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A police officer heard wailing as he approached the house in a farming community near Idaho Falls, Idaho. It was freezing cold in the predawn darkness of 6:10 a.m. on Feb. 1, and Alexis Cooley was “hysterical,” the officer wrote later. He followed her into the house.

To Alexis, nothing felt real in that moment. It was like her eyes were a video screen playing a movie. More officers and sheriff’s deputies arrived. An ambulance pulled up. When Alexis called 911 minutes before, she’d said between sobs and frantic pleas for help that the baby wasn’t breathing and his body was cold. Medics performed CPR on her newborn son’s 12-pound body, though it was futile.

Still, the medics asked: Would you like us to take him to the hospital? Yes, save my baby, Alexis remembers saying, and soon she was in her husband Diamond’s pickup truck, following the ambulance to the hospital.

The doctor pronounced Onyxx Cooley dead two minutes after arrival.

In the hours that followed, as Alexis and Diamond Cooley sat with their baby’s body, the search for answers about what took his life was supposed to begin. The person whose job is to find those answers, the elected coroner of Bonneville County, failed to do so.

He never asked Alexis and Diamond about the days preceding Onyxx’s death, never visited the scene, never performed a reenactment of the infant’s sleeping position, never ordered an autopsy. Some or all of these steps are prescribed by the Centers for Disease Control and Prevention, the U.S. Department of Justice, the National Association of Medical Examiners and the American Academy of Pediatrics when an otherwise healthy infant dies.

The guidelines exist to help coroners identify accidental suffocation, abuse or medical disorders that went undetected. The guidelines also make it possible to flag risks that, if discovered, may help keep other children alive.

“If you don’t look, you’re not going to find,” said Lauri McGivern, medicolegal death investigator coordinator in Vermont’s Office of the Chief Medical Examiner, chair of the National Association of Medical Examiners’ medicolegal death investigation committee and past president of the American Board of Medicolegal Death Investigators. “We need to know why infants are dying.”

But nothing in Idaho law says an elected county coroner must follow any national standards for death investigations. So, many of them don’t.

A child who dies unexpectedly or outside of a doctor’s care in Idaho is less likely to be autopsied than anywhere else in the United States.

In the case of baby Onyxx, without a word to Alexis or Diamond, Bonneville County coroner Rick Taylor simply decided the death was an unsolvable mystery.

A Frantic Moment

Alexis Johnson and Diamond Cooley met on Tinder shortly after high school and became parents to Jasper in 2019, Stohne in 2021 and Onyxx in 2023.

The Cooleys got married after Jasper was born. They separated a few years later, while Alexis was pregnant with Onyxx. The breakup wasn’t painless, but they worked through it. These days, they still speak in the shorthand of old friends and try to comfort each other; when Alexis starts to cry while talking about Onyxx, Diamond cracks a joke at his own expense, and she laughs.

They agreed to share custody of the boys. Diamond moved in with his mother in Idaho Falls, while Alexis stayed at her parents’ house in Shelley, about 20 minutes away.

Based on prenatal ultrasounds, they weren’t surprised when Onyxx was born with a cleft palate and lip. It required road trips to see specialists in Salt Lake City and made feeding a little more complicated. Onyxx couldn’t breastfeed. He needed a special bottle. After a couple of scares — Onyxx choked on spit-up when she put him on his back — Alexis talked with his doctors and learned she should keep his upper body elevated for 30 minutes after he ate, to leave time for him to digest the formula.

But otherwise, Alexis couldn’t believe what an easy baby he was. He almost never cried — just smiled, cooed and kept his eyes on his big brothers. Alexis loved to watch Jasper or Stohne get up close to Onyxx, hold his hands and play with him; he would burst into kicks and smiles. Diamond remembers that as soon as Onyxx figured out how to smile, he never seemed to stop.

What happened during the baby’s final hours is captured in police reports, 911 dispatch logs, a 911 call recording, Onyxx’s hospital records and Alexis’ recollections.

The night of Jan. 31, after putting their two older sons to bed, Alexis sat in the living room feeding Onyxx until he dozed off around 11 p.m. She carried him downstairs to their basement bedroom, where he lay propped on her legs facing her, while she sat playing Fortnite in bed.

