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After their 4-month-old son died in a Honolulu day care, Cynthia King and Jeff Muir vowed to try to get on with their lives.

The Honolulu medical examiner told them Wiley died of pneumonia, King said. They were confused by that diagnosis. Wiley had suffered through a cold three weeks earlier but seemed fine the day in February 2014 when his grandmother delivered him to day care.

Still, they had an official explanation they felt allowed them to start working through their grief. They saw a counselor who encouraged them to talk about Wiley and look for physical releases for their heartache. They surfed. Jeff fished, and Cynthia did yoga.

And they had another child, Dexter, born in early 2015.

But on what would have been Wiley’s second birthday last October, the couple saw something that tore up whatever peace of mind they had achieved and sent King on a fruitless quest to answer questions about what happened to her son.

They had taken off work that day to do something peaceful and healthy to commemorate Wiley. As they were lacing up their hiking boots at a trailhead in the Koolau Range, they saw the woman who had run Wiley’s day care, wearing scrubs and escorting an elderly man walking on the sidewalk near a nursing home.

Why, they wondered, was Therese Manu-Lee no longer running her in-home day care?

That question would lead to a cascade of unsettling revelations. King discovered that, a year and a half after Wiley’s death, the day care had been shut down for taking in more children than allowed by law. She found out that Wiley did not die of pneumonia, but rather of an undetermined cause.

She learned that Manu-Lee appeared to have given contradictory reports about Wiley’s whereabouts when he stopped breathing. The ambulance crew reported that she said she had put the baby down for a nap and found him unresponsive 10 minutes later. But she told the police that Wiley had been in her arms.

And while the police report said that Manu-Lee’s female assistant had called 911, King got the tape and heard the voice of a man identifying himself as Manu-Lee’s son.

Ultimately, though the case technically remains open, her questions led to more questions and a feeling that the institutions entrusted with looking out for vulnerable infants did not care about what happened to her son.

“It’s shocking to me the lack of oversight, the lack of transparency … and I think the overall lack of interest in making the child care environment safe for kids,” she said. “It’s like everything I brought up was just an inconvenience.”

King gave her account to Civil Beat in several interviews and shared a variety of documents, including the police report, autopsy and communications among various parties.

In a brief interview, Manu-Lee said, “The child was ill. It was not my fault.” She said two different autopsies had shown as much.

When a reporter pointed out that the Honolulu medical examiner had changed the cause of death to undetermined, she replied, “Still, it was not my doing. Any further contact with me will be harassment. Thank you.”

She then hung up.

The state , which registers in-home child care operations like Manu-Lee’s, refused to give Civil Beat records of its investigation of Wiley’s death or the one from the following year that resulted in the facility’s closure. Likewise, the department would not produce any routine inspections of the day care or make someone available to answer questions about the case.

The department cited a in the state Uniform Information Practices Act — Hawaii’s public records law –that allows a day care investigation to be withheld from the public if it relates to a criminal proceeding that could be jeopardized by the release.

A spokesman for Honolulu Prosecuting Attorney Keith Kaneshiro says the case is still open. But there’s little evidence it’s going anywhere.

A ‘Baby Ambassador’

In his short life, Wiley defied all the accepted wisdom about babies, King said. Almost right away, he slept through the night and never fussed when handed over to someone other than his parents.

“We joked that he was a baby ambassador,” said King, an entomologist with the state Department of Land and Natural Resources. “He made having a baby look really easy.”

Finding day care for an infant in Honolulu was extremely difficult, she said, but eventually she and Muir narrowed it down to two family child-care homes. This type of facility, in a private home, must register with the state. They are limited to caring for six children, including no more than two infants under the age of 18 months, or four if another adult is there to help.

Muir found Manu-Lee warm and caring, and King appreciated the convenient location, on Williams Street just off Kapahulu Avenue. Manu-Lee said that she would use their deposit money to buy a brand of crib King wanted, and promised to communicate with them about how Wiley was doing during the day.

Manu-Lee had told them that she did not allow parents inside the house, because it might upset the other children to see adults coming and going, King said. Wiley’s parents thought that sounded considerate. They figured as they got to know the other parents, the rule might be relaxed. They were unaware of a state regulation that requires day care operators to allow parents to visit.

Wiley started day care on Feb. 3, 2014. That day, King said, she was surprised and upset when she didn’t hear from Manu-Lee, and later found that Manu-Lee did not enter any information about Wiley’s day into the log book. Manu-Lee, she said, was very apologetic and in the following days texted a few pictures.

On Thursday, three days after Wiley started day care, King was in a meeting about containing the spread of an invasive insect, the little fire ant, when she got a call from Manu-Lee. King recalls that Manu-Lee said she had found Wiley unresponsive, and that King should go as quickly as possible to Kapiolani Medical Center for Women & Children.

Three days after Wiley started day care, his parents were summoned to the hospital. He died a few hours later.

Muir got a similar call, and the couple made it to the hospital just before the ambulance arrived. A team of doctors and nurses descended on their child, inserting IVs and pumping his chest in an hours-long effort to revive him.

King can’t forget the sight of her child’s perfect, unblemished body bleeding from needle insertions, his chest crushed from the attempts to save his life. He was pronounced dead by mid-afternoon, a few hours after he stopped breathing.

Two days later, they visited Manu-Lee’s home and discovered that the day care owner had not bought the crib she had promised for Wiley. King said Manu-Lee told them Wiley had napped strapped into a baby bounce chair. The day care operator said it was irrelevant to Wiley’s death, anyway, since he had stopped breathing while sitting on her lap.

