in North Carolina’s numbers suggest “nobody is in charge.”

Mission not accomplished

In its mission statement, the N.C. Office of the Chief Medical Examiner promises it will “ensure consistent and competent” death investigations.

But the Observer’s analysis shows the state has missed that goal.

On Sept. 11, 2012, a 57-year-old Union County man was found dead at his home with a gunshot wound to his head and a gun beside him.

That same day, in the mountains of Madison County, law enforcement officials found a similar scene: A 51-year-old man was found dead at his home with a gunshot wound to his head and a gun beside him.

Both deaths were ruled suicides. But the investigations differed markedly.

In the Madison case, the medical examiner went to the death scene and ordered an autopsy – two measures that experts say help ensure accurate death rulings; in Union, the medical examiner took neither step.

That’s typical. Madison’s autopsy rate for suicides is about three times as high as Union’s, data show.

Steve Teeter, the medical examiner who handled the Union case, said that while he can’t remember the details of that death, he often calls pathologists at the Mecklenburg County medical examiner’s office for guidance on whether to order autopsies.

Teeter, a nurse and paramedic, became a medical examiner in late 2011. He has visited death scenes in about 5 percent of his cases since then. Asked why he doesn’t attend scenes more often, he said he can usually get details about scenes by talking to police officers or paramedics.

‘Making assumptions’

Johnston, an Eastern North Carolina county known for its farms and historic sites, appears to be among the places where death investigations are least thorough.

In addition to being the county where medical examiners are least likely to request autopsies, it’s also among the spots where medical examiners are least likely to view bodies in cases of unexplained death.

From 2001 to mid-2013, medical examiners there failed to examine corpses in about 44 percent of cases – a higher percentage than any county but Chatham County, the Observer found. State rules require medical examiners to view bodies in the cases they investigate.

Since 2001, all but a small fraction of medical examiner cases in Johnston have been handled by one physician – a pathologist named Dr. Leslie Taylor III. Taylor did not respond to questions and to repeated requests for an interview.

Dr. Deborah Radisch, the state’s chief medical examiner, suggested the numbers for heart disease in Johnston may be distorted because Taylor appears to have accepted cases that are, in fact, natural deaths – not suspicious cases that should fall under the jurisdiction of medical examiners.

Since 2001, medical examiners have investigated about 26 percent of deaths in Johnston – twice the state average.

Robert Anderson, chief of the mortality statistics branch of the Centers for Disease Control and Prevention, has another theory for Johnston’s unusual statistics.

“I think what’s happening is they’re making assumptions,” he said. “ ‘We’re pretty sure it was a natural death. No need to autopsy it. We’ll just sign it out as chronic ischemic heart disease.’ They’re not doing a very thorough job .”

Johnston isn’t the only county where medical examiners appear to be quick to attribute deaths to natural causes. Dr. Gordon Arnold, a Guilford County medical examiner, said that when he’s unsure why someone died, he will often “write it off as a cardiac arrest.”

“That seems to satisfy everyone,” said Arnold, 78, a High Point internist.

Trucker’s brutal death

The inadequate investigations conducted in some counties can have worrisome consequences, experts say. “People may be getting away with murder in some instances,” said Anderson, of the CDC.

That, family members say, is almost what happened in Tom Cooper’s case.

Taylor, the medical examiner who handled the case, did not go to the bloody death scene – a step that many experts say is key to thorough investigations. Instead, he viewed Cooper’s body at a hospital morgue and quickly ruled that the 80-year-old man died of natural causes.

Taylor did not respond to questions about how he arrived at his conclusion. His report gives no indication of an attack.

If sheriff’s deputies had not insisted on an autopsy, family members say they would not have learned that Cooper’s head had been bashed three times, resulting in skull fractures and extensive brain injuries.

The revised manner of death: homicide.

Interviews led Johnston County detectives to Crystal Worley, a drug user who had done house and yard work for the elderly man.

Cooper, a father of five, once ran his own trucking company. In his retirement years, he was happy “as long as he had someone around to talk to,” said Franks, his daughter.

Investigators contended Worley befriended Cooper, then killed him and stole his Social Security money before leaving to buy crack cocaine.

Charged with voluntary manslaughter in connection with Cooper’s death, Worley in 2012 entered an Alford guilty plea – meaning that she did not admit guilt, but conceded there was enough evidence to result in a conviction. Now 41, she is serving six to eight years in prison.

Catherine Baggett, a daughter of Cooper’s who lives in Indian Trail, questioned how anyone could have concluded that her father died naturally.

“If he fell face first on the floor, how did he get the gashes on the back of his head?” she asked. “ If they examined his body, it seems to me it would be very obvious that he had cuts and gashes.”

Said Paul Jackson, the Johnston County prosecutor who handled the case: “When you look at the injuries he sustained, it’s kind of hard to mistake that with natural causes.”

Slow to change

State officials say they are working to bring more consistency to state investigations.

Radisch, who took charge of the office in 2010, says she has tried to improve communication with medical examiners by requiring them to have email – and by encouraging them to read it.

Radisch says she would also like to require training for medical examiners. It has been 13 years since a blue-ribbon panel called for mandatory training and continuing education for medical examiners – a step that experts say would lead to more consistent investigations statewide.

But the state has not yet devised a training plan.

“That’s a big project,” Radisch said. “It takes time.”

Staff writers Fred Clasen-Kelly and staff researcher Maria David contributed.