Switched bodies give light to larger problem
Published: October 15, 2013
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Lyra Elvira Sewer Collazo, 95, of St. Thomas, and Erin Carmel Parsons, 79, of St. John, both died of natural causes Aug. 29. They did not look alike, according to Collazo's niece, but since their deaths, they have swapped clothing, caskets and, apparently, a burial plot at Bath Cemetery in Nevis because loopholes in how deaths are handled in the territory somehow allowed their bodies to be switched.
The case of mistaken identification has raised concerns among medical professionals about the integrity of the territory's system for handling medical, or non-suspicious, deaths. The discrepancies in how the two women were handled after their deaths, and contradictions in statements from the V.I. Justice Department - which oversees the medical examiner's office - and the front-line responders, reveal a lack of clear-cut protocols that some say needs immediate redress.
Attorney General Vincent Frazer denied that the medical examiner's office had any involvement in or notification of the deaths. He also said neither body had gone to the morgue at Schneider Hospital and described that circumstance as "highly irregular" because both women died outside of a hospital.
But the doctor and the St. John Rescue worker who dealt directly with the deceased women told The Daily News accounts of what happened on Aug. 29 that cast doubt on Frazer's statements.
Lorna Johnson, Collazo's niece, said she did feel better when - three weeks after her aunt's funeral was supposed to have taken place but had to be cancelled because Davis Funeral Home could not locate the body in their cooler - she was able to finally view the body, confirm it was her aunt and see her buried in Western Cemetery last week.
Exactly how the chain of custody over the two elderly women's bodies - from 911 dispatchers, to police, to medical professionals and the staff of Davis Funeral Home - broke down and allowed the switch to occur is not entirely clear.
Johnson said a Davis driver had told the family at an emergency meeting called after a Sept. 19 viewing when shocked, aggrieved relatives saw someone other than Collazo in her casket, that he had not tagged the body but had instead taken Collazo's death certificate to the office upstairs.
Johnson said the driver did not clarify how Parsons had been misidentified as Collazo in the cooler at Davis Funeral Home. She said her family was especially befuddled because Davis' general manager, Joycelyn Connor, had said that the Parsons family had two viewings and never noticed the body in the casket was not their loved one.
Connor eventually told the Collazo family to wait until health officials on Nevis approved the exhumation of the body in a plot in Nevis, Johnson said.
Where was the M.E.?
Frazer, who testified at a June 26 budget hearing before the Senate' Finance Committee about the medical examiner's office being inadequately staffed to meet the demands of the population, also denied that such shortages had "anything to do with this."
According to Frazer's testimony, Dr. Francisco Landron, who works part-time, is the territory's sole forensic pathologist. He has two assistants on St. Croix, one assistant on St. Thomas and a death investigator to assist him.
"The procedure is that if a person dies outside of the hospital, the medical examiner's staff will be called to pick up the body and take the body to the morgue, and the medical examiner makes a determination of death. Once a determination of death is made, the body is released," Frazer said Sept. 27. "I can tell you it didn't come into our morgue. The bodies went straight to the funeral homes."
In a follow-up interview Oct. 9, Frazer said: "I confirmed that our attendants were not called to pick up the bodies."
V.I. Code only explicitly requires the medical examiner to transport bodies away from the scene of death in the case of a suspicious or violent death or "a death while unattended by a physician, so far as can be discovered, or where no physician able to certify the cause of death as provided by law can be found."
Frazer said that "they didn't follow the procedures" in either case and that the "medical examiner's office was not involved."
No written policy
However, he also said that there is no written set of procedures governing the handling of dead bodies for whom foul play is not suspected.
"No, we don't have a written policy. We just have the past practice and tradition that we have operated with," Frazer said. He added that the development of written policy is a "work in progress."
Dr. Linda Callwood, who pronounced Collazo dead at her Foothills Plaza office, said the body switch should be a wake-up call to do just that.
