A question of homicide: Rulings by medical examiners raise doubts about protocols

After deputies found a young woman dead in her van with a trash bag over her head, the Jackson County Medical Examiner’s Office called the death a suicide.

Ten days later, a man confessed to killing her.

After bicyclists spotted a woman’s half-naked, bleach-covered body along a Northland road with a red mark across her neck, the medical examiner’s office ruled the death an overdose.

Sixteen months later, a budding serial killer confessed to strangling her with his hands and a belt.

Jackson County medical examiner officials continue to defend both death rulings as accurate — even though prosecutors and police consider both deaths to be murders.

The cases illustrate deeper problems with protocols in the medical examiner’s office, The Kansas City Star found during a four-month investigation that included reviewing hundreds of pages of case files, analyzing autopsy statistics from more than a dozen jurisdictions and interviewing experts across the country.

Consider the woman with the bag over her head. The medical examiner’s office elected not to autopsy her — or 119 other suspected suicide victims who died last year.

In fact, Jackson County typically fails to fully autopsy three-quarters of suspected suicides every year, The Star found. This counters best practices nationally and could allow staged or accidental deaths to more easily slip through as suicides.

Then consider the bleach-doused woman. Although the medical examiner’s office did not diagnose strangulation, police saw the signs. So did a nationally acclaimed expert who examined crime scene and morgue photos at The Star’s request. But Jackson County settled on an accidental overdose ruling based on high drug levels.

That overdose ruling helped shutter the police investigation — until a second bleach-covered woman’s body turned up in the Northland.

Forcing death rulings on questionable cases can shut down investigations and turn out to be wrong, experts say. Instead, confusing or evidence-thin cases should be labeled “undetermined,” experts say, leaving them open for more investigation.

Jackson County Chief Medical Examiner Mary Dudley said she limits the use of “undetermined” to skeletons, charred remains or badly decomposed bodies — a philosophy more restrictive than experts advise, The Star found.

Jackson County’s protocols create a system more likely to make mistakes, experts said. And the practices can leave killers on the street and allow evidence to be lost.

Every medical examiner and coroner’s office makes mistakes, experts say, but it’s hard to know how many because most errors are buried along with the victims.

Dudley, who has been running Jackson County’s office since 2007, said her staff makes decisions with information available at the time and can make amendments if new information surfaces. The office, which also handles cases for Clay, Platte, Cass and other area counties, performed more than 1,300 death investigations last year.

Asked if her office needed to learn or change anything after prosecutors accused men of crimes in cases that her office ruled accidental or suicide, Dudley said no.

“There is probably something that law enforcement can learn from and work on with their agencies,” she said without elaborating.

“We followed our protocols. I don’t think these particular cases make any difference to the way we do our work. We meet and exceed the national standards.”

But the accidental death ruling of the first bleach-covered woman particularly concerns recently retired deputy police chief Jerry Gallagher, who had doggedly pushed for the case to be reopened.

“I’m appalled by it,” he said. “If the medical examiner could miss a case with that many red flags, what else could the medical examiner’s office be missing that isn’t as obvious?”

It’s important for forensic pathologists to get rulings right, experts say.

Just ask Teresa Wicks, whose daughter was found dead in a ditch, doused with bleach, 10 months after the other bleach-covered woman. Wicks believes the accidental death ruling in the first victim’s case helped a killer stay on the streets.

“I think they overlooked it because she was on drugs,” Wicks said. “If they did the first body right, we may not have had to bury my daughter.”

Jackson County officials hired Dudley in 2007 to fix an office under fire from area prosecutors, who had been complaining about the chief medical examiner’s erratic testimony and a deputy’s credibility issues. Prosecutors wanted that deputy’s role reduced, but the chief medical examiner refused.

A former nurse, Dudley had earned a medical degree from the American University of the Caribbean before specializing in forensic pathology.

Her first stop as a full-time medical examiner had been at the Maricopa County Medical Examiner’s Office in Phoenix, where she became embroiled in controversy after an inmate died in a scuffle with jailers. The victim’s family accused her of missing the victim’s broken larynx and other injuries during an autopsy. In 1999, the county settled a wrongful death lawsuit with the victim’s family for $8.25 million.

