RICHMOND HEIGHTS • Anna Brown wasn't leaving the emergency room quietly.
She yelled from a wheelchair at St. Mary's Health Center security personnel and Richmond Heights police officers that her legs hurt so badly she couldn't stand.
She had already been to two other hospitals that week in September, complaining of leg pain after spraining her ankle.
This time, she refused to leave.
A police officer arrested Brown for trespassing. He wheeled her out in handcuffs after a doctor said she was healthy enough to be locked up.
Brown was 29. A mother who had lost custody of two children. Homeless. On Medicaid. And, an autopsy later revealed, dying from blood clots that started in her legs, then lodged in her lungs.
She told officers she couldn't get out of the police car, so they dragged her by her arms into the station. They left her lying on the concrete floor of a jail cell, moaning and struggling to breathe. Just 15 minutes later, a jail worker found her cold to the touch.
Officers suspected Brown was using drugs. Autopsy results showed she had no drugs in her system.
Six months later, family members still wonder how Brown's sprained ankle led to her death in police custody, and whether anyone — including themselves — is to blame.
There seems to be no simple answer.
St. Mary's officials say they did all they were supposed to do for Brown. Richmond Heights police said they trusted a doctor who said she was fit for jail.
Brown's mother, Dorothy Davis, isn't sure what to think.
"If the police killed my daughter, I want to know," she said. "If the hospital is at fault, I want to know. I want to be able to tell her children why their mother isn't here."
Davis also faults the St. Louis County Family Court, which she said forced her into a heartbreaking dilemma after the state took away Brown's children on a claim of neglect. Davis could take in her grandchildren or her daughter, a judge said, but not both.
"I'm mad at myself because if I hadn't listened to the courts, she would still be here," Davis said. "If she had been here at this house, she would be here today."
STREETS BECAME HOME
Anna Brown was one of 10 children. She graduated from Kirkwood High School. At 18, she had her first child, a boy. She had a daughter nine years later. Brown was raising them alone when a tornado destroyed her north St. Louis home on New Year's Eve 2010. She moved to Berkeley.
Shortly after, she lost her job at a sandwich shop. Bills lapsed. The electricity was turned off. So was the gas. And the water.
Family members say Brown and her children appeared fine during visits at Davis' home in Normandy.
In April, a state Children's Division representative found Brown's toilet filled with feces. Burn marks scarred the floors and sinks where Brown had used small fires to stay warm. One refrigerator could not be opened. Insects and rotting food filled another, according to state reports given to the Post-Dispatch by Brown's family.
Brown was not lucid and seemed confused as Berkeley police arrested her for parental neglect. The courts awarded legal custody of the kids to the Children's Division. Davis could have physical custody, as long as Brown didn't live with her.
Brown's home was condemned. She ended up on the streets. She lived in four homeless shelters from May to September 2011.
At first, she visited her children at her mother's home. That ended in June, when Brown started telling the children they didn't have to listen to their grandparents and called the police to report they were being abused. Police found no evidence of abuse.
After that, Brown had supervised visits with her children at the Children's Division. She also called her mother daily to check on them.
Brown struggled with officials' requirements for reuniting with her children. She passed two drug tests but balked at others. "She felt that she had passed them, so there was no point in doing them again," Davis said.
A court-ordered psychological evaluation to determine whether Brown had cognitive, developmental, behavioral or mental illnesses came back inconclusive. So the courts ordered a psychiatric evaluation to determine whether Brown needed medication or a doctor's treatment.
But Brown resisted, not understanding the difference between the two evaluations, according to her caseworker's notes.
Still, she may have known something was wrong. She joined the St. Louis Empowerment Center, a drop-in center for the mentally ill.
"It was like a light bulb went on when she heard others tell their stories," said Kevin Dean, a peer specialist at the center. "She was just starting to make progress."
Brown's witty comments often broke the ice during group meetings, said Warren Brown, another peer specialist and no relation to Anna.
Anna Brown one day said she hurt her ankle while walking near a ditch, Dean and Warren Brown recalled.
The last time they remember seeing her was in August 2011; she said she couldn't walk up the stairs.
Brown told her caseworker on Sept. 14 that she had been admitted to St. Louis University Hospital for a sprained ankle.
Bills her mother received show Brown stayed at that hospital from Sept. 13-15 and underwent an EKG, some radiology services, lab work and cardiovascular services.
