A state review board has issued a scathing report that concludes the
Department of Mental Retardation contributed to the deaths of dozens of its
disabled clients because it failed to provide them with adequate health care
services.
The Fatality Review Board for Persons with Disabilities identified several
key weaknesses in the state agency's health care services: inadequate
coordination of services for people living in the community, the discharge
of hospital patients into shoddy nursing homes, insufficient nursing care
and a lack of educational wellness programs.
The report, released Friday, summarizes the board's review of DMR client
deaths from July 2003 through June 2005. The board is supposed to issue such
a report annually, but officials said it didn't have enough staff to publish
one last year.
The board reviewed the deaths of 361 clients, ranging from people who live
in state institutions to those living independently or with family, and
conducted 35 in-depth investigations. The board found abuse or neglect in
many of the cases.
"We can and must do better by these people," said board Chairman James
McGaughey, who is also the executive director of the Office of Protection
and Advocacy for Persons with Disabilities. "DMR is getting better, but it's
not good enough. People are still dying who should be alive."
The department is reviewing the findings of the board and plans to use them
to enhance the agency's existing efforts to improve its health and safety
programs, according to a statement DMR released Friday. It said it has
already enacted some of the board's previous recommendations.
The department held a supported-living symposium last year to refocus agency
attention on the health care coordination needs of people receiving services
in their homes. The seminar was prompted by the high-profile death of a DMR
client in his Hartford apartment building in 2003.
Ricky Whistnant, 39, died of a heart attack while he was being assaulted by
five young men in the lobby of his apartment building. The medical
examiner's office ruled that the heart attack was brought on by his enlarged
heart.
The review board in March 2005 disagreed with this finding, claiming the
assault triggered an undiagnosed medical condition known as "Pickwickian
Syndrome" that led to his heart attack. The board ruled that Whistnant would
have survived the beating if he had been in better health.
The board attributed Whistnant's untreated conditions to poor communication
between his primary doctor, the private company hired by DMR to support
Whistnant while living on his own, his home health agencies and DMR itself,
which was supposed to oversee his case.
It also found that Whistnant was taking a medication for his bipolar
disorder, prescribed by one of a string of psychiatrists that DMR had
assigned to him, that should not be taken by somebody with his heart
condition. His psychiatrist and doctor never consulted about the medication.
The review board, in its report issued Friday, cites Whistnant's death as an
illustration of the poorly coordinated health care received by DMR clients
living in the community, as well as someone who might be alive now if DMR
offered more wellness programs.
The report also notes several clients who have died because of slipshod care
in nursing homes. Whenever possible, the report says, DMR should return
clients to their own group homes for recovery after hospitalization for
illness or injury, even if it means hiring extra help.
The board cited a 46-year-old man who died in a Bridgeport-area nursing home
in October 2004.
The nursing home's doctor knew that he carried an antibiotic-resistant
infection, but sent him to the hospital to have all his teeth extracted
anyway, which triggered a fatal fever.
The board also urged DMR to improve nursing at its residential and day
programs.
For example, the board noted a 46-year-old Trumbull woman who died of
pneumonia in November 2003.
Although she was deemed too sick with flu-like symptoms to attend her normal
day program, neither the program nor her group home evaluated her until it
was too late.
In its report, the review board also notes its own failures, admitting that
it lacks the staff it needs to independently investigate all of the DMR
deaths that merit review, and those cases that are investigated are often
closed far later than the public, or the victims' families, should tolerate.
"There are at least another 10 or 12 cases over the last two years that we
would have liked to investigate but couldn't because we just didn't have the
resources," McGaughey said. "And in Ricky's case, our investigation took so
long it couldn't be used to prosecute his attackers."