As she lay down to sleep, Alexis propped a swaddled Onyxx in the crook of her outstretched arm. She woke expecting to feed him again around 3 a.m., but for the first time in his 10 weeks of life, Onyxx wasn’t ready for another meal. He was sound asleep, so she moved him off her arm and onto his back. She scooted over to the other side of the king-size bed, checked her phone, took a puff from an e-cigarette on her nightstand, then went back to sleep.

When she woke again around 6 a.m., Alexis rolled over to find Onyxx in the same position, swaddled. He was cold. A half-inch of yellowish-white foam came from his mouth. It looked like saliva with a little bit of blood in it.

Alexis tried to clear his airway — first with her finger, then by turning him over and doing the Heimlich maneuver she learned in a health care course. She ran upstairs with Onyxx, screaming for help. She called 911 and got some words out before handing the phone to her mother. Then Alexis called Diamond, who jumped in his truck and got to the house as the ambulance doors closed.

With Alexis and Diamond following behind in the pickup, the ambulance carrying Onyxx arrived at the emergency room of Eastern Idaho Regional Medical Center at 6:43 a.m. An ER doctor looked at the baby’s heart through an ultrasound. There was no life. Onyxx’s parents walked through the ER doors and, minutes later, the doctor delivered the news.

In an hour, at most, the doctor gave Onyxx a best-guess diagnosis of sudden infant death syndrome, or SIDS, according to the medical chart.

This was not supposed to be the final word, however.

Idaho law says when a child dies “without a known medical disease” like Onyxx did, a coroner must investigate.

As the ER doctor was finishing with Onyxx, a nurse made a phone call to the coroner for Bonneville County, where the hospital was located, to let him know a baby had died in his jurisdiction.

The Part-Timer

Rick Taylor considers himself a part-time coroner, even if his annual pay is $95,928 and the county payroll lists the position as full-time. He said he spends at least five hours a day in the office and is on call the remainder of the day.

If the county told him to work full time right now, “I’d send in my resignation,” he said. His hands are full attending to the health needs of his family, he said. He also travels often.

At age 68, his voice is reedy and soft. He has a full head of gray hair and wears a trim mustache to match. In a recent interview at work, he wore knee-length jean shorts and a short-sleeve plaid shirt. In contrast to the casual look, he rarely smiled and came off as reserved, even a bit stern at times.

Taylor works out of a squat, grayish building on a residential street near the railroad tracks. It doubles as the county morgue, with a walk-in cooler to store bodies. Taylor says visitors expect it to smell like death; it smelled like mint when a reporter stopped by in July.

During this visit, Taylor logged on to the state’s online portal for managing death certificates and worked through his list for the day, clicking electronic approvals for cremation and other paperwork. He took a phone query about a missing parolee who might have died. On his desk sat a file on the death of a man, reported missing in 1986, whose DNA was recently matched to a tibia bone found in 2009.

Taylor grew up in East Idaho, joined a local fire department in the early 1980s, got married and raised six children. Coroner seemed like a logical career progression; most Idaho coroners are first responders or morticians, jobs that already require them to evaluate people’s injuries and talk with grief-stricken families.

A Republican, Taylor was appointed to the office in 2012 after about 11 years as the coroner’s chief deputy. The job back then was part time and paid $18,000 a year.
He said that when he recently persuaded commissioners to make it a full-time job at higher pay, he was merely setting up the office for future coroners to make a living wage.

Although some states hire licensed forensic pathologists as medical examiners, many others, like Idaho, have elected coroners who often have no medical degree.

But even states that elect coroners have some oversight. Some have professional boards that write regulations. Some require autopsies for all unexpected or unexplained child deaths. Some offer funding to ensure a baseline level of service. Some offer state money to transport bodies, a big expense in the vast expanses of the West.

Not Idaho.

One of its few requirements is to attend “coroner’s school” within a year of taking office and 24 hours of training every two years after that. There’s no penalty for failure, unlike in neighboring states, where consequences can be severe: suspended pay, forfeiture of the office or a misdemeanor charge. One in 4 Idaho coroners have repeatedly fallen short, according to records provided by the state coroners association. Those same records indicate Taylor hasn’t come close to hitting 24 hours since 2017-18; he didn’t respond to emails asking about the apparent shortfalls.