"She wasn't very eager to go home, but we do all we can to take care of the whole patient, and we want to make sure that we do not push someone out the door as soon as she came here," said SLU spokeswoman Laura Keller. She said there was no indication of a blood clot in Brown's leg.
Krystle Brown said she saw her sister for the last time after she was discharged from SLU. She dropped Anna off on Market Street downtown, where Anna said she wanted to be.
Davis didn't want her daughter out in the rain and ordered Krystle to bring her home — regardless of the court order. It was too late. Krystle couldn't find her sister.
Four days later, Brown had her last supervised visit with her children. She was on crutches.
State inspectors working for the Centers for Medicare and Medicaid Services — a federal agency that regulates hospitals — interviewed St. Mary's staff and reviewed medical records after the Post-Dispatch asked about Brown's case in January.
They found that on Sept. 20, Brown returned to SLU Hospital for knee and ankle pain. X-rays of her knees were negative and she was given a prescription for a painkiller.
She refused to leave. Hospital security called St. Louis police, who responded about 5 a.m. Brown told them she wanted to go to a better hospital but refused to go in an ambulance, police said.
She then wheeled herself next door to Cardinal Glennon Children's Medical Center, where doctors found tenderness in her legs. They told her she was at a pediatric hospital. She said she wasn't leaving unless someone took her to an adult hospital, according to the inspectors.
An ambulance then took her to St. Mary's, inspectors found. She arrived at 11:45 a.m. Her left ankle was swollen. She was there for about seven hours, during which ultrasounds on both of her legs were negative for blood clots. A nurse said she saw her stand up. A social worker gave her a list of shelters and a phone number for transportation.
She returned eight hours later by ambulance complaining of abdominal pain only, inspectors said. She refused to sign discharge papers but was discharged at 7 a.m.
Richmond Heights Officer Jason Tharp was at St. Mary's on another call about 10 a.m. when a security officer, Steve Schaffer, told him a woman was claiming she "did not receive adequate medical attention and did not have to leave."
She was sitting in a wheelchair and told officers she was waiting for a ride. Tharp told her to wait outside or face arrest for trespassing.
"You can't arrest me. I know my rights, I can't even stand up!" she yelled, according to police.
Officer Scott Stebelman said he waited for about three hours for a doctor to examine Brown before taking her to jail. At 12:30 p.m., a doctor issued a "Fit for Confinement" report, according to the state inspectors.
The inspectors' report, however, contains some differences from reports written by Richmond Heights police and the county medical examiner's office:
• Police and medical examiner reports, based on interviews from that day, quote St. Mary's staff as saying Brown did complain of leg pain on her return visit, not just abdominal pain.
• A St. Mary's nurse told the medical examiner that Brown was still complaining of leg and abdominal pain at 12:40 p.m.: "She was advised that she had already been treated and needed to leave the hospital."
• Police said the doctor's "fit for confinement" decision was made at 1:20 p.m., not 12:30 p.m. Police also said Brown yelled "My legs don't work!" as they wheeled her out after the exam.
DYING IN JAIL
Once in custody, Brown initially cursed at Tharp inside his patrol car during the ride to jail and asked for a wheelchair after officers ordered her out of the car, according to surveillance tapes.
"I can't put any pressure on my legs," she told them.
Two officers then pulled her into the station by her arms. Police listed "suspected drug use" as Brown's physical state and "unknown leg pain" under medical notes.
While at the police station, Brown's condition worsened. Officers carried her by her arms and legs into a cell and left her on her back on the floor. She moaned and moved her head back and forth. She's last seen moving on the tapes at 2 p.m.
A dispatcher with East Central Dispatch zoomed a surveillance camera in and out on Brown because "it was difficult to determine if the prisoner was still breathing later due to the pixilation grain on his monitor," police reported.
Fifteen minutes later, a jail worker readying meals found Brown unresponsive. Several responders shocked her with a defibrillator and started CPR. Paramedics rushed Brown back to St. Mary's.
Within hours of being declaring fit for confinement, Brown was pronounced dead.
Back in the jail cell, Richmond Heights Fire Chief Kerry Hogan was putting away the jail's defibrillator when, according to a recording of the conversation, a Richmond Heights officer told him: "We got a 'fit (for confinement') on her a half hour ago. I mean, literally, a half hour ago we brought her in here."
"Where at?" Hogan asked.
"What was, uh. Any problems at all?"
"No, they thought she was a drug seeker."
"Well, that could very well be ... And that's a shame."
