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

By Fred Clasen-Kelly, frkelly@charlotteobserver.com

The N.C. Department of Health and Human Services has determined that no state employees “erred” in the events surrounding three carbon monoxide deaths at a Boone hotel.

“The department’s direct involvement in investigating the deaths in Boone was limited to processing the specimens submitted to the State Toxicology Lab for analysis,” state spokesman Ricky Diaz said in an email to the Observer. “Based on our review of the facts, we do not believe that any state employee erred in performing their responsibilities.”

The statement follows a June declaration from DHHS Secretary Aldona Wos that the deaths “should have never happened” and vowed to make changes.

“I have instructed my staff to work with local officials to identify measures to ensure tragedies like this never happen again,” Wos said at the time.

Wos has declined repeated interview requests from the Observer. Diaz said in a statement that the state lab has made it a practice to require pathologists to submit the history of any specimen provided.

An Observer investigation has uncovered a series of investigative missteps by multiple local and state agencies, including the N.C. medical examiner’s office, which is part of DHHS.

Fire officials did not test the hotel for carbon monoxide after the first two deaths occurred in April. Watauga County Medical Examiner Dr. Brent Hall did not visit the death scene when the first deaths occurred, even though experts say it is a crucial first step in determining how a person died. Documents show Hall wrongly suspected that a drug overdose might have caused those deaths.

Six weeks vs. 20 minutes

On April 16, Shirley Mae Jenkins, 72, of Longview, Wash., and her husband, Daryl Jenkins, 73, were found dead in Room 225 at Best Western Plus Blue Ridge Plaza.

Officials took about six weeks to produce the toxicology tests results for the Jenkinses that experts say could be completed in less than 20 minutes.

On June 1, the state medical examiner’s office learned that Shirley Jenkins had a lethal level of carbon monoxide in her blood when she died at the Best Western.

But the office did not alert local police, fire or health officials until after 11-year-old Jeffrey Williams of Rock Hill was found dead in the same room on June 8. The medical examiner’s office didn’t finish the toxicology report for Daryl Jenkins until June 9, the day after the boy died.

Boone police, who are conducting an investigation to determine whether criminal charges should be filed, have said they did not receive those test results until June 10, after Jeffrey died. Police said the department renewed a request for the Jenkinses’ toxicology reports on May 29.

DHHS has blamed Hall for the delay, saying he failed to make officials aware the tests results were needed urgently.

The state appoints medical examiners and oversees their investigations into suspicious deaths. They are paid $100 per case, and are not considered state employees.

A state lab sent test results to Hall, but neither he nor the state warned the hotel or Boone authorities about the threat to public safety, the state has said. Diaz said officials have now reminded medical examiners that they can request expedited lab testing.

Hall, who resigned in June, could not be reached for comment.

Family, legislator unsatisfied

Darrell Williams, Jeffrey’s uncle, said his family is upset with the state’s death investigation.

“The delay in the cause of death announcement in the Jenkins family is very troublesome,” Darrell Williams said. “To have that information, after the unnecessary two-month delay and then, not release it, is inexcusable.”

State Rep. Jonathan Jordan, a Republican who represents the Boone area, said there are still unanswered questions about the medical examiner’s handling of the case. Told about Diaz’s statement that state employees had properly performed their duties, he said that is “certainly not a satisfactory response.”

Jordan said he will request a detailed report about what went wrong.

“To the extent there was a delay, it seems to me we could have stopped the third death if more was known about the first deaths,” Jordan said.

Families, law enforcement, insurance companies and researchers depend on medical examiners to find the cause of death in shootings, suicides, and other sudden or suspicious deaths.

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

Dr. Joseph Prahlow, a past president and board chairman of the National Association of Medical Examiners, said he questions why death investigators did not immediately identify carbon monoxide as a possible cause of death when the couple died at the hotel. A pool heater is now suspected of leaking poisonous gas.

“The fact you’ve got two people in an enclosed space and no obvious explanation, is a red flag and carbon monoxide is at the top of the list,” Prahlow said.

Unlike states and counties with leading death investigation systems, North Carolina does not require training for medical examiners.

Prahlow said North Carolina should mandate training for medical examiners. Officials should also make them accountable for the quality of their work.

“Does the state have the protocols that specify to all medical examiners that you should do this, this and this?” Prahlow asked. “From the outside, it seems that either the protocols are not there, or, if they are, they are not being followed.”

He added: “The prudent thing is to take a tragedy like this and learn from it and improve the system.”

Staff writer Rick Rothacker contributed.