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Grayson Beyer was just short of a month old in May 2016 when his parents, an Air Force couple stationed at Joint Base Pearl Harbor-Hickam, brought him to the hospital limp and unresponsive.

Testing at showed bleeding in the infant’s brain and skull. Grayson was transferred to the pediatric intensive care unit, but the damage was so great, little could be done except comforting him. Two weeks later, he died.

Grayson and his mother, Natasha Beyer, tested positive for the antibody for the herpes simplex virus, which can cause symptoms like Grayson’s. Despite no evidence of an active infection in the newborn, an autopsy at Tripler pinpointed that as the culprit and ruled the manner of death as “natural.”

But there were signs it was anything but.

A CT scan had shown four rib fractures.�� Grayson had also suffered bleeding in the retinas, a classic sign of abuse.

The Tripler doctors, however, did not report these suspicious symptoms, despite a law requiring them to alert police or the Hawaii Child Welfare Services when they have reason to believe abuse or neglect has occurred. Nor did they disclose facts that shed doubt on their finding of a natural death to , who could have done his own investigation of the causes.

It was not until a little more than a year later that Grayson’s death got more scrutiny, after his parents arrived again at Tripler with another child, Avaline, born a mere nine days earlier.

This time, there was no mistaking the nature of the symptoms. Avaline suffered bruising to the left side of her face, a skull fracture, brain bleeding, rib fractures and bone lesions typically caused by infants flailing their limbs when shaken.

In light of these injuries, Medical Examiner Happy investigated Grayson’s death and concluded it had been a homicide, caused by blunt force trauma to the head. He said he had been unaware of the rib fractures and Grayson’s negative herpes virus results until Avaline was hurt.

Beyer and her husband Caleb Humphrey now face a court-martial in Grayson’s death and Avaline’s injuries, including charges of involuntary manslaughter and negligence resulting in grievous bodily harm. Their trial is scheduled to begin in February.

Abuse “should have been more thoroughly considered.” — Lt. Col. Shelly Martin, a child abuse pediatrician

The case opens a window into Hawaii’s system for reporting child abuse, and what happens when those charged with the responsibility fall short.

The Air Force’s own pediatrician reached unsettling conclusions about how it was handled.

Abuse “should have been more thoroughly considered” in Grayson’s case, wrote Lt. Col. Shelly Martin, a child abuse pediatrician. In a letter dated Aug. 3, 2017 to other Air Force officials, Martin wrote that Grayson’s rib fractures were “highly suspicious.” The retinal bleeding needed further investigation.

And though the parents had not reported that Grayson had been hurt, “that is a feature of abusive injury,” she wrote.

In hindsight, it can be far easier to see the signs of abuse, especially when parents have no known history of such behavior. Doctors must make complex judgments about which of dozens of causes led to the symptoms they see. This can be particularly challenging with infants, who cannot describe their symptoms or the events leading up to them and are prone to medical perils.

But the Tripler doctors are mandated reporters under Hawaii law, meaning they are required to report the suspicion of abuse or neglect to the police or state Child Welfare Services even if they are not sure and have taken no steps to prove it. Every state has such a law, although the details differ.

reporters such as doctors must have “reason to believe” that child abuse or neglect has occurred.

A published by the state’s Child Welfare Services goes into more detail. Evidence of abuse includes, among other things, “internal bleeding,” “fracture of any bone” and “subdural hematoma.” Grayson’s injuries included brain and skull bleeding, retinal bleeding and four fractured ribs.

It’s unclear from the public record which Tripler doctors who worked on Grayson’s case knew about which of his symptoms.

All the Tripler doctors named in Grayson’s medical reports remain in good standing with the . In Hawaii, a mandated reporter who “knowingly” fails to report suspected abuse can be charged with a petty misdemeanor. None of the doctors are facing any such charges.

They could not be reached and Tripler said it could not comment because of the pending criminal case.

A Rarely Used Law

Consequences for those who fail to report appear to be rare. Either that, or Hawaii’s mandated reporters — from doctors and other medical professionals to teachers and others who work with children — are all living up to the requirement.

A spokesman for the Hawaii Judiciary said a search did not turn up any cases involving a violation of the that makes failing to report a crime.

The , which can take action against professional licenses for various lapses, is unable to search its records for cases involving failure to report. But spokesman William Nhieu said that no one there could remember failure to report abuse being the basis for a disciplinary action.

The checked its records for the past five years and could find no cases involving mandatory reporters.

Hawaii’s mandatory reporting law is in some ways more lenient than those in other states. Hawaii’s maximum sentence of 30 days is at the bottom end of the range, which goes as high as five years, according to . Florida considers it a felony, and other states will upgrade it to a felony under certain circumstances.

Some laws also contain provisions that refer cases involving a professional such as a doctor to the state licensing board.

Grayson’s medical records show that Dr. Min Sang Ro performed the autopsy five days after Grayson’s death and relayed the results to pediatrician Dr. Christopher Naun.

The case was reviewed by Dr. Christopher Gordon, a pathologist at in Delaware, in consultation with Dr. Christina Belnap, a Tripler pathologist. Gordon wrote that the symptoms were “consistent with, but not diagnostic for, herpes encephalitis.”

But Gordon also pointed out inconsistencies and potentially troubling evidence. Tests for active herpes infection in Grayson came up negative and “leave open the possibility of other” causes.

Grayson’s rib fractures were “concerning,” he wrote. But with “no known suspicion of foul play” and considering other factors, it was possible that Grayson’s ribs had been cracked during child birth, he wrote. That’s a rare event, but documented in the medical literature.

A Story That Didn’t Add Up

Based on his own autopsy and reports from Gordon and a neuropathologist at , Ro concluded that Grayson’s death had been caused by the herpes infection and opined that the manner of death was “natural.”

According to a later report on Grayson’s case, “law enforcement’s involvement was deemed not warranted at the time.”

In Avaline’s case, Humphrey told Tripler staff he was carrying his newborn daughter when he tripped and “overcompensated” by slamming the infant against his shoulder.

His story didn’t add up. In light of Avaline’s severe injuries, it wasn’t long before authorities were taking a much closer look at Grayson’s death.

Witnesses have told Air Force investigators that Beyer and Humphrey were living beyond their means, purchasing a house in Kapolei and a new truck and eating out many nights. Beyer supposedly had credit card debt of $15,000 to $20,000. Shortly after Grayson’s death, court records show they got a life insurance payout of about $10,000.��

In federal court documents, Beyer and Humphrey deny that their lifestyle was in any way extravagant or that their credit card debt was out of the ordinary.

Avaline is apparently in foster care on the mainland, and her case also has led to controversy over a different kind of notification.

Steve Lane, a Honolulu social worker and private investigator who has served as a court-appointed special master in other child abuse cases, says that Avaline may have legal claims against Tripler and the state to help offset the costs of lifelong medical treatment.

A Hawaii court protocol in child protective cases requires certain parties to notify the court in writing if they learn that a child may have suffered injuries that could lead to litigation. Among those parties is the guardian ad litem and court appointed special advocates, assigned by a judge to protect the interests of the child.

Lane alleges that these parties failed to file a notification with the court about Avaline’s injuries or support his attempt to do so himself. , which provided an advocate in Avaline’s case, said it could not comment because of confidentiality in child abuse matters.

In the meantime, a judge approved Lane’s request to serve as an advocate to protect Avaline’s legal interests, allowing him to seek outside counsel to pursue any litigation.