This story originally appeared here and is published on Carolina Public Press through a content-sharing agreement with The Charlotte Observer.

By Fred Clasen-Kelly, frkelly@charlotteobserver.com

BOONE — Long before three deaths at a Boone hotel this spring, experts warned North Carolina officials that failings in the state medical examiner system posed a threat to the public.

A 2001 legislative study group questioned whether medical examiners had the training to properly investigate suspicious and violent deaths.

The study was triggered by an Observer investigation that uncovered a litany of problems in the state medical examiner system.

But instead of hiring professional death investigators and making other reforms, state officials largely ignored the recommendations.

The inaction left the state vulnerable to faulty death rulings and shoddy investigations, and inhibited researchers’ ability to spot dangerous health threats.

Now, the recent deaths at Boone’s Best Western Plus Blue Ridge have provoked renewed debate about the competency of state-appointed medical examiners.

A state medical examiner report existed three weeks ago showing that carbon monoxide might have killed an elderly couple in April but no one alerted local police and fire authorities until after an 11-year-old Rock Hill boy died in the same room.

Authorities later determined that all three died from carbon monoxide poisoning.

Experts say medical examiners should warn police and fire officials immediately after carbon monoxide poisoning is suspected, to prevent future deaths.

Former N.C. Chief Medical Examiner Dr. John Butts acknowledged problems with the investigation into the hotel deaths. But he told the Observer that state lawmakers shoulder some blame because they failed to heed warnings about budget shortages and other problems that have dogged the agency for decades.

“When you have a high volume of cases and part-time people, there’s a risk of things slipping through the cracks,” said Butts, who helped produce the legislative study. “It was a tragedy (in Boone). That was something we hoped would never happen.”

Dr. Marcia Herman-Giddens, who was a member of the 2001 medical examiner study group, said the mishandling of the Boone hotel deaths was “appalling,” but hardly surprising.

“There are huge holes in the system,” said Herman-Giddens, who is now a professor at the UNC Chapel Hill School of Public Health.

Some current and former state lawmakers said they did not recall the 2001 study. They said they were unaware of existing problems in the medical examiner system.

“I don’t remember hearing that it is a problem,” said State Sen. Stan Bingham, a Davidson County Republican, who is listed as a sponsor of the bill that created the N.C. Study Commission on Medical Examiners in March 2001. “I am sure that will change now. … Sometimes it takes a tragedy like this to correct (problems).”

Ricky Diaz, a spokesman for the N.C. Department of Health and Human Services, did not respond directly to questions.

Diaz emailed a statement, saying agency leaders have been “engaging local experts and actively pursuing opportunities for improvement.”

State Rep. Beverly Earle, a Charlotte Democrat who supported the legislative study in 2001, said the medical examiner system has been severely underfunded for years.

“It’s probably worse now,” Earle said. “If anything, it’s been cut.”

But she said that lawmakers likely have been unfairly faulted.

DHHS has tremendous influence over how it spends money allocated from the General Assembly, Earle said.

DHHS Secretary Aldona Wos has said the three deaths “should have never happened” and the state is reviewing its role in the troubled investigation.

Missteps

The public, law enforcement, insurance companies and researchers count on medical examiners to find the cause of death in shootings, drownings and other sudden deaths.

Their work can help solve crimes, determine insurance payouts, identify public health threats and ensure nothing is overlooked in a suspicious death.

The Observer found a series of investigative missteps following the deaths of Daryl Dean Jenkins, 73, and his wife, Shirley Mae Jenkins, 72, both of Longview, Wash., and Jeffrey Williams of Rock Hill.

The Jenkinses died of carbon monoxide poisoning on April 16 after staying in room No. 225 at the Best Western. Emergency workers found Jeffrey dead and his mother, Jeannie Williams, seriously injured in the same room on June 8.

Reports show that Watauga County Medical Examiner Dr. Brent Hall did not view any of the three bodies at the scene – even though experts say it is a crucial first step in determining how someone died.

Unlike states and counties with leading death investigation systems, North Carolina does not require medical examiners to visit scenes. The 2001 task force recommended mandatory scene investigations and professional investigators to do the work.

Hall did not ask for an expedited carbon monoxide test of the bodies or the hotel, the state has said. It took nearly two months for the medical examiner’s office to complete toxicology tests on the couple.

