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Back in April, Daryl and Shirley Jenkins, an elderly couple from Washington state, died in their Boone, North Carolina hotel from carbon monoxide poisoning.   Earlier this month, 11-year-old Jeffrey Williams died of CO poisoning while staying in the same room the Jenkinses had stayed in two months earlier.  There's a lot of fail to go around here, but one of the most outrageous fails is on the part of the medical examiner who worked the case of the Washington couple, Brent Hall.  As I mentioned last week, Hall knew as early as a week before Jeffrey's death that Shirley Jenkins had ingested a lethal dose of carbon monoxide.  But he never told state or local officials about the urgency of the matter once he got the results, and also never asked state officials to expedite the Jenkinses' tests.  As a result, it took two months for the tests to be performed, and Boone police didn't know about those tests until two days after Jeffrey died.

As horrific as this may sound, this and other shortcomings in the medical examiner system were amply exposed in a 2001 study.  However, according to a horrifying front-page story in today's Charlotte Observer, those warnings have largely gone unaddressed.

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.

The panel made over two dozen recommendation.  However, most of them weren't implemented because the state was unwilling to spend the money.  As a result, North Carolina still relies on contracting out medical examinations to 400 pathologists who get paid $100 per case.  Incredibly, the examiners aren't required to visit the scene of a suspicious death, even though the panel recommended mandatory scene investigations with professional death investigators.  This system was implemented in 1967 to take the place of county coroners who often had no medical training at all.  However, this system was implemented when North Carolina was still mostly rural, and simply doesn't work for a state that now has almost 10 million people.

What happened in Boone appears to lay threadbare the shortcomings of the system.  While Hall's failure to expedite the case is inexcusable, he really wasn't qualified to handle it in the first place.  According to the Observer, Hall's field of expertise is natural death, not suspicious death.  However, the state has a severe shortage of qualified forensic pathologists.  As a North Carolinian, this comes as a rather unpleasant surprise.  After all, we've got three medical schools in this state--Carolina, Duke and Wake.

North Carolina's current chief medical examiner, Deborah Radisch, says she wants to bolster training, but doesn't have the money to do so.  Presently, her office offers a free one-day course attended mostly by law enforcement.  She claims that the only way to stage a full-fledged multi-day course under current conditions would be to make medical examiners pay to attend--and since most of them are physicians, they'd likely have to shut down their practices to do it.

The exact reason for the lack of money has triggered a lot of finger-pointing.  Radisch's predecessor, John Butts, claims that the General Assembly has refused to appropriate money for improving the system despite numerous warnings of budget shortfalls.  However, at least one state legislator claims the Department of Health and Human Services, which oversees the medical examiner system, has considerable influence over how it spends money.  

Regardless of who's to blame, there's a chance changes will come soon--and not voluntarily.  This week, the North Carolina Industrial Commission is going to hear cases from four families who claim the state should be held liable for blunders by medical examiners.  They claim that medical examiners don't follow generally accepted practices.  The state claims that medical examiners work for the public and have no duty to individual families.  By that logic, however, it would seem that the state is in hot water.  After all, common sense dictates that public confidence is undermined when medical examiners fail to uncover potential health risks or warn about them in a timely manner.

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