Dudley said she could not comment on the case because she didn’t have permission from those authorities or the victim’s family. But she said she stands by her autopsy findings.

The next year, Dudley took the top job at the Sedgwick County medical examiner office in Wichita after the county fired its coroner. In her six-year stay, she got the office accredited by the National Association of Medical Examiners. Later she began a six-year tenure on that association’s board.

In Dudley’s first year in Jackson County, the county boosted her office’s budget by nearly 25 percent. That eventually allowed her to hire two additional full-time deputy medical examiners, better balancing the workload. Previously, doctors had performed up to 390 autopsies a year, way above a nationally recommended cap of 250. Two years later, Dudley earned accreditation for the office, a voluntary process that involved meeting a checklist of 350 items and allowing random reviews of case files.

Dudley, who makes $230,000 a year from the county, now oversees a 22-member office with a $2.8 million annual budget. Her eight investigators respond to death scenes while she and her three deputy medical examiners, all certified forensic pathologists, examine bodies at the office.

She stresses that her office isn’t an arm of law enforcement but rather serves a neutral public health role by providing medical opinions.

But police detectives rely heavily on medical examiner rulings, said Capt. Jeff Emery of the Kansas City homicide unit.

“If their ruling comes back non-criminal and we have nothing to show otherwise, then the case is closed,” Emery said. The ruling “is a major part of our investigation. You’re looking at the expert witness on death.”

Jackson County Executive Mike Sanders, who hired Dudley, said she is a national leader and he has heard no complaints about her office. Area prosecutors say she has improved the office’s functions, and they are happy with the services provided. They describe Dudley as accessible, considerate and professional.

“That was not always the case in Jackson County,” Jackson County Prosecutor Jean Peters Baker said, referring to Dudley’s predecessor. “She is a refreshing change to the administration of that office.”

But there have been criticisms, such as when her office failed to send investigators to scenes of some bloody deaths. That eventually changed in 2009 after The Star chronicled problems involving two homicide victims — one with a slashed throat and the other with three bullet wounds — whose bodies had been sent straight to funeral homes as natural deaths.

Weeks after The Star’s stories appeared, Dudley began sending an investigator to nearly all deaths that occur outside of medical facilities, something experts had recommended.

Now, with the recent questionable rulings, there are new criticisms.

Robert Pietak, the deputy medical examiner who handled the suffocated woman’s case and autopsied the first bleach-doused body, also oversaw at least one other controversial case.

“I stand by my rulings in all of these cases,” he said, citing his 14 years of experience as a forensic pathologist and 14 additional years of education and hard work.

Dudley, who is his boss, said she has no concerns about his work.

“I have complete confidence in his abilities and fully support him,” she said.

A year ago, the day before Halloween, Jackson County deputies found a 27-year-old newlywed and committed Christian, Bethany Deaton, dead in the back seat of her van at Longview Lake with a white plastic bag tied loosely over her head.

“I chose this evil thing,” a note on the console said in part. “I did it because I wouldn’t be a real person and what is the point of living if it is too late for that?”

Sheriff’s deputies believed it was a suicide note. At the scene, a medical examiner investigator could put fingers between the tie of the bag and Deaton’s neck. Later, at the medical examiner’s office, Pietak examined the body, took notes and drew blood. He decided an autopsy was unnecessary and released the body to a funeral home.

An hour before the funeral service in Texas, where Deaton’s parents live, a detective called Deaton’s mother with shocking news: The sheriff’s office needed the now-embalmed body back for a homicide investigation. Dazed, Deaton’s parents proceeded with the funeral but awkwardly announced that the burial would be postponed.

As Deaton’s parents later learned, a friend of Deaton’s husband had gone to police and confessed he had been told to kill Deaton. He said he put a bag over her head and “held it there until her body shook,” according to court records.

Jackson County prosecutors filed a murder charge against Micah Moore, who said he and others had sexually assaulted Deaton in the months prior to her death, court records say. Moore, who later recanted, is awaiting trial.

