NORMANDY • One morning nearly a year ago, a 46-year-old mentally ill resident of the Normandy Nursing Center told employees at the home that he wasn't feeling well.
William Christopher Jones, described by the nursing home staff as well-liked and affable, didn't eat his breakfast that day and didn't take his medicine. He told a staff member he wanted to be left alone.
Later, a staff member saw Jones sprawled across his bed. He had stopped breathing. At 12:27 p.m. Aug. 12, he was pronounced dead.
Medical workers and the St. Louis County medical examiner's office initially believed the cause of death was cardiac arrest. But the next month, forensic experts discovered there was more to it than that.
Toxicology tests disclosed that he had died of a morphine overdose. Jones, however, wasn't prescribed the drug, or any other opiate, and was not known to seek out drugs.
Normandy police and county and state officials investigated the death and looked into a second incident two months later involving another mentally ill resident found to have opiates in her system.
But nearly a year after Jones' death, the Normandy police investigation has been labeled inactive, and an investigation by the Missouri Department of Health and Senior Services has been closed. Just how Jones ended up with a fatal quantity of morphine in his body remains a mystery.
"His death is just very suspicious," said Jeff Kays, an Ashland, Mo., attorney who represents Ron Jones, William Christopher Jones' brother. "From the records I've seen so far, nobody knows how he got it."
A toxicology report says William Christopher Jones' blood contained 0.75 micrograms of morphine — three to four times more than what is considered a normal dose, said Dr. Christopher Long of the medical examiner's office. Long said tests on Jones' liver did not indicate long-term use of the drug, suggesting that the morphine in his system was probably a one-time dose.
Long said lingering questions about the death concerned him. "Things just seemed very strange about the whole thing," he said. "It's very, very confusing."
Normandy Police Detective Louis Porzelt said he, too, was troubled by the case. His department has categorized the case as inactive, pending further leads.
Porzelt's investigation focused on the nursing home, which has a checkered history, and the Northeast Ambulance and Fire Protection District. The fire district's employees treated and transported to hospitals Jones and the other resident found with opiates in her system.
Both the nursing home and the fire district have supplies of morphine. But the Normandy police investigation determined that the nursing home's supply had been well-secured and accounted for, and that the fire district doesn't keep on hand the amount of morphine it would have taken to kill Jones.
"I looked at it from all the angles: from the nursing home to the hospital to the fire department, and nothing fell," Porzelt said. "The whole thing was a mystery. ... I just wish I was able to solve it."
NEEDED SECURE CARE
Jones' remains are buried along with those of his mother, father and a brother beneath a gray granite tombstone in Glasgow, Mo.
It was with his family that Chris, as he was known, was most happy, said his brother Ron Jones, of New Franklin, Mo. But their father died in 2004, and their mother became unable to care for Chris, who had been diagnosed with schizophrenia as a teen. When she died in 2006, Chris was living in a psychiatric center in Columbia, Mo.
Chris was helpful, personable and would strike up a conversation with anybody, Ron Jones said. But his mental illness led him to strip off his clothes and behave inappropriately. He'd even been found naked in church, talking to God.
Ron Jones said that with a family of his own to take care of, he couldn't take care of Chris.
In 2006, the Howard County public administrator became Chris' court-appointed guardian. Chris was allowed to leave the psychiatric center to live in a residential care center in Vandalia, Mo., then a skilled-nursing center in Salisbury, Mo.
But Chris was a wanderer who would sneak out to go Dumpster diving, Ron Jones said, and that wasn't acceptable at the nursing homes. It was decided that Chris would live in a home that would be difficult to leave. So in May 2008, Chris was moved to the Normandy Nursing Center, a secure skilled-nursing center at 7301 St. Charles Rock Road in Normandy.
It was there that Ron Jones last saw Chris, after taking him to a family reunion in Fayette two months before his death, Ron Jones said. Chris was thrilled to be with family, he recalled, and saddened at having to return to the nursing home.
NO DRUG VIOLATIONS
The first 911 call came in at 11:24 a.m. Aug. 12. Two minutes later, a second caller from the Normandy Nursing Center told the North Central County dispatch center of a nonresponsive patient at the home. "We've initiated CPR," the caller said.
A Northeast fire district ambulance headed to the scene, followed by a Northeast fire truck. The fire district crew took over resuscitation attempts and started an IV to give Jones medication intended to stimulate his heart, according to fire district and other records.
By 12:14 p.m., the ambulance was hurrying Jones to St. Mary's Health Center in Richmond Heights. At 12:27, a physician at the hospital pronounced him dead.
Jones had suffered from chronic obstructive pulmonary disease, hypertension, anemia and schizophrenia. For a month after his death, his passing didn't seem suspicious. But that changed in September, when toxicology tests revealed he had died of acute morphine intoxication.
The medical examiner's office reported the findings to the state health department via a hotline, and to the Normandy police.
In October, Porzelt, the Normandy police detective, began trying to determine just where the morphine had come from. He was told that the nursing home's morphine supply was kept under triple lock — in a locked box, on a locked cart, in a locked room — and that the center required two staff members to sign off whenever the drug was administered.
