A soldier's death, a family's fight
Army probe finds failures in care at Fort Knox unit
By Maureen Groppe
Star Washington Bureau
FORT KNOX, KY. — When Sgt. Gerald Cassidy died alone from a prescription drug overdose at the Army's Warrior Transition Unit here, at a facility set up expressly to help wounded soldiers, he had more than 600 prescription pills in his room.
His body was found Sept. 21 in a chair in his room, after he had missed required morning and afternoon check-in for three days.
A sergeant was supposed to have taken attendance and tracked down anyone not present. Instead, the sergeant ignored Cassidy's absence the first afternoon, missed the next daily check-in with car trouble and the following day marked Cassidy present even though he wasn't.
Cassidy was found dead more than eight hours after his wife, Melissa, began calling Fort Knox in an escalating panic on Sept. 21.
Finally, after she called at 6 p.m. and told a sergeant that she was getting ready to drive down from Westfield to look for her husband herself, the sergeant checked Cassidy's room.
Two hours later, Melissa was told over the telephone that her husband had been found dead in his small room. Four hours after that, about midnight, an Army chaplain arrived at Melissa's home.
The Army pronounced Cassidy's death an accidental overdose. The 31-year-old soldier took too many prescription drugs that, in combination, suppressed his respiratory system. In his system were methadone, the antidepressant citalopram, multiple opiates, a tranquilizer and a hypertension drug.
These and other details about how Cassidy lived his last few days and how he died were revealed recently by his wife and mother in an interview with The Indianapolis Star.
Cassidy's family also provided to The Star key documents from the Army's investigation of his death that had not previously been released and shared some notes Cassidy wrote at Fort Knox about his anxiety over loud noises and lack of sleep and his concern for the impact of his illness on his family.
The family says it is speaking out in hopes that greater public awareness will help other soldiers get better treatment.
The family found an ally in Indiana Sen. Evan Bayh, who is calling for numerous changes in the way the military handles mental health services for wounded soldiers.
"The pain is never going to go away," said Cassidy's mother, Kay McMullen, Carmel. "You've got to do something then to change the outcome for other people."
Failure at Fort Knox
Too little staff, too little training, Army finds
The Army investigation of Fort Knox after Cassidy's death concluded that "the unit was not resourced properly to accomplish its mission" and "failed to provide effective leadership."
The problems included not having enough staff to fill the three key positions — a squad leader who wounded soldiers are supposed to see daily, a nurse case manager they see weekly and a primary care manager they see monthly.
Army investigators also found the staff didn't have the proper training or appropriate skill levels; there was not a simple and direct chain of command; and soldiers were not properly accounted for.
The unit also did not have controls to track prescriptions and no established process to communicate prescription reactions with alcohol.
Officers told investigators that they had raised concerns about the lack of resources but said no one paid attention — until Cassidy died.
"We are told that WTU is the Army's priority, and yet we are not receiving the NCOs (non commissioned officers) that we need to get the job done, nor the facilities we need," a captain told investigators. "WTU was set up for failure."
Fort Knox was not the only unit short-staffed last year. The Government Accountability Office, the investigative arm of Congress, reported that in mid-September, fewer than half of the 32 U.S.-based units had enough key personnel.
In an updated report last month, the GAO commended the Army for making substantial progress but said it still faces problems hiring medical staff in a competitive market, replacing temporary borrowed personnel with permanent staff, and getting eligible soldiers into the units.
"Following the Walter Reed controversy, there was a burst of activity, a sense of urgency about making sure that medical care and conditions for our soldiers was improved," said Bayh, who has been demanding answers about Cassidy's care. "But then that dissipated as soon as the spotlight moved on to something else.
"We can't let that happen again. We need to continue to focus on this to make sure that the government not only says the right things but does the right things for our soldiers."
The Army initially called Cassidy's death an isolated incident. But last month, the Army said it was investigating 11 accidental deaths or suicides in its Warrior Transition Units. At least three deaths, including Cassidy's, were accidental overdoses.
A soldier from the start
"The thing that he loved the most was the camaraderie"
Cassidy, or "G.J." as he was known to friends and family, grew up playing soldier, wearing camouflage and toting wooden guns.
He pestered his mother until she let him spend summers at the Culver Military Academy in Northern Indiana, where he became a member of the Black Horse Troop, an elite equestrian detail. By age 17, he was an adjutant commander.