The death continues to be ruled a suicide, according to the death certificate filed in Jefferson City. Dudley declined to discuss the case because of the pending trial.

Prosecutors would not say how they planned to tackle the suicide ruling. Deaton’s relatives did not want to talk either, fearing it could further complicate the case, which possibly lost evidence because of the delayed autopsy.

“We don’t want to harm the integrity of the case,” said Carol Leidlein, Deaton’s mother.

Many medical examiner and coroner offices autopsy all, or a large majority, of suspected suicides to avoid the situation Jackson County faces in the Deaton case.

“We know there are rare cases that look like suicide that are staged,” said Robert Bux, the coroner of El Paso County in Colorado Springs, Colo. “We all know that.”

In Georgia, where state law requires autopsies in suicide cases, death investigators have caught some homicides staged to look like accidents or suicides, said Michael Alsip, a forensic death investigator in Atlanta.

Last year, Jackson County fully autopsied 21 of 162 suicide cases, or 13 percent. Add in partial autopsies and the statistic rises to 26 percent — still well below the 86 percent average of 13 other accredited offices with forensic pathology training programs contacted by The Star.

Since Dudley took over, Jackson County has performed only about half as many autopsies on suspected suicides as during her predecessor’s tenure.

The only office contacted by The Star with a lower rate was in St. Louis. That unaccredited office conducted full or partial autopsies on 15 percent last year.

The Johnson County coroner’s office autopsies nearly all suicide cases. Wyandotte County autopsied 60 percent last year.

The National Association of Medical Examiners doesn’t require a certain percentage in suicide cases. But its president, Greg Schmunk, said offices should perform as many as budget and staffing allow.

“The gold standard is always going to be the autopsy,” said Schmunk, the Polk County chief medical examiner in Des Moines, Iowa. “The more you can do, the better your confidence should be in your ruling.”

Experts say autopsying most suicides reduces the chance for mistakes, ensures death benefits aren’t unnecessarily lost and provides important information to grieving families.

Dudley said her staff knows which cases need to be autopsied.

“Generally with suicides, it’s very obvious what the cause of death is,” she said. “An autopsy will not reveal any additional information.”

But other medical examiners say they approach cases with an open mind.

“We treat cases as unknown until we know otherwise,” said Ken Betz, the office director for the Montgomery County Coroner’s Office in Dayton, Ohio, which autopsies all suspected suicides for one-third of the state. “If you treat a case as a suicide, and believe it’s a suicide, that’s the way it’s going to turn out.”

In San Diego, doctors autopsied 89 percent of last year’s suicide cases, said Chief Deputy Medical Examiner Jonathan Lucas.

“I’ve learned not to underestimate the kind of questions that can come up,” he said.

With hangings, a recurrent question is whether the person was strangled first, Bux said. His Colorado Springs office autopsies all cuttings, overdoses, hangings and bag suffocations. Even if someone commits suicide in front of relatives, Bux’s office still might perform an autopsy to confirm the witnesses told the truth.

“Same thing as someone who drowns and no one witnesses,” he said. “How the hell do you know what happened? Was it a bad heart, were they high on drugs or whether someone clobbered them over their head?”

A violent nursing home death automatically earns an autopsy in Colorado Springs, said Bux.

But not in Jackson County.

In October 2012, Terry Bartlett, 64, was found hanging from a rod in his nursing home closet. A recent transfer to the Kansas City home, Bartlett had three roommates, none of whom saw or heard anything from within their curtained living spaces. Neither the police, who didn’t consider the case suspicious, nor the medical examiner explained an abrasion over his right eye in their reports.

Forensic investigators say they usually check if the victim is right-handed or left-handed because a person usually ties or buckles a rope or belt on the opposite side. But nothing in the 10-page police case file or the medical examiner report identifies Bartlett’s handedness.

Given the facts and circumstances of this case, “it was not necessary to conduct an autopsy,” Dudley said. Information about the abrasion and his dominant hand “had no bearing on the final determination of this case,” she said.

