Death Investigation in America

Post Mortem




Death Investigation in America

Post MortemA year-long investigation into the nation’s 2,300 coroner and medical examiner offices uncovered a deeply dysfunctional system that quite literally buries its mistakes.




Gone Without a Case: Suspicious Elder Deaths Rarely Investigated



A retired U.S. government scientist, Shepter spent his final two years dwelling in a nursing home in Mountain Mesa, Calif., a small town northeast of Bakersfield. A stroke had paralyzed much of his body, while dementia had eroded his ability to communicate.

In collaboration with the Investigative Reporting Program at the UC Berkeley Graduate School of Journalism

He died in January 2007 at age 76. On Shepter's death certificate, Dr. Hoshang Pormir, the nursing home's chief medical officer, explained that the cause was heart failure brought on by clogged arteries.
Shepter's family had no reason to doubt it. The local coroner never looked into the death. Shepter's body was interred in a local cemetery.

But a tip from a nursing-home staffer would later prompt state officials to re-examine the case and reach a very different conclusion.

When investigators reviewed Shepter's medical records, they determined that he had actually died of a combination of ailments often related to poor care, including an infected ulcer, pneumonia, dehydration and sepsis.

Investigators also concluded that Shepter's demise was hastened by the inappropriate administration of powerful antipsychotic drugs, which can have potentially lethal side effects for seniors.

Prosecutors in 2009 charged Pormir and two former colleagues with killing Shepter and two other elderly residents. They've pleaded not guilty. The criminal case is ongoing.

Health-care regulators have already taken action, severely restricting the doctor's medical license. The federal government has fined the home nearly $150,000.

John Shepter with his wife. (Photo courtesy of the Shepter family)

Shepter's story illustrates a problem that extends far beyond a single California nursing home. ProPublica and PBS "Frontline" have identified more than three-dozen cases in which the alleged neglect, abuse or even murder of seniors eluded authorities. But for the intervention of whistleblowers, concerned relatives and others, the truth about these deaths might never have come to light.

For more than a year, ProPublica, in concert with other news organizations, has scrutinized the nation's coroner and medical examiner offices [1], which are responsible for probing sudden and unusual fatalities. We found that these agencies -- hampered by chronic underfunding, a shortage of trained doctors and a lack of national standards -- have sometimes helped to send innocent people to prison and allowed killers to walk free.

When it comes to the elderly, the system errs by omission. If a senior like Shepter dies under suspicious circumstances, there's no guarantee anyone will ever investigate. Catherine Hawes, a Texas A&M health-policy researcher who has studied elder abuse for the U.S. Department of Justice, described the issue as "a hidden national scandal."

Because of gaps in government data, it's impossible to say how many suspicious cases have been written off as natural fatalities. However, the limited evidence available points to a significant problem: When investigators in one jurisdiction comprehensively reviewed deaths of older people, they discovered scores of cases in which elders suffered mistreatment.

An array of systemic flaws has led to case after case being overlooked:

•When treating physicians report that a death is natural, coroners and medical examiners almost never investigate. But doctors often get it wrong. In one 2008 study, nearly half the doctors surveyed failed to identify the correct cause of death for an elderly patient with a brain injury caused by a fall.

•In most states, doctors can fill out a death certificate without ever seeing the body. That explains how a Pennsylvania physician said her 83-year-old patient had died of natural causes when, in fact, he'd been beaten to death by an aide. The doctor never saw the 16-inch bruise that covered the man's left side.

•Autopsies of seniors have become increasingly rare even as the population age 65 or older has grown. Between 1972 and 2007, a government analysis [2] found, the share of U.S. autopsies performed on seniors dropped from 37 percent to 17 percent.

Dr. Michael Dobersen, a forensic pathologist and the coroner for Arapahoe County, Colo., said he worries about suspicious deaths in nursing homes. "Sometimes, if I don't want to sleep at night, I think about all the cases that we miss," Dobersen said. "I'm afraid we're not looking very hard."

With the graying of the baby boom generation, such concerns will only grow in urgency. Within a few years, nearly one-third of all Americans will be over 60.

In a handful of locales, coroners and medical examiners have begun to view older Americans as a vulnerable population whose deaths require extra attention. Some counties have formed elder death review teams that bring special expertise to cases of possible abuse or neglect. In Arkansas, thanks to one crusading coroner, state law requires the review of all nursing-home fatalities, including those blamed on natural causes.

But those efforts are the exception. In most places, little is being done to ensure that suspicious senior deaths are being investigated.

"We're where child abuse was 30 years ago," said Dr. Kathryn Locatell, a geriatrician who specializes in diagnosing elder abuse. "I think it's ageism -- I think it boils down to that one word. We don't value old people. We don't want to think about ourselves getting old."

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http://www.propublica.org/article/gone-without-a-case-suspicious-elder-deaths-rarely-investigated

Editor's note: It is to be noted in the matter of the Estate of Alice R. Gore, deceased, a 99 year old ward of the Probate Court of Cook County, Judge Kawamoto's courtroom, Alice had a nursing home bracelet with DNR (do not resuscitate) at the time of her death. The express wish of Alice as noted on court record was to use all means necessary to resuscitate.  Funeral directors also found Alice to be extremely dehydrated.  These facts would make a reasonable person wonder if there was a conspiracy to eliminate Alice since her 1 million dollar estate was already depleted by the court in less than three years.  Lucius Verenus, Schoolmaster, ProbateSharks.com

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