A Georgia coroner mistakenly ruled a natural cause of death in the case of a man who was later found to have suffered stab wounds to his neck.
The Gwinnett County Medical Examiner’s Office also responded to the scene. According to 11alive, Gwinnett County Coroner Shannon Byers investigated and ruled Neal’s death to be from natural causes. She claimed Neal’s arteries had burst, resulting in the presence of a large amount of blood.
Neal had several known illnesses—including high blood pressure. They may have been construed to account for all the blood. His sister said she was immediately skeptical of the coroner’s assessment.
“There’s no way,” Smalls told WSB-TV. “It was too much blood.”
Small’s suspicions were confirmed when a funeral home employee, who was also a coroner in a neighboring county arrived. He found that Neal’s body bore evidence of multiple stab wounds.
“When the funeral home director got there, he asked us to leave so we wouldn’t see what was about to happen,” Small told 11alive. “When he came back out, he went to the police car and reported there was a hole in his [Neal’s] throat.”
Gwinnett County Medical Examiner’s Office acknowledged the error in a statement cited in the 11alive report. The report suggested that when Byers initially examined Neal, she may not have been sufficiently thorough out of concern for exposure to blood-borne pathogens.
The Medical Examiner’s Office noted in a statement that “the investigator conducted a scene investigation and given information Mr. Neal had medical conditions which caused the investigator to minimize exposure to pathogens that were potentially present at the scene. In doing so, the investigator did not see injuries to Mr. Neal.”
Gwinnett County Coroner’s Office Chief Medical Examiner Carroll Terry conducted a full autopsy on Neal’s body on Monday, the report noted. She found suspicious injuries believed to be stab wounds and ruled the cause of Neal’s death to be a homicide.
The story was posted by 11alive on its Facebook page, where one commenter with apparent knowledge of the investigation wrote that the coroner worked under difficult conditions, adding, “this wasn’t negligence, but a confluence of a whole set of circumstances.”
The commenter wrote: “It was dark, the examiner had to wear double (or was it triple?) gloves due to blood born pathogens due to hep C, had to use a flashlight to conduct the exam (this was done at the scene, not at the medical examiner’s office), could not feel anything under the jaw due to the gloves, hep C causes blood issues and often hep C patients will have blood from the mouth (there’s a term for it actually). There was no evidence of any struggle or crime, in fact, the door had been locked prior to anyone arriving on scene, everything appeared in place. The examiner had absolutely no cause to suspect foul play, conducted an exam in the conditions that were available to her at the time with the information she had available to her at the time.”
The commenter continued: “Did the cops say, ”Hey, we suspect foul play?“ No. I don’t see anyone saying anything about that. They would’ve been first on scene. If they thought something was off, that there was a possibility that this wasn’t natural causes, they would have indicated that to the examiner so she'd know to look for possible evidence.”
Cpl. Michele Pihera said the mistaken cause of death assessment has not hindered the investigation.
“We were aware of the situation prior to getting that final classification from the medical examiner’s office,” Pihera told WFTV.
He did not indicate whether the police had any suspects, but said that it was probably someone who the victim was acquainted with.
“ ... he knew them because he wouldn’t let just anyone into his home,” Pihera said.
