All autopsies are important, but the autopsy of Michael Anthony Kerr was especially so.
Kerr, a 53-year-old inmate at Alexander Correctional Institution in Taylorsville, died of dehydration in March after spending five days handcuffed in solitary confinement, lying in his feces and urine.
But before prison officials at the Department of Public Safety would share its records, they required the state medical examiner to sign a form specially drafted by lawyers for the prison system. The form said the medical examiner could look at prison records but not keep copies.
"I've never seen anything like this in all my career, and I've been doing this for 28 years," said Dr. Greg Davis, a University of Kentucky pathologist who worked as a medical examiner at Wake Forest Medical School for five years.
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The Office of the Chief Medical Examiner has broad authority to conduct death investigations, including the power to subpoena any records helpful to its investigation. Davis said the unusual "read but don't copy" memo raised a big red flag: "What are you hiding from me and why?"
Dr. Susan Venuti, who performed Kerr's autopsy, found that the cause of death was dehydration. But she did not make a finding on the manner of death: accident, natural, suicide or homicide. Instead, she wrote "undetermined."
Deputy Director of Prisons Gwen Norville allowed Venuti to review an internal investigation known as a Sentinel Event Review. "However, no reports were permitted to be retained by the OCME and no additional reports were provided for review," Venuti wrote in her autopsy report.
Venuti wrote that it was unclear whether prison officials withheld fluids, whether Kerr refused them or whether some other factor led to his death.
The details of Kerr's death could result in criminal charges or civil lawsuits. The department has not released its investigations into Kerr's death.
Details on his treatment and death have to be gleaned from a variety of sources: the autopsy report; inmate letters; letters to the nine prison employees fired after Kerr's death; and court files begun by fired employees fighting to get their jobs back. Investigations by the State Bureau of Investigation and FBI will not be made public unless charges are filed.
After the release of the autopsy on Sept. 25, federal prosecutors in Raleigh began a grand jury investigation into Kerr's death. The SBI had started an investigation in April in response to a request by David Guice, commissioner of adult correction and juvenile justice.
Frank Perry, the secretary of public safety, said his department is not hiding anything.
"I wanted a full, fast and fair internal review," Perry said. "The medical examiner's office got what they needed. Something like this is so important, we want to take the right steps."
A claim of privacy
Perry, who retired after 22 years in the FBI, most recently as head of the Raleigh/Durham office, said he was concerned about releasing Kerr's records while other investigations were in progress.
Perry said he didn't want to release the personnel records of prison employees or run afoul of HIPAA, the federal law covering the privacy of individual medical records.
"There is no right to privacy in a North Carolina medical examiner investigation, and HIPAA does not apply," Davis said. "This guy should have been better prepped by his legal counsel."
North Carolina has a prison population of 37,500. Scores of inmates die every year from illness, old age or accidents. Under state law, the prison system must report every death to the Office of the State Medical Examiner, which decides whether to perform an autopsy. The medical examiner has performed six autopsies on the 89 inmates who died in 2014.
Have HIPAA concerns ever entered into the death investigations of any other inmate besides Kerr?
"I don't know," Perry said.
Death from dehydration
Kerr, a Sampson County native, was a 12-year Army veteran and preacher. He had run-ins with the law in the 1990s with a string of larceny convictions. Brenda Liles, his sister, said Kerr had a series of nervous breakdowns after two of his sons were murdered.
Shortly after the second murder, in October 2008, Kerr fired nine shots into a house in Garland. He was convicted and sent to prison. He was diagnosed with schizoaffective disorder and bipolar disorder.
Around October 2013, Kerr stopped taking the drugs prescribed for his mental illness. According to prison records, inmates with mental illnesses generally develop behavioral problems three months after they stop taking medications.
On Feb. 18 of this year, prison officials put Kerr in solitary confinement, known as disciplinary segregation, for disobeying orders and tampering with a lock. Three days later, a captain wrote that medical staff were worried that Kerr could become dehydrated.
On March 8, staff at Alexander called a Code Blue - a medical emergency - because Kerr was unresponsive. Staff entered his cell and put Kerr in handcuffs and leg restraints while a nurse examined him.
They removed the leg restraints upon leaving but left him handcuffed for the next five days. During those days, guards observed him several times an hour, noting once that he was standing and all other times noting that he was lying on his bunk.
On March 12, prison officials prepared to move him to a hospital at Central Prison. They found Kerr in his cell with his pants and underwear at his ankles, lying in his own feces and urine.
"Staff could not unlock the handcuffs because they were clogged with dried feces," according to the letter of termination delivered to a former captain at the prison. A sergeant called for bolt cutters and cut off the handcuffs.
Prison officials drove Kerr to Raleigh. When he arrived three hours later, Central Prison staff found him dead and cold to the touch.
Venuti performed the autopsy the next morning, on March 13. Autopsy reports generally take six to 12 weeks to complete. In the course of the investigation, medical examiners routinely review medical, psychiatric and other records.
On Aug. 6, almost five months after the autopsy, a top prison official allowed Venuti to see a Sentinel Event Review. Venuti signed the form crafted by lawyers working for the prison system.
"The documents included confidential personnel information and confidential inmate records," said the document, written on Department of Public Safety letterhead. "While reviewing the documents, I made notes relating to my inquiry. I understand that DPS intends to maintain all documents reviewed by me and that, if necessary for the cause of death inquiry, I may have access to the same information in the future."
Though the document says that Venuti made notes, no notes exist in the autopsy file. Kevin Howell, a spokesman for the Office of the Chief Medical Examiner, said there were no other notes. Howell also said Venuti would not be available for an interview.
Davis, the University of Kentucky pathologist, said that Venuti performed an excellent autopsy, with the correct cause of death, dehydration, and the appropriate manner of death, undetermined.
He commended Venuti for telegraphing to the discerning reader, such as a pathologist or lawyer, that she did not receive all the necessary records.
"They should have opened up every bit of discovery they have," Davis said. "It's the right thing to do. And do not they think that a civil lawsuit will burst this case wide open?"