The lack of regulation may help explain why the state has the nation’s lowest autopsy rate in child deaths attributed to unnatural or unknown causes — a category that includes suicides, homicides, crashes, drownings, overdoses and sudden infant deaths. A review by the state’s Office of Performance Evaluations this year found 49% of those deaths were autopsied in Idaho from 2018 through 2022, far below the national average of 79%.

A logbook that Taylor provided to ProPublica in response to a records request shows an even lower rate in Bonneville County during those years. He ordered autopsies in 33% of the 39 child deaths whose causes were, based on his notes, unnatural or unknown.

The unautopsied deaths included a 17-year-old girl found hanged at a juvenile detention center, which Taylor ruled a suicide. Taylor said he needed to look at his case file to comment on why he didn’t order an autopsy, when national guidelines say all deaths in detention should prompt one. He didn’t respond to subsequent requests to discuss it.

Taylor said he always orders autopsies in a sudden infant death without an obvious explanation, even when a parent is suspected of rolling over on the baby. But he makes exceptions, like if police don’t suspect a crime and the parents object to having an autopsy. Or if a doctor has already offered up a cause of death.

“Then we go with that,” he said. “There’s no reason to second-guess the doctors. I’m not a doctor.”

Guidelines from the National Association of Medical Examiners say an autopsy from a forensic pathologist is needed. The guidelines say nothing about an ER doctor’s examination sufficing.

Barrett Hillier, a former police detective who ran for coroner against Taylor in 2022, said police and coroners have different jobs to do when a baby dies — and one of those jobs isn’t getting done in Bonneville County.

“There’s nobody really out there investigating these deaths,” said Hillier, noting that police investigate “the criminal side” but that not all deaths are crimes, and the police aren’t always right. “There should be checks and balances.”

Taylor addressed such criticism in a 2022 campaign Facebook post praising the presence of law enforcement at death scenes, “doing what they do best.”

“The Coroner on scene is doing what is required and what we do best!” Taylor’s post said. “There is no need for duplication!”

Tensions With the Coroner

In the weeks leading up to baby Onyxx’s death, Bonneville County had come very close to losing its access to autopsies altogether.

Ada County, home to the state’s largest urban center, does autopsies under contract with Taylor and more than 30 other coroners around the state. With Taylor, this relationship was badly fraying.

Rich Riffle, the elected Ada County coroner and a fellow Republican, wrote a letter in January to the Bonneville County board of commissioners saying there were “multiple issues” with Taylor’s death investigations.

Taylor’s office “consistently furnishes inadequate information” ahead of autopsies, he wrote. Riffle said Taylor’s office sent over “mere summaries of the case, sometimes just a few sentences on homicide cases.”

For example, the only photographs Ada County was getting from death scenes were those taken by law enforcement officers. Their job is to document a possible crime scene, not to capture the details that a trained coroner would, like how a person’s skin color changes after they die.

Riffle’s pathologists needed more than Bonneville County was giving them to decipher deaths at an autopsy table 300 miles from the death scene.

Riffle said his staff made numerous attempts to tell Taylor what they needed and why, but Taylor’s response was “backlash and, at best, temporary cooperation.”

All of Riffle’s senior staff agreed “that this relationship, under the current circumstances, must end,” he wrote.

Taylor, in an interview, said his reports were brief because he didn’t see the point of duplicating the work of police. Riffle has been “real hard to work with since he got elected,” Taylor said.

In the end, Riffle relented — at the behest of police.

Local law enforcement officers, worried about the fate of their criminal cases if they had to go without autopsies, reached out to Riffle’s office: Would Ada County keep serving Bonneville County if officers volunteered to get coroner-style training?

Ada County contacted Taylor to see if he was interested, and he told them he was. Ada County sent three people to eastern Idaho to teach some basics. The police were enthusiastic about the training. Taylor attended. Riffle was satisfied and sent another letter to Bonneville’s commissioners, this time saying his office would continue to do their county’s autopsies.

“However,” Riffle wrote, “I must make this clear, we will not tolerate any reports that fall short of the basic level industry standards.” Sending the pathologists complete reports in preparation for autopsies was Taylor’s job, Riffle wrote, not law enforcement’s.

Riffle’s letter to Bonneville County happened to be dated Feb. 1, the same day Onyxx died. Taylor took the nurse’s call about Onyxx early that morning.

Taylor told the nurse he “would probably rule the cause of death as SIDS and would not be responding to the hospital,” according to a detective’s report. Nor did Taylor plan to order an autopsy.

