COFAR blog

In what appears to be a rare reversal, the state has rescinded an abuse charge against Christine Davidson for giving her son John an “undetermined” amount of cough syrup and Tylenol last June.

Robert A. Reed, an assistant general counsel with the Disabled Persons Protection Commission (DPPC), stated in a February 17 letter that he was changing the agency’s conclusion regarding the abuse allegation against Christine from “substantiated” to “unsubstantiated.” The letter was addressed to Thomas Frain, an attorney who is representing Christine and who is also COFAR’s president.

Reed’s letter stated that his decision was the final decision of the DPPC, which is a state agency that is charged with investigating abuse and neglect of adults under 60 with disabilities.

“I’m so relieved,” Christine told us. “I’m so glad they understand that I love my son and have never done anything to harm him. The truth has finally won out.”

Christine and John Davidson

Frain had filed an appeal of the original abuse charge with the DPPC in November. COFAR has maintained that the Tylenol and cough syrup with codeine that Christine provided her son had been prescribed by his primary care doctor, and that there was no evidence presented by the DPPC that she did not follow the prescriptions.

In accusing Christine in October of abuse, the DPPC alleged that in addition to giving him an “undetermined amount of cough syrup and Tylenol,” she had failed to provide him with prescribed breathing therapy support “causing (John) to lose consciousness” while he was home with her on the morning of June 21. The prescribed therapy was the use of a Bi-PAP breathing assistance machine at night.

Christine maintains that the Bi-PAP machine was not delivered to her until June 22, the day after John’s episode of low oxygen or hypoxemia. She also said she did not receive necessary training in how to use the machine.

Christine was unable to wake John up on the morning of June 21, while he was home for a weekend visit, and called 911. John was brought to the Newton Wellesley Hospital ER. He quickly recovered after being given oxygen.

Reed’s February 17 decision acknowledged that an October DPPC report, wich had substantiated the abuse charge, had based its conclusions on an uncertain opinion about the cause of John’s hypoxemia rather than on conclusive evidence of the cause.

Reed further acknowledged that the DPPC had blamed what it alleged to be excessive Tylenol use and the lack of use of breathing machine solely on Christine, when in fact Tylenol had also been given to John in the group home. Reed further noted that the breathing machine had apparently not been used in the group home either.

“Given these unresolved factual disputes which bear directly on the causation analysis of (John’s) injury, including the confusion about the type and use of (John’s) prescribed and unprescribed cough medicines … I do not find that the conclusions of the Report were supported by the weight of the evidence,” Reed’s decision stated. “As such, I amend the Report to unsubstantiated.”

In the wake of the original abuse charge, John has been subject to a prohibition on visits home to his mother. Earlier this month, two medical specialsists stated that John has been declining physically in his group home where he is currently receiving no physical therapy and few, if any, other activities.

The group home is run by WCI, Inc., a corporate provider to the Department of Developmental Services (DDS).

Final DPPC decision said cause was uncertain

As we reported in January, doctors at Newton Wellesley Hospital, who were interviewed by DPPC, did not appear to have provided the investigator with a conclusive cause of John’s episode of hypoxemia on June 21.

One Newton Wellesley hospital official told the DPPC investigator that Christine’s son had an enlarged liver, which was likely caused by a drug toxicity. The official said, however, that John’s Tylenol levels were not elevated when he was examined at the hospital. Nevertheless, the hospital official said that toxicity in John’s liver could be due to small amounts of Tyleol built up over time.

Christine maintained, however, that since her son had only been with her over the weekend of June 18 to June 21, when he was hospitalized, she believed it was possible that any toxicity buildup in his liver from Tylenol use could have happened previously at the group home. The DPPC report did not mention that possibility.

In his February 17 decision overturning the abuse charge, Reed appeared to accept Christine’s argument. He noted that the Newton Wellesley Hospital official, who he identified as John’s treating physician, “did not wholeheartedly endorse (the) theory” that Tylenol use was the cause of John’s liver enlargement.

Reed added that:

Even if (the hospital physician’s) couched opinion about the cause of (John’s) enlarged liver is accepted, it begs the question of why (Christine) would be more accountable for a long-term overdosing of (John’s) acetaminophen (Tylenol) —when (John) spent limited time under her care.

Decision stated that Bi-PAP machine not used in group home either

Even though the DPPC’s October report had accused Christine of failing to use the prescribed Bi-PAP machine on John, the report acknowledged that it appeared the group home staff rarely if ever used the machne either.

In his final decision, Reed stated that John’s attending doctor at Newton Wellesley Hospital had “partially attributed (John’s) unresponsive state to the failure to use (John’s) Bi-PAP, and again assigned this omission to (Christine), when there were conflicting accounts from medical professionals about the use of this device generally.”

Like Christine, we are relieved that the DPPC recognized that its standard for substantiating abuse based on the proponderance of the evidence was not met in this case. We hope, among other things, that this case prompts DPPC to reassess its investigative policies and practices. All too often, both DPPC and DDS do not appear to reach the right decisions in these cases. (See examples of that here, here, here, and here.)