A state investigation into the death of Jerome Lackner, an iconoclastic California health care leader who served as a physician for Cesar Chavez and Martin Luther King Jr., has found that Sutter VNA & Hospice provided his caregivers with excessive amounts of morphine that, if administered, may have contributed to his death or killed him.
The report by California Department of Public Health investigators faults the Sutter hospice for continuing to provide morphine to Lackner’s lay caregivers, despite nurses’ concerns that he was being overmedicated. It notes that during one nine-hour period, he was given morphine at almost double the maximum dosage prescribed.
The investigation comes nearly six years after Lackner, a physician who led California’s health department in the 1970s, died at age 83 in his Davis home. The Department of Public Health reviewed his case following a series of Sacramento Bee stories about his July 2010 death and a formal complaint filed in August by his daughter, Zelda Lackner, alleging improper treatment.
The Bee stories revealed questionable actions by Lackner’s primary lay providers – his second wife, Rebecca Lackner, and Joseph Poirier, described by friends and family members as her romantic partner at the time. Rebecca Lackner and Poirier strongly disputed claims that they had harmed Jerome Lackner, but became subjects in a murder investigation by the Davis Police Department and Yolo County district attorney.
The District Attorney’s Office ultimately decided not to file charges in the case, saying the evidence was too thin. But Davis police Lt. Paul Doroshov said in a recent interview that he was reviewing the new report and that it would factor into the ongoing investigation.
The Department of Public Health declined to make an official available for comment. In a written response to questions from The Bee, a spokesman said, “CDPH must report any findings of elder abuse, as a mandated reporter … (and) made all appropriate referrals in this case.”
The health department’s report came in response to Zelda Lackner’s complaint. The department’s investigation, by design, was not focused on whether Rebecca Lackner and Poirier engaged in possible criminal conduct, but on the care and supervision provided by Roseville-based Sutter VNA & Hospice, which was overseeing his care.
The report raises the possibility that an overdose of morphine could have caused or contributed to Lackner’s death, but draws no conclusion.
The state report does not name the patient and his caregivers, but most names could be determined by comparing it with previously released hospice documents. Several issues described in The Bee series were amplified in the report, including the following:
▪ Communication breakdowns among hospice professionals meant “Excessive amounts of opiates were provided to the caregivers, then were unaccounted for, in the 35 hours prior to the patient’s death.” Hospice professionals suspected Lackner was a victim of “overmedicating,” and warned his wife and Poirier against that practice.
▪ During one nine-hour period, the state report shows, Lackner received about 1.7 times the highest prescribed dose. Prior to that, he was heavily medicated, and displayed no reaction to the insertion of a specialized catheter – an often-painful procedure, particularly in patients who suffer from prostate problems, as Lackner did.
▪ Rebecca Lackner added water to a vial of morphine, making it impossible to know how much had been used. Hospice officials called that “a red flag,” yet continued to supply morphine.
▪ The report noted Lackner’s post-mortem morphine blood level as far higher than that found in two comparison cases involving morphine-related fatalities.
Zelda Lackner, a daughter from Jerome Lackner’s first marriage, maintains her father was improperly placed in end-of-life care, which was hidden from his children until after his death. She noted that secrecy, and Rebecca Lackner’s financial ties to her husband’s estate and the alleged affair with Poirier, in a 39-page letter filed in July 2013 to state Attorney General Kamala Harris, asking for a more thorough investigation. Harris’ office declined to pursue the case.
In an interview last year, Rebecca Lackner called doubts about her actions unfounded, saying, “I was shocked that anyone could think I could hurt him.” She and Poirier, who also previously denied wrongdoing, declined to comment about the state report.
The Department of Public Health report focuses heavily on the apparent mishandling of Lackner’s medications during the last few days of his life.
“We were very much monitoring (Lackner’s) medications, suspecting (Rebecca Lackner) was overmedicating him,” Linda Boehm, a nurse, told the state investigator. “... things weren’t counting up right.” Due partly to breakdowns in communication among nurses and doctors, more morphine was supplied.