But detectives from neighboring Bingham County, who’d just arrived at the hospital to question Alexis and Diamond, were not ready to let Taylor’s decision go unchallenged.

They decided to look for a second opinion.

A Matter of Public Health

An hour after Onyxx was pronounced dead, a detective from Bingham County called Jimmy Roberts, according to Roberts’ phone records.

Roberts remembers the detective telling him what Taylor planned to do — or not do — including the decision to forgo an autopsy. Could Roberts try to change Taylor’s mind?

Roberts is the elected coroner of Bingham County, where Alexis lived and where medics, police and detectives had responded to her call about Onyxx’s lifeless body. But the baby was pronounced dead in a hospital 10 miles away, in Taylor’s county. Had Alexis opted not to send Onyxx to the hospital in a desperate grasp at the impossible, had he been pronounced dead at the scene, it would have been Roberts’ case without question.

Roberts, 57, has a different way of approaching his work than Taylor. Death investigations in Roberts’ office are consistent with national guidelines, a review of his reports shows. He sends most child and infant deaths to Ada County for autopsy.

Personal tragedy planted the seed in Roberts’ mind to become a coroner. He spent most of his adult life as a military corpsman, civilian emergency medic and firefighter. But in 2004, his father died of a gunshot wound to the chest in Boise County. Authorities at the time said they found the death suspicious but hadn’t ruled out the possibility of suicide.

The coroner’s written report, obtained by ProPublica through a records request, noted clues from the scene that contradicted statements of the man later convicted of voluntary manslaughter in the death. But Roberts didn’t like what he saw of the process. He was frustrated that Idaho entrusted death investigations to laypeople, elected coroners who can take office without any medical or legal training.

Roberts eventually took a job as a deputy coroner and later ran successfully for coroner of Bingham County in 2022, vowing to give every death its due. He worked 50 hours a week, using retirement pay from his past careers to supplement the coroner’s part-time salary, which was about $22,000 when he took office. He reopened old cases when families asked him to review a prior coroner’s work and he found it lacking.

Roberts has asked county commissioners for more money so that, when faced with two suspicious deaths, he wouldn’t have to decide which was more worthy of a full investigation.

His tenure has not been without controversy or criticism. Roberts was charged in 2022 with sexual battery, accused of grabbing a woman’s breasts. The allegation prompted county officials to call for his resignation and his deputy coroners to quit. A jury found him not guilty in 2023.

Roberts argues that getting sound answers in unexplained deaths is a matter of public health and safety. It’s a case he makes to anyone who will listen, and it’s why he joined the state’s child fatality review team, a volunteer group that meets year-round, under a governor’s executive order, to spot patterns that could save lives.

Taylor, in Bonneville County, has failed to provide any records to that committee for at least eight years. He’s been too busy, he told ProPublica. “It’s time, just, you know, to sit down and do it,” he said. (It took three months, and intervention from the county’s attorney, for Taylor to fulfill ProPublica’s request for his records of child death investigations.)

Roberts said the coroner’s job is to piece together a person’s final days to make sense of what happened. It honors a person’s life and ensures their death isn’t a black box from which no knowledge can ever be gained.

If the death of an infant or anyone else is written off as a senseless tragedy, Roberts said, “who the hell are you helping?”

The moment that Roberts understood what the Bingham County detective was telling him about Taylor and the death of Onyxx Cooley, he felt helpless.

“Somebody rolls into the emergency room with an infant, and they say, ‘Well, everything looked fine.’ The ER doc looks at him and says, ‘Oh, yeah, I can’t determine why they died.’ And the coroner decides not to send them to autopsy but sign it out as SIDS?” Roberts said in an interview. “That’s 100% bullshit.”

He knew that no one can call something SIDS without a full autopsy, toxicology testing, scene investigation, interviews with caregivers and reenactments with the people who saw the infant right before and after the death. “You cannot make that diagnosis without all of that information,” Roberts said.

Roberts wanted to help in the Onyxx Cooley case. He simply didn’t have the authority to override Taylor.

“Paperwork Autopsy”

At the hospital, Alexis and Diamond Cooley were talking with police. Family members had started to arrive, and everyone sat in a hospital room as the young parents reckoned with reality. Diamond remembers police asking a series of questions about their marriage and separation, which sounded to him like a suggestion that Alexis harmed Onyxx.

