For all his life, someone was responsible for taking care of Henry David Vernon.
Deaf, mute, developmentally disabled and mentally ill, Vernon, who went by David, needed help with even mundane tasks: doing laundry, preparing meals, paying bills. He sometimes needed to be reminded to attend to his personal hygiene.
Vernon’s brother, Earl, wants to know why no one is responsible for the 55-year-old man’s death.
David Vernon died of hyperthermia on July 29, 2009, in a Tacoma group home, the only known Pierce County fatality attributed to the abnormal heat wave that blasted the region that summer. In layman’s terms, his body temperature rose to lethal levels.
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A caregiver for Aacres LLC found him unresponsive on his bedroom floor just before 5 a.m. A reading later taken at St. Joseph Medical Center – where Vernon was taken by ambulance – showed his temperature to be 107 degrees.
The Mayo Clinic recommends people with a temperature of 104 seek immediate medical attention.
The Pierce County Medical Examiner’s Office ruled David Vernon’s death an accident, and at least three other investigations into his death placed no blame on Aacres.
Earl Vernon’s effort to hold someone accountable is hindered by a state law that prevents him from bringing a wrongful death lawsuit on his brother’s behalf. The law limits beneficiaries in wrongful death suits to the deceased person’s surviving spouse, state-registered domestic partner, children or stepchildren. David Vernon had none of those.
Parents and siblings can seek damages in a wrongful death only if they relied on the dead person for support and there is no spouse, domestic partner or children to bring a suit.
As a last resort, Earl Vernon has asked the Prosecutor’s Office to file criminal charges in the case.
“There’s no justice without some sort of criminal penalty,” Earl Vernon said recently. “There’s no accountability.
“Aacres knew the heat wave was coming, and they failed to provide him with extra water, a cold shower or place him in a cooler environment. Aacres also knew that the medicines he was taking made him susceptible to heat stroke.”
Mike Stickell, a regional director for Aacres, said earlier this month that state and federal privacy laws and Aacres’ policies prohibit him from discussing Vernon’s case.
“As a general matter,” he said via e-mail, “Aacres cares a great deal for its clients and always takes the best precautions possible when caring for its clients. Generally, Aacres took reasonable precautions to address heat-related issues during the abnormal heat wave in the summer of 2009.”
Prosecutors are looking at the case and waiting to see whether more evidence arises pointing to a specific crime committed by a specific person, said Phil Sorensen, Pierce County’s assistant chief criminal deputy prosecutor.
“We’re determining whether charges can be filed and against whom,” Sorensen said. “There needs to be some sort of criminal liability that we can attribute to somebody before we can charge.”
NOT A NORMAL LIFE
David Vernon never had a chance at a normal life.
His mother contracted rubella while pregnant, and her first child was born with birth defects that left him deaf and, it would be determined later, mentally disabled.
When David turned 4, his parents moved from the East Coast to Vancouver, Wash., to enroll Vernon in the Washington State School for the Deaf. For the next 51 years he lived in institutions, communicating through sign language, some spoken words and notes written on paper.
His ability to communicate and understand his world was significantly limited, according to a 2007 state Department of Developmental Disabilities assessment.
“David is not cognizant what medications he takes or dosages,” the assessment states. “He is not able to procure medication or to report adverse reactions to medication. David has to be engaged and assisted with safety and emergency needs. He will not initiate interactions with others and needs to be drawn out by staff.”
Aacres staff members reported after his death that he communicated well with them.
“David was able to use sign language to the staff, and staff would understand what he meant,” Vernon’s caregiver wrote in an Aug. 21, 2009, report to his superiors, a copy of which Earl Vernon provided to The News Tribune. “Staff listen (sic) to David and was able to understand what he was saying.”
Vernon’s mental illness and developmental disabilities began to manifest themselves at the School for the Deaf.
Psychological examinations performed by the Clark County Mental Health Center when Vernon was 15 showed he had an IQ of 51. Narrative portions of the reports described him as nervous and easily upset.
Later that year, Vernon was placed at the Child Study and Treatment Center on the Western State Hospital campus in Lakewood. He moved into the psychiatric hospital itself three years later, according to records of his admittance to Aacres.
Eventually he moved to L’Arche Tahoma Hope farmhouse, where he lived happily for several years until he was accused of abusing another resident, his brother said.
“David was allowed to seek and have a sexual rela- tionship and was in a relationship when the allegations of sexual misconduct occurred,” his brother said.
Vernon never was arrested or charged with a crime, but in 2005 he was moved into a more restrictive environment with 24-hour-per-day monitoring in a home run by Aacres, Earl Vernon said.
Aacres has $1.3 million in state contracts to provide services as part of the state Department of Social and Health Services’ Community Protection Program. The voluntary program provides housing, counseling and support for developmentally disabled people with a propensity to commit sex crimes.
“This is a unique group of offenders,” according to a guide published by DSHS. “First, they are often both dangerous and vulnerable.”
As of June 1, 454 people statewide were enrolled in the program, which costs taxpayers more than $4 million annually.
