COFAR blog

The disabled are often treated as second-class citizens, even in hospitals, says Dorothy O’Rourke.

O’Rourke is concerned that may have been the case with a resident of a state-operated group home in Chelmsford.  The 51-year-old man, whose name is being withheld, died earlier this month after having been taken twice in two days to Lowell General Hospital and sent away each time, apparently without any significant treatment. 

The man had been having difficulty breathing and was sweating profusely when he was taken to the hospital on both February 6 and 7.  He died, apparently en route to the hospital, after the group home staff called an ambulance for the third time on the afternoon of February 7.

The cause of death is listed on the death certificate on file in the City of Lowell as acute respiratory failure and aspiration pneumonia, which can indicate choking.  A death report form filed with the Disabled Persons Protection Commission, however, states that the man died after experiencing cardiac arrest.

Despite the possible discrepancy in the stated causes of death, the Chief Medical Examiner’s Office declined to do an autopsy, and the man’s remains were cremated.  He had lived in the same group home as O’Rourke’s son.

O’Rourke strongly defends the staff of the group home, which is managed by Northeast Residential Services, a division of the Department of Developmental Services.  “The staff there are wonderful,” she maintains. “They did all they could for him, including performing CPR.  It’s the hospital that kept sending him home.  I thought they would have at least kept and monitored him. I don’t understand it.”

O’Rourke has no information about what actually happened in the hospital after the man was taken there on each occasion.  But she maintains that many hospitals are ill equipped to deal with intellectually disabled people, particularly those who are non-verbal, as this man was.  “I think hospitals tend to ignore the mentally disabled,” she said. “I think they may need a special unit to handle mentally disabled people.”

A spokeswoman for Lowell General said the hospital would have no comment on the case due to privacy issues.

According to sources, the man had been sent to his day program in Lowell on the morning of February 6, and the staff at the day program made the first call to 911 to take him to the hospital.  A Lowell Police Department official said a squad car was sent to the day program site at 8:30 a.m. in response to a call about a male having trouble breathing.  (A police car was dispatched in addition to an ambulance each time, and the man was accompanied by a staff member to the hospital each time.)

The hospital released the man shortly after his arrival, however, and sent him back home.  The following morning, the man reportedly looked exhausted and “out of sorts,” and the group home staff made a decision not to send him to his day program that day.  By about 8 a.m.,  the man was slumped over in his wheelchair and sweating heavily, a source said.  A group home staff member called 911 shortly afterward.  A Chelmsford Police official said a squad car was dispatched to the residence at 8:30 a.m. 

However, once again, the hospital made a decision to send the man back to his home.  The DPPC report form on the death states that the man had been observed at the hospital on the morning of February 7 to be sweating profusely, but his vital signs were good when he arrived.  According to the report form, the man was sent home with a prescription (the name of which was redacted).

By the time he was back at the group home, he was leaning over the side of his wheelchair and was “sweating terribly,”   a source said.   After the staff noticed the man’s lips turning blue, they immediately called 911 again.  A staff worker couldn’t find a pulse. 

The DPPC death report states that shortly after arriving back at the group home, the man began to vomit and then lost consciousness, and that the staff began mouth-to-mouth CPR until the paramedics arrived.  According to the Chelmsford Police Department, a squad car arrived at the house at 1:45 p.m.  The group home received a call from the hospital later that afternoon that the man had died.     

The man was formerly a resident of the Fernald Developmental Center.  His case is the third we have heard about in which a former developmental center resident in his 50s died suddenly at a state-operated group home managed by Northeast Residential Services.  In this case, however, there doesn’t seem to be any indication that the group home was in any way at fault.

“The staff did a tremendous job,” one source said, echoing O’Rourke’s assessment.  “They did exactly what they were trained to do.  “They jumped right in and did their best to save his life.”

“We hope the DPPC does a thorough investigation of this case,” said Colleen Lutkevich, Executive Director of COFAR, a statewide, family-supported nonprofit organization that advocates for persons with intellectual disabilities and their families and guardians.  “If indeed this hospital was at fault in failing to treat this man adequately, we need to find out why.  In particular, we need to know whether his disability played a role in the apparent lack of care he received.”