Abused adults: Silent casualties

 

jpetchel@MiamiHerald.com

Essie Weaver, dead from bedsores and infection, lived the last of her 83 years mostly in a wheelchair in a vermin-infested crack den where authorities believed she was raped.

Idora Smith, a widowed homemaker, died after living in a state-licensed foster home where she lay motionless for weeks, high on Haldol, while blisters and bedsores rotted her skin to the bone.

And Richard Daniels, a retarded paraplegic killed by a blow to the abdomen, spent his entire adult life in a state institution where no one noticed he was dying.

All were the victims of what authorities believe was blatant abuse or neglect.

Not one person was charged, prosecuted or punished.

A Miami Herald review of hundreds of Florida abuse and autopsy reports shows that in the past five years, dozens of frail and disabled adults have died sick, starved, ridden with bedsores, bruises and broken bones -- the silent casualties of abuse, neglect and a welfare system that did little to protect them.

"It's cruelty. It's disgusting," said Harriet Roberts Martin, granddaughter of Idora Smith. "I can't stand that my grandmother suffered and no one was made to pay for her neglect. She was dead. No one cared. Case closed."

Few find justice.

Despite Florida laws making adult abuse a felony, rarely has a caregiver gone to jail in the past five years for neglecting or abusing the frail and disabled to death.

In Dade County: Never.

In Broward, one case is pending.

Most of these deaths have been forgotten, filed away, their cases closed without action by police, prosecutors, pathologists and state welfare investigators.

Yet, the stories behind their deaths reveal the startling symptoms of a nation's health and social welfare system gone awry. More adults than ever are living at the mercy of others, many of them poor and sick, many without health insurance, all helpless to fight back when the standards of medical care fail them.

"What we're seeing is more neglect, people who don't get care, people who are left to languish, people who lay in their own feces all day, people who are forgotten and who die," said Deborah Sokolow, head of one of Florida's Long-term Ombudsman councils, empowered by the Legislature to investigate adult abuse.

"And who's listening? Who seems to care? No one. There's no muscle. There's no enforcement."

The Herald's investigation found a troubling string of deaths by alleged abuse or neglect over the past five years. Not one case was prosecuted. And some were never investigated.

They include, among others, the stories of:

* An 84-year-old woman who lived in an unlicensed boarding home for eight years until she was hospitalized because of malnourishment, mammoth bedsores, a broken leg and infection. The sores were so bad on her toes that doctors had to amputate them. One sore engulfed her right ear.

Cause of death: malnourishment, complications from the bedsores.

* A 26-year-old mentally retarded man, under the Florida welfare department's protective supervision, who spent much of his life tied up or caged by his mother. Despite a lengthy history of abuse reports against the mother and "an escalating pattern of neglect," state welfare workers never found a better place for him.

Cause of death: craniocerebral trauma. His skull was crushed -- while in his mother's care -- when he fell from a six-floor window just days before welfare workers claimed they were going move him.

* A 99-year-old woman found dead in her urine-soaked bed at an unlicensed foster home. Her caretakers waited at least 24 hours -- maybe longer -- to call a funeral home to pick her up. The home was filthy. Her body, already partially decomposed, was infested with ants and maggots.

Cause of death: heart disease.

* A 78-year-old man left in his bed at home for nearly a year, his only caretaker his son. Police found him dead, lying in his own feces, his feet gangrenous, and a bedsore so severe in his groin that his penis was nearly severed.

Cause of death: infection.

* An 88-year-old woman living in a state-licensed, skilled nursing home who fell -- no one knows how -- and fractured her skull. For days she laid in her bed, catatonic, her brain slowly bleeding. When she was finally sent to a hospital, doctors noted she hadn't been nourished in days. She was filthy, feces and dried food caking her body.

Cause of death: blunt head trauma.

* An 89-year-old woman who hadn't seen a doctor in months, but lay in her bed at home, slowly dying. Police found her dirty, with open wounds on her back and legs, her spine and bones exposed. The family couldn't afford special care, so her 66-year-old daughter cared for her.

Cause of death: bronchopneumonia.

* A 92-year-old woman who slowly starved: No one at her nursing home repaired her abdominal feeding tube when it malfunctioned.

Cause of death: infection, starvation.

* A 75-year-old man who arrived at the hospital from a Miami nursing home with nine bedsores covering his body, most of them necrotic and infected. The home waited to send him for treatment until one day before his Medicare benefits at the home lapsed. The Long-Term Care Ombudsman Council concluded the home kept him "for the Medicare payments, while providing inadequate care."

Cause of death: unknown. No autopsy was performed.

"I see abuse all the time; it's absurd," said Olivia Graves, a South Dade physician who treats the elderly and frail. "But nothing ever happens on behalf of these people because of it. Nothing."

Florida's elderly and disabled population is growing in age and in numbers. There are far more aging, retarded and disabled adults who need medical help and social services than there are places to put them or people to care for them.