Bartlett’s cousin, Steven Ashley of Lee’s Summit, said nursing home officials told him Bartlett had fought another resident over a community television before his death.

“It really didn’t add up,” said Ashley, who would have liked to have had an autopsy. “If it was definitely a suicide, it was definitely unexpected.”

Hard and fast rules for handling suicides can help examiners avoid questionable rulings, Bux said.

“You can’t get in trouble for autopsying someone,” he said. “You can only get in trouble for not autopsying someone and then someone gets embalmed and buried or, worse, cremated.”

Bartlett was cremated.

The October 2011 death appeared suspicious to Kansas City police.

A 40-year-old woman’s body had been dumped along a Northland road, 20 miles from where she worked as a prostitute, with her shirt pulled up, her pants pulled down and a jacket covering her face. Bleach poured on her body had stained her clothes. Tamara Sparks had apparent injuries that included a “possible ligature mark” on her neck, Detective Michael Satter noted in his report, and hemorrhaging to her eyes, a classic sign of asphyxiation.

Satter also noted apparent bruising and abrasions on Sparks’ back, right hip and abdomen, a possible bite mark on her right hip and bruising under her left eye. Her bra had been torn in half. A man’s bleach-splattered shoe had been left near her knees.

Pietak, the deputy medical examiner who performed the autopsy, didn’t consider her injuries suspicious. Instead, he noted “two linear dark brown drying abrasions on the right side of the neck,” abrasions to her jaw and right ear, and a superficial hemorrhage to a left-side neck muscle.

“The remainder of the deep muscles of the neck and associated soft tissues show no abnormalities.” He noted “congestion” to her eyes but not petechial hemorrhaging.

“In my opinion, Tamara Reabecca Sparks died as a result of an acute cocaine and phencyclidine intoxication. The manner of death is accident,” Pietak wrote.

Police continued to investigate for months, trying to figure out at least who dumped the body.

But their investigation went nowhere, and in January 2012, Satter wrote a new report.

“Based on the ruling of an accidental death and all current leads being exhausted, this investigation is now closed.”

Seven months later, on Aug. 21, 2012, Kearney police found a woman’s body along a desolate gravel road. Her shirt was torn and pulled up. Her bleach-stained shorts were pulled down.

The body of Nicoleone Reed, 23, had been under the hot summer sun long enough for moderate decomposition to occur. Police did not note injuries but immediately saw similarities to the Sparks case.

Dudley’s autopsy report detailed much more about the circumstances of the death than Pietak’s report on Sparks had — although many circumstances were the same.

She ruled the death a drug overdose by homicide.

“It appears that she was given excessive amounts of cocaine and methamphetamine and the body was possibly dropped off from a vehicle onto the roadside,” Dudley wrote without explaining what evidence supported the theory that the drugs came from someone else.

Asked about the different rulings in similar cases, Dudley said she had information in the Reed case that allowed her to rule it a homicide: “The body in a similar fashion being left at the side of the road and appearing to be steps made to, again, to abandon the body.”

Four months after Reed’s body was found, Pietak changed the manner of death in Sparks’ case to homicide without explaining it in his report.

In February, police identified Derek Richardson as a suspect in both killings. Investigators found his DNA in the shoe left near Sparks’ body and in evidence found in Reed’s mouth.

Richardson eventually detailed to police how he strangled the women in his home. He told police he thought the first body had not been found since he never saw it reported in the news. He said he probably would have killed again if not arrested.

He later hanged himself in jail.

Richardson’s confession didn’t change any minds at the Jackson County Medical Examiner’s Office. Dudley maintains the women died from overdoses. She said recently that she reviewed photos and saw no medical reason to call either death a strangulation.

Clay County Prosecutor Dan White said he hadn’t been worried about convicting Richardson. He said he thought the autopsy findings of Sparks’ injuries corroborated Richardson’s strangulation claims.

“Was it going to be a problem?” White asked. “Possibly, but not one I wasn’t willing to try to overcome.”

When asked about Dudley’s assertion that Richardson had killed Reed by giving her an overdose, White said: “I don’t know if I could prove that or if that was the truth. The fact that they had really high levels of drugs was not out of the ordinary for them.”

