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ENNIS -- Harbor only got to play with his Thomas the Train set once before he died at the age of 6.

Jaritt deWaard gave his son the toy as a Christmas present last year, and sometimes, the grown man sits on the floor and plays with the train by himself.

On the living room wall above hang Harbor's baseball bat and drawings, reminders of the smiling child who spent too little time in his parents' lives.

The little boy who loved to play hockey and to ski died Jan. 12.

Within a couple of weeks, his parents had been told two different causes of death.

One, at least, was wrong.

In the weeks that followed, officials led the family on a bewildering search to corroborate a supposed head injury -- one the State Medical Examiner's Office later said never existed.

"I just hope and pray this will never happen to another family," said Candice Brownmiller, Harbor's mom, in a telephone interview. 

"It doesn't need to be like that for anybody else. That's for sure," deWaard said.

Wrong call

In Missoula, the recent resignations of two seasoned state medical examiners are linked to the work of the former associate examiner, the same pathologist who made the wrong call in Harbor's death.

Dr. Thomas Bennett conducted Harbor's autopsy as a private physician, and he is no longer doing autopsies for county coroners in Montana.

The experience of Harbor's parents and friends, though, shows the emotional consequences when a doctor makes a bad call in an autopsy.

At first, physicians at St. Vincent Hospital in Billings said the death could be attributed to parainfluenza.

Then, Bennett declared the cause was "blunt force trauma," likely from a head injury.

"It was very sickening thinking that he died of a blunt force trauma injury and how much pain he was in," deWaard said.

The coroner's office released the incorrect cause to news outlets, and Brownmiller received attacks on social media.

"People thought that Jaritt and I beat our child to death," Brownmiller said. "There's still people out there that believe Harbor died of blunt force trauma because they (Gallatin County) haven't released the correct information."

The family only received a correct death certificate nearly three months after Harbor passed away. It said he died of natural causes from complications of the parainfluenza virus.

Diagnosis of croup

On Jan. 5, deWaard picked up Harbor from the bus stop, and the youngster was breathing hard and coughing. Harbor had gone to school in Big Sky, where Brownmiller lives and deWaard works.

The parents are not a couple.

"He was in pretty bad shape," deWaard said.

The following day, Harbor seemed better, but his father took him to the doctor Wednesday morning, and she diagnosed him with the croup. On Thursday evening, Harbor was wheezing and coughing, and he made a comment that worried his father.

"He told me he was afraid he was going to die," deWaard said.

The declaration was completely out of character for the rough-and-tumble boy, deWaard said.

"I said, 'No, you're not going to die, buddy. Let's just go down to the doctor's.' "

The doctor called instead of showing up at the clinic, and over the phone, she told deWaard he could take his son to the emergency room if he believed the situation was urgent, he said. She didn't think it was.

"I was told this is normal. This is how he's been the last couple nights," deWaard said.

So deWaard took his son home. For five hours, he tried to help him breathe, but Harbor remained gasping and uncomfortable.

Around 1:30 a.m., he unzipped his flannel pajamas, tumbled out of bed, and started crawling toward the bathroom. He collapsed against the tub, and his hands seized.

"I rolled him over, and he was unconscious," deWaard said.

Autopsy requested

Neither deWaard nor emergency responders could revive Harbor.

Life Flight couldn't head to Big Sky because of the weather, so on Jan. 9, Harbor was driven to Bozeman, and then flown to Billings.

He was pronounced brain dead at the hospital on Jan. 12, and his organs were donated on Jan. 14.

At the hospital, the doctors swabbed Harbor before he died, and they determined he had parainfluenza, or croup, documents said.

Harbor had suffered through a bout of croup when he was 2, and his parents requested an autopsy to learn more about how it had led to his death.

Instead, they got a totally different determination. According to the autopsy, the cause of death was accidental blunt force trauma to the head.

The cause itself disturbed the family, and it led to a painful investigation that lasted more than two months. Katie Coleman, a friend of deWaard's, said it seemed like officials changed their minds every week.

"There was no closure," Coleman said. "Every week, it was more confusing. It was reopening the wound."

No evidence of trauma

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The futile search for evidence of a head injury made deWaard feel like he was being forced to play a bad game of "Ring Around the Rosey." He was strung along while doubting the conclusion.