Several weeks later, the told King and Muir that Wiley had died of pneumonia. The parents concluded that no one had been at fault and that it was time to face their grief.

And that’s the way things stood, until King and Muir saw Manu-Lee on what would have been Wiley’s second birthday in October 2015.

A Surprising Discovery

King was aware that Manu-Lee had been forced to shut down the day care after Wiley’s death while the state Department of Human Services investigated.

But King also knew that Manu-Lee had reopened four months later because she had returned there several times to collect money that Manu-Lee owed from their deposit and first month’s payment.

For two days after the hike, she tried to put it out of her mind. But then she Googled Manu-Lee’s name and learned from Yelp reviews that the day care had been shut down for taking in too many children.

After the weekend, she called the Department of Human Services and confirmed that Manu-Lee had been charged with caring for too many children at one time. When the department inspected, Manu-Lee was looking after 14 children, including eight infants, King said a DHS worker told her.

DHS spokeswoman Keopu Reelitz said the department would not discuss the case or confirm these details.

“It’s like everything I brought up was just an inconvenience.” — Cynthia King

Whatever composure King had gained now fell apart. She recalls that she crumpled to the floor and started crying, overwhelmed with the thought that her understanding of Wiley’s death was now shot through with questions. Were the problems identified by DHS going on when Wiley was there a year and a half earlier?

“From that point on, I was obsessed with finding out what happened,” she said.

Muir, a research technician at the Hawaii Institute of Biology Shark Research Group, also wanted answers, but found revisiting the details too painful and entrusted King to pursue it.

During her lunch hour one day, King walked to the police station and got the report, which she had never read. In a written statement, Manu-Lee described putting Wiley on her lap after feeding him. His eyes rolled up in his head and he began to shake, she wrote. She stated that she put him on the floor to check his breathing, and then started performing CPR and told her assistant, Jamie Chung, to call 911.

But a report from the ambulance crew told a much different story. In an addendum to the police report, the first responders wrote that the “babysitter” said that Wiley had been put down for a nap shortly after being fed. About 10 minutes later, she checked on Wiley and found him unresponsive, according to the EMS report. King also got a 911 recording of the ambulance crew speaking to emergency room staff in which a first responder said the same thing.

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This was consistent with King’s recollection. In the frantic moments when Wiley was being rushed to the hospital, she recalls Manu-Lee saying that she had “come back” to find the baby unresponsive.

Next, King got in touch with the Honolulu Department of the Medical Examiner to ask for a review of Wiley’s autopsy. She had received the autopsy shortly after Wiley’s death, but had not been able to bring herself to read it. Now, she did, and was surprised to find that the cause of death was listed as bronchiolitis, a lung infection common in infants, rather than pneumonia, as she had been told at the time.

A friend at UCLA arranged for two colleagues, a pulmonary pathologist and pediatric pathologist, to review the autopsy for free. They concluded that it was impossible that Wiley had died of bronchiolitis. But they recommended that she get another opinion from a pediatric forensic pathologist. They connected King to a specialist in New York, who she said came to the same conclusion.

Honolulu Chief Medical Examiner Christopher Happy, after consulting with a pediatric pathologist at Kapiolani Medical Center, agreed to change the cause of death to “undetermined.”

But because the police had not found any new information about the circumstances, King said, he declined to change the manner of death from “natural” to “undetermined.”

Happy could not be reached for comment.

Who Called 911?

In the meantime, King had unearthed another inconsistency. She had obtained the 911 call made from the day care after Wiley stopped breathing. It was not, as the police report had stated, Manu-Lee’s female assistant. It was a man identifying himself as Manu-Lee’s son. She wondered why the police had never interviewed him.

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King also had tried to obtain the day care’s records from DHS. The department, she said, denied her phone and email requests. Did investigators examine the inconsistencies she had found, or answer the questions that plagued her? She could not know.

King took the new information to the Honolulu Police Department. A detective wrote in an email that the inconsistencies could all be explained.

Maybe the ambulance crew had misunderstood what Manu-Lee told them about Wiley’s whereabouts when he stopped breathing, the detective wrote, or maybe in those frantic moments the day care operator simply got confused.

King later talked to the ambulance crew’s supervisor, who assured her that the one who made the report was a capable veteran who was careful to report accurate information. And King found it unlikely that Manu-Lee would have mistaken a basic fact such as Wiley’s whereabouts, even during the confusion.

As for the 911 caller, the detective said she had spoken to Manu-Lee’s assistant, who told her she was so shaken up that she handed the phone to Manu-Lee’s son. The detective admitted that she had erred by not including that fact in her report, according to an email exchange provided by King.

Because the medical examiner had left the manner of death as “natural,” the detective wrote, HPD would not refer it to the Honolulu city prosecutor. The detective also pointed out that there was no evidence of abuse or trauma, or that Manu-Lee had intentionally caused Wiley’s death.

King, recalling that Medical Examiner Happy had told her that he couldn’t change the manner of death in the absence of new information from the police, saw a case of circular logic. It appeared to be a classic Catch-22.

She enlisted the aid of some elected officials — City Councilwoman Ann Kobayashi and state Sen. Josh Green — and approached HPD again to reopen the case. This time, the department agreed.

As of now, the case is still considered open by the prosecutor’s office. But King has little faith that it’s going anywhere.

“From the very beginning, I wanted to know what happened,” she said. “I’m very much a researcher and have a lot of trouble moving forward if I don’t understand something … realizing you might never have that, it makes it really difficult for me to process that grief and move forward.”