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Baby's death highlights requirements, or lack thereof, for death investigations

Mystery of death

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William King still mourns the loss of his baby, Lincoln, who died unexpectedly in late 2015. - PAM ZUBECK
  • Pam Zubeck
  • William King still mourns the loss of his baby, Lincoln, who died unexpectedly in late 2015.

William King headed for the chapel at Memorial Hospital Central on Dec. 11, 2015. He wanted to pray for his son Lincoln, just 70 days old. He found the chapel occupied so he called an Army chaplain on his cell phone asking for prayers.

While waiting to be notified that a breathing tube had been successfully inserted into Lincoln, his wife, Roslynn, called him, crying. Their son had lapsed into respiratory failure, she sobbed. As King ran toward the pediatric intensive care unit, he heard "code blue" being called.

Arriving in the ICU, he found the medical staff performing life-saving measures on the baby, including making an incision in his stomach to relieve distension, and administering 16 rounds of epinephrine during 41 minutes of CPR efforts. At the end, one nurse asked the others if they had any other ideas of how to revive little Lincoln, he says. They said "no," and Lincoln's time of death was called at 2:23 p.m.

Recounting that day now, 18 months later, King gets choked up. He's still grasping for answers.

"He was healthy," King says, "and he never made it out of the hospital."

Lincoln's body underwent an autopsy at Children's Hospital five days after he died, because Memorial doesn't perform death investigations. But no clear cause emerged, so the reason for the baby's death remains hazy.

The incident underscores how death investigations are carried out in Colorado, or not carried out. The El Paso County Coroner's Office, an independent investigator of cause and manner of death, doesn't autopsy many people who die in hospitals, because there's no legal requirement to do so. And deaths in nursing homes are virtually never scrutinized by coroners. While that might come as a surprise, it appears to be common across the country.

Lincoln was the Kings' fifth child, born Oct. 2, 2015, at Evans Army Hospital. Shortly after his birth, the baby experienced breathing problems, which his father calls "blue spells." The child wouldn't breathe for a time and would start to turn blue, or he'd cry until he turned blue.

"We had mentioned it to our primary doctor and was told it was normal and he'd grow out of it," King says.

On Nov. 28, Lincoln had two spells back-to-back within an hour. The second one prompted his dad to perform CPR and call 911. Paramedics placed the child on oxygen and raced him to Memorial.

A round of tests showed no apparent cause, King reports. Then, he and his wife were told three doctors had determined the best solution was a Nissen fundoplication surgery, a procedure that strengthens the valve between the esophagus and stomach in order to stop acid from backing up into the esophagus. It's considered a standard surgical approach to treating severe gastroesophageal reflux disease (GERD).

King became suspicious, though, when the doctors, who told the couple the procedure would last 45 minutes to an hour, remained in surgery for six hours. During the surgery, doctors also repaired an umbilical cord hernia, an operation he says they weren't told about in advance.

On Dec. 10, the child was moved to the pediatric intensive care unit, King says. That morning, when he and his wife went to Memorial, they found their son's stomach was "rock solid," and mucous was oozing from his naval. "They were trying to stabilize him to send him back to surgery, but he never made it that far," King says.

The couple asked that an autopsy be performed. But it provided few answers to a list of questions the couple still has: What caused their son's death? Was the surgery necessary? Why did doctors perform the additional surgery without their consent? Why did the El Paso County Coroner's Office refuse to get involved? Why was Lincoln given morphine?

The autopsy, performed by Dr. Kelley E. Capocelli at Children's Hospital Colorado in Aurora on Dec. 16, resulted in a report issued on Feb. 22, 2016.

In it, the doctor notes that the relationship between apparent life-threatening events (ALTE) and sudden infant death syndrome (SIDS) "is controversial" and the underlying causes of death can't be ascertained in 40 percent of cases despite exhaustive examination.

While rare, SIDS continues to take a toll. Of the 66,581 births in Colorado in 2015, the most recent available, 37 infants died of SIDS, according to the Colorado Department of Public Health and Environment.

But the autopsy also notes underlying causes of SIDS and ALTE are GERD and apnea (breathing interruptions), both of which were present in Lincoln's case. The autopsy found "no significant abnormality" in the respiratory system and that "repair sites" from the surgery were "intact and appropriate." It also noted that "brainstem gliosis could have contributed to the terminal central apnea episode." Gliosis is a process that creates scars in the central nervous system.