The result: They end up anywhere their frustrated family and social workers can put them, often powerless prey for abuse and neglect. The abuse seems particularly pathetic since many victims die too doped up, too sick, too disabled and too confused to ask for the help that could save them.

"What's out there is the underbelly of Miami, lots of elderly and developmentally disabled people living at the mercy of who knows what," said Jim Towey, the state's chief of social services in Dade. "Some are dying. It's tragic. It's an embarrassment."

In Dade, hundreds of cases of adult abuse have been referred over the past five years by the state Department of Health and Rehabilitative Services (HRS) to the Dade state attorney's office for criminal investigation.

Not one death by alleged abuse or neglect has been prosecuted.

In fact, many of those cases examined by The Herald never even made it into the hands of prosecutors -- but instead were shuffled haphazardly through dozens of state social workers and bureaucrats. Often, one investigating agency didn't even know what another was doing, or if they were doing anything at all.

Sometimes, the cases were never reported to Florida's abuse registry, as required by law.

And of the more than 900 HRS reports of adult abuse reviewed by Dade state attorneys that didn't involve death over the past five years, only six resulted in criminal charges being filed. Those dealt with financial exploitation, rather than medical abuse or neglect.

"Is our track record the greatest? No." said Katherine Fernandez Rundle, Dade's chief assistant state attorney. "It sounds like we don't care. But we do care. These are difficult, time-consuming cases. I can't tell you how many hours we've spent going back and forth analyzing a case because they're so disturbing and what you see is the end product: shameful abuse or shameful neglect or both."

Dade chief investigator George Havens said his office reviews every file it gets from HRS, but often can't prove "willful, wanton neglect" by one particular suspect.

Adult abuse and neglect is not limited to nursing and boarding homes, where the perpetrators are easier to find. Many cases involved retarded and elderly people who died in the care of their own families, private nurses and doctors, or in hospitals and state institutions.

"And we have to find someone who's criminally culpable, someone who knew what was happening, or who should have known," Rundle said. "You've got to have investigators and prosecutors with this expertise. And, really, like the rest of the country, we're in the dark ages with that."

The failings are complex -- and many.

The Herald found shoddy police investigations of suspicious adult deaths, health care workers who tampered with medical documents to hide neglect or poor medical care, and doctors who failed to properly report suspicions of abuse.

Death investigations for the elderly and disabled are often mishandled -- in part because of poor law enforcement training, lack of coordination among investigating agencies and a systemic ignorance of Florida adult abuse laws.

"I don't mean to sound callous, but the fact is, sometimes, the mistakes just get buried," said Broward prosecutor Jeffrey Driscoll.

Hospitals and health facilities, for example, often break the law by not sending the bodies of people who die under suspicious circumstances to the county medical examiner where a proper cause of death can be found -- and then, if necessary, a criminal investigation could follow.

Instead, doctors just sign a death certificate and send the body to a funeral home with a general cause of death like "heart failure" or "heart disease."

Those deaths go unnoticed forever.

In fact, Florida authorities have no idea how many deaths among disabled or elderly adults involved abuse, neglect or substandard medical care. No state or national agency even attempts to find out.

"The question is whether people are getting away with negligent deaths? The answer is, yes." said Broward Medical Examiner Ronald Wright. "When we have a neglectful-looking death, I report it to all the agencies, the police, HRS. But I have very little faith that anything happens.

"What I worry about are the ones I don't even see."

At least twice in the past year, Wright has fired off letters chastising county agencies for not sending suspicious deaths to the medical examiner for autopsies.

"I am finding out about these deaths days or weeks after the fact," he wrote the North Broward Hospital District. "I shudder to imagine how many I won't find out about until they are in litigation."

One of those deaths involved a disabled inmate who used a wheelchair. He was jailed on a probation violation and died in Broward Sheriff Nick Navarro's custody of complications relating to bedsores. One of the sores was infected, foul-smelling and had engulfed his right hip.

"As it turns out, this was doubly disconcerting, or even triple disconcerting," Wright told Navarro. "It could be alleged that (the victim) died as the direct result of negligence on the part of your personnel and/or contractors, allowing his decubitis ulcers to form abscesses. This makes failure to notify begin to suggest a cover-up."

Authorities in the Broward Sheriff's Office did not return phone calls.

In many cases uncovered by The Herald, family members were never contacted by authorities and never made aware of allegations or investigations of abuse or neglect. Instead, family members did in death what they did in life: They trusted, relying on caregivers, police and welfare workers to protect a loved one's health.

That trust is betrayed every day.

Galilee Lawrence, 84, lived in the same unlicensed boarding home for eight years. She arrived at Victoria Hospital nearly starved, with infected, crater-sized bedsores that, along with malnourishment, contributed to her death. Autopsy records show hospital workers called HRS to report her condition.

