"I keep thinking I should have seen something, that if my wife was alive, she would have noticed there was a problem," Tony Rosco said. "And I feel guilty."

Rosco's wife was killed in an auto collision just months before his mother died. His wife had visited his mother regularly.

"You wonder, who else does this happen to?" Tony Rosco asked.

Sue Rosco's condition astounded her doctor and the pathologist who performed her autopsy. Raul Vila, Broward associate medical examiner, said Rosco's skull was severely fractured and the injury had gone untreated, probably undetected.

"She had fallen or something, and they just left it at that," said Vila, who noted that the internal brain injury covered half of her head. Vila estimated that the injury was at least a week old and had been slowly bleeding.

But when Tony Rosco talked to his mother's doctor, the doctor told him that he had never seen someone fail so fast, with so little warning and that her death was suspect. Doctors at the hospital told Tony Rosco that it looked as if his mother hadn't eaten in seven to 10 days. There was old, decaying food in her mouth.

HRS abuse investigators turned the case over to the Broward state attorney's office. The investigators said there were indications that Sue Rosco wasn't properly cared for: She was dehydrated and covered with dried feces and food when she arrived at the hospital.

State law only requires doctors to see their nursing home patients once a month, leaving the burden of responsibility for daily health care with overworked, sometimes inexperienced nurses and aides.

Although numerous state agencies are responsible for making sure the frail are properly cared for in licensed facilities, that protective net often fails to detect neglect and abuse problems. Overlapping jurisdictions, poor investigative coordination and ignorance about abuse and neglect have made a growing problem worse.

"Among the care-givers, it is pretty well-known that it's rare that anybody is prosecuted for crimes against the elderly," said Robert Lee, a prosecutor in Fort Myers. "It's rarely a crime that's witnessed by anyone, and usually, even if it is, there's pressure not to do anything about it or to document it."

Lee spent months attempting to bring criminal neglect charges against the Cross Key Manor Nursing Home on behalf of Mildred Buie, an 80-year-old Fort Myers woman who died while a patient there in 1990. Lee claimed workers at the home didn't notice that Buie was critically sick even though the woman hadn't had a bowel movement in 18 days. Her medical records failed to explain why.

By the time the home sent her to a hospital, she was filthy, dehydrated and had rectal bleeding. Feces was so severely impacted that her colon ruptured, infecting her with bacteria that probably killed her. But no autopsy was performed. HRS's abuse registry wasn't called until days after her death. By the time criminal investigators were involved, Buie's body had been sent to Minnesota and buried. In the first attempt in Florida to prosecute a corporation on charges of abuse, Lee brought criminal charges against Crossgates Medical Inc., a Pennsylvania firm that ran the home.

The corporation pleaded not guilty, but agreed to settle the case by paying the state a $10,000 fine.

"You had neglect that led to her death, no doubt," Lee said. "But we couldn't identify one individual who was responsible. We just know that someone somehow failed to detect that she was in trouble.

"And because of that, she died."