The records don’t show Lackner as being in much pain, but were unclear about how much morphine might have been required to control his shortness of breath. Some details of events could not be reconstructed by investigators, because Sutter, the hospice provider, could not locate some records, contrary to state standards.
Cynthia Wolff, a nurse who directed patient care for the hospice at the time, told a state investigator that large amounts of unaccounted-for morphine and a powerful antipsychotic drug, Haldol, often used to treat delirium, “could have been administered” to Lackner. She added, “That’s terrible.”
A Haldol overdose can cause deep sedation, and can cause or contribute to death.
“Sutter hospice had an opportunity to intervene and protect Jerome from harm, and failed over and over and over again,” Zelda Lackner said, calling the lapses “unconscionable.”
According to Sutter’s plan of correction for the lapses, which is included in the report, two involved employees were “counseled” about the failures. Five others left the company prior to the report’s release.
Sutter spokeswoman Sue Kratochvil called the Lackner case an “isolated incident.” She said no fines were issued and that the state had accepted Sutter’s plan to correct the failures. Some changes were made prior to the state investigation, and others – including measures meant to ensure proper handling of medications – took effect during the state review.
Sutter will still be allowed to delay documenting patient visits for up to 48 hours. In Lackner’s case, that would not have prevented communication problems that caused excess morphine to be provided to the caregivers.
The state report also showed that Lackner received an antibiotic and urinary catheterization without consent, a violation of state standards if he was of sound mind. The report notes that in the days before he was placed into hospice, health professionals twice had found him to be “alert” and “oriented.”
For all the clarity it added to the Lackner case, the state report left some key questions about the use of medications unanswered.
It said some of the morphine and Haldol went unused, but noted that hospice records do not verify that leftovers were destroyed.
The report described Rebecca Lackner improperly adding water to the morphine and Haldol. It assumed that half a vial of morphine was wasted, without confirmation.
Another hospice official, whose name could not be identified, also suggested to the state investigator that some morphine could have been stolen by Rebecca Lackner or Poirier. Both were in recovery for drug or alcohol addictions at the time, but neither was known to have been actively using.
John MacMillan Jr., a physician who directs the hospice and palliative medicine fellowship program at UC Davis, called the case an “exceptional” example of problems that can occur when care is fragmented among several providers. MacMillan said he had not seen a similar case in more than a decade of hospice practice.
“We say in hospice programs that you still have to practice good medicine,” he said. That includes a safety plan to prevent abuse of controlled substances such as morphine, he said.
“You don’t just keep prescribing, you develop an action plan that would restrict the flow of morphine if needed,” MacMillan said. “The lack of oversight – that’s where the biggest error occurred.”
After leaving government service, Lackner spent decades in private practice providing care to the poor and downtrodden, and was a revered figure in the local community of recovering addicts.
In the months leading up to his death, Lackner had been estranged from his wife, and stayed with his daughters in the Santa Cruz area. He filed for legal separation and decided to disinherit Rebecca Lackner. But he later opted to attempt a reconciliation and voluntarily returned to Davis to live with her.
A medical evaluation just before his return to his wife found him in stable and relatively good health despite chronic heart disease, and cognitively unimpaired.
One day after his return to Davis, Lackner was hospitalized, then placed in hospice care. Soon after, he died under the care of his wife and Poirier.
An autopsy concluded that Lackner died of heart disease, with morphine toxicity as a secondary cause. The coroner concluded Lackner died of natural causes. A Bee review of the coroner’s report found numerous errors, omissions and incorrect references to medical records had been used to support that conclusion.
Forensic medicine experts said that in such cases, it can be hard to reach firm conclusions. But some national authorities who reviewed the case questioned the coroner’s ruling.
Charles Piller, a former investigative reporter at The Sacramento Bee, now works for STAT, a national publication covering health and medicine. You can reach him at firstname.lastname@example.org