Pathologist challenges coroner's report on inmate death
OREGON – At least two jailers in Ogle County cautioned the sheriff's administration about the risk a 34-year-old burn victim posed just 10 days before he was found pale, sweaty and unresponsive in solitary confinement.
He was pronounced dead 57 minutes later at KSB Hospital in Dixon. The Lee County coroner reported the official cause of death as congestive heart failure.
But doctors involved with an upcoming Lee County coroner's inquest differ on what caused Patrick J. McCann's heart to stop and whether it could have been prevented.
James Bryant, a forensic pathologist hired by the McCann family, said McCann never should have been released from OSF St. Anthony Medical Center in Rockford and that the Ogle County sheriff should have refused to take the burn victim.
"He'd still be alive, I think, if he had been in a hospital," Bryant said in an interview. "He should never have been released. ... He did not get adequate medical care."
Representatives of St. Anthony Hospital declined to explain why they released him, saying federal regulations prevented them from discussing patients.
Ogle County Sheriff Greg Beitel suggested it might have involved a lack of insurance.
Photos taken when Bryant did an autopsy of McCann reveal a horrific case: His back was burned from waist to neck, his shoulders were coal black with swaths of mottled skin and blood red sores across the rest. He had hardly slept and had been given heavy doses of methadone for pain.
That was after a month of recovery, including 3 weeks in St. Anthony's renowned burn unit.
"He needed a lot more medical attention," including skin grafts, prescription monitoring, and mental health care, Bryant said.
McCann had been diagnosed with schizoid personality disorder and bipolar disorder, a volatile combination, Bryant said.
He had been living with his mother in Polo when, police say, he choked her then set her house ablaze, killing one of her two dogs and nearly killing himself in the process.
"In so doing what a mental patient might do, he burned himself," Bryant said.
Something went wrong
When Winnebago County deputies took McCann to the Ogle County Jail, he was prescribed a cocktail of antidepressants, antipsychotics and painkillers, according to the sheriff's investigation into McCann's death.
He was in terrible pain and hardly slept, but his health was improving, according to a written account by jail Capt. Wendy Kerwyn.
"The burn on his back appeared to improve each day," Kerwyn wrote. "I observed Nurse [Cindy] Mongan to be optimistic about the medical care she and correctional staff could provide McCann."
The day before he died, "McCann was very alert, talking, ate well, played cards, read," Mongan wrote in her report.
Something changed overnight.
Around 8 a.m. on April 30, Mongan and Deputy Juan Carreno entered McCann's solitary cell to give him medication in spoonfuls of applesauce, Mongan wrote.
McCann was unusually drowsy, and jail staff already was abuzz about the rapid deterioration of his health. They had checked on him every half-hour, and he was hardly responding, the jail report notes.
Carreno wrote: "McCann appeared to doze off while Nurse Mongan was feeding him."
Mongan phoned Stephen Cullinan, a doctor with Health Professionals Ltd., which contracts medical care for penal institutions.
"I expressed my concern about the difference from yesterday to today," Mongan wrote. "Dr. Cullinan advised to decrease the methadone."
The morning that McCann died, he took 18 pills – one multivitamin, two Benadryl, six methadone, two lithium, one Colace, one Risperdal, one Prilosec, and four Prozac, according to Mongan's report.
Bryant said the medications, coupled with an altered blood chemistry from such extensive burns, likely contributed to McCann's heart failure.
Such potent cocktails may be necessary but require extensive monitoring, especially when medications change and patients are ailing, Bryant said. In particular, a combination of antidepressants, antipsychotics and methadone can be lethal, he said.
"The drugs are a double-edged sword," Bryant said. "Somebody's giving him the drugs, but nobody's monitoring him."
Jesse Partington, Lee County coroner, said his pathology report makes no such connections.
At the request of McCann's family, Partington plans to hold an inquest to settle the dispute. A date for the public hearing has been tentatively set, but Partington said he was waiting for confirmation from witnesses and family before he releases a date.
Asked whether Cullinan ever saw McCann or what changes in medication he might have ordered, officials from Health Professionals' parent company, Denver-based Correctional Healthcare Companies, declined to comment, citing a company policy against discussing inmate deaths.
Nowhere else to go
James Macchitelli, a lawyer representing McCann's family in the upcoming inquest and a possible lawsuit, called it "criminal what happened."
"There's no way he should have been released from that hospital," Macchitelli said, "and prisons are not dealing properly with these persons who have bipolar disorder."
Just after midnight on March 31, Polo police had found McCann lying in the middle of North Adams Street, badly burned and unresponsive, his mother's house an inferno, said Tony Carroll, Polo's fire chief.
Oregon Ambulance Service rushed McCann to KSB Hospital, and he was transferred to OSF St. Anthony Medical Center in Rockford, where he stayed for the next 3 weeks.
When OSF discharged McCann, administration in Winnebago and Ogle counties started scrambling.
McCann was released into the custody of the Winnebago County Sheriff's Department in Rockford, where deputies promptly put a heavily bandaged McCann into a transport van and drove him to Oregon.
