The beginning of the end of Joshua Sharp's short life was an ear infection.

The 17-month-old boy, who'd been a resident of Child Haven since June 29 of last year, died on Aug. 15 after he stopped breathing and could not be resuscitated. On Friday, the Clark County coroner's office released the official manner and causes of death, findings delayed by the time it took outside laboratories to complete microscopic tissue analysis and a toxicology report.

"In layman's terms, Joshua Sharp had a prolonged infection in his ears that developed into an infection in his blood," said Samantha Charles, spokeswoman for the coroner's office. "As a result of the strain to his organs, his heart stopped and he died."

Charles said the coroner ruled that the manner of Joshua's death was natural. The causes of death were listed as:

• Sepsis, an overwhelming blood infection caused by toxin-producing bacteria.

• Otitis media, or ear infection.

• Influenza.

Joshua's death is one of several that have been fuel for ongoing government inquiries into the operations of Clark County Family Services and of Child Haven, the county government-run emergency shelter for abused and neglected children.

In the late spring and summer of 2006, Child Haven experienced chronic overpopulation, which led welfare advocates to question the quality of care minors in government custody were receiving. The population at the facility, on Pecos Road near Bonanza Road, fluctuates from the low 100s to 200-plus. In July, the month before Joshua died, the facility reported having 228 infants and children in residence.

At the time of Joshua's death, he was one of about 18 infants sharing a cottage at the shelter, according to the county. He had been taken to the shelter by a relative who could no longer care for him. Television news reports said Joshua's parents were homeless.

The coroner's pronouncement angered child welfare advocates, who said the manner of Joshua's death raises serious questions about whether proper medical attention is available to Child Haven residents.

"This little boy died of an ear infection," said Donna Coleman, a children's advocate and longtime critic of Clark County's child welfare services. "That's what babies die of in Third World countries that don't have antibiotics."

Police reported that on Aug. 3, Joshua received antibiotics for an ear infection. Additional details of his medical record while at Child Haven were unavailable. Clark County Family Services spokeswoman Christine Skorupski said Friday that federal HIPAA laws prohibit the release of the medical records of minors in county care.

Dr. Harold Naiman, a Las Vegas pediatrician and a past president of the local chapter of the American Academy of Pediatrics, said that a death such as Joshua's is extremely rare -- perhaps one child would succumb out of tens of thousands. Ear infections seldom progress in such a manner, Naiman said. And while he understands that the coroner's finding is a term of art -- natural death as opposed to homicide -- there's nothing about the death that seems natural to him as a physician.

"I don't think it's natural at all to see a child die this way," Naiman said. "To me, it seems pretty unnatural."

Naiman said such infections generally can be cleared up with antibiotics. The key is early treatment and follow-up care. If treatment isn't received -- or if the child's immune system is compromised or the infection is drug-resistant -- sepsis can develop over a matter of hours or days. The symptoms can include high fever, vomiting, lethargy, unresponsiveness and an unwillingness to eat.

"With sepsis, you can get to the point where it can be irreversible," Naiman said.

Bill Grimm, senior attorney for the National Center for Youth Law, said Joshua's death underlines the concerns that his group has raised. The center is a California-based advocacy organization that has filed a federal court lawsuit against the state and county citing child endangerment of minors in public custody. Child Haven, as a facility, is not required by state law to be licensed by child welfare entities and lacks proper oversight, he said. The very young, Grimm said, should not even be placed in group-care settings but should go to foster families who can give them individual attention and care.

"We know that children who have been abused and neglected have a higher incidence of health care needs," Grimm said.

According to Clark County officials, Child Haven staff members discovered that Joshua wasn't breathing during an afternoon change in staff. At the time, eight or nine staff members were in the cottage, along with two nurses. Paramedics spent about 25 minutes trying to revive the child, who later was pronounced dead at North Vista Hospital.

"To me, this is a clear case of medical neglect," Coleman said. "This is the kind of thing that's concerned me for years about Child Haven. With the overcrowding, especially in the infant area, there's no way you can monitor that many babies at once."

Tom Morton, director of Clark County Family Services, said he appreciates the concern of child advocates but said they are basing conclusions on speculation, not facts.

"I saw nothing in the autopsy report that alluded, one way or another, to medical negligence," Morton said. "There's no evidence to support the conclusions they are drawing at this point."

Morton said the county's own review of the circumstances in Joshua's death has been on hold while waiting for the coroner's determination.

Two months after Joshua's death, Child Haven staff members spoke anonymously to the Review-Journal, expressing concerns that children needing medical attention weren't getting it. At the time, staff members said children placed on the sick call list weren't always getting in to see medical providers. Examples given by staff members included the case of a vomiting toddler born prematurely and exposed to drugs. The girl was scheduled to be seen by medical staff. She never was treated because a nurse decided to take her name off the list.

Subsequently, Child Haven phased out the triage system that staff members complained about and revamped its medical services. A full-time pediatrician has been added to the staff. Clark County Family Services also is committed to developing medical passports that document the history and treatment children in government custody have received, county officials have said.

Joanne Thompson, a member of the Blue Ribbon Panel on Child Death Review that is reviewing practices in Southern Nevada, has reviewed the case history of Joshua Sharp but was prohibited by state law from disclosing any details.

Grimm said it's his hope that the panel uses its authority to investigate further the details of Joshua's death, including what medical care he did -- or did not -- receive while at Child Haven.

Grimm also said he wants to see Nevada lawmakers pass laws compelling greater public disclosure in cases of child death.