"He was so passionate about being a soldier," his wife, Melissa Cassidy, said. "I think the thing that he loved the most was the camaraderie, knowing that you're standing beside someone who would give their life for you."
His last civilian job was with a landscaping company, although his goal was to get a full-time National Guard job and finish college so he could teach high school or junior high history.
Cassidy enlisted in the U.S. Army Reserve in 1992 and joined the Indiana National Guard in 2003. He volunteered in 2004 to go to Iraq, where he served with a Guard unit from Minnesota.
Cassidy decorated his quarters in Iraq with an American flag, its stripes formed by tiny ink handprints made by his daughter, Abbey, and her preschool classmates.
He was escorting a convoy to Camp Scania in Iraq in August 2006 when an improvised explosive device went off about 11 yards from his Humvee, spraying it with shrapnel. Cassidy lost hearing for a few minutes, then had a strong headache that lasted at least six hours. That was the beginning of the migraines that began to plague him every seven to 10 days.
The last days
Soldier's family said
he got worse, not better
When his tour in Iraq was finished in March 2007, seven months after his injury, Cassidy was evaluated at Fort McCoy in Wisconsin where he was diagnosed with mild traumatic brain injury and post-traumatic stress disorder.
He arrived in Fort Knox in April, about two months before the Warrior Transition Unit was up and running.
Soldiers are supposed to be given a job or be taking classes, but that wasn't initially enforced.
Melissa Cassidy said her husband was bored at Fort Knox and filled his room with movies, books and games.
Soldiers are told their main purpose is to heal so they either can return to duty or make the transition back to a productive civilian life.
Cassidy's family, however, thought Cassidy was getting worse, not better, at Fort Knox.
He was still suffering from migraines, which could last from a few hours to nearly a full day. In addition to the narcotics he was prescribed at Fort Knox or during visits to the emergency room in Indiana, he drank beer and rum to dull his pain, although no alcohol was found in his body at the time of his death.
Soldiers in the units are allowed to have beer and a pint of liquor in their rooms.
"I don't think alcohol has a place in a Warrior Transition Unit for folks like G.J.," Melissa Cassidy said. "With all the medications he's on, he doesn't have any business drinking alcohol."
A Fort Knox official said the Army is evaluating whether to ban alcohol from the units.
Cassidy knew his illness was rough on his family, writing in a notepad shortly before he died that, "When I'm there, sometimes I'm still not there."
"I find myself wanting time alone or just wanting to be lazy," he wrote. "I know she needs the help, but sometimes I just can't get motivated to get off the couch."
During his weekend visits and a monthlong convalescent leave over the summer, Melissa Cassidy said it was increasingly difficult for her to get him to go swimming or to a cookout with the children, 5-year-old Abbey and 3-year-old Isaac.
At Fort Knox, Cassidy saw a psychiatrist nine times in July, August and September but made only one visit to the private neurologist in nearby Elizabethtown that the Army contracts with.
He did not agree with the neurologist's therapy plan and told his case manager at Fort Knox that an appointment with a different neurologist was unnecessary because he was taking medication prescribed during visits to Indiana, where he went to an emergency room and saw his family doctor.
Cassidy's psychiatrist, Dr. William Kearney, agreed that the second neurology appointment was unnecessary, according to the case manager's report.
Kearney told The Star that Cassidy pleaded with him to prescribe pain relievers, even though Kearney said he told Cassidy he should be following the neurologist's treatment plan.
"They're the ones that do pain management," Kearney said he told Cassidy.
When Kearney agreed to prescribe methadone at Cassidy's request, Kearney said they had a long discussion about how it should be taken.
If used improperly, methadone can build up in the body to toxic levels because the drug stays in the body long after the pain relief ends, according to the National Drug Intelligence center.
Fort Knox officials said they can't comment on Kearney's care of Cassidy because it is still under review. In a Feb. 12 letter to Bayh, Secretary of the Army Pete Geren said multiple reviews of Cassidy's medical care include an ongoing independent assessment, but the investigations' results are "privileged and confidential" under U.S. law.
Kearney, whose work at the base has been suspended, said he was being set up as a scapegoat.
"This was a clear case of a patient who tragically overdosed on drugs," he said.
Cassidy's family does not think Cassidy was sufficiently instructed on the dangers of methadone.
