(Cross-posted from the COFAR blog)
We reported last week that the Patrick administration was refusing to provide any information about — or even confirm — a report that a man in his 50s, who had lived at the Templeton Developmental Center, died four days after being transferred to a community-based group home.
We have since gotten confirmation of the man’s death from the state’s Chief Medical Examiner’s Office and from a newspaper obituary, and have learned that the cause was a pulmonary embolus, or blood clot in his lung. We also learned that a contributory cause of his death was a history of deep venous thrombosis, or a blood clot in his arm or leg.
We are withholding the name of the man until we are able to contact his guardian.
Although the initial report we received was that this man had been healthy prior to his transfer out of Templeton, we now know he had a serious medical condition. That, however, doesn’t fully explain why he died so suddenly after the transfer.
Given that the Department of Developmental Services is citing privacy and confidentiality grounds to avoid discussing this particular case, we have very little information to go on. We did receive a report that this man’s familiar staff at Templeton may not have accompanied him to his new residence and may not have been appropriately involved in the transfer process.
Templeton is one of four developmental centers in the state that have been targeted by the administration for closure by the end of the next fiscal year. In some cases, as we understand it, DDS has been careful to ensure that familiar staff accompany residents who are transferred from these centers as the administration phases the facilities down. But it appears DDS may not have uniform policies or procedures on whether familiar staff are made available to accompany transferred residents to their new locations.
Is it likely that this man would have died anyway, had he continued to live at Templeton? Or did the stress of the move contribute in some way to his death? Was his death the result of a medication error or a lack of proper medication for his medical condition after his transfer from Templeton? Was his death the result of any other negligence in his treatment or care? Was his death due in any way to the fact that familiar staff were not available to him during or after the transfer process?
Moreover, given this man’s medical condition, why were his familiar staff not more involved in his transfer, if it was indeed the case that they were not? He was presumably treated at Templeton for his thrombosis, possibly with anti-coagulants to prevent blood clots. There are a number of potential causes of a traveling blood clot that results in a pulmonary embolus, like the one that caused this man’s death. One cause can be long periods of inactivity or immobility — something which this person’s familiar staff would most probably have known about, but which unfamiliar staff in his new residence might not have known about. How much communication was there between the two staffs about this person’s medical condition?
Is DDS asking any of these questions? We don’t know. We have reported this death to the Disabled Persons Protection Commission in the hope that they will investigate the circumstances surrounding it.
In the 1997 House Post-Audit committee report on then-DMR, the committee called for the Department to make a clear report each year on deaths of persons in its care. Those reports have been issued in recent years, but only in summary form and well after the fact.
considers those reports to be public information?