Jeffrey’s preventable death must be the last

The seeds of Jeffrey Williams’ death were detected just before he was born.

In February 2001, an Observer reporter named Debbie Cenziper produced a series of stories detailing extensive problems with North Carolina’s medical examiner system. Less than 10 months later, Jeffrey was born. And in June of this year, Jeffrey died, a victim of a system no one bothered to fix. He was 11 years old.

Cenziper uncovered a death-investigation system in North Carolina that failed to do its job. Medical examiners declined to go to death scenes. They sent bodies off for autopsies without looking at them. Unnatural deaths were overlooked. Grieving families were left with unanswered questions. Holes at every level meant there was no accountability.

As Jeffrey’s family can tell you, much remains the same. Following Cenziper’s series, N.C. leaders vowed to fix things. A legislative committee was charged with examining the set-up and proposing remedies. The state’s public health director gathered doctors, lawyers and others to find repairs. A powerful senator at the time, Fountain Odom, called the situation “tragic” and “appalling” and said the General Assembly needed to “overhaul” the system.

Here we are in 2013 faced with another tragedy because, as reporter Elizabeth Leland shows today, the state still waits for that overhaul. There were failures at every level, and if N.C. leaders let things slide like they did in 2001, future tragedies are sure to follow.

Daryl and Shirley Jenkins were discovered dead in Room 225 of a Best Western in Boone on April 16. At age 73 and 72, they loved to travel and had no health conditions that kept them from leading active lives.

There was no sign of foul play. Their adult children immediately suspected carbon monoxide and told investigators that. Yet no one tested the room for the deadly gas. The medical examiner suggested it might have been a drug overdose or natural causes. Toxicology tests took 40 and 47 days to complete, though one can be done in 15 minutes.

Despite that, the state knew by June 1 that Shirley Jenkins had died of carbon monoxide poisoning in Room 225. Yet nothing was done with her toxicology report to close the room. Nearly a week later, Jeffrey and his mother, Jeannie, checked in to the Best Western and ended up in Room 225. Jeffrey died in the bed, and his mother nearly died as well.

Aldona Wos, the state’s health and human services secretary, declined repeated requests for interviews and her spokesman says no state employee erred in the case. Wos’ recalcitrance is puzzling, because the problems are obvious and not of her making. She could and should be out front in demanding that they be addressed.

The legislature took one needed step, requiring carbon monoxide detectors in certain hotel rooms starting Oct. 1. Few hotels seem to be complying with the law, though. In Mecklenburg, the health department found 21 of 31 buildings it inspected had failed to install the detectors.

Breakdowns by nearly everyone involved contributed to Daryl and Shirley Jenkins and Jeffrey Williams losing their lives. The deadly gas came from a corroded and improperly installed pool heater. The fire department did not test the room for gas. The medical examiner system failed repeatedly.

This time, state officials need to make things right. What little boy is being born right now who could die a few years down the road if they don’t?