The Kansas City Star from Kansas City, Missouri on January 26, 2014 · A9
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The Kansas City Star from Kansas City, Missouri · A9

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Sunday, January 26, 2014
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Still, nobody has yet proved Hedrick experienced a jump in code blues far be- yond the norm, said St. Luke’s attorney Schnieders: “By their very nature, code blues are random. They can go in clusters.” And when questioned re- cently by The Star, Hall said she never expressed a love for code blues or mentioned “excitement” when arriving at work. Hall said she couldn’t even recall her colleagues buzz- ing about a spike in unex- pected deaths. Livingston County Coro- ner J. Scott Lindley in an affi- davit cited a total of 18 suspi- cious code blues and nine deaths over a 14-week peri- od. Seven families would lat- er sue. The deceased Nearly all nine of the de- ceased patients named in civil documents — seven men and two women — were longtime residents of the Chillicothe area. Some of them: Coval Gann, 82, was a re- tired state conservation agent who had served on the local parks board. Charles E. O’Hara, 89, was a former town councilman and World War II veteran who fought at Okinawa. Shirley Eller, 49 and a re- cent widow, was a dietary aide. Clarence B. Warner was 74, a retired school principal who folks called “Curly.” “He enjoyed quail and phea- sant hunting, raising bird dogs, gardening and playing snooker,” Warner’s obituary said. Irvin Rounkles, who died the following year at Liberty Hospital, was a farmer, plumber and longtime lead- er of a country music band called the Tater Hill Gang. His family’s suit alleges that Rounkles survived a suspi- cious code blue at Hedrick, but he suffered injuries that lasted until his death at 90. The youngest to die was David W. Harper, 37, of near- by Ludlow, Mo. According to a deposition taken last May of a former Hedrick nurse, Harper had been admitted for treatment of pneumonia. He was walk- ing in his gown and chatting it up with nurses at their sta- tion the night before he was to go home. But later Harper coded and breathing stopped. He couldn’t be revived. “Everybody was just, like, what happened?” the nurse testified. Harper’s death certificate indicated a history of lung problems. For others who coded and died during the time of Hall’s employment, the stated causes of death ranged from cardiac arrest to pneumonia to heart dis- ease. In all cases, the certifi- cates indicated the manner of death as “natural.” But physician Greenlaw suspected something foul. Secret meeting A month after that Febru- ary night when he struggled to keep his patient’s blood sugar from zeroing out, Greenlaw called a secret meeting in the intensive care unit. He told the gathering of nurses, two doctors and the nursing director that he thought “someone on staff at Hedrick … was attempting to kill and sometimes succeed- ing in killing patients,” ac- cording to his 2011 affidavit. The affidavit describes a plan for catching that killer. Greenlaw had relayed his concerns to his good friend and hunting companion, coroner Lindley, who con- tacted the sheriff’s office and then-county prosecut- ing attorney Doug Roberts. They decided that Green- law would arrange a March 26, 2002, meeting with He- drick’s administrator at the time, James K. Johnson, to suggest that video cameras be placed around the respi- ratory therapy department, Greenlaw’s affidavit states. “After the meeting,” Greenlaw said in the affida- vit, Johnson “told all nurses that if they were seen talking to me or even walking with me that they would be fired.” The retired Johnson, in a sworn deposition last year, sharply denied threatening workers and said such a meeting with Greenlaw nev- er took place. At some point, Greenlaw began to chart the suspi- cious codes and deaths on calendar software on his personal computer. His calendar is now a key exhibit filed with the law- suits. But there is at least one puzzling glitch: He cites patient Rounkle’s death as occurring in February 2002 at Hedrick, when in fact Rounkle died 22 months lat- er at Liberty Hospital. Greenlaw told The Star the mixup resulted from misinformation he received from nurses trying to recall early cases. In late May 2002, coroner Lindley and prosecutor Ro- berts met with the Hedrick administration. “I asked Mr. Johnson if he had tapes of the video sur- veillance. … He replied, ‘No,’ ” Lindley