The criminal investigation into more than a dozen Legionnaires’ disease deaths at the state-run Quincy veterans’ home appears to be focusing, in part, on the errant release of stagnant water into the facility’s hot-water system, new records show.
A criminal grand jury in downstate Adams County, where Quincy is located, issued a subpoena in late August to the Illinois Department of Public Health. It asked for a series of documents pertaining to the mistaken discharge of what a former state public health official characterized as a “broth of Legionella” – a mistake that may have caused the first deadly Legionnaires’ outbreak in 2015.
The document, which the state agency provided WBEZ on Thursday in response to an open-records request, also sought information about the state’s delay in installing special faucet filters first recommended in 2015 by the Centers for Disease Control and Prevention.
A spokeswoman for the Illinois Department of Public Health did not immediately respond to a request for comment.
The grand jury request for documents dated Aug. 22 represents the first tangible sign in almost a year that the criminal investigation remains very much active. The probe was first begun in October 2018 by former Democratic Attorney General Lisa Madigan, and it was continued by her successor, Democrat Kwame Raoul.
The last sign of activity came late last year when the grand jury directed a subpoena at the state health department; the Illinois Department of Veterans’ Affairs, which oversees the facility; and former Republican Gov. Bruce Rauner’s office.
The public health crisis at the state’s largest veterans’ home helped scuttle Rauner’s 2018 re-election bid as he and his administration struggled to justify the state’s efforts to prevent multiple Legionnaires’ outbreaks between 2015 and 2018. The outbreaks have been tied to 14 deaths.
As a result of a WBEZ investigation into the government’s mishandling of the outbreaks, state lawmakers voted to authorize a $230 million rebuild of the facility and changed state law to require 24-hour notification of communicable disease outbreaks, like Legionnaires’.
The new subpoena to the state’s public health department, however, is more targeted than the sweeping request for documents filed last year.
The grand jury wants “all documents relating to the July/August 2015 central hot water tank shut down…and its subsequent reactivation…at the Quincy Home.”
State records showed Rauner’s administration knew the Quincy veterans’ home had bungled a water system repair in violation of state health codes just before the initial 2015 outbreak. But the state’s top health official chose not to cite the facility for the mistake.
Then-state Public Health Director Nirav Shah detailed in an email obtained by WBEZ how a bacteria-laden “broth of legionella” was mistakenly released into the Illinois Veterans Home water system before the first outbreak, which would kill 12 residents.
That revelation was buried in a dump of more than 132,700 pages of documents released by Rauner’s administration to WBEZ days before November’s election. Democratic Gov. JB Pritzker went on to defeat Rauner handily.
Illinois Democratic U.S. Senators Dick Durbin and Tammy Duckworth called for Shah’s resignation after WBEZ published the damning email.
Pritzker heavily criticized Rauner’s handling of the outbreaks throughout his campaign for governor, though Legionnaires’ victims’ families who are suing the state for neglect have recently criticized both Pritzker and Raoul for not doing more to resolve their ongoing lawsuits.
The Adams County grand jury also subpoenaed bids, contracts and invoices related to the repairs of that water tank malfunction.
A Raoul spokeswoman would not comment on the latest subpoena to the public health department.
Shah is now the director of the Maine Center for Disease Control & Prevention. He could not immediately be reached for comment late Thursday afternoon.
No one has been charged with wrongdoing.
The Adams County grand jury additionally requested documents “relating to the rationale for not installing point-of-use filters campus-wide at the Quincy Home until 2018.” Those filters on sink faucets and shower heads are supposed to block legionella bacteria. The subpoena also requested documents related to any observed flushing of plumbing fixtures in the presence of residents.
Since taking office in January, Raoul’s office has said the criminal investigation into the deadly Legionnaires’ disease outbreaks remained open, and the legal roadmap outlined in the newly released subpoena zeroes in on findings in a state audit initiated in response to WBEZ’s reporting.
Auditor General Frank Mautino’s audit earlier this year also focused on the discharge of hundreds of gallons of stagnant water that mistakenly occurred when the hot-water tank was improperly returned to service ahead of the 2015 outbreak.
Mautino also criticized the state veterans’ affairs agency for not adhering to 2015 recommendations by the federal Centers for Disease Control and Prevention that special filters be attached to all fixtures fed by the home’s hot-water system. That didn’t happen until April 2018, the audit said.
Tony Arnold and Dave McKinney cover Illinois state politics for WBEZ. Follow them @tonyjarnold and @davemckinney.