Alexis couldn’t shake the feeling that everyone was watching her, looking at her, eyeing her as the only person in the room when Onyxx died of some unknown cause.

The Cooleys remember nurses trying to help them cope with the grief, letting them sit with Onyxx until about 6 p.m., when it was time to take his body away. The hospital gave the family Onyxx’s handprints and footprints and plaster casts of his hands and feet.

By the time they walked out of the hospital, it was nightfall.

An officer that day had told Alexis that the coroner might want to do a reenactment of Onyxx’s sleeping environment, using a doll. She said she’d do it.

But the Cooleys learned from a funeral-home employee later that week that Taylor decided he didn’t need to do that part of the investigation. He had closed the case. He’d never contacted them.

The question of why Onyxx died lingered.

“It didn’t make any sense to me, right?” Diamond says. “He was a super healthy baby. And I was like, I don’t understand how it could be SIDS. Like, what else could it have been?”

The reenactment of the baby’s sleeping position that Taylor opted to skip might have offered clues. It is considered so crucial that Idaho’s coroners were offered specialized training in it in 2019. The class came with a doll for coroners to use in their counties. Taylor did not attend.

Here is what we know.

Safe sleep guidelines say babies should be placed on their backs in a crib or bassinet, with a firm mattress and no blankets, loose sheets, pillows or stuffed animals.

Onyxx was in an adult bed when he was found unresponsive. But Alexis said he was several feet away from her with no suffocation hazards nearby. Onyxx had suffered from dangerous reflux when sleeping on his back, but typically it happened immediately after a feeding; four hours had passed between when he last ate and when he was laid on his back.

The opportunity to understand what went wrong vanished when Onyxx was cremated.

In a one-page form labeled “Death Investigation,” provided in response to a record request, Taylor noted Onyxx’s cleft palate, recorded that Onyxx was last seen alive at 3 a.m. in bed with his mom and estimated the time of death as 4 to 4:30 a.m. Taylor’s handwritten narrative consisted of this: “found in bed w/mom — ‘foam’ in airway — unresponsive. Fed @ 23:30 — arrived ER in assystole — no response — EMS or ER.”

“We did basically what I call a ‘paperwork autopsy,’” Taylor said in a recent interview.

Asked about the fact that national guidelines require true, physical autopsies and other investigative steps when an infant dies suddenly, Taylor said Idaho law doesn’t require those guidelines to be followed. He didn’t see a need to go out to the hospital, visit the house where Onyxx died or speak with Onyxx’s parents. He’d talked with the doctor and with law enforcement officers who were at the scene.

“I don’t try to not figure things out. I don’t try to do the easy thing,” he said. “I haven’t been in this damn work for 23 years by just doing what is the easiest and the fastest way out.”

Less than a month after Onyxx died, 275 miles away at the state Capitol in Boise, a legislative committee heard about the structural problems plaguing Idaho’s coroner system.

An evaluator from the Office of Performance Evaluations, a nonpartisan watchdog agency, told the panel Idaho’s coroner system has fallen behind the U.S. for years and that the gap is widening as the state grows and forensic science matures.

The evaluator’s report suggested legislators consider policies used in other states, like requirements and state funding for autopsies in child deaths. Two efforts to require autopsies for SIDS deaths in Idaho failed 20 years ago, according to legislative records.

Alexis no longer blames herself for her baby’s death. Her therapist encourages her to avoid the “what if” questions because “it will just eat at me,” and no answer is capable of bringing Onyxx back.

Still, she said, had the facts of Onyxx’s death been properly examined, it might have helped spare another set of parents from what she and Diamond are going through.

It also might have answered one of the primary questions that drive the need for an autopsy: Are the other children at risk of dying from whatever killed the baby?

These days, after she puts the boys to bed, an alarm will go off six or seven times a night in Alexis’ traumatized brain: time to confirm her surviving children are still alive.

Diamond Cooley does it, too, on nights the boys are with him.

He stands there and watches 5-year-old Jasper and 3-year-old Stohne until their chests rise and fall. Stohne is a light breather, which means Diamond has a moment of panic until he can get a hand on the toddler’s chest.

While he’s there, sometimes Diamond adds another blanket. He can’t stand the feeling of cold skin anymore.