That length of time is typical without a request to expedite the process. Hall listed an overdose as the probable cause of death in his request for the toxicology test. He also requested that the state screen for carbon monoxide poisoning, among other causes.

The state says a June 1 report was sent to Hall from the state medical examiner’s office showing Shirley Jenkins had a lethal concentration of carbon monoxide in her blood. It remains unclear why no one took action after that finding.

The toxicology report for Daryl Jenkins wasn’t completed until June 9, the day after Jeffrey died. It showed dangerous levels of carbon monoxide in his blood.

Boone police have said the department renewed a request for the Jenkinses toxicology reports on May 29.

They said they did not receive the lab results for the couple until June 10, after the child was dead.

Through an open records request, the Observer obtained emails exchanged between Hall and current Chief Medical Examiner Dr. Deborah Radisch from June 10-14.

Hall performed autopsies on the Jenkinses in April, but as of June 11 still had not completed their autopsy reports, email shows. The deaths of the Jenkinses and Jeffrey had been the subject of national attention for days by then.

“Because of the many requests we are getting for the reports, can you please complete your autopsy reports on Mr. and Mrs. Jenkins as soon as you have the time, taking into account your primary responsibilities? Thank you!” Radisch wrote to Hall on June 11.

State officials released the autopsy reports for the Jenkinses and Jeffrey two days later.

Hall, who resigned as the county medical examiner June 14, declined comment.

Shortages

A pathologist, Hall is president and medical director of Pathology Associates of Boone, a private practice that conducts lab testing, according to the company website.

He also is laboratory medical director for at least four western North Carolina hospitals, including Watauga Medical Center in Boone.

Fellow medical examiners said he had earned a reputation for doing solid death investigations. They said he once completed a fellowship at the Office of the Chief Medical Examiner.

“I was surprised that he was involved (in the hotel case),” said Butts, who retired in 2010. “I have a high opinion of his work. Something obviously went wrong.”

But Hall is professionally trained in the study of natural death and not suspicious death. Experts say it is preferable to have a certified forensic pathologist conducting autopsies.

In North Carolina, Butts said, a significant number of autopsies are performed by doctors who are not certified forensic pathologists because there is a shortage.

Diaz said state officials are worried about finding qualified candidates to fill the void. The N.C. Office of Chief Medical Examiner has openings for two pathologists in Raleigh but no one has applied, he said.

States and counties with leading medical examiner systems often hire trained professional death investigators.

Herman-Giddens noted that North Carolina medical examiners are state appointees, paid $100 per case. Some medical examiners have little or no training because the state does not require it, she said.

Current chief medical examiner Radisch “is between a rock and a hard place,” Herman-Giddens said. “She has no real authority over the medical examiners because you can’t require training.”

Radisch, who replaced Butts, did not return phone calls or respond to emails seeking comment.

Recommendations ignored

A 2001 Observer investigation found:

•  Medical examiners failed to detect at least five homicides over a five-year period.

•  Errors and oversights jeopardized hundreds of investigations.

•  As many as 4,400 apparent suicides, drownings and fire deaths were not autopsied.

State policymakers responded by forming a legislative study commission to find ways to improve death investigations.

An expert panel made nearly two dozen recommendations, including calls for mandatory training for medical examiners, improved death scene investigations and the creation of trained death investigators who would assist medical examiners.

Officials followed up by raising medical examiners’ pay to $100 from $75 per case, but not by creating the more expensive model of using full-time professionals. The agency recently moved its central office into a new $52 million facility in Raleigh it shares with the North Carolina Laboratory of Public Health.

But most of the major recommendations from the study were not implemented because the state refused to spend the money, medical examiners and pathologists said.

Similar statewide medical examiner systems spend about $1.76 per capita, but North Carolina allocates less than $1 per capita, they said.

In an interview last year, Radisch told the Observer that she wants to bolster training, but money is a roadblock.

The Chief Medical Examiner’s office offers annual free one-day training. Law enforcement officers are the primary attendees; relatively few medical examiners are present.

Radisch said her office does not have the money to stage a full-fledged multi-day conference and she said it would be wrong to ask medical examiners to pay to attend.

About two-thirds of North Carolina’s 450 medical examiners are physicians, meaning they would likely miss work to come to training, Radisch noted.

“We can’t require them to shut down their practices for three days,” she said. “That’s a lot of lost income.”