DDS client’s death raises new questions about care
We reported last week that the Patrick administration was refusing to provide any information about — or even confirm — a report that a man in his 50s, who had lived at the Templeton Developmental Center, died four days after being transferred to a community-based group home.
We have since gotten confirmation of the man’s death from the state’s Chief Medical Examiner’s Office and from a newspaper obituary, and have learned that the cause was a pulmonary embolus, or blood clot in his lung. We also learned that a contributory cause of his death was a history of deep venous thrombosis, or a blood clot in his arm or leg.
We are withholding the name of the man until we are able to contact his guardian.
Although the initial report we received was that this man had been healthy prior to his transfer out of Templeton, we now know he had a serious medical condition. That, however, doesn’t fully explain why he died so suddenly after the transfer.
Given that the Department of Developmental Services is citing privacy and confidentiality grounds to avoid discussing this particular case, we have very little information to go on. We did receive a report that this man’s familiar staff at Templeton may not have accompanied him to his new residence and may not have been appropriately involved in the transfer process.
Templeton is one of four developmental centers in the state that have been targeted by the administration for closure by the end of the next fiscal year. In some cases, as we understand it, DDS has been careful to ensure that familiar staff accompany residents who are transferred from these centers as the administration phases the facilities down. But it appears DDS may not have uniform policies or procedures on whether familiar staff are made available to accompany transferred residents to their new locations.
Is it likely that this man would have died anyway, had he continued to live at Templeton? Or did the stress of the move contribute in some way to his death? Was his death the result of a medication error or a lack of proper medication for his medical condition after his transfer from Templeton? Was his death the result of any other negligence in his treatment or care? Was his death due in any way to the fact that familiar staff were not available to him during or after the transfer process?
Moreover, given this man’s medical condition, why were his familiar staff not more involved in his transfer, if it was indeed the case that they were not? He was presumably treated at Templeton for his thrombosis, possibly with anti-coagulants to prevent blood clots. There are a number of potential causes of a traveling blood clot that results in a pulmonary embolus, like the one that caused this man’s death. One cause can be long periods of inactivity or immobility — something which this person’s familiar staff would most probably have known about, but which unfamiliar staff in his new residence might not have known about. How much communication was there between the two staffs about this person’s medical condition?
Is DDS asking any of these questions? We don’t know. We have reported this death to the Disabled Persons Protection Commission in the hope that they will investigate the circumstances surrounding it.
COFAR blog 
This is a disturbing story, even if there was no negligence. The questions need answering.
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Dear Dave,
familiar staff are not always needed for a transfer. This would have been discussed at the transfer meeting and the plans would have been agreed by with the guardian. Dppc tends to investigate unexpected deaths but 90% of their investigations are handed back to DMR/DDS to do the actual work. Like you I hope no medical errors were made.
BGN
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Thank you for the news. I am anxious to learn the name of the former Templeton resident. I will need to comfort my cousin who lives at Templeton and knows each and every resident. This will terrify him as he is “on the list” for placement. I too am so sorry tolearn of this death.
Mary Ann
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i am a former retard who grew up at belchertown state school i went there in 1949 and spend 12 years there. i was lucky that i left there when i was young enough to adapt to the community way of life
i spend a lots of years calling the governor”s office trying to close the states institutions until i found out that the care was better in the state institution than in the private programs.
i was hoping that the federal court system would close all the institutions when they sent out their own investigators to check out the of care in the state run programs. the investigators reported the finding that the state institutions provided better care than the private programs and i broke down in tears, since then i have been working to keep the institutions open or improve the quality of care in the private sector.
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Familiar staff are most definately needed for a successful transition! The staff who care for these clients every day know them as much and sometimes even more than their families. I too hope that a medical error did not occur. We know already that clients have died soon after a move. Transition’s are done in a hurry, and sometimes seems like they are not even in the client’s best interest. It is very sad.
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Under the best of circumstances, moving can be stressful for all of us, regardless of one’s mental capacity or state of health. Leaving familiar surroundings, people, routines, and going to a strange place with all of its unknowns isn’t easy, even when it’s by our own choice. What must it be like, then, to be forced to move — not because of work relocation, but basically because you’re being evicted? And what if you are already medically fragile and lack the ability to express yourself? Even in the absence of any negligence, abuse, or error, for a resident of an ICF, the mere act of moving itself can be life threatening.
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