Oregon’s chief medical examiner will step down Monday after a short but tumultuous tenure beset by conflict with several top prosecutors and capped by ongoing finger-pointing over who failed to secure a forensic autopsy in the death of an infant who stopped breathing at a Eugene day care.

The dispute between state and county officials exposes continued dysfunction despite a 2017 pledge under Oregon Gov. Kate Brown that all child care deaths must receive comprehensive investigations.

But after 9-month-old William Cannon died in August 2018, no alarms unified law enforcement agencies to coordinate their response. Ineffective communication in the days after he died meant that the pathologist who performed his autopsy was not a state medical examiner trained to look for signs of trauma that could indicate a crime.

As of Monday, the Lane County district attorney’s office blamed the state medical examiner, Dr. Michele Stauffenberg, for refusing to conduct a forensic autopsy. Stauffenberg asserts a hospital autopsy was sufficient because doctors who cared for William did not express concerns about foul play. The Multnomah County medical examiner’s office, the bureaucratic middle-man in the case, contends that Eugene police never requested an autopsy from them. Eugene police declined to comment.

It’s impossible to know what bearing the lack of a forensic autopsy may ultimately have on Lane County prosecutors’ decision to pursue criminal charges in William’s death. However, the case remains under criminal investigation. The day care owner has not been accused of wrongdoing.

On Friday, an attorney for William’s mother said she was unaware of government in-fighting over whether the state should have conducted an autopsy. She said doctors told the family immediately after his death that no medical examiner would perform an autopsy but provided no rationale.

Doctors told the family the baby died because his heart stopped and his brain lacked oxygen, but offered no explanation as to what caused what they described as a brain injury, said Alexander Pletch, a Portland lawyer representing the family.

The mother remains concerned that the lack of a forensic autopsy could jeopardize any potential criminal case.

“She was understandably confused about why that would be the case and upset.” Pletch said.

Stauffenberg, 58, will return to her former position of deputy state medical examiner.

Oregon’s regulation of day cares has become a major political issue since The Oregonian/OregonLive began spotlighting safety gaps and lax enforcement two years ago. The governor’s hand-picked child care administrator, Miriam Calderon, pledged reforms in October 2017 following the death of an infant at a Northeast Portland day care. The news organization reported this month how state regulators chose not to publicly disclose William’s death, which occurred amid last year’s contentious gubernatorial race, because they said the case was under criminal investigation.

Brown on Friday declined to address whether her mandate for thorough investigations is being fulfilled. The state medical examiner’s office is a branch of the Oregon State Police, which reports to Brown.

“Governor Brown’s highest priority is keeping Oregon children safe,” spokeswoman Lisa Morawski said in a statement. “When a child tragically dies, the Governor expects all agencies involved to work together to ensure a thorough investigation.”

Autopsies an issue

The day William was found unconscious, Stauffenberg was in Pendleton with her boss and four district attorneys to address a widening rift between her office and law enforcement -- including on the issue of autopsies.

Stauffenberg had worked at the medical examiner’s office for only a year when she rose to the top post in February 2018. She swiftly changed longstanding practices established by her predecessor, Dr. Karen Gunson, who led the office for nearly two decades and was generally revered among law enforcement and prosecutors.

“She was pretty clear when she came in that she was going to run things differently,” said Eric Nisley, the Wasco County District Attorney, in reference to Stauffenberg.

Among other things, Stauffenberg insisted that police agencies stop transporting bodies in patrol vehicles. The practice became an issue last summer after Stauffenberg discovered that Malheur County law enforcement transported two bodies across the state in a pickup truck with a canopy that lacked air conditioning or refrigeration. She also crafted new rules intended to keep law enforcement officials in a designated viewing area during autopsies at the state office in Clackamas.

Her changes made scientific sense, several district attorneys interviewed by The Oregonian/OregonLive unanimously agreed. But many said the new procedures surprised officers who drove hours to Clackamas for an autopsy because Stauffenberg hadn’t looped them in about changes before they arrived.

