N.C. Medical Examiners

Fewer questions asked when elderly die in N.C.

When Virginia Gregg died at home, investigators blamed old age. Gregg was 88 and had health problems. She could no longer drive. A widow, she lived alone in a little white house on Plainview Road in west Charlotte.

“They said she was found in the closet,” said her brother, Robert Cooke. “I knew good and well somebody had killed her or something.”

Because there was no obvious sign of foul play, and despite abrasions on her nose and neck, a Mecklenburg County medical examiner ruled Gregg died of natural causes. It was only after her family discovered someone used her credit card that the investigation was reopened and an autopsy performed.

Her brother was right. Gregg was strangled.

While a handful of jurisdictions recognize the elderly as a vulnerable population whose deaths warrant special attention, North Carolina does not. Even when deaths are suspicious, sudden, violent or unattended – the types of cases medical examiners are called on to investigate – there’s typically far less scrutiny. An Observer analysis of more than 12 years of state data and documents found that:

The Observer discovered that medical examiners sometimes incorrectly assumed older people died of natural causes, overlooking evidence that pointed to wrongdoing. Though the facts of the cases differed, age was a constant.

An 80-year-old Johnston County man was found covered in blood on his kitchen floor, and the local medical examiner called it heart disease. His former housekeeper was eventually charged with manslaughter and is serving time in prison. (See Day 3 of series at charlotteobserver.com/examiners.)

A 74-year-old woman collapsed in bed in Chatham County and the medical examiner diagnosed heart failure without viewing her body. A private autopsy showed she died of complications from a hiatal hernia. (See Day 2 of series at charlotteobserver.com/examiners.)

A married couple in their 70s died in a Watauga County hotel room, and some authorities speculated they both died of heart attacks. The medical examiner’s office waited more than a month to complete a toxicology test that showed carbon monoxide poisoning. Even then, the information was not passed along in time to save an 11-year-old boy who later died in the same room.

“If a kid dies in some of these conditions, we’d be all over it. If a dog dies, too,” said Laura Mosqueda, director of the National Center on Elder Abuse. “You can always find a reason that a 90-year-old person died without it being nefarious.”

The misdiagnosis

State guidelines require autopsies anytime a young adult, child or infant dies suddenly and unexpectedly and doesn’t have a well-documented illness. But the same types of deaths in the elderly are considered case by case.

Dr. Gregory Davis, a Kentucky forensic pathologist and former North Carolina medical examiner, said medical examiners nationwide are statistically less likely to perform autopsies on older people because older people are more likely to die of natural causes – including cardiac arrest, diabetes and hypertension.

“We’re not ageist,” Davis said. “There is usually a medical history that could explain the death.”

Virginia Gregg had a medical history.

She had been in and out of the hospital, her brother said. But even at 88, they could still count on “Maw Maw” to bake pound cake for family reunions. When Gregg was younger, he said, she enjoyed surf fishing and trailer camping. She worked for Union Carbide 22 years and later for Frito-Lay and Hamrick’s.

Gregg and her husband, Oscar, settled on Plainview Road in 1950 and raised two sons there. Though she was robbed at night a few years ago, she refused to move. It was home.

The day she died, June 6, 2013, a neighbor saw her in the yard picking up twigs. Her brother suspects the killer slipped into the house then.

That evening, one of her sons drove over to check on her after she didn’t answer her phone. He looked through the house and around the neighborhood, her brother said, before eventually finding her body upright, leaning on boxes, in a narrow linen closet no deeper than a coat hanger.

Police investigators theorized Gregg suffered a heart attack. An investigator from the Mecklenburg medical examiner’s office also went to the scene and reached the same conclusion.

The next day, a pathologist did an external exam of Gregg’s body but chose not to perform an autopsy despite several irregularities:

A small abrasion on the bridge of her nose, which could have resulted from her falling face-first onto the boxes. Small abrasions on her neck, which might have been caused by her necklaces. Hemorrhaging and tiny spots in her eyes and gums, which could have been caused by vessels rupturing because she was face down.

All are also signs of strangulation.

Fewer autopsies of elderly

Elderly deaths receive less attention from medical examiners than all deaths combined by three measures: visits to the death scene, examinations of the body and autopsies.

In 11 rural counties, medical examiners did not go to death scenes in any case involving victims 75 and older, an analysis of state data from 2001 through mid-2013 shows. Not a single elderly case in more than 12 years.

Dr. Deborah Radisch, the state’s chief medical examiner, said visiting the scene of the death is not always necessary. She said many elderly deaths are caused by falls. If the victim is taken to a hospital to be treated and dies there, nothing is gained by visiting the hospital.