Howard Robin of La Jolla, California, is a pathologist and consultant who testifies as an expert in court. He reviewed the autopsy at the Independent's request and termed it "excellent and complete."

Gliosis of the brainstem, he says, has been found in children with central respiratory depression and apnea. "We don't know if it's cause or effect," he writes in an email. "But it may indicate the 'root cause' for his respiratory failure and death."

But Robin is left with questions of his own. Was the surgery necessary? Did the morphine given to Lincoln post-op trigger his respiratory problems? Should a breathing tube have been inserted sooner? With his history of apnea, should Lincoln have been monitored more closely?

Dr. Leon Kelly, deputy chief medical examiner in the El Paso County Coroner's Office, was aware of Lincolns' death because his office was notified by the hospital, but the death fell outside parameters that trigger a coroner's investigation. If a death involves drugs, poison or self-inflicted injury, the coroner will conduct an autopsy, unless the person was in the hospital for more than 24 hours and it was clearly a natural death, Kelly says.

"The death occurred in the hospital under the care of a doctor," he notes. "It doesn't fall into our jurisdiction."

He goes on to say that autopsies performed by hospitals can answer questions about inherited genetic conditions and other issues that aren't central to the purpose of a coroner's autopsy.

"On rare occasions," Kelly explains via email, "our office will perform autopsies on folks who have died in the hospital if there are concerns about medical error or medical neglect, which is often raised by the family. But in those cases the jurisdiction would belong to the Coroner because there are suspicions of injury or neglect."

While Kelly admits it might seem like a conflict of interest for a hospital where a patient died to conduct the autopsy, which happens frequently, it's common practice. "Hospital autopsies are an essential part of medical training, education and quality improvement," he says.

Robin, the pathologist in California, agrees, saying he doesn't suspect a lot of cases are slipping through the cracks. "Doctors are honest and have a great deal of integrity, and pathologists do too," he says. "If they found something that was amiss, they would report it."

Memorial Hospital cited federal privacy laws in not commenting on Lincoln's death. The city-owned hospital, run by UCHealth through a lease, doesn't have autopsy capability, so it contracts with Children's Hospital Colorado to perform physician-requested pediatric autopsies.

Children's Hospital also cited privacy laws in declining to discuss the King case, but noted in a statement that state law requires hospitals to promptly report all deaths to the county coroner.

The city's other hospital, Penrose-St. Francis Health Services, reports that an independent pathology physician group conducts about 33 autopsies per year at Penrose Hospital. They're performed if ordered by the attending physician and authorized by next of kin.

Unlike hospital deaths, which are reported to the coroner, there's no requirement that a coroner be notified of deaths in nursing homes.

"It's up to them whether it's a coroner case or not," Kelly says in an interview. "A lot could go on in nursing homes. It's completely and entirely up to them to report neglect, trauma or abuse. If a coroner is going to miss a homicide, that's what's going to get missed."

That's understandable, he says, because most people in long-term care aren't expected to survive, placing them at risk of abuse and neglect, especially if they suffer from diminished capacity, such as dementia, which makes them "unreliable narrators of their own lives," Kelly says.

Kelly knows of a few cases reported by family members, but those are rarely legitimate cases of abuse and neglect.

One backstop is funeral homes, which occasionally notify the coroner if they observe suspicious bruises, in which case, "We would investigate every one of those deaths," Kelly says. The coroner also would notify law enforcement if evidence suggests a criminal investigation is warranted, he adds.

All that said, Kelly says it's impossible to imagine conducting autopsies on all long-term care deaths. "There's no scenario where we have the capacity to investigate all nursing home deaths," he says.

And Robin agrees. "If we had to autopsy every single person who dies," he says, "you'd be doing autopsies on 3.2 million individuals [a year]. That would stress the system and pose an incredible cost."

The world of postmortem investigations was thrust without warning on King, an Army vet who served three Middle East tours. He didn't understand what to do, and hasn't been satisfied with a report without definitive answers. He filed complaints with Memorial, but they only resulted in letters saying all communications must go through lawyers. He's considered legal action, but can't find an attorney willing to take the case.

The passage of 18 months hasn't cured a hole left by his son's passing, and King is nagged by guilt and uncertainty. "I feel bad," King says, suppressing tears, "because I made the decision to take him to the hospital. I have to live with that guilt. If someone said, 'Your son died of cancer,' it would still hurt, but we would know. I guess we just have to go on living our lives."

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