"The boy had a big head to begin with, and he hit it every day. He skied. He did hockey. He mutton busted," deWaard said.

"If he was going to die from blunt force trauma, it would have happened a long time ago."

Bonnie Whitman, deputy coroner in Gallatin County, talked to Harbor's hockey coaches and teachers to try to find a possible source of trauma, and she took the child's sports helmets for inspection.

But the investigation revealed no evidence of head trauma.

"That's when these two medical examiners (Dr. Gary Dale and Dr. Walter Kemp) got called in because Bonnie had no idea. So we requested help," deWaard said.

Case reviewed

The State Medical Examiner's Office took on the case and enlisted the help of a couple of specialists.

In an April 7 letter to Gallatin County, Kemp offered the medical examiners' conclusions. DeWaard provided the letter and other documents to the Missoulian.

"There is no evidence of a head injury causing death," Kemp said in the letter.

Harbor had been declared brain dead, but doctors kept his body alive to harvest his organs.

"With brain death, but a living body, the brain undergoes changes ... as it is literally a dead organ inside of a living body, and begins to break down," the letter said. 

"During this breakdown process, numerous changes (occurred) including softening of the brain and dusky discoloration of the cerebral parenchyma (functioning brain tissue), as is evident in the autopsy photographs.

"Hemorrhage, production of thrombi (or blood clots), and vascular ruptures also occur as part of this process."

The doctors who reviewed the case agreed the "cause of death was not head trauma."

Death ruled as natural

In the letter, Kemp said the cause of death was due to complications from parainfluenza virus type 1.

The virus likely blocked his airway, caused asphyxiation and led to brain death, he said. The same virus also could have inflamed his heart and led to pulmonary arrest.

Either way, the death was natural, and it was attributed to the virus, Kemp said.

"Dr. Bennett and I have shared email correspondence regarding the above death, and held a phone conference on April 7, 2015, to discuss the cause of death.

"Dr. Bennett agrees that the most significant process in this child's death was the parainfluenza virus infection, and he concurs with the cause of death as listed above."

In a phone call, deputy coroner Whitman said she amended the death certificate as soon as possible.

Multiple times, Whitman described the process as painful for the family. They were not only grieving, she said, they were subject to accusations of bad parenting from the public.

"I know it was absolutely devastating to the family to have all these accusations and rude information, which made a tragic situation that much worse," Whitman said.

She agreed the family would not have been subjected to the experience if the pathologist had identified the correct cause of death in the beginning.

Whitman did not blame the doctor, though; she said it was a complicated process, and medical examiners do their best.

Beleaguered Bennett

In response to a request for an interview, Bennett offered a brief remark by email. He said he worried about talking without the permission of the parents.

“This is a good example of how information evolves, and you work through getting a cause of death as best you can,” Bennett said.

Bennett's work has come under scrutiny because it is linked to the recent resignations of Dale and Kemp as head state medical examiners. 

Before he came to Montana in 1998, Bennett's infant autopsies in Iowa came under fire and led to two wrongful convictions.

At 6 years old, Harbor was not an infant. It is unclear if deWaard's case was an anomaly or if it is evidence that Bennett's problematic autopsies were not limited to infants. 

In Montana, Bennett conducted some 61 autopsies on infants for county coroners from 2006 through 2015, according to data from the Montana Attorney General's Office.

The doctor did so despite a directive from the head medical examiner that Bennett refrain from work on infants. Bennett has argued the head examiner had no authority over his work for coroners, and he said a children's hospital repeatedly requested his services.

Bennett is no longer doing autopsies for county coroners, but he continues his private practice, Forensic Medicine and Pathology in Billings.

Montana Attorney General Tim Fox changed the structure of the State Medical Examiner's Office so all the pathologists are state employees who can be hired and fired by the head examiner. Coroners, in other words, will no longer call on doctors in private practice to do autopsies.

Glowing light

Coleman and Harbor were neighbors, and she remembers Harbor wishing her a good day on his bicycle when he was just 3 years old. She called the child a glowing light.

"It's a short period of time to have somebody in your life," Coleman said.

Last week, deWaard got a medal in the mail inscribed with the words "Gift of Life Donor" from LifeCenter Northwest.

Harbor deWaard was an organ donor, and a memento with his name will hang from a tree in Helena.

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