After investigating the matter for more than two years, Illinois Attorney General Kwame Raoul is closing a criminal investigation without filing charges relating to the state’s mishandling of deadly Legionnaires’ disease outbreaks at a downstate veterans’ home.

Starting in 2015, dozens of residents and employees of the state-run Illinois Veterans Home in Quincy were sickened with the preventable, water-borne form of pneumonia. Outbreaks at the home occurred again in 2016, 2017 and 2018. Another case was reported at the home last December.

The deaths of up to 14 residents have been tied to the outbreaks and 12 of their families sued the state for neglecting their loved ones.

Raoul’s decision not to file criminal charges stemming from the crisis effectively brings to an end a six-year saga that was the subject of a years-long WBEZ investigation, which changed state law, shaped a gubernatorial election and triggered construction of a new, more than $230 million veterans’ home in Quincy.

Public health officials waited a crucial six days before notifying the public of the initial outbreak, leaving some residents and their families unaware of why they were getting sick. A bungled water repair operation — a citable offense — was thought to be a possible factor in the cause of the initial outbreak. The state’s own Labor Department found the Veterans’ Affairs agency that managed the home did not adequately notify staff of the dangers they faced. And a resident was found dead in her room only days after she had died.

WBEZ’s investigation also revealed that then-Gov. Bruce Rauner’s office repeatedly overruled its own top experts in order to control and constrict what information was made public about the fatal outbreaks.

In a recent interview with WBEZ, Raoul explained his decision not to file criminal charges in the case.

“You have to follow the evidence and match it up to the law, and it’s a very dangerous thing to have the presumption at the initiation of an investigation that there has to be a charge,” Raoul said. “Sometimes, the evidence is just not going to lead you there. That doesn’t mean it wasn’t worthwhile to investigate it in the first place.”

After WBEZ investigated those matters and more, Raoul’s predecessor, Democratic Attorney General Lisa Madigan, announced her office would be investigating the state’s response for criminal wrongdoing.

Her announcement came just a month before the 2018 November election, when then-Republican Gov Bruce Rauner was in a bitter campaign against his Democratic challenger, now-Gov. JB Pritzker.

At the time Rauner, who came under so much criticism for his handling of the crises that he stayed at the veterans’ home in an attempt to show the water was safe, dismissed the criminal investigation as a “political ploy.”

Pritzker hounded Rauner during the 2018 campaign for his “fatal mismanagement” of the crisis and ran a campaign ad featuring a family member whose father died in the 2015 outbreak.

In his first public comments about the closed investigation, Raoul told WBEZ that he does not question Madigan’s motives in launching the probe. He noted that, after studying the state’s response, he didn’t see a way to show anyone’s mental state was such that they intentionally sought to bring harm to anyone on the Quincy campus – the threshold he needed to bring charges.

“I have a responsibility — given this immense power as to making a decision whether to charge a case or not – to follow the law, not to follow politics or emotion,” Raoul said.

“Nothing replaces a life”

Raoul’s decision not to prosecute comes as former Michigan Gov. Rick Snyder faces two state misdemeanor charges for willful neglect relating to how his administration mishandled the Flint water crisis. In that instance, Legionnaires’ disease linked to the city’s drinking water led to the deaths of at least 12 people and sickened at least 80 more.

Michigan’s attorney general also charged Flint city officials, Snyder’s chief-of-staff, the state’s former Health and Human Services director and other city officials. The defendants have pleaded not guilty.

Raoul said he was unfamiliar with Michigan’s criminal statutes, but he warned of a “danger of wanting to make policy to criminalize too many things” in the case of the Quincy outbreaks.

WBEZ reported that the attorney general’s office convinced an Adams County grand jury to subpoena Rauner’s office in November 2018. In addition, the office twice subpoenaed the Illinois Departments of Public Health and Veterans Affairs.

The attorney general’s office sought documents related to a 2015 hot water tank repair that officials later described as being so bungled it likely released a “broth” of legionella through the campus. Dr. Nirav Shah, who was the state’s public health director at the time, wrote in an email that the department made a “citable offense” but chose not to because “it’s a standard, not a rule.”

The attorney general also sought documents from the IDVA and from the Adams County Health Department “relating to the rationale for not installing point-of-use filters campus-wide” until 2018.

The attorney general’s office did not bring any witnesses to testify before the Adams County grand jury, nor did it recommend any charges be filed, Raoul told WBEZ.

It is rare for prosecutors to publicly announce they are closing a criminal case, let alone explain why they have decided not to charge someone they are investigating.

In explaining the rationale behind his office’s decision, Raoul likened the state’s mishandling of the outbreaks to a fatal car accident.

“If I’m the one who lost a loved one, in the moment I might want the other person to be held accountable in whatever way possible, but that’s not how we decide to enact our statutes,” he said. “There are a whole lot of circumstances – that’s the reason why we have civil remedy that doesn’t mirror criminal remedy.”

In fact, Raoul’s office settled all 12 lawsuits from the families that lost loved ones to the outbreaks for a total of $6.4 million. When the families brought their lawsuits, Illinois had a limit on how much they could recover in court at $100,000 each – the lowest such cap in the U.S. Following WBEZ’s reporting, state legislators increased the limit on all cases against the state to $2 million – over Rauner’s veto. They also made the new cap retroactive for the Quincy families.

Raoul said his office undertook the unprecedented act of establishing a firewall between the attorneys who settled the civil lawsuits and the attorneys conducting the criminal investigation. He said he grappled with standing alone at the top of the firewall overseeing both legal teams.

“Me inheriting the responsibility to be on both sides of the wall – it’s an emotional one,” Raoul said. “Emotionally you know that there’s nothing that replaces a life. Nor would trying to make a criminal charge where it doesn’t exist. You can acknowledge that a wrong has taken place and still at the same time acknowledge that it’s not criminal.”

Tony Arnold and Dave McKinney cover Illinois politics for WBEZ. Follow them @tonyjarnold and @davemckinney.