Under Texas law, a death is reportable to the medical examiner in a number of circumstances, and one of them is a death that is unexpected or unexplained in a person who has not been recently attended by a physician.

The night physician did not report it, because she had been told there was an attending physician and that he was coming, and because she had been on for eleven hours, and because — she said this in an interview and it is the most honest sentence in forty pages — the family was standing right there and I have never once had a family lie to me about that.

The facility had no pediatric death protocol. It has one now.

It was written in the following August and it is nine pages long and the first page says that any death of a patient under eighteen is reported to the medical examiner regardless of history, without exception, by the pronouncing physician, before the body is released.