Acting Police Chief Maj. Roy Wright refused to identify the officer on the tape. He also wouldn't let the Post-Dispatch interview Stebelman, who sat with Brown for three hours waiting for a doctor's exam. Wright said his officers had no way of knowing Brown's dire condition.
"A lot of times people don't want to stay in jail and will claim to be sick," he said. "We depend on medical officials to tell us they're OK."
Likewise, the dispatcher monitoring Brown as she died had no way of knowing she wasn't just sleeping, said Mark Dougherty, general manager of East Central Dispatch.
"It's not unusual to have someone lay there lethargic," he said. "If he felt it was more severe, he would have called."
SEARCH FOR ANSWERS
All nine of Brown's siblings went to St. Mary's after learning she was gravely ill. Confusion and frustration took over as they waited 45 minutes for a doctor to tell them their sister was dead.
"They told us she came in from the jail unresponsive and, 'We don't know what happened,'" Krystle Brown recalled.
Davis said she did not receive a bill from St. Mary's, as she had from SLU Hospital. She said she has been told she cannot see the medical records without proving a legal right to them.
She vowed to not give up.
"When you lose a child, it's like a part of you you will never, ever get back," Davis said. "It's like a part of your soul, a part of you is totally gone. And when you don't know why, you keep wondering, you keep guessing."
Brown's cause of death puzzles Davis because immobility is a risk factor for deep vein thrombosis, the medical term for clots in the legs. "My daughter was homeless. She had to move around constantly."
But trauma, such as a sprained ankle, also is a risk factor. So is obesity, said Dr. Samuel Goldhaber, a Harvard Medical School professor and director of Brigham and Women's Hospital's Venous Thromboembolism Research Group. At autopsy, Brown was 5 feet tall and weighed 189 pounds.
"The body responds to trauma by revving up the coagulation system to prevent the individual from bleeding to death from the trauma," Goldhaber said. "But half the time, DVT is silent and there are no symptoms whatsoever."
In most cases, diagnosed patients take blood thinners and walk out of the hospital, said Dr. Elliott Haut, an emergency medicine expert for Johns Hopkins Medicine.
"Relatively small periods of immobility can potentially cause DVT," Haut said. "Not every test is 100 percent, but if you do the test and see the veins you are supposed to, you shouldn't miss it."
St. Mary's staff leaned heavily on the state's investigation in defending its actions.
"Our records show that, in this case, everything that should have been done medically was done properly. We found nothing that would have changed this tragic outcome," according to a statement.
Hospital spokesman Neil Keisel said, without providing specifics, that the medical examiner's report had inaccuracies and, "If that information was true, we would've been cited by the" state inspectors.
Brown's family hired an attorney, but a lawsuit hasn't been filed.
Should the matter make it to court, it will rest on whether St. Mary's violated state medical malpractice laws, said Sean Fosmire, a Michigan attorney with more than 30 years of experience representing hospitals and physicians.
Centers for Medicare and Medicaid Services "must have seen there was enough … medical testing to satisfy the federal law," Fosmire said. Federal law does not require accurate treatment, he noted.
If St. Mary's doctors "went through an exam, did testing and determined that the diagnosis was something else like a leg cramp, they may have been wrong, but that doesn't mean they're in violation of the federal law," he said.
The family's success in court also would depend upon how much a jury finds her life was worth — in dollars, said Tom Keefe, a Belleville-based personal injury attorney.
"If you kill a homeless man with no job, he's not worth very much. But if you wipe out (Cardinals star) Matt Holliday, who is making $20 million a year, it's worth a lot of money," Keefe said. "Even though they are both human beings and both victims, the truth is, death cases are evaluated by the losses you can prove the survivors have suffered."
Davis said she still has trouble sleeping and eating, and constantly questions whether she should have taken in her daughter. She said she wants permanent custody of her grandchildren, now 11 and 2.
Brown's son is in counseling to deal with his mother's death but is earning A's and B's. The girl kisses a picture of her mother whenever her grandmother wears a T-shirt bearing her image.
The family wore the shirts to Brown's burial on Oct. 8. Krystle Brown still wears hers to bed.
"She was not a drug dealer or a hooker or doing other things that she could've ended up dead for," the sister said. "People assume things because of they way they talk or the way they live or the things they do.
"My sister is not here today because people passed judgement."
Blythe Bernhard and Jeremy Kohler of the Post-Dispatch contributed to this report.