Security is a key component of the program. Most houses, including the one in which Vernon died, have alarms on the doors and windows to prevent residents from leaving undetected and to protect them from other clients.
That’s most likely the reason Vernon’s window was opened only 2 inches and his bedroom door closed the night he died, his brother said.
David Vernon went to bed about 10:30 p.m. July 28.
It had been unseasonably hot that week, and health officials warned people to take measures to keep cool.
The temperature climbed to a high of 95 degrees on the 28th, one degree short of the record set 11 years before. The high temperature reached 102 on July 29, a record at Sea-Tac Airport.
Vernon slept on the second floor of a house at 816 S. 40th St., which he shared with two other Aacres clients and two live-in staff members. The home had no air conditioning.
One of the two windows in Vernon’s room was partially opened when he went to bed, according to a medical examiner’s report.
The fan in his room was not turned on. Caregivers later said Vernon did not like the way air pushed by the fan felt on his skin. He would turn off the fan, even if they left it running for him.
They also reported that he had not complained of being hot or shown signs of heat exhaustion on July 28.
At the time of his death, Vernon was taking two drugs prescribed to treat his mental illness: olanzapine and paroxetine. Olanzapine is used to treat schizophrenia; paroxetine is given to treat depression and other mood disorders.
Both can make someone taking them prone to hyperthermia.
“You should know that olanzapine may make it harder for your body to cool down when it gets very hot,” according to a brochure about the drug published by American Society for Health-System Pharmacists. “Tell your doctor if you plan to do vigorous exercise or be exposed to extreme heat.”
Paroxetine is known to cause serotonin syndrome, a potentially deadly reaction that can occur in people taking certain therapeutic drugs. Hyperthermia can result.
“The onset of symptoms is usually rapid, with clinical findings often occurring within minutes after a change in medication or self-poisoning,” according to a study on the syndrome published in the March 17, 2005, issue of The New England Journal of Medicine. “Patients with mild manifestations may present with subacute or chronic symptoms, whereas severe cases may progress rapidly to death.”
Symptoms of the syndrome are tough to spot and often missed by physicians, according to the article, which also points out that a single dose of paroxetine is enough to cause the condition. Death from the syndrome is rare, according to medical literature.
Laboratory tests found unusually high levels of paroxetine – more than 16 times normal levels – in Vernon’s blood at the time of his death, according to the medical examiner’s report. He was taking 50 milligrams of paroxetine each night before bedtime, according to DSHS records.
It was unknown how Vernon – who was about 5 feet 7 and 180 pounds – built up such a high level of the drug in his system.
Caregivers are required by state law to be familiar with their clients’ drug regimens and must report to the “prescribing professional” when “any changes in client behavior or health that might be adverse side effects of the medication(s).”
About six hours after Vernon retired for the night, his caregiver reported hearing a thump in Vernon’s room. He went upstairs to find Vernon on the floor. He was unresponsive.
The caregiver “stated the decedent was extremely hot to the touch and he was limp so he called 911,” according to a report written by Melissa Baker, an investigator with the Medical Examiner’s Office.
The caregiver performed CPR on Vernon until firefighters arrived and took over, Baker’s report states. They drove him to St. Joseph Medical Center, where he was pronounced dead.
Vernon’s death generated several investigations, none of which found anyone to blame.
The first was by the Medical Examiner’s Office.
Baker and a fellow investigator went to the group home the morning of July 29 to make observations and interview staff members. They took a temperature reading in Vernon’s room at 10 a.m. “It was 82 degrees F,” Baker wrote in her report.
No one took a reading when Vernon collapsed, but “fire personnel reported the decedent’s apartment was extremely hot,” according to a report written by Karen Barr, another investigator with the Medical Examiner’s Office.
Eric Kiesel, the county’s appointed medical examiner at the time, performed an autopsy the afternoon of July 29. Kiesel determined the cause of death to be “exogenous hyperthermia.” Kiesel also noted the paroxetine intoxication and the fact that Vernon had heart disease.
“In view of the information available at this time concerning the circumstances surrounding his death, the manner of his death is classified as an accident,” Kiesel said in his written opinion.
DSHS conducted at least two investigations into the matter.
Investigator Julie Mehan of Residential Care Services looked into Vernon’s death in October 2009 after receiving an anonymous complaint about how Aacres responded to his collapse July 29, according to the summary of her report.
Mehan interviewed Aacres staff members and DSHS officials involved in the case and reviewed several documents associated with his medical history and death. She concluded that Aacres handled Vernon’s death appropriately and recommended no citations.
“Agency staff followed agency procedure in a medical emergency and no provider practice issue was identified,” Mehan wrote. “There was no evidence to demonstrate a lack of response on the part of the staff or agency.”
Aacres, which runs group homes across Washington state and in Nevada and California, received one DSHS citation in 2009, according to agency records.
The citation – which did not involve the facility where Vernon was living – was filed because the home lacked an adequate emergency food supply and because its logs were not always updated at the time patients received medication. Both issues were corrected, records show.
Mehan went on to say that Aacres appeared to be complying with DSHS advisories during the heat wave of 2009.
