Records show medical examiner's office was notified of deaths of 2 women whose bodies were switched
Published: October 19, 2013
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ST. THOMAS - After the bodies of two women were switched and the mistake was discovered by shocked relatives at a Davis Funeral Home viewing Sept. 19, Attorney General Vincent Frazer said that at no point was the medical examiner's office notified or involved.
While no one who handled the bodies - including St. John Rescue workers and doctors who pronounced the women dead - can explain exactly how the mix-up occurred, they also said that the medical examiner's office was notified.
Records of 911 calls supplied by the V.I. Territorial Emergency Management Agency substantiate their accounts, with documentation of calls made to agent Troy Titley, a coroner who routinely picks up bodies for the medical examiner, following both deaths.
In neither case did Titley arrive on the scene or handle or view the bodies, according to the records.
Frazer has not responded to further calls from The Daily News for comment on this story.
The mixing up of the bodies has led some in the medical and first responder community to question what they perceive as a hole in regulations that, if unaddressed, could lead to other or more serious flukes when it comes to dead bodies.
Frazer has said that no written procedures exist for the notification and transportation process. In a budget hearing before the Senate Finance Committee earlier this year, Frazer said that the medical examiner, Dr. Francisco Landron, is chronically short-staffed, with only one death investigator and a handful of assistants working under him.
However, in an interview with The Daily News, Frazer also denied that the staffing shortage contributed in any way to the mysterious misidentification of Lyra Elvira Sewer Collazo, 95, who died on St. Thomas, and Erin Carmel Parsons, 76, who died at her Chocolate Hole home on St. John.
"I confirmed that our attendants were not called to pick up the bodies," Frazer said Oct. 9.
Both women died Aug. 29 of apparently natural causes, according to Dr. Linda Callwood and to Dr. Joseph DeJames.
Callwood pronounced Collazo dead when she went to examine her mid-morning at Callwood's Foothills Plaza office and found Collazo without vital signs.
DeJames is one of two physicians who works at the Myrah Keating Clinic on St. John, where Parsons' body was taken by St. John Rescue. There is a small holding area at the morgue at Schneider Hospital on St. Thomas where bodies are routinely kept for pick-up.
In cases where deaths are suspicious and the medical examiner must perform procedures, the V.I. Justice Department makes the pick-up; in cases of non-suspicious deaths, funeral home employees can retrieve the body.
DeJames said Dr. Elizabeth Barot pronounced and certified Parsons as dead and that at all times before Parsons left Myrah Keating she was labeled on her toe and the bag containing her remains was labeled.
"She came in as Erin Parsons, and she left as Erin Parsons," DeJames said, after reviewing Myrah Keating records.
Callwood and Bob Malacarne, chief training officer for St. John Rescue and one of the people who took Parsons to Myrah Keating, both recalled getting in touch with the medical examiner's office prior to seeing the bodies off to their next destination.
Callwood said she called 911 after discovering Collazo was dead and knew she had to get authorization from the medical examiner's office before a driver from Davis Funeral Home could take the body.
Callwood's first call is noted at 11:31 a.m. in VITEMA's emergency call blotter.
According to further records supplied by VITEMA, emergency dispatch notified Titley of the death eight minutes later, and the V.I. Police Department was notified at 11:42 a.m.
Forensics was en route 10 minutes later.
Callwood said the whole process of securing authorization and getting the body released from her office took about three hours.
While seeing other patients and during her lunch break, Callwood called again after a police officer had responded and a forensics technician had photographed Collazo.
Callwood said she had to call 911 again because she was unsure, at that point, about when the permission would come from the medical examiner's office.
Her second call was logged in VITEMA's records at 1:07 p.m.
"Dr. Callwood called 9-1-1 requesting ETA of Coroner," the VITEMA record states. Dispatch then called Titley two minutes later, and at 1:09 p.m., according to the record, "9-1-1 calls back Dr. Callwood's office and was informed that family has notified Davis Funeral Home."
At 1:11 p.m., "Titley notified 9-1-1 that it is okay for body to be turned over to Davis Funeral Home."
A final entry in the call record reads, "14:08 hours Body left."
According to Malacarne, earlier that morning on St. John, he called Titley at some point while tagging and picking up Parsons' body.
VITEMA's call log of the early morning death states that an initial call was received by 911 at 4 a.m. Two minutes later, 911 dispatch was informed that Davis Funeral Home had already been called, and three minutes later the police department was notified.
A third entry in the call log reads "407 hours-Agent Titley (Coroner) notified."
St. John Rescue, and an ambulance arrived on the scene shortly after 5 a.m., and at 5:14 a.m. emergency medical services confirmed they had a death on arrival.
DeJames, Malacarne and Callwood all said they did not perceive that anything was amiss in the chain of custody when either woman died, suggesting that the mix up probably occurred at Davis Funeral Home.
DeJames told The Daily News on Friday that the Myrah Keating log for the checking out of bodies was unavailable, so he could not be sure who signed the log when Parsons' body left the facility. However, he also said he was very sure that hers was the only body in the holding area at the time.
DeJames also said that the Justice Department has never issued Myrah Keating a written set of procedures to follow for holding and handling bodies and that all practices are instituted internally.
Malacarne said that, even though he likewise followed a strict and specific set of procedures crafted by St. John Rescue, a volunteer agency which has taken on the responsibility of transporting bodies for the Justice Department, it is troubling that no memorandum of understanding exists between his agency and the Justice Department.
The body switch exposes a gap in the death system that could have more serious consequences for non-suspicious deaths.
"This is why we have been pushing the Department of Justice for seven years to come up with an MOU," Malacarne said.
- Contact Amanda Norris at 714-9104 or email firstname.lastname@example.org.