Some district attorneys also say they encountered resistance from Stauffenberg’s office when they requested autopsies. Under state law, a medical examiner or district attorney may order an autopsy performed in any death requiring investigation. Some district attorneys say they had to personally contact the medical examiner’s office to push for an autopsy when subordinates were initially told no.

“We don’t request them just on a whim, and I think they were being treated as though they were being requested on a whim,” Malheur County District Attorney David Goldthorpe said.

The growing tension over Stauffenberg’s changes prompted the meeting in Pendleton. During the Aug. 22 meeting, Stauffenberg “verbally agreed that if a district attorney requested an autopsy in the future that she would honor that request,” according to her direct supervisor, Police Services Bureau Major David Anderson, who attended the meeting.

Two days later, William died. Stauffenberg’s office did not perform a forensic autopsy. Officials involved in the case have blamed one another for why it didn’t happen.

‘Plausible alternative’

Autopsies in Oregon are exceedingly rare. The state ranked 49th nationally between 2013-2017 in the percentage of deaths that resulted in an autopsy, according to data from the Centers for Disease Control and Prevention. Autopsies were completed in only 3 percent of Oregon deaths during that span, a rate that is about one third as frequent as autopsies in Washington and California.

Gunson, Stauffenberg’s predecessor, asked lawmakers in 2017 for money to hire more medical examiners to address the growing pressure of the state’s population boom and drug overdose crisis. But short-staffing remained an issue after she left office.

During the same month that William died, government officials were publicly blaming short-staffing for slow autopsy results.

An autopsy by a state medical examiner trained in forensic pathology is the gold standard for a criminal case, said Josh Marquis, the former Clatsop County district attorney. An autopsy conducted by someone who lacks such specialized training could be picked apart by a defense attorney if a case advances to a criminal trial.

The defense will have a forensic pathologist review records and be prepared to testify, Marquis said. “They’ll suggest a scientifically plausible alternative.”

Dr. Clifford Nelson, a deputy medical examiner who works for Stauffenberg, said that generally forensic autopsies may not find anything that doctors trained to detect child abuse have not already discovered during their own examinations of a child while the patient was still living. But forensic pathologists are trained to look for signs of trauma that others may miss, he said.

“Some of the things that we would look for, they wouldn’t necessarily look for in trying to find a cause of death,” he said.

The ‘best option’

Governor Kate Brown, left, and Director of Oregon's Early Learning Division Miriam Calderon, right, pledged fixes to the state's oversight of daycares. The Oregonian/Courtesy photo.

Authorities arrived at a Eugene day care Aug. 22 after receiving reports of an unresponsive infant. William was transported to OHSU Doernbecher Children’s Hospital, where he died two days later.

Unexpected infant deaths in Lane County almost always result in autopsies by a Eugene-based deputy state medical examiner to rule out foul play, said District Attorney Patricia Perlow. Under Stauffenberg’s predecessor, the body would be transported from Portland back to Lane County for an autopsy.

Perlow initially told The Oregonian/OregonLive that Stauffenberg refused to complete a post-mortem exam despite repeated requests from a Eugene police detective.

In a March 25 email, Perlow provided a statement from a subordinate who wrote that Detective Cliff Sites “attempted multiple times to persuade Dr. Stauffenberg to do a post but she continued to refuse” the autopsy request.

“She had the opinion that the death was from a brain injury and that autopsy would not demonstrate anything further,” the email said.

Perlow’s email also said Sites contacted Lane County officials on Aug. 28, four days after the death, to express frustration.

In an interview, Perlow criticized the decision not to perform a forensic autopsy. “I just can’t imagine a decision to not do that,” she said.

But state and Multnomah County medical officials dispute Lane County’s characterizations. And Perlow, upon additional questioning, walked back her office’s statements.

Stauffenberg declined to be interviewed but said in a statement that she relied on conversations with doctors who treated William at OHSU. Stauffenberg had been told William’s death was “natural,” according to Anderson, her boss.

