Man’s death raises questions of negligence — (The Pekin Times)

SSRI Ed note: Down's syndrome man with 6 times acceptable level of antidepressants in his system chokes to death, investigation follows.

Original article no longer available

The Pekin Times

By Nick Vogel,Times staff writer

Published: Friday, October 26, 2007 10:08 AM CDT

PEKIN – A Tazewell County coroner’s jury ruled the death of a man with Down syndrome who choked on food an accident, but has recommended further police investigation into the death because of possible negligence by caretakers.

On July 11, Dwayne Mann, 32, of the PARC group home in East Peoria, was taken with three other residents to Bradley Park in Peoria for a picnic.

Later that afternoon, investigators would find Mann’s dead body on the floor of his bedroom, clad only in an adult diaper.

At an inquest into his death Thursday, Detective Brian Despines of the East Peoria Police Department told jurors that when he arrived at the PARC group home, a nurse said Mann had choked.

The coroner’s jury made several recommendations in its findings, including more training and competency testing at PARC for employees and further investigation into the death.

“We are disturbed by the extreme negligence and incompetency by PARC and house manager Jim Schneckenburger,” the jury wrote. “We suggest further investigation.”

Despines said that recommendation will be taken back to the East Peoria Police Department and the investigation will likely continue. The results of any investigation could be turned over to Tazewell County State’s Attorney Stewart Umholtz for possible prosecution. Despines said East Peoria officials will likely talk with Peoria police to determine who should do the investigation because Mann may have died in Peoria County.

Coroner’s jury testimony revealed that at around 4 p.m. on July 11 three PARC employees took Mann and the three other residents to the park with the intention of giving them some fresh air. On the way, employees stopped at several KFC restaurants in search of baked chicken for Mann to eat.

According to Despines, the employees told investigators that Mann began eating his food more quickly than he was supposed to.

“One of the workers went over to get him to stop,” said Despines.

The PARC employees told investigators that Mann began striking his head against the picnic table, calmed down, then proceeded to strike his head against the concrete pavement. Mann even bit his own arm.

One of the workers called a supervisor at PARC, Jim Schneckenburger, who told the men to bring the residents back to the group home.

“They stated (Mann) was pale,” said Despines. “They stood him up and he collapsed.”

The employees brought Mann back to the group home and called a nurse. After about 25 minutes, the nurse arrived and started CPR. It was then that 911 was called, Despines said.

Anna Richter, an investigator from the Illinois Inspector Generals Office Department of Human Services – who also performed an investigation – testified Thursday that Mann suffered from several medical set-backs, and that he was allergic to certain foods. “He required constant supervision,” Richter said, later adding that Mann ate his food extremely fast.

Richter said KFC food was not included in Mann’s special diet. Richter said that through her investigation, she found that statements from the employees “just did not look right to us.”

When she re-interviewed one of the employees, who was recently hired, Richter learned that one of the employees, a man with the last name of Richardson, cut Mann’s chicken pieces. The new employee told Richter that the chicken pieces were too large for Mann to swallow. The names of the other employees involved could not be obtained.

Conover referred questions about the names of the employees to Richter.

Richter referred all questions about the investigation to a media spokesperson for the Illinois Department of Human Services, who said the case is being investigated and they can’t release the names of the employees.

The new employee also told Richter that the two other employees ate their food at a separate table leaving him to watch Mann and the other three residents.

“(Mann began) choking and was unable to express himself,” Richter told the jury. “I believe those bites on his wrist were because he couldn’t breath.”

Richter testified that the employees believed Mann went limp because he had recently changed medication.

“I believe he was dead in the van (used to bring him back to the group home),” Richter said.

At that point during the inquest, Tazewell County Coroner Dennis Conover asked Richter if the employees had called 911.

“No sir,” she said.

Conover said after the coroner’s jury had made its ruling that he is dictating letters to PARC, Schneckenburger and the Inspector General’s Office, “in the hope that something is done with that home and the people that run it.”

“Basically, based on the testimony given, these people in essence let this gentleman choke to death in Bradley Park, put him in the van and took him back to the home, undressed him and put him in bed and then called the nurse,” said Conover. He said the participants took part in a cover-up to hide the truth.

“This would be a non-issue if the (two long-term) employees had let the newer employee call 911 like he wanted to,” said Conover.

At the inquest, Conover also said toxicology tests revealed Mann had six times the amount of antidepressant medication he should have had.

Richter said the amount of the medication was toxic, but not lethal. She added that she does not believe Mann was given too much medication, rather, his metabolism and small size were responsible for the high dosage.

When asked if the PARC employees responsible for Mann’s safety are still working for the company, Roy Ricketts, PARC’s CEO said, “We can never comment on any employee matters.”

When asked to comment on PARC’s level of responsibility concerning Mann’s death, Ricketts said he has not seen an “official report” about the inquest. “You’re asking me to comment on things on which I have no basis to comment.”

Ricketts said the PARC group homes are in both Peoria and East Peoria. “All of those group homes have 24-hour care, with staffing levels based on need,” he said.

Conover said that calling three witnesses to testify at an inquest – as he did for Mann’s inquest – is something he has never done in his years as a coroner.