The Quandary Behind A Quincy Legionnaires’ Victim’s Death: ‘Where The Heck Was She?’
Steve French learned his mother had died from Legionnaires’ disease at the Quincy veterans’ home in 2015.
If that news wasn’t bad enough, a phone call from the local coroner on the day she was discovered revealed an unexpected and cruel reality.
Based on the decomposed condition of her body, an open-casket funeral wouldn’t be possible.
In fact, the family was told she couldn’t even be embalmed.
A lifelong Chicago Cubs fan, Dolores French had been a resident of the Illinois Veterans Home for six weeks when she was found dead in her independent-living unit on Aug. 29, 2015. She was one of 13 elderly residents at the facility to die from Legionnaires’ since that first outbreak.
Her tragedy represents one of the most grotesque threads of what arguably is the worst public health crisis to have confronted Republican Gov. Bruce Rauner’s administration since taking office in January 2015.
Last December, WBEZ reported French may have laid dead in her room for two days before anyone found her.
State officials have ruled out that possibility categorically.
“What we know to be sure, she was not dead in her room for two days with nobody knowing about it,” then-state Veterans’ Affairs Director Erica Jeffries told reporters after a January legislative hearing into the outbreaks.
But in his first interview about French’s case, the local coroner who delivered the sobering news to Steve French about his mother’s condition has a very different take. He tells WBEZ that she could have been dead between 36 and 48 hours before she was found.
And newly obtained health documents related to her case demonstrate a litany of questionable procedural and record-keeping practices at Illinois’ largest state-run veterans’ home, which takes in residents from across the state, including the Chicago area.
Dolores French’s medical records, which her family turned over to WBEZ, show little effort by the facility at investigating her disappearance — after other residents and her son questioned her well-being.
Those records also don’t appear to be “current” or “complete” as state rules require. Key information that might have led authorities to her sooner wasn’t entered into the facility’s medical logs for more than 24 hours. In another instance, queries about her wellbeing weren’t documented at all before her body was found.
“The conduct of this facility in this case, in my opinion, was reckless — if not more than reckless,” said Steve Levin, a Chicago attorney who has represented a number of victims and their families in nursing home abuse and neglect cases.
Coroner: Woman may have been dead 48 hours
WBEZ first reported on Dolores French last December, when it launched an investigation into the Rauner administration’s inability to contain Legionnaires’ outbreaks at the home in 2015, 2016, and 2017. Her family is one of 11 suing the state for neglect in connection with those outbreaks.
Her only major health malady, the family said, was deafness — something that arguably could have put her at even greater risk because that made telephone contact difficult.
After learning of the outbreak, Steve French called the facility shortly before noon on Aug. 28, 2015. He wanted to check on the well-being of his mother and father, a U.S. Army veteran who lived separately from her in a skilled-nursing section of the facility. Steve French’s phone records confirm that call.
French said he was told by an employee at the home not to worry and that someone would contact him if something was wrong.
At 9:52 a.m. the next day, an employee at the facility called, asking for permission to enter his mother’s room because residents had been asking about her whereabouts.
Twenty minutes later came word that his mother had been found dead in her room. And in less than two hours, Adams County Coroner James Keller was on the phone with Steve French and his wife, Deann, relating details about the state in which Dolores French was found.
In an interview with WBEZ, Keller recalled encountering a potent odor outside the door to her unit. And when he peered inside, he could see her bed and two recliners. Between the two chairs lay her body, dressed in a striped blue and white shirt and blue jeans. Only her outstretched leg was visible from the unit’s doorway, he said.
Based on her condition, Keller said he advised the family against an open-casket funeral and that she had likely been in her unit for some time.
“My estimation of death was 36 to 48 hours [earlier],” said Keller, who was unequivocal when asked whether it was possible she could have died on the day she was found.
“She did not die the same day that she was found. That would be my opinion just due to … the state of decomposition.