She is joined in that sentiment by St. John Rescue Chief Bob Malacarne, who said that he has been pushing the V.I. Justice Department to develop a memorandum of understanding with his volunteer agency precisely because it is tasked with handling the deceased for the department because Landron and his staff cannot provide coverage of the island.
Callwood said that when she went to examine Collazo, it was apparent she had "no vital signs, no blood pressure." Callwood said she called 911 immediately and that police responded within an hour and a half.
An entry in the VITEMA blotter indicates the call came through about 11:31 a.m. as a "deceased person/death on arrival."
According to Callwood, an officer arrived along with a forensics technician who took photographs of the body.
Callwood said she was not sure whether the forensic technician is employed by the police department or the medical examiner's office but she thought that neither she nor the officer were authorized to take the body to the morgue.
As a licensed physician who has signed death certificates at the hospital, Callwood said, she knew she had to get authorization to have a Davis driver pick up Collazo's body after it had been in the office for hours because, dispatch told her, the medical examiner "was too busy to respond."
Her requests were routed through a 911 operator who called back and gave her express permission from the medical examiner's office to sign the death certificate and let the Davis driver take the body away, she said.
"I was told he was the only one covering St. Thomas, St. John and Water Island and that he's too busy, he can't come no time now," Callwood said of her second call to 911.
However, the VITEMA blotter does not show any other call issuing from Callwood's office Aug. 29.
The final permission came, Callwood said, when the 911 operator called her office back in response to the second, undocumented call to tell her that she had spoken to the medical examiner's office and it was okay to bypass the morgue.
Callwood said that, about three hours after finding Collazo lifeless, she gave the death certificate to the driver from Davis.
Callwood said she did not see whether he had placed a tag on the body, which was shrouded.
Callwood said she had done everything she knew to do as the pronouncing physician.
"If nothing comes of this case, then it just becomes gossip, okay, and I want action," Callwood said. "I want them to have a protocol. I want them to have a back up system for when more than one person dies. I called and asked. There's no protocol. What protocol are they talking about?"
According to Malacarne, he reached Parsons' home in Chocolate Hole, St. John, about 5 a.m. Aug. 29, after receiving a call at 4:31 a.m. from 911 dispatch. Police and EMS already had arrived and established the death as an expected, medical death. Malacarne said he tagged Parsons' toe and the body bag after obtaining identifying information from police.
"I got the tags from the police officer. When I got them from the officer, I looked at the name, I knew that was the name I was given verbally, and I tied it on her myself. Obviously if it falls off the body, the hope is, it's not going to fall off the bag. It was placed securely on the zipper handle, and we proceeded to Myrah Keating," he said.
Malacarne said that it is not unheard of for bodies to be picked up by funeral homes from the Myrah Keating morgue in cases where the medical examiner's office had deemed the deaths non-suspicious. He also said Friday that Parsons' body was the only body in the morgue at the time and that there had been no other deaths on St. John since. He said pronouncement of death and filling out a death certificate would have been the duty of Myrah Keating physicians at the morgue.
Malacarne said the mix up exemplifies why the Justice Department needs to write policy for deaths occurring outside of hospitals. As the head of the agency responsible for transporting the dead, it is disturbing that no solid regulatory framework follows a body from its place of expiration into the ground, he said.
"We have our written procedures, but we don't know what they expect of us," Malacarne said.
Regarding who on St. John is responsible for notifying the medical examiner's office, he said: "We don't know."
"We have no idea. That's why we have been pushing for an MOU," Malacarne said, referring to a memorandum of understanding.
Parsons' husband, Vernon Parsons, has declined to comment for this story, citing potential litigation. Davis Funeral Home owner Philip Davis has also declined to comment.
However, according to Alecia Wells, a friend of the Parsons family and an administrative aid at St. Ursula's Episcopal Church on St. John, the Sept. 7 service for Parsons there was closed casket and there were no viewings at the church prior to the service. Parsons' obituary contains no mention of any scheduled viewings either at Davis or St. Ursula's Episcopal Church.
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