“At the time of the incident agency staff were instructed to purchase fans and to monitor clients for signs of heat exhaustion,” she wrote. “The Named Client had not demonstrated any signs or symptoms of heat exhaustion on the date of the incident and had in fact engaged in his regular daily routine up to going to bed for the night.”
Stickell, the Aacres regional director, said his staff worked with clients to keep windows open and fans running during the heat wave.
“Staff provided special attention to any signs of heat-related discomfort,” he said. “The Division of Developmental Disabilities does not cover the cost of air conditioning units as part of the start-up funding for clients moving into the community nor does DDD supplement clients’ income to pay for air conditioning units.”
Dr. Christian Dahl, medical director of Rainier School near Buckley, conducted a mortality review for DSHS.
Dahl wrote in a March 18, 2010, report that Vernon’s death was unexpected but not suspicious.
"In regards to preventing Mr. Vernon’s death, it appears that the heat spell was a contributing factor, and his medications may have aggravated the situation although that cannot be said with any degree of certainty,” Dahl wrote.
It is difficult to say whether Vernon’s caregivers should have been aware of the “unusual heat-related side-effect risks (of drugs) in the absence of complaints by an individual,” Dahl continued.
“The risk of side effects causing an inability to regulate core body temperature is not well recognized or understood outside the medical profession,” Dahl wrote.
Stickell said his staff monitors clients’ prescriptions and “know to report any medication-related problems immediately.”
He declined to say whether anyone was disciplined as a result of Vernon’s death.
Dahl made four “quality improvement suggestions” for group homes across DSHS:
Alert caregivers to the potential side effects of antipsychotic drugs on the body’s ability to regulate its temperature.
Recommend that caregivers monitor indoor air temperatures during extreme heat waves, especially if there are health risks identified with medication side effects.
Increase education for caregivers regarding drug side effects, including rare and unusual ones.
Ensure that caregivers are aware of side effects observed by drug prescribers.
Tacoma police homicide detective Gene Miller began investigating Vernon’s death in October 2009 after DSHS notified the department that an unexpected death had occurred.
“I did not believe I had probable cause to arrest any one person, but I believed it merited a review by the prosecutor’s office,” Miller told The News Tribune last week. He forwarded the case to prosecutors in July.
Earl Vernon, who owns a court-reporting business with his wife, believes his brother’s death constitutes neglect and criminal mistreatment at the very least.
David Vernon was totally dependent on Aacres for his care and well-being, his brother said.
“You don’t take somebody and put them in a hot car or lock them in a hot room. You don’t do that to an animal,” he said. “I don’t know why they would think that was OK to do that to David. Vulnerable adults are the least represented in society.”
Earl Vernon also is convinced his brother was showing signs of paroxetine poisoning in the months before his death, including developing a limp and diarrhea.
He has paid for medical experts to review his brother’s case and provide information to prosecutors. Some of that information has not yet been turned over.
That evidence might show, among other things, whether Vernon was dehydrated before he died or whether he ingested too much of his medicine in the days or weeks before his death.
Earl Vernon also hired Tacoma attorney Barbara Corey recently to help him push for accountability for his brother’s death.
Corey, a former Pierce County deputy prosecutor, has met with Sorensen, Prosecutor Mark Lindquist and chief criminal deputy prosecutor Mary Robnett several times to discuss the case.
Corey said prosecutors should be able to make a criminal-mistreatment charge stand up against some or all of Vernon’s caregivers.
“My point is if a baby died at day care, they’d vigorously investigate it, and my belief is charge everybody in the food chain,” she said. “Somebody was responsible for David. They had a legal, moral and ethical obligation to David. When that fails and it results in a death, it is at least recklessness, and Aacres was deliberately indifferent to those needs.”
Susan Kas is a staff attorney for Disability Rights Washington, a group that advocates for disabled people. She said Vernon’s death points up problems in the state’s system for housing vulnerable residents in regard to preparing them for severe weather.
“It’s a major concern as we approach winter time,” she said. “Do they have plans? Are they adequately resourced? We’re not entirely convinced that’s something being conveyed to providers or enforced by the state.”
DSHS spokeswoman Kathy Spears said the agency “periodically sent out caregiver alerts and provider letters covering hot topics.”
“The department depends largely on a bi-annual certification/re-certification process to ensure Supported Living agencies are in compliance with the rules and regulations, which include maintaining a safe and healthy environment,” Spears said.
Kas said Vernon’s case also is an example of the need to reform the state’s wrongful death law, which can be an effective tool in bringing change to flawed bureaucracies.
Under the current system, there’s more accountability for someone who survives in a case like Vernon’s than for someone who dies, Kas said.
“That’s backwards,” she said.
In the end, Earl Vernon said, he just wants someone held responsible for the death of his brother, who enjoyed putting together jigsaw puzzles, taking photographs and bowling.
“My aim is really justice for David, and at this point the only way we’re going to have justice is through a criminal prosecution,” he said. “They just didn’t provide for his safety and health. It’s just not right.”