“I’m going with … what the decedent is telling me,” he said.
Since WBEZ interviewed Keller, he has encountered negative national publicity. Earlier this month, he faced harsh scrutiny over his move to charge poor people $1,000 to obtain the remains of loved ones too poor to afford a funeral. He said the new charge was precipitated by the state cutting off funding for indigent burials.
Steve French said that disclosure has not shaken his faith in Keller’s judgment in his mother’s case.
“We absolutely took him for his word. I still trust him. He seemed very professional. He was being honest with me. Why would he not?” he said.
‘Absolutely shocking’ that no one went looking
Meanwhile, shortly after Dolores French was found in her unit on Aug. 29, a nursing supervisor at the facility made an entry into French’s electronic medical log.
The entry related how a nurse opened French’s room at about 9:30 a.m. on Aug. 28, the day before French was found dead, because another resident had grown concerned about not seeing her.
The nurse “did not witness Dolores in her room. Reports room was tidy, bed was made and no concerns noticed,” the supervisor wrote.
The document went on to state that French often would go to another building to spend time with her husband and that the last time the nurse reported seeing her was at 9:30 a.m. on Aug. 27.
“Mrs. French was not in her room on Friday, Aug. 28,” Jeffries told the legislative panel in January based on that medical log, which was not shared with lawmakers.
Jeffries explained that because French resided in an independent-living section of the facility, she had freedom to come and go from her unit.
“She could have been any number of places,” Jeffries testified. “If a resident in the … independent-living part of our home is not at home, there’s no reason for us — and no protocol for us — to go looking for that person.”
Jeffries also said French had shown no signs of pneumonia-like illness up to that point.
“We did not have record of her ever reporting any signs of illness, and therefore, we didn’t have any reason to have concern about whether or not she was sick, somewhere else, or lost,” Jeffries told lawmakers.
But at that point, illness later linked to Legionnaires’ was swamping the facility.
State records show that eight people later confirmed to have had Legionnaires’ disease died by Aug. 28. Thirty-nine others, who were eventually diagnosed with Legionnaires’, had begun displaying symptoms of their illness on the day Dolores French was reported missing. State officials acknowledge knowing they had an epidemic by Aug. 21 but waited six days before telling the public.
And so, despite the facility being in an epidemic and fielding queries of concern from both Dolores French’s son and at least one resident who knew her, the staff didn’t go looking for her for more than 24 hours before her body was found.
“To me, that’s absolutely shocking,” said Levin, the Chicago attorney. “So now, they had not only general knowledge of the potential harm that would occur to residents as a result of the outbreak. But they had specific knowledge, specific concern, as to where this long-term care facility resident was.
“Based upon what we believe the coroner concluded, it is very likely that this person either died or was extremely sick at the time that the nurse claims she went into her room and didn’t see her there,” Levin said. “So where the heck was she?”
Patient safety expert urges state probe
On French’s medical record, there is no notation of the nurse’s visit to her room on the day it allegedly happened — that notation was put into the record only after French turned up dead.
“To document something after a patient has been found dead when activity should have occurred the day before is pretty odd,” said Dr. Timothy McDonald, a patient safety advocate from west suburban Burr Ridge who reviewed French’s medical log at WBEZ’s request.
He is a physician, an attorney, and president of the Center for Open and Honest Communication at the MedStar Institute for Quality and Safety, a patient safety think tank affiliated with MedStar Health, a Maryland-based health system.
McDonald said he finds it peculiar a supervisor would be making note of the earlier room visit on behalf of the nurse who did it — and making that entry after French was found.
“I’ve been reading records for a long time, and that is just very, very unusual,” McDonald said.
Since the home had been in the throes of an infectious disease outbreak since Aug. 21, McDonald said it should have been documenting on a daily basis the health of vulnerable residents like Dolores French. Before her body was found, the most recent entry in her log in which a physician reviewed her case was Aug. 6, 2015.