When asked if the death rulings concerned him, White said he didn’t know.

“That’s a hard question,” he said. “The reality of the situation, regardless of medical evidence, (Sparks) didn’t partially clothe herself, pour bleach on herself and put herself in a ditch.”

Had Richardson not committed suicide, White said he likely would have asked Dudley to discuss the death rulings prior to trial. But even if she had changed the causes to strangulation, defense attorneys would have used that against the prosecution, he said.

“If she changes it, you get attacked,” he said. “If she doesn’t change it, you get attacked. You’re always going to get attacked.”

Nationally acclaimed forensic pathologist Michael Baden — a former chief medical examiner for New York City who has re-examined the slayings of President John F. Kennedy, Martin Luther King Jr. and Medgar Evers — agreed to review crime scene and morgue photos of both cases at The Star’s request.

He saw strangulation signs on Sparks.

“The photographs do show bilateral petechial hemorrhages in both eyes and a horizontal mark on the right side of her neck that are consistent with homicidal ligature strangulation,” he wrote in an email.

Decomposition of Reed’s body made a determination more difficult, Baden said.

Other medical examiners found it hard to believe that a belt strangulation wouldn’t leave a mark, and if it did, that Jackson County could miss it.

But evidence and injury signs can be missed for several reasons, said Marcella Fierro, who retired in 2008 after 14 years as Virginia’s chief medical examiner.

“Sometimes it’s an issue of the condition of the body,” she said. “Sometimes the person (pathologist) doesn’t recognize what they are seeing. And sometimes it’s a failure to look.

“The eye sees what the mind knows. If you don’t know what strangulation with a belt looks like, then you’re not going to see it.”

James Gill, Connecticut’s chief medical examiner, who previously worked 15 years in New York City’s medical examiner office, recently studied more than 70 strangulation deaths and found nearly all left evidence.

In his study, which he presented in October at the national association’s annual meeting, he found that 80 percent of strangulations bore signs of external injury. Dissecting neck tissue revealed evidence of injury in 93 percent of the deaths.

Bleach is a sign that a victim has been sexually assaulted, Gill told The Star. Deaths involving sexual assault often are the result of strangulation, he said.

“One thing we teach new medical examiners is, if you see a case where sexual assault is apparent, think strangulation,” Gill said. “And if you see a strangulation case, think sexual assault.”

Either way, the death of a prostitute should raise red flags, Gill said.

“Usually for most medical examiners, their antenna kind of goes up because they’re at risk of violence,” Gill said. “Usually a very careful investigation is done, or should be done.”

Although both Sparks and Reed had high levels of drugs in their systems, that was not unusual for them, according to friends interviewed by police.

The amount of drugs necessary to kill can be tough to determine, experts say, because addicts can tolerate doses that would kill others.

“I’ve seen a man shot in the head, and when you do the autopsy, his coke levels are sky high,” Gill said. “But he was walking around functioning just fine.”

PCP is an uncommon cause of death, Fierro said. But cocaine is common. Either way, calling an overdose a homicide “could happen, but it would need to be revealed by the investigation.”

Dudley said her office has a range for toxic drug levels. If a person’s level falls in that range, absent other injuries or medical problems, the death could be ruled an overdose. Overdoses usually are accidental, she said.

Reed’s mom was incredulous when detectives first told her they thought her daughter died of an overdose.

“I said, ‘Look, she had no way to get out there, and why would someone pose the body?’ If you’re going to dump someone after an overdose, you’re not gonna get out and pose the body and pull her shirt and everything up. You’re not going to do it.”

Detectives didn’t respond to her suspicions, she said.

“To me, you should be looking at a death as a murder just to rule it out.”

Dudley insists that her office assign a cause and manner of death for each body, unless the bodies are charred, skeletal or badly decomposed.

But that can be difficult, other medical examiners say. Some cases with intact bodies remain perplexing, and those should be ruled undetermined, they say.

“Maybe you don’t know,” said Bux, the Colorado Springs coroner. “But it’s important to not say it’s one thing and it turns out to be something else. That’s what undetermined is for.”