The home's director of nursing told police that neither Jones nor his roommates had been on morphine. She said the three residents who did take the drug, because of cancer, had rooms across from the nurse's station and were watched closely. Those patients, staff told police, could not have given Jones their morphine pills because they are checked to assure that their pills are swallowed.
Porzelt also noted that the home's medication log sheets were in order and that there didn't appear to be any discrepancies.
The investigator also was told that Jones was not one to seek out drugs or leave the nursing home campus.
Shortly after Porzelt began trying to track the morphine, a second incident involving opiates took place at the nursing home.
At 12:06 p.m. Oct. 19, the nursing home dialed 911 when a mentally ill female resident was found unresponsive. Nursing home staff started CPR on the woman. By the time a Northeast ambulance arrived, she had started breathing on her own, reports say.
Before an ambulance took the woman, now 46, to DePaul Health Center in Bridgeton, a Northeast paramedic gave her the drug Narcan to reverse the effects of what appeared to be a narcotics overdose, according to fire district records and district officials. The patient's pupils were "pinpointed," indicating an overdose, officials said.
After learning of the incident, the woman's physician, Dr. Susan Pearson, contacted DePaul and ordered a drug test, according to the police report. The test showed there were opiates in the woman's system, despite the fact that she hadn't been prescribed any and that she was "most likely incapable of obtaining other patients' meds," police were told.
After investigating both incidents, the state health department was unable to substantiate any violations, according to department spokeswoman Charisse Pappas.
Porzelt asked the fire district in March for records in the Jones case. Northeast Fire Chief Angelia Elgin denied the request, but Porzelt obtained a county grand jury subpoena to get the records.
In April, Porzelt asked the U.S. Drug Enforcement Agency to help determine whether Northeast's vehicles carried enough morphine to have killed Jones. Elgin again refused to hand over records, until presented with a federal grand jury subpoena.
(Elgin told the Post-Dispatch that she had denied the requests on the advice of fire district attorney Anthony Gray. He confirmed that account, saying formal written requests were needed.)
Elgin said district employees had done nothing wrong regarding Jones or the female resident. Further, she said, at the time of Jones' death the district was carrying another pain medication, fentanyl, on its vehicles, not morphine.
After the federal subpoena was served, the DEA noted "many violations" from its inspection of the fire district and its records, a police report said. But the inspection determined that Northeast "does not have enough morphine on hand, in all of their vehicles or in their supply, to have killed Jones," the report said.
While waiting for the federal subpoena, Porzelt received word from the medical examiner's office that the morphine that had killed Jones was believed to have entered his system at least two hours before his death.
But the question of just how that had happened remains.
On June 17, Jones' family filed a wrongful death suit against the nursing home in St. Louis County Circuit Court.
The suit said the home failed in its duty to monitor Jones and "to implement adequate medication-control measures and precautions." The nursing home's administrator, Kerry Kaufmann, told the Post-Dispatch she couldn't discuss any of the home's residents. But she emphasized that the center cooperated with all investigators and that the home keeps its morphine under tight control.
The suit over Jones' death isn't the only suit alleging critical failures at the home.
On Dec. 21, 2008, a mentally and physically disabled female resident allegedly was taken from her room and raped. Santonio McCoy, a custodian at the home at the time, has been charged with forcible rape and is awaiting trial. In the meantime, the resident's mother has sued the nursing home and McCoy, who was hired despite a lengthy criminal record.
The 116-bed Normandy Nursing Center was opened in 1994 and is owned by Normandy Associates Inc.
The federal website, medicare.gov, gives the home a one-star rating — meaning "much below average." Medicare uses a five-star scale to rate homes and takes into account health inspections, staffing and quality measures.
Harvey Tettlebaum, a Jefferson City attorney who represents the home, said the Medicare website wasn't up to date on the home's most recent inspections.
Past inspections of the home by the state health department reveal a range of violations, many of them serious. However, a June 21 inspection revealed no deficiencies, Pappas said.
Secretary of State filings list Normandy Associates' president as Shael Siegel of Skokie, Ill. The other officer listed is Morris Esformes, a nursing home operator and philanthropist whose nursing homes have been the target of law enforcement investigations in Missouri, Illinois and Florida.
Esformes owned the since-renamed Leland Health Care Center in University City in 2001, when four elderly female residents died after temperatures in the building reached 95 degrees.
Tettlebaum, who also represents Esformes, said that Esformes no longer owned homes in Missouri and that he was only "a passive investor" in the Normandy home.
Regarding Jones' death, Tettlebaum said the nursing home was frustrated by unanswered questions surrounding the case.
So, too, are Porzelt and the medical examiner's office.
As it stands, Jones' manner of death is listed as "undetermined."
"To us, 'undetermined' is a huge red flag," said Gwen Haugen, a forensic investigator with the medical examiner's office.
Porzelt said Jones' was the first death he had investigated that hadn't been solved. The detective said that he felt for Jones' family and that he was troubled by the lack of closure.
"But any time this could be reopened again," he stressed. "I don't like to leave something like this."