Last month, the Palm Beach County medical examiner made a fairly routine finding. In studying the death of Pahokee, Fla., resident John Henry Barrett, who died in May at the age of 77, it determined that his cause of death was homicide. There’s just one catch — Barrett died of sepsis, and was shot nearly 60 years ago.

To the average person, it’s an unusual-sounding case, but Dr. Reinhard Motte, associate medical examiner for Palm Beach County, said he sees one to two of these cases a year.

“It doesn’t really stand out,” said Motte. “We do get people with injuries — shootings, motor vehicle accidents … that happened decades ago that ultimately lead to someone’s life being lost.”

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One well-known similar case involved James Brady, press secretary to President Ronald Reagan, who was shot during the assassination attempt on Reagan in 1981. Brady’s death in 2014 was declared a homicide. Other such cases make headlines from time to time as well — sometimes even resulting in murder charges for the assailant if he or she is identifiable and still living.

But those cases present an intriguing medical mystery in which forensic examiners have to trace one condition to its cause, and then the cause before that — a chain that sometimes stretches back decades.

Ordinary death, extraordinary cause

On the surface, Barrett’s death was a simple case of sepsis, a runaway immune response to infection that destroys vital organs. Barrett had first had a urinary tract infection, and sepsis can result when bacteria escape the bladder into the bloodstream.

Based on this information, Barrett’s doctor listed his manner of death as natural. Ordinarily, a medical examiner would just have to file the death certificate. But when forensic supervisor Richard Long read the certificate, one word caught his eye: paraplegia.

“Whenever we see ‘paraplegia,’ that automatically raises the question, ‘what caused the paraplegia?’” said Long, who worked with Motte on Barrett’s case. “If it’s from a car accident, a fall, or an injury, or even being shot … then that automatically falls under our jurisdiction.”

Because the existing death certificate did not provide the reason for Barrett’s paraplegia, Long needed to investigate and prepare a new one. He reached out to Barrett’s family and discovered that Barrett had been shot in 1958, when he was 19 years old, during a fight with a friend that quickly escalated.

The bullet injured Barrett’s spinal cord and paralyzed him from the waist down, so he spent the rest of his life in a wheelchair. Paraplegics and those with limited mobility are at increased risk for urinary tract infections, and Barrett was no exception. Elderly individuals are also especially vulnerable to sepsis.

Because the chain of events leading to Barrett’s death traced back to his gunshot wound, his death was ruled a homicide by the medical examiner’s office.

“When we certify a death, we always go back to the initiating event,” said Motte.

Sometimes filling in the exact details of the event is hard. Police records from the time of Barrett’s shooting no longer exist, for instance, so Long was only able to connect the dots on Barrett’s death because his sister provided details.

Another challenge, according to Motte, is that plenty of people die with gunshot wounds, but not of them. He says that an examiner can usually tell the difference with an autopsy. In Barrett’s case, because his death was initially declared to be natural, he was buried soon after and no autopsy was performed.

During his 25 years of forensics experience, Motte has dealt with similar cases among veterans who fought in Vietnam, Korea, and World War II before dying decades later.

Oftentimes the gunshot wound reduces patients’ mobility, making them susceptible to infection, as in Barrett’s case. Other times, blood clots form in the legs, travel to the lung, and block blood flow.

Despite the gunshot injury, Barrett led an active life. He served for over three decades as a Baptist preacher and was the director of his local housing authority.

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