By Debra Jasper and Spencer Hunt
Photos by Michael E. Keating
The Cincinnati Enquirer
The 12 questionable deaths identified by the Enquirer occurred in places from Cincinnati to Niles, a small, decaying steel town in northeast Ohio. They include a man under county care who wandered off from his apartment and froze to death, and a woman who vomited and struggled to breathe for 2 1/2 hours before her institution called an ambulance.
In eight of the cases, the state threatened to decertify nursing homes for problems related to the deaths. Decertification would cut off the homes' Medicaid funds, in effect shutting them down. Administrators showed improvements were made, and the state never carried out its threats.
The state faulted a ninth facility for conditions related to another death, but never threatened to cut off funds. In three other cases, people who were supposed to be monitored by county caseworkers died at their homes.
The list of 12 is by no means a full accounting of people who haven't survived in the system.
Dr. Andrew Eddy, medical director of the state Mental Retardation Department, estimates that of the average 600 deaths each year, 80 to 120 are "avoidable."
Even he can't say for sure.
He won't name counties, homes or workers. But in e-mails and memos to other department officials, obtained by the Enquirer under Ohio's freedom-of-information law, Dr. Eddy raised questions in 147 deaths dating back to January 2000.
Questions ranged from how a 13-year-old girl drowned in a pond to whether workers had enough training to prevent deaths from feeding-tube complications.
In one e-mail, Dr. Eddy questioned whether a county investigator knew the difference between a "Do not resuscitate" order and a "Do not restrain" order.
In one of every five cases he questioned, Dr. Eddy also criticized the lack of basic information in death reports. In one case in which a 44-year-old woman died of alcohol poisoning, he blasted an unidentified county official for not doing a good job.
"I am disturbed by the . . . statement, 'This incident could not have been prevented,' " he wrote. "If the county board feels this incident truly could not have been prevented, then I expect at least some rudimentary information supporting this claim."
Dr. Eddy also was troubled by 13 cases in which coroners either weren't called or didn't do autopsies.
He was particularly vexed by a report about the death of an unidentified 68-year-old whose powerful drug for psychotic disorders was missing.
"Now my curiosity has peaked," he wrote. "A 68-year-old dies unexpectedly, there are Haldol missing, and the case is not referred to the coroner. Unless someone can convince me otherwise, simply based on the two-page incident statement provided, I believe that this was a suspicious death."
In an interview with the Enquirer, Dr. Eddy says officials don't always know if people are getting good health care.
"I've seen instances where we don't have a good idea of why a person died," he says. "If the coroner isn't called, there is nothing we can do about it.
"For most people, are they getting access to care when they need it? My sense is it's not there."
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