“If this is what they do in the midst of an epidemic, I’m pretty worried as a public citizen,” he said. “If in the midst of an epidemic — and you have this elderly lady who’s deaf, which to me puts her at even greater risk for a wide variety of reasons — the fact there’s no documentation anywhere in here about how she’s doing from the 21st on till she’s dead is the most troublesome thing to me.”
McDonald said the state Department of Financial and Professional Regulation should open an inquiry into the record-keeping in this case.
The nurse’s visit that was documented more than 24 hours later in Dolores French’s medical file is a detail Steve French said he knew nothing about until he and his wife were listening on their computers to Jeffries’ legislative testimony in January — 28 months after his mother’s death. Had that visit been logged in her file when it happened, it might have been something the facility could have relayed to him when he called the home about two hours later on Aug. 28.
Even in the following weeks and months when he was at the veterans’ home frequently and arranging to have his father transferred from the facility, no one mentioned to him anything about the nurse’s visit to his mother’s room, he said.
“I was there every week for two more months, and somebody, you’d think, could have told me, ‘Well, we checked on your mom on Friday, and she wasn’t there.’ Why didn’t that come up when I was asking all the questions?” French said. “It just didn’t sit right.”
On that point, Keller said he empathizes with Steve French.
“I think if the shoe was on the other foot, I would feel the same: Why didn’t I know?” the coroner said.
Son: ‘Some good is coming out of this’
Also noteworthy about the supervisor’s entry, and others that were made on the day French was found dead, is the fact there is no documentation in her medical record of Steve French’s phone call to the facility, asking about his mother.
The state administrative code says resident records at long-term care facilities and state veterans’ homes “shall be kept current, complete, legible and available at all times.”
Besides disputing Dolores French may have been dead in her room for a lengthy period, Jeffries has taken issue with the notion that the elderly woman’s body was in an advanced state of decomposition when she was found.
After the January hearing, she pointed to an Aug. 31, 2015 autopsy report and made clear to reporters that there had been specific mention that no evidence of decomposition was identified on Dolores French’s left side — a detail she said invalidated Steve French’s account in a WBEZ report last December.
“It goes on to say more than that, but at this time, you can certainly pull the coroner’s report. It’s a public document. But the coroner’s report does completely contradict the story that you both provided into the news,” she told two WBEZ reporters at the time.
French’s autopsy, which tied her death to Legionnaires’, was performed in Bloomington by Dr. J. Scott Denton, a former interim Cook County medical examiner who now works in the McLean County coroner’s office.
A half-dozen other times, Denton’s report identifies decomposition in various parts of French’s body.
Denton declined to be interviewed by WBEZ.
Jeffries also noted Denton’s report listed French’s date of death as Aug. 29, 2015, the day she was found.
However, the Centers for Disease Control and Prevention, in its death registration guidance to coroners and medical examiners, recommends that in cases where the exact date of death cannot be approximated, the date found is what should be recorded as the date of death.
Jeffries’ last day as director of the state Veterans’ Affairs Department was May 18. Last month, amid growing political fallout over her agency’s handling of the Quincy Legionnaires’ crisis, she announced her resignation.
An agency spokesman did not respond to a list of questions WBEZ submitted May 15 about the home’s record-keeping in Dolores French’s case.
French’s death — along with the others — has helped spur passage of legislation that followed WBEZ’s investigation. One measure that sailed through the House and Senate, without any opposition, would require 24-hour notification of state veterans’ home residents and their families of infectious disease outbreaks, including Legionnaires. Rauner has indicated he’s prepared to sign the bill.
“Sometimes, I just think my mom is up there, smiling down, saying, ‘Hmmm, some good is coming out of this because that bill will certainly save people’s lives,’” Steve French said. “I certainly think if that law had been passed five years ago, there wouldn’t have been 13 people who passed in Quincy since 2015.”
Dave McKinney covers state government and politics for WBEZ. Follow him @davemckinney.