"We probably had him for an hour at most," said Andrea Tack, administrator of the Winnebago County Jail.
Jailers in Ogle County immediately recognized a problem and phoned administrators at home about 2 hours after processing McCann.
Sheriff Beitel phoned State's Attorney Ben Roe, and the two decided to look for another caregiver.
"Quite frankly, I didn't want him in the jail," Beitel said. "We had to make sure he wasn't a danger to the public, ... but nobody else wanted him."
Ogle deputies tried contacting Winnebago County, which has a 24/7 infirmary. The larger jail declined, saying McCann was too much of a risk.
They tried a home nursing provider, which said it couldn't help because it didn't have enough notice.
Nursing homes wouldn't accept him because of an existing criminal record, Beitel said, and no family was willing to take him.
So Ogle's jail nurse set up McCann on an air mattress in the nurse's station, and staff did what they could to keep him comfortable.
On the second day, Nurse Mongan suggested McCann be moved to a single cell, and Kerwyn moved him into a solitary confinement cell where jailers could watch him on a control room camera.
Deputies did manual checks by peering through the small "chow chute" normally used to deliver food. Mongan administered medication and applied medicated burn salve with the help of a correctional officer.
Nine days later, McCann was dead from congestive heart failure.
"If he'd had insurance, he'd still be alive in the hospital," Beitel said, "I think."
Timeline of Patrick McCann's last day
The following is a timeline of what happened on the morning of April 30, the day Patrick J. McCann died in Ogle County sheriff’s custody. It is assembled from a sheriff’s internal investigation, which Sauk Valley Newspapers requested and received.
6:50 a.m. – Deputy William White notices McCann struggling to stay awake while eating breakfast cereal. White advises Deputy Juan Carreno that McCann “was taking new medication which made him drowsy, unsteady, and was causing him to sleep a lot.”
7:04 a.m. – Welfare check: Carreno observes McCann “laying down in a hunched over position.” Carreno hits buzzer, which startles McCann and he shifts a bit in his bed.
7: 31 a.m. – Welfare check: McCann in same hunched position. Carreno peers through chow chute and sees inmate’s stomach moving up and down.
7:45 a.m. – Jail Nurse Cindy Mongan arrives. Clark tells her about McCann’s unusual sluggishness.
7:55 a.m. – Welfare check: McCann still sleeping in same position.
8:09 a.m. – Nurse Mongan enters McCann’s cell to give him medication. Mongan reports he was “sleepy while eating the applesauce but was able to swallow after each bite. No unusual signs of distress were noted.”
Carreno reports that McCann “appeared to doze off while nurse Mongan was feeding him.” McCann sat up while Mongan applied lotion to burns and jailers changed bed linens. He ate some applesauce with a cocktail of medication, including 60 milligrams of methadone.
Jail staff helped McCann back to bed, and he was able to scoot into position on his stomach. Mongan reports McCann seemed better yesterday.
8:34 a.m. – Welfare check: McCann in same position he was after medication. Carreno thinks McCann looks uncomfortable but unable to find a comfortable position.
8:47 a.m. – Welfare check: McCann still on stomach, appears uncomfortable and unable to sleep.
9 a.m. - Mongan contacts Dr. Stephen Cullinan, the Health Professionals Ltd. doctor in charge of McCann’s care. Mongan expresses concern about unusual drowsiness. On the previous day, McCann was “very alert, talking, eating well, played cards, read.” Cullinan orders methadone decreased to 40 milligrams twice a day.
9:04 a.m. – Welfare check: McCann still moving and breathing but not sleeping.
9:32 a.m. – Welfare check: McCann sleeping and snoring.
9:59 a.m. – McCann still asleep. Mongan tells Carreno that McCann is likely very sleep deprived.
10:15 a.m. – Clark relieves Judy Martin, a corrections assistant, at watch post. Martin leaves to get mail.
10:23 a.m. – Welfare check: McCann still asleep. Carreno hits buzzer on wall, which rouses McCann enough to move his head a bit.
10:48 a.m. – McCann sleeping. Carreno watches him move “a small bit.”
11:07 a.m. – Jail nurse and Corrections Officer Juan Carreno bring McCann lunch. “His color was off and he was sweating.” Nurse Mongan takes a closer look and sees McCann not breathing. Mongan and Carreno start CPR. Carreno radios for 911 call.
From control room, Clark calls dispatch for ambulance, then grabs an automated external defibrillator and runs to “O” Block, leaving Control 3 unattended. AED advises against electric shock to stimulate heart. AED removed.
11:10 a.m. – Oregon Ambulance Services EMS arrive and take over McCann’s care. Deputies help EMS carry McCann “up the stairs and into the ambulance.” Deputy Jeremy Pennington follows McCann to KSB Hospital in Dixon.
11:31 a.m. – Carreno makes another round, then locks down O Block.
12:04 p.m. – Emergency room doctor pronounces McCann dead from an unknown cause.