stated in 2011. “I was so shocked and angry. … I said nothing further and left the premises.” It was around this time that Hedrick Medical placed Hall on paid administrative leave. The hospital prepared a document a year later, when St. Luke’s Health System was preparing to acquire He- drick. The document, now part of the open court rec- ord, laid out what hospital officials knew at the time. The one-page report, ti- tled “Synopsis of Jennifer Hall Investigation,” was stamped confidential and signed by then-administra- tor Johnson: “In the first five months of 2002, a pattern of increased code blue and diabetic criti- cal events was noted by nursing service. This pattern numbered 15 in occurrenc- es… “A growing concern arose … related to the coincidental nature of our night respira- tory therapist Jennifer Hall’s behavior, demeanor and proximity to these unex- pected events.” In early May 2002, hospi- tal administrators appointed its legal counsel and an out- side evaluator to look into the matter. “The review did not indi- cate cause for concern,” the document stated, though the “nursing staff was encour- aged to monitor the ther- apist’s behavior” from then on. Just 10 days after the re- view, 75-year-old patient Fern Franco coded and died, the last of the suspicious deaths on the coroner’s list. And the hospital told Hall to leave, with pay, “pending investigation of the inci- dents,” Johnson’s synopsis said. It concluded: “The county coroner and prosecuting at- torney were informed of our concerns although our con- cerns were unsubstantiat- ed.” As for the families of pa- tients who died at Hedrick, they would not learn of the hospital’s concerns for sev- eral years. Contacted recently by The Star, Johnson declined to comment. Several others whose names surface in the civil cases — including nurse Boyd, former prosecu- tor Roberts and the attorney general’s office — also de- clined. Attorney Schnieders said no one at Hedrick concealed anything from law enforce- ment officials. In fact, he said, hospital officials ap- proached them. “Since then,” he said, “there’s never been any proof of wrongdoing in any way, shape or form.” Terminated Hall told The Star the hos- pital never mentioned any- thing to her about suspi- cious deaths when Hedrick let her go. The reason Hedrick offi- cials gave for placing her on leave, according to Hall, is that they found out about the arson conviction. She was terminated with- out pay in February 2003. And by that summer, her freedom would run out. The appeal of her 2001 ar- son conviction was denied, and Hall would enter the maximum security prison in Vandalia, Mo. Her cellmate was a wom- an serving four consecutive life sentences. Hall said she feared for her life. Her parents in Shawnee took extra jobs at a pizza de- livery call center to pay for her ongoing appeals. Hall’s lawyer, O’Connor, finally scored a legal victory in 2004 when he filed a mo- tion for the original judge on the arson case to reconsider Hall’s conviction on grounds of ineffective counsel at her trial. O’Connor had lined up an expert to examine the charred evidence of the Cass Medical fire — something Hall’s first attorney hadn’t done. The expert concluded the fire was electrical in nature, not arson. Judge Cook set aside Hall’s sentence and Hall was paroled from Vandalia. Cook wrote that expert testimony citing an electrical cause to the Cass Medical fire “clear- ly … could have changed the outcome of the trial.” Cass County prosecutors decided to retry Hall in Feb- ruary 2005, even though she already had served prison time. The jury deliberated three hours before acquitting her. “It was a no-brainer” that the fire was sparked by a short circuit in the cord of an old clock, said Carl E. Martin, who offered expert testimony at the second trial. The founder of Indepen- dence-based Engineering Perspective Inc., Martin had spotted the problem within seconds of stepping into an evidence locker to examine remnants of the fire. A molten chunk of copper bulged out of the clock cord, signaling a burst from with- in the wiring. Any fire inves- tigator who saw that should have ruled out arson, Martin told The Star. Photographs of the alleged crime scene cinched it for him. “Jennifer Hall’s purse was sitting there near the desk,” recalled Martin. “When I told that to my wife, she said, ‘No woman is going to set a fire and leave her purse behind.’ ” An exonerated Hall moved in with her parents and turned inward, spending less time with friends. She wondered aloud if things would ever be the same after spending a year behind bars. “I think everybody sees me different,” she said at the time. “I will always be the girl who went to prison.” Hall told that to The Star in April 2005, when the newspaper chronicled her ride on the legal roller coas- ter. Nothing about her stint at Hedrick Medical Center had yet made the news. Hard to prove Lindley, the county coro- ner, is known around Chilli- cothe as a hard-charging perfectionist who doesn’t cotton to lazy criminal in- vestigators. The owner of Lindley Fu- neral Home, he earns less than $15,000 a year as the elected coroner. But he pours his all into investigat- ing suspicious deaths, often scolding and alienating those around him, he con- cedes. In rural counties with lim- ited investigative resources, “you need to have laypeople like me on it or the job doesn’t get done,” Lindley said. He had autopsy samples from two of the deceased Hedrick patients. But prov- ing they were poisoned would be tricky, if possible at all, given the medications that were suspected to have been used. The leading candidates were insulin and a paralyz- ing drug called succinylcho- line, often referred to as “sux,” which is used in sur- gery to deaden the muscles just long enough to intubate patients. An overdose will paralyze the lungs. “You can see and think un- til you slowly slip into the blackness of suffocation,” said Brian D. Andresen, for- merly of the Lawrence Li- vermore National Laborato- ry in California and one of the forensics experts whom Lindley consulted. In the body, succinylcho- line rapidly breaks apart into molecules that naturally ex- ist in dead tissue. Only the most sophisticated toxicolo- gy tests can detect a possible death by overdose, and even then the results wouldn’t rule out other causes. According to Lindley’s af- fidavit in civil court, he sent samples from the kidney of Hedrick patient Franco to two labs. The results, which he received in 2004 and 2005, confirmed the pres- ence of succinylcholine, he said. He then sent the lab find- ings, autopsy reports and medical records of Franco and eight other deceased pa- tients to Michael M. Baden, a forensic pathologist in New York. Notable for hosting HBO’s “Autopsy” and for his fre- quent appearances on the Fox News Channel, Baden wrote back to Lindley in a CERTIFICATES: All indicated the manner of death as ‘natural’ FROM A8 SEE CHILLICOTHE | A10 “Complete shock. We were devastated. I couldn’t stop shaking.” SHERRI HARPER, WIDOW OF PATIENT DAVID HARPER Coval Gann of Chillicothe (left) worked for the Missouri Department of Conservation for 35 years. He was a patient at Hedrick Medical Center in Chillicothe when he died. David Harper of Ludlow, Mo., (above) died while in Hedrick Medical Center in Chillicothe. A TIMELINE 2000 June: Jennifer Hall hired as respiratory therapist at Cass Medical Center in Harrisonville. 2001 Jan. 24: Fire at Cass Medical casts suspicion on Hall. Sept. 26: Jury finds Hall guilty of second-degree arson. December: Sentenced to three years, Hall hires new attorney to file appeal. 2002 January: Free on appeal bond, Hall takes full-time job at Hedrick Medical Center. Feb. 3: First of several suspicious deaths recorded. March 12: Code blues and deaths discussed at secret meeting of doctors and nurses. May 6: Hospital review indicates no “cause for concern.” May 18: Patient Fern Franco dies, bringing coroner’s count of suspicious deaths to nine. May 21: Hall placed on paid administrative leave. May 24: Hedrick contacts authorities, turns over records of seven patients. 2003 Feb. 12: Hedrick terminates Hall without pay. July 25: Arson appeal denied, Hall begins prison sentence. 2004 June 30: Judge finds Hall received inadequate counsel in trial, sets aside conviction. July 23: Hall paroled. 2005 February: In Cass County retrial, Hall found not guilty of arson. 2006 Aug. 7: Authorities meet to discuss forming Major Case Squad in Hedrick deaths. 2008 July: First of several wrongful-death suits filed. 2012 March: Livingston County prosecutor asks police to conduct another investigation. 2013 Nov. 26: Missouri Court of Appeals allows five wrongful-death suits to proceed. Matthew O’Connor, an attorney with The O’Connor Law Firm in Kansas City, is representing Jennifer Hall. She hired him after being convicted of arson. DAVID EULITT | THE KANSAS CITY STAR WWW.KANSASCITY.COM HH SUNDAY, JANUARY 26, 2014 A9FROM THE COVER | THE KANSAS CITY STAR.

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