SPRINGFIELD -- A special investigator found problems with more than a quarter of the death-related cases investigated by the Illinois Department of Human Services' inspector general, according to a report released Friday.
Michael McCotter was appointed in July by Gov. Pat Quinn to look into problems in the office after the Belleville News-Democrat revealed that since 2003 the inspector general hadn't investigated 53 cases involving disabled adults living at home who were allegedly abused or neglected and later died.
The newspaper found that the office headed by William M. Davis, who was named inspector general in 2006, was interpreting state law as barring it from investigating deaths because "the dead are ineligible for services." Davis stepped down from the post Aug. 1.
Quinn issued an executive order stating "immediate improvements must be made" in referring, documenting and following up on the deaths of adults with disabilities when abuse, neglect or exploitation is suspected.
McCotter's team looked into 72 cases and found that about 20 had errors or omissions, according to the report. In the remaining cases, McCotter found the inspector general's office acted properly and turned a case over to police.
"It was painfully apparent during this review that the investigators assigned to this unit were lacking in the area of training regarding basic investigative practices," McCotter said.
McCotter recommended the office establish a death review team made up of coroners, legal and law enforcement officials and a member from the office to review investigations involving deaths that were due to abuse, neglect or financial exploitation of the homebound disabled.
He also suggested the department's Quality Care Board should act as a "fresh set of eyes" to review the office's investigative practices. He also says the department should use the Illinois State Police's Medicaid Fraud Unit to investigate allegations of financial exploitation, abuse or neglect.
"We will immediately review the findings and work with members of the General Assembly and advocates to implement a comprehensive solution that reforms this office and ensures all people are treated with dignity and respect," Quinn said Friday in a statement.
Among the 20 cases in which McCotter found the inspector general's office came up lacking was that of a woman who was admitted into a hospital with sepsis, which results from the body's reaction to bacteria. The woman later died. According to the report, a hospital social worker contacted the Department of Human Services about the case, but the inspector general's office did not contact her. The patient had unhealed fractures caused by blows. McCotter said the case should have been referred to law enforcement.
Another case involved a woman suffering from lung cancer who was receiving hospice care from home. Her son who was caring for her wasn't turning her in bed, resulting in bed sores. When questioned, the man allegedly said the woman was going to die anyway. McCotter said because of the son's attitude, local law enforcement should have been contacted.