But HRS has no records of the report. Authorities don't know if an investigation was done.

Her nephew, Dade County corrections chief Lonnie Lawrence, said he knew nothing of her condition. He thought she had died of old age.

"I didn't know about any of it," he said. "I thought everything was OK."

Without swift response by welfare workers, without autopsies, without sound police investigations and without solid medical testimony to rely on, prosecutors say they are hard- pressed to make a criminal case out of adult abuse or neglect in death.

In part, they blame the high number of workers in the health care system for their lack of prosecutorial power: In other words, so many caregivers are involved with one patient that it's difficult and time-consuming to implicate just one.

"Where do you point the blame?" said John Morris, chief of the state's Medicaid Fraud Unit in Tallahassee. "You have to take these cases to a jury and try to convince them beyond a reasonable doubt that one or two or three people neglected someone and that led to their death."

Also, prosecutors rarely get expert medical witnesses to testify or give statements for their investigations. Medical judgments often vary, are inconsistent, and Florida's doctors typically are reluctant to testify against each other or the facilities and hospitals they work for.

"You'll get one expert medical witness to say someone was neglected or abused, or should have been treated one way, and the next witness will say something different," said Havens, who supervises criminal investigations in the Dade state attorney's office. "Who do you believe?"

In Monroe County last year, prosecutors had to drop felony manslaughter and neglect charges against a Marathon doctor after their key medical expert, a Miami doctor, recanted his testimony. Prosecutors said they believed a pressure campaign from the Florida Medical Association intimidated the doctor into backing out.

But the Miami doctor, Fuad Ashkar, claimed the state withheld key medical evidence that would have dramatically changed his expert opinion had he known about it. It was the state's first attempt to prosecute a doctor under felony abuse laws.

Prosecutor Kirk Zuelch had hoped to prove that Dr. Kenneth Swords, former medical director of the Key West Convalescent Center, neglected the medical needs of an 89-year-old diabetic who died -- presumably from lack of insulin.

Like many cases, though, no autopsy was performed. Doctors and prosecutors could only speculate about his death. And Swords repeatedly denied the allegations, saying overzealous investigators didn't know the first thing about medicine or diabetes.

"There was never anything there that anyone could find fault with me on," he says.

Zuelch ended up dropping the case. He had no autopsy findings. No witnesses. No case.

"This is not the type of crime that takes place in public," said John Pietrofesa, a state prosecutor in Fort Myers. "You have to rely on medical evidence, which is difficult to get, and on victims who can testify, which, in these death cases, you just don't have."

In fact, a caregiver is more likely to be prosecuted if their victims are still alive, prosecutors say.

A major problem with prosecution is the way the law is written. The Florida statute on adult abuse and neglect demands that prosecutors prove the perpetrator willfully and knowingly neglected and abused the victim. It is not enough to prove the victim's death was caused -- or hastened -- by abuse. And it's not enough to identify a suspect. Prosecutors must show the death was caused on purpose.

"That law, in my humble opinion, is a paper tiger," said Robert A. Lee, another Lee County prosecutor. "That's like proving premeditated murder. Why have we created a higher standard of proof for those least able to protect themselves?"

Not one Florida prosecutor interviewed for this series knew of any successful death prosecutions using the state's abuse and neglect laws. Worse, some said, is the fact that caregivers know they'll never get caught, and even if they do, they won't go to jail.

"There's an attitude out there that older people, especially, aren't productive and it's easy to discard them," said Dr. Raul Vila, a Broward associate medical examiner, who has performed numerous autopsies on suspected abuse and neglect victims. "We're supposed to be a compassionate and developed society. Why should these people rot like this?

The social welfare network that protects the elderly and disabled is a disjointed one. At least seven local, state and federal agencies have investigative jurisdiction in an adult death-by-abuse case. But some of them -- like the Florida Department of Professional Regulation and the state attorney's office -- move slowly, taking months to conclude investigations that rarely result in punitive action.

The state Office of Licensure and Certification, which monitors adult homes, has the power to close a facility. But in the few cases where a home has been shut down for abuse, it has taken as long as three to five years to do it.

A close examination of these death cases shows that, all too often, the way one agency deals with a neglect or abuse complaint is to pass the problem on to another.

The end result: Each assumes the other has taken action. But no one has.

Nearly two years ago, a Dade County grand jury chastised the state's investigative agencies for their lack of coordination and prompt action; it criticized caregivers and state regulators for not enforcing proper standards of care. Grand jurors were "pessimistic" and left with "feelings of consternation and helplessness," they reported.

But there has been no real pressure for change. Neither has the problem been pushed to the political forefront nationally.

"These people literally die regularly and no one knows," said Toshio Tatara, director of the National Aging Resource Center for Elder Abuse in Washington, D.C. 'It's indifference and a matter of other priorities. And it's very sad."

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