He said Stauffenberg had no recollection that she ever spoke to a Eugene police detective nor that she had ever learned of an autopsy request.

“The decision to refer jurisdiction to OHSU was made after consultation with the attending doctors at OHSU and with consideration that OHSU was better positioned to perform this type of autopsy,” Stauffenberg said in a statement. “In reviewing the case I firmly believe this was the best option to ensure the most thorough analysis of this case.”

An OHSU spokeswoman said the decision about a forensic autopsy ultimately falls to the state. If the examiner decides not perform one, doctors will offer to complete an autopsy for the family, Tamara Hargens-Bradley said in a statement.

“The goal of an autopsy performed by OHSU/Doernbecher pathologists is to understand the patient’s disease process, not for medicolegal determination of cause and manner of death,” she said.

If a Eugene police detective had asked for an autopsy in William’s death, the request would have passed through the Multnomah County medical examiner’s office because the death occurred in Portland.

The county examiner’s chief death investigator, Kimberly DiLeo, said her office’s notes do not say that any detective requested an autopsy from the state. Such a request would have been documented, she said.

Instead, DiLeo said, the notes say a Eugene detective called once -- on Aug. 28, four days after William died -- to ask questions about CPR and 911.

By then, Stauffenberg had already declined to perform an autopsy. An OHSU pathologist completed the autopsy Aug. 27.

The autopsy report, obtained by The Oregonian/OregonLive from attorneys representing William’s family, says that he was a normal 9-month-old with no developmental abnormalities. He was diagnosed with a “diffuse acute hypoxic-ischemic brain injury with cerebral edema” and the report referenced an “unexplained prolonged cardiac arrest” -- medical terminology for someone whose brain was swollen and deprived of oxygen and whose heart stopped for a prolonged amount of time.

Perlow on Friday said only Sites, the Eugene police detective, could clarify what requests were made for an autopsy.

A spokeswoman for the Eugene Police Department said officials would not comment.

“This is an active, open criminal investigation and we do not want to jeopardize the case,” Melinda McLaughlin said.

‘Great pathologist’

Stauffenberg told lawmakers in February that she was excited about the future of the medical examiner’s office under her leadership.

The office was rolling out a new records system, pursuing national accreditation and preparing to meet increased demand.

Outside the statehouse, concerns persisted about Stauffenberg’s leadership. Anderson, the state police major, said he heard from Marion County District Attorney Paige Clarkson who wanted to meet after an “interaction with her deputy district attorney and Dr. Stauffenberg could have been better.”

Other people approached Boardman Police Chief Rick Stokoe, who serves in a governor-appointed seat on the medical examiner’s advisory board. Stokoe said he called State Police Supt. Travis Hampton and was assured concerns about autopsies were being addressed.

Stauffenberg sent statewide officials a letter on March 20, dated one day earlier, announcing she had decided to step down to “focus on doing autopsies and teaching medical students and pathology residents.” She will return to her former position as a deputy state medical examiner, a post that paid her $48,000 less a year.

The office’s most junior member, Dr. Sean Hurst, will take the helm through June on an interim basis.

The changes were so sudden that no one informed the advisory board, two current members told The Oregonian/OregonLive.

“I’m truly shocked,” Stokoe said.

“That’s news to me,” said Mark Steehn, a Milwaukie funeral director who also serves on the board.

The governor’s office also was not notified about the changes before they occurred, Morawksi, the spokeswoman, said.

Oregon State Police have not provided documents about Stauffenberg’s performance or “self-demotion” in response to a public records request.

Anderson said the decision to step down was Stauffenberg’s alone.

“Dr. Stauffenberg is a great pathologist who loves forensic pathology,” he said. “It was the other areas of being chief that she decided weren’t for her.”

Fedor Zarkhin of The Oregonian/OregonLive contributed to this report.

-- Molly Young and Brad Schmidt

myoung@oregonian.com

bschmidt@oregonian.com