A medical examiner issues two rulings in every death: one for cause, which is the medical reason a person died, and one for manner of death, which represents the circumstances. There are many possible causes but just five accepted manners: natural, accidental, homicide, suicide and undetermined. A doctor can use undetermined as a cause or manner, or both, but it is more commonly used for manner, experts say. An acceptable range is 1 to 5 percent of cases, they said.

Too many undetermined manners can mean doctors aren’t doing their jobs, but too few could mean doctors are overreaching, experts say.

Before Dudley arrived, Jackson County’s undetermined numbers were red-flag low three times in four years. They improved after she came but have hovered near the low end of the acceptable range. In 2011, the rate was only 0.5 percent.

Dudley said she believes any figure under 5 percent is good.

“We try very hard, by doing a thorough examination and autopsy, and work very well with other agencies as far as looking at the circumstances surrounding the death that we usually can provide an answer,” she said.

Recent statistics The Star gathered from 14 other accredited offices across the country show they ruled an average of 3.6 percent of deaths undetermined in manner.

Johnson County doesn’t track its rulings, but Wyandotte County Coroner Alan Hancock said he ruled 2.2 percent last year as undetermined in manner, mostly involving baby or overdose deaths. He also has used undetermined for causes of death in several old homicide cases, including the death of a woman found with her shirt pulled up and pants pulled down in a ditch 3 miles from her car, which had blood inside.

Dudley said that her pathologists aren’t locked in to cause and manner of death. They may amend rulings if new information surfaces, she said.

She noted that she generally does not mix her rulings, meaning if she can find a cause, she will find a manner.

But Schmunk disagreed with that philosophy, saying he could have a gunshot victim but still not know whether the victim died of homicide, suicide or accident. And vice versa, he could have a woman die under suspicious circumstances but not be able to determine a medical cause of death because of decomposition.

“You need to take into account the scene and circumstances,” he said.

A baby’s death in Kansas City in April 2011 could have been a candidate for an undetermined ruling in light of the child abuse signs revealed during an autopsy, some experts told The Star.

The baby’s father told police his 4-month-old daughter, Jaila McDaniel, fell unresponsive while sleeping on his chest in their apartment. He said his rescue efforts caused bleeding from her nose and mouth, but the mother said she saw blood in the baby’s nose before those efforts began, according to police reports.

An X-ray showed five healing fractures: a broken rib and breaks in the tops and bottoms of both legs. An investigation by Missouri’s Children’s Division confirmed that the bones were broken in different instances of abuse and that the parents were the sole caretakers, but it could not determine who inflicted the injuries.

Pietak noted in his autopsy report that the fractures were non-accidental but ruled the death an accident due to positional asphyxiation, with bronchitis as a contributing factor.

The broken bones did not cause Jaila’s death, Dudley said.

But the cause of the fractures should be explained in order to fully determine the cause of death, said Baden, the former New York City chief medical examiner who has been conducting autopsies for more than 45 years.

Smothering cases can leave little physical evidence, which magnifies the importance of witness statements and other detective work, experts said.

A year after Jaila’s death, her father had a baby with another woman. When 7 weeks old, that baby arrived at a hospital with a fracture to his left femur, old and new brain hemorrhaging, and fractured ribs. The father claimed he had dropped the baby while bathing him.

Relatives told police this was the second time the father claimed to have dropped the baby during a bath. Jackson County prosecutors charged Jamaal McDaniel with child abuse and endangerment.

Seven weeks after Jaila’s death, Kansas City police closed that investigation, citing the medical examiner ruling. Prosecutors declined to comment since McDaniel’s parenting history is part of the abuse case.

Jackson County officials stress that the medical examiner does not work for law enforcement.

But ruling a case undetermined encourages detectives to dig deeper, said Gill, of Connecticut.

It tells police, “I’m suspicious about this,” he said. “She’s not stabbed or shot, but there’s some subtle findings. And let them do the investigation in case something new comes up.

“Once you call it an overdose or an accident, people, the police and everyone else lose interest.”