By Sam Levin
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The FBI exhumed 13 bodies of veterans whose deaths were suspicious and retained the services of famed forensic pathologist Dr. Michael Baden, who also served as an expert witness in the O.J. Simpson murder trial. Agents sifted through thousands of pages of documents and interviewed hundreds of witnesses.
"When the FBI guys were on this, they were great. They worked with great speed. It's amazing, the amount of data they collected in a very short amount of time," Adelstein remembers. He says he was impressed with the FBI's experts' work on the autopsies of the exhumed bodies, one of which he watched, and says the FBI "did everything right."
Barred from patient care but armed with a letter of recommendation from Kurzejeski, Williams started working weekends at Ashland Healthcare, a new nursing home near his mobile home. The number of deaths began increasing there, first on weekends, then during the week after Williams quit the VA to work full-time as Ashland Healthcare's nursing supervisor. As the deputy medical examiner for Boone County, in addition to his duties at the hospital, Adelstein began reviewing the data from Ashland Healthcare and sought Christensen's analysis. The two found that whereas 33 people had died in the year Williams worked there, only six had died in a 10-month period before he started.
The Missouri Board of Nursing investigated Williams and eventually put him on probation for three years for "misdemeanor stealing" and "failing to adequately supervise staff at the facility to ensure their compliance with state and federal law." He then voluntarily surrendered his nursing license, according to records from the nursing board.
Frustrated with hospital administrators and feeling that he was being punished for speaking out about the deaths, Christensen in 1993 wrote to the head of the inspector general's office, accusing hospital administrators of trying to cover up murder and alleging that the inspector general's office was not attempting to conduct a serious investigation into the cover-up. That move apparently backfired: Within months, the FBI investigation seemed to stop cold.
Both Christensen and Adelstein say that the FBI agents stopped contacting them and for the first time were refusing to return their phone calls. The two doctors persisted in calling agents to try to find out why the investigation had stalled, and both were told by various agents that the decisions were being made "in the very high levels of the FBI."
One agent told Adelstein that the FBI had gotten busy with other matters, "like Waco and the Oklahoma City bombing." Eventually Adelstein obtained a copy of a letter written by Baden stating that of the 13 bodies that had been exhumed, no physical cause of death could be found for any of them -- a fact that, as a medical examiner, Adelstein found very strange.
"So I called Dr. Baden on the phone, and I said, 'What's going on?' I mean, most of these deaths were unexpected, so you'd expect that you'd see some physical evidence of cause of death -- their heart would have ruptured or they would have had a bleed in an aneurysm or they would have had pneumonia or they would have something. It's true, in the world of autopsies, there are times we don't know why people died ... but of 13 like this you'd expect at least six or seven of them you would have a cause of death," Adelstein remembers.
"So Baden said to me on the phone, 'Well, aren't you going to ask me the most critical question?' And I said, 'Well, what is the most critical question?' And he said, 'Well, where are the toxicological studies?' And I said, 'Where are the toxicological studies?' And he said, 'Oh, that required a special act of Congress, and we haven't gotten it done.' I mean, it was amazing."
Only after Helen Havrum sued the U.S. government in U.S. District Court, and the case went to trial in 1998, was her lawyer, Kurtz, able to obtain detailed documents from the FBI's investigation, although data from deaths after Havrum's has never become public. A report by National Medical Services, a lab used by the government, said that Elzie Havrum's heart and lung tissues contained levels of codeine in the "lower range of fatal." But in a subsequent report, the lab recanted, reporting that the two Tylenol 3 pills on Havrum's chart probably accounted for the codeine in his tissues, so codeine was "unlikely the cause of death." Experts for Havrum showed in court that the level of acetominophen, the primary painkiller in Tylenol 3, was not high enough in Havrum's body to indicate that the fatal dose of codeine came from Tylenol 3.
Baden, appearing as a witness defending the VA, testified that Havrum had died of "natural causes" and may have had pneumonia, even though his charts show that he had no fever and no chills. U.S. District Court Judge Nanette Laughrey found for Helen Havrum and ordered the government to pay her $450,000 in compensation. Laughrey said she found the government's experts "self serving" and that there was a "noticeable trend among the [government's] experts to overstate the evidence and to give inconsistent statements."
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