At 1:06 p.m. on March 27, Jeffery Alan Hall, 39, was booked into the South Central Regional Jail on charges of domestic violence and failure to pay child support.
A little more than 16 hours later, he was dead.
He was found alone in his cell, lying face down on his right cheek, with orange jail-issued trousers on and a wool blanket wrapped around his waist, according to statements by jail officers obtained through a Freedom of Information Act request.
“He had spit coming out of the side of his mouth, drool, and he appeared blue in color and he was unresponsive,” one officer wrote.
Three and a half months after Hall died, it’s still unclear how he died.
The West Virginia Medical Examiner’s Office has not filed a report on his autopsy.
Three of the state’s six medical examiner positions are unfilled, resulting in a backlog and delays in processing and completing autopsies.
“A lot of times, there’s only so much that we can do until we have the records from the Medical Examiner’s Office,” said Joe DeLong, director of the state’s regional jails. “It does create problems.”
DeLong said he’s not expecting any surprises in Hall’s case but that, if there were surprises, the delays would be especially unhelpful.
“Time is of the essence for us to follow up on that, not only to figure out what happened, but to make sure it doesn’t happen again in the future,” he said.
DeLong isn’t the only one who’s expressed concern about the delay in completing autopsies.
“Is anyone having problems getting medical examiner reports on homicide cases?” Putnam County Prosecutor Mark Sorsaia wrote in an email to other lawyers in June.
“We had a murder in August of 2013, indicted going to trial in July 2014 and we can’t get autopsy report. Sent subpoena in April, called, wrote letter two months ago . . . this problem will push into a motion to continue the trial.”
Sorsaia and DeLong made clear that they were not criticizing Chief Medical Examiner Allen Mock but that the understaffing is causing problematic delays.
“We have people sitting in jail, you have a grand jury meet, you have an indictment and the judge sets a trial date, and you have to have the autopsy report that’s vitally important to your case,” Sorsaia said.
Donald Raynes, administrative director for the Medical Examiner’s Office, said staff members try to work with law enforcement to prioritize autopsies that are needed in an upcoming case.
An autopsy can take anywhere from 45 minutes to two days, Raynes said. However, once the autopsy is done, it takes more time to write the report. There are further delays in any case in which the medical examiner has to consult with another agency or professional, such as toxicologists, the fire marshal, the Drug Enforcement Administration or the FBI.
And there can be even more delays when medical examiners are called to testify on their work in court.
“Unfortunately, bodies keep coming in, so when you come in on a Monday and you have nine autopsies and you have two doctors on, by the time they do those, you’re pretty much exhausted and you come in the next day and there’s six or seven autopsies,” Raynes said. “And this is on a continual basis; it’s just staggering.”
The National Association of Medical Examiners recommends that each doctor perform no more than 250 autopsies per year.
Many larger states have county medical examiners, but West Virginia has just the one office for the entire state.
Relief is coming, though.
Raynes said the office has hired two pathologists, both of whom will start by Aug. 1. One of the current pathologists is quitting, though, which will still leave two vacant positions. Raynes said the staff has scheduled interviews with two more candidates and is hopeful the spots can be filled.
It’s not just a West Virginia issue. A 2009 study by the National Academy of Sciences found that there were fewer than 500 licensed forensic pathologists in the country.
“There is a shortage of pathologists,” Raynes said. “The priority is integrity and accuracy of the investigation, regardless of how long it takes.”
Reach David Gutman at firstname.lastname@example.org or 304-348-5119.