"He was sitting there with a cornucopia of medications to choose from, and he was the one who had to decide which ones he took," his mother said.
On Sept. 18, Cassidy filled his prescription for 16 methadone tablets, which were supposed to be taken only twice a day. The bottle was empty when his body was discovered Sept. 21.
Death goes unnoticed
Platoon sergeant didn't check
on soldier missing for days
Cassidy spoke with his mother for the last time on Sept. 18, a Tuesday, complaining in a phone call about construction work on his barracks' roof.
He also wrote about it Sept. 17. "As I write this my hand is shaking," Cassidy wrote in a notepad. "The roofers keep throwing down big blocks of shingles on the roof and with me being on the 3rd floor it sounds just like mortars coming in."
A few hours later, Cassidy wrote of taking the antidepressant citalopram and the anti-anxiety medication Klonopin "because of the whole shingle thing earlier" — some of the more than a dozen prescription drugs and over-the-counter medications he had in his room. Still awake at 3 a.m., Cassidy took the antidepressant Elavil.
"Looks like it's going to be one of those nights," he wrote.
When Melissa Cassidy spoke with him Tuesday, he was happy to be coming home for good soon and looking forward to seeing his family over the weekend. They agreed to talk again that night, but Melissa's call about 11 p.m. went into her husband's voice mail.
She followed up with three messages Wednesday, asking him to call.
"I'm kinda worried about you, hope you're all right," she said Wednesday night.
Calls she left Thursday were not returned, either.
When she still hadn't heard from him Friday morning, Melissa Cassidy accessed his voice mail and was alarmed to discover he hadn't listened to any of his messages, starting with a good night message she'd left Tuesday.
Melissa started calling officials at Fort Knox for help, including her husband's platoon sergeant, the officer responsible for taking attendance at the daily formations.
The sergeant later told investigators that he last saw Cassidy on Wednesday morning, outside of one of the barracks. He said Cassidy told him he had a migraine and wanted to rest. Cassidy did not show up for the afternoon formation.
On Thursday, the sergeant wasn't there for the morning accountability check because his car had broken down.
When Cassidy was not in formation Friday morning, the sergeant said, he assumed Cassidy was being processed for his weekend trip home and marked him down as being present on the daily status report, even though he hadn't seen or spoken with him for two days.
When the sergeant heard Cassidy's wife was looking for him, he left a message for Cassidy on his cell phone Friday afternoon but didn't check Cassidy's room.
"I wish I would've done things differently," the sergeant later told investigators.
After being put off all day, Melissa Cassidy told a different sergeant shortly before 6 p.m. that she would come down herself. That sergeant said he would get a key and enter Cassidy's room. When she called the sergeant back about an hour later, his voice was quavering, she said.
" 'I haven't got in there yet. I haven't got in there yet. Let me call you back, sweetie, let me call you back,' " Melissa recalls him saying. "That was all he said, and I knew something was terribly wrong."
Cassidy's body was found seated, head tilted back, in front of the computer he used to play games.
Pathologist says soldier was alive, unconscious, for hours
The Army's autopsy report does not include an estimated time of death.
"It's virtually impossible to determine a time of death because there are just too many variables involved," said Paul Stone, spokesman for the Armed Forces Institute of Pathology.
Dr. Stephen Radentz, a forensic pathologist Cassidy's family hired to do a second autopsy, agreed that time estimates are difficult. But he said the condition of the body and other evidence, such as when Cassidy was last seen and last used his cell phone and computer, enabled him to estimate that he had been dead about 24 hours when found, though it could have been as much as 36 hours or as little as 12.
Radentz said the depression of Cassidy's respiratory system "basically knocked him out of commission" so he wasn't awake but in a comalike state before he stopped breathing.
"There's certainly a good possibility that if they had found him when he was still breathing, he would have come out OK," Radentz said.
When she thinks back about what happened at Fort Knox, Melissa Cassidy said, it's "very clear that there was no system that was working there."
What's worse is how many times she believes tragedy could've been avoided, starting with her husband getting better care in Iraq and ending with someone checking up on him in his final days.
"There are so many things," she said. "If one of those things had changed, he might be alive today."
Contact Star Washington Bureau reporter Maureen Groppe at (202) 906-8118 or at firstname.lastname@example.org.