Whether or not they go to the scene, medical examiners are supposed to examine every body in every case they investigate. But if a person is elderly, a medical examiner is twice as likely to skip that crucial step.

In about 1,400 elderly cases statewide, medical examiners ruled the deaths were natural without ever viewing the bodies or getting autopsies. That’s 1,400 deaths over 12 1/2 years that were questionable enough to be referred for investigation, but medical examiners did not take the time for any type of physical examination.

Radisch acknowledged the concern about elder abuse and said “things can always be missed.” But she said people could draw the wrong conclusion from the data. Short of performing an autopsy on everyone, she said, the hope is that whistleblowers would alert authorities about potential problems.

Digging up bodies

The lack of scrutiny in elder deaths is not unique to North Carolina.

“There are states with good death investigation systems, but if you’re over 55 years old, you are not getting an autopsy,” said Dr. Steven Shapiro, chief medical examiner for Vermont, a nationally accredited system. He said there is simply not enough money when a case doesn’t appear suspicious.

As a result: “We are missing homicides in our elderly population.”

In Arkansas, Mark Malcolm did something about it.

Malcolm is former coroner of Pulaski County, which includes Little Rock. After suspicious deaths in nursing homes in the 1990s, his office exhumed six bodies. The deaths initially were ruled natural; autopsies showed four victims suffocated and two died because of medication errors.

Malcolm pushed for a state law that requires nursing homes to report all deaths to the local coroner, who must alert law enforcement and state regulators about possible maltreatment.

“The perfect crime is committed every day; we just never find out about it,” said Dr. Michael Dobersen, a forensic pathologist and elected coroner of Arapahoe County in Colorado, who has pushed for more scrutiny of elder deaths. “If I want to lose sleep, all I have to do is think about what’s falling through the cracks.”

‘Elder neglect is huge’

North Carolina requires nursing homes and hospitals to report suspicious deaths to medical examiners, but not all deaths. Malcolm believes all deaths should be reported.

“If you’re a facility and you accidentally give someone the wrong medication and they die, you’re not exactly going to pick up the phone and tell an investigative authority,” he said.

In King County, Wash., which includes Seattle, funeral homes must submit death certificates to the medical examiner’s office for review before a body can be buried or cremated. The system has uncovered 50 to 100 serious misdiagnoses a year, including elder abuse and neglect.

“Anyone aware of what is going on knows the potential for elder neglect is huge,” said Dr. Richard Harruff, chief medical examiner for King County.

Mosqueda, of the National Center on Elder Abuse, believes there need to be established criteria for what would trigger an autopsy for an elderly person.

In Gregg’s case, a clue came two days after her death.

Missing credit card

A family member discovered her Visa card was missing and had been used. The funeral was postponed. Her body was sent back to the medical examiner.

This time, a pathologist performed an autopsy. He noted the same abrasions evident in the earlier external examination, as well as bruises on her neck and face. A dissection of her neck revealed multiple fractures. The autopsy also uncovered hemorrhaging in her neck muscles, esophagus and tongue, as well as broken ribs.

The autopsy showed what the external examination did not: She died from a lack of oxygen due to strangulation.

Charlotte homicide Capt. Cecil Brisbon said investigators had no reason initially to suspect foul play because there was little external evidence of trauma.

Dr. Michael Sullivan, who was chief medical examiner for Mecklenburg County at the time, agreed. “We see cases on a daily basis where people die a sudden death, collapse and have trauma,” Sullivan said. “There was very minimal evidence of trauma in an elderly lady and nothing, at least initially, to indicate a non-natural death.”

The medical examiner’s office in Mecklenburg County is unique among the state’s counties; it has a full-time, professional staff funded with $1 million from the county. The office includes trained investigators and three medical examiners who are forensic pathologists, skilled in the study of violent deaths.

Around the rest of the state, many of the roughly 350 medical examiners are full-time doctors and nurses who investigate deaths as a secondary role.

“It’s very complex, lots of judgments have to be made and things are very subtle,” Sullivan said about death investigations. “The real world doesn’t work the way the retrospective does.”

Neighbor charged

Police traced Gregg’s credit card to transactions at a CVS and a Marathon Petro Station. Surveillance videos showed a man matching the description of one of Gregg’s neighbors making the purchases.

In an application for a search warrant, police said Robert Nixon confessed to killing Gregg and stealing the card.

All for Newport cigarettes and a cherry Coke.

“If we hadn’t found out about her credit card, they would have just went ahead and buried her,” Cooke said. He lamented that the killer did not ask his sister for money. “She never met a stranger. She would have given him money.”

Eight days after she died, Gregg was buried. Nixon, 45, is charged with first-degree murder.

Ames Alexander contributed.