Carlifonia: An 8-year-old was taken off life support, his organs donated. Now, police are investigating

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By the time Cole Hartman arrived at Ronald Reagan UCLA Medical
Center, he was in grave condition. The 8-year-old had gone into cardiac
arrest after nearly drowning in a washing machine at his Castaic home.
Paramedics had gotten his heart beating again, but he remained in a coma
and on a ventilator.

Physicians at UCLA’s pediatric intensive care unit told Cole’s family
that the child was not brain-dead but “would never recover normal neuro
function and … could never awaken,” according to an entry in his
medical chart.
The Hartmans decided to take Cole off life support
and donate his organs. He was removed from the ventilator and, 23
minutes later with his family at his bedside, pronounced dead by an
anesthesiologist.
The seemingly peaceful death four years ago is
now the subject of an investigation by Los Angeles police and the
district attorney’s office. Homicide detectives are looking into an
allegation by a coroner’s investigator that the anesthesiologist gave
Cole a fatal dose of the opioid fentanyl to hasten his death and
increase the likelihood his organs could be harvested. No charges have
been brought.
A lawyer for the anesthesiologist, Dr. Judith Brill, said the allegation was “factually wrong and patently offensive.”
Brill’s
“only concern was to assure that this child, who had drowned and was
never going to recover, would not suffer any pain following the removal
of life support,” attorney Mark Werksman wrote in an email to The Times.
A rare criminal investigation
The
probe is one of only a handful of known criminal investigations into a
doctor’s role in an organ donation, and it offers a window into the
ethical issues that can play out during a donor’s last moments of life.
“As
you can imagine, this is very complicated,” said LAPD Capt. William
Hayes, who oversees the elite Robbery-Homicide Division conducting the
investigation. “We need to clearly understand what was done and the
implications of those actions.”
Detectives opened the case earlier
this year. Denise Bertone, a veteran coroner’s investigator who
specializes in child deaths, first flagged the use of fentanyl at the
time of Cole’s 2013 autopsy and campaigned for years to persuade
supervisors to reexamine the case. Her efforts resulted in the coroner’s
office amending Cole’s death certificate in December to add fentanyl
toxicity as a “significant cause” of his death.
“To me, this was not an academic question,” Bertone said in an interview.
Bertone
filed a whistle-blower retaliation lawsuit last month accusing the
coroner’s office of giving her less-desirable assignments as punishment
for raising questions about Cole’s death.
Cole’s father, Jeremy
Hartman, learned only recently of Bertone’s allegations and the criminal
investigation. (Cole’s mother died in 2009.) Hartman and his wife,
Elizabeth, who helped raise Cole and adopted him in 2012, declined to
comment, saying through a relative that they wanted to wait until the
outcome of the investigation to speak publicly.
A tragedy at home
Cole was born with fragile X syndrome, a genetic abnormality that causes intellectual and physical disabilities.
On
July 31, 2013, his father came in from mowing the lawn and found Cole
headfirst in a running washing machine, according to the coroner’s
report and a recording of a 911 call. By his parents’ estimation, Cole’s
head could have been underwater for as long as 25 minutes.
Cole
was taken to a Santa Clarita hospital by ambulance and then flown by
medical helicopter to UCLA later that night for more advanced care. In
the pediatric intensive care unit, the Hartmans met Brill.
A
professor emeritus of clinical anesthesiology and perioperative medicine
at UCLA, Brill, 65, is a well-regarded expert in the treatment of
seriously injured children. She helped write the state guidelines for
pediatric critical care and spent much of her free time on medical
missions to treat poor children in Africa, Asia and Latin America.
With
other members of the medical team, she informed the Hartmans that a
brain scan was “markedly abnormal” and suggested extensive damage from
lack of oxygen, according to notes she made in Cole’s chart.
The
family “unanimously stated that they would prefer to withdraw support”
and subsequently decided to donate his organs, Brill wrote.
Because
Cole wasn’t brain-dead, the organ retrieval was to occur after the
ventilator was removed and his heart stopped beating on its own under a
procedure known as donation after cardiac death, or DCD. This type of
donation began in the U.S. in the mid-1990s and has become increasingly
common in the last decade as the medical community tries to meet the
overwhelming need for organ donors. DCD accounted for about 10% of
deceased donors last year.
DCD comes with time pressures. Organs
can begin deteriorating immediately, and some are not suitable for
transplantation after 30 minutes.
Cole was removed from the
ventilator at 10:40 a.m. as a transplant team waited outside. He did not
stop breathing immediately. What happened next is unclear. The full
coroner’s report is sealed from public view pending the outcome of the
police investigation, and UCLA declined to comment.
Easing the boy’s pain
Bertone,
who said she reviewed the full medical charts and autopsy records,
alleged in her lawsuit that the boy “continued to gasp for air” and that
Brill then gave him fentanyl “with the purpose of inducing his death.”
Bertone’s suit and coroner’s records state that the administered dose
was 500 micrograms.
The suit does not identify Cole by name, but
Bertone said in an interview that he was the patient referenced, which
law enforcement officials confirmed.
Brill’s lawyer declined to
answer questions about the fentanyl allegation. In a portion of the
chart reviewed by The Times, Brill does not mention fentanyl but wrote
that “comfort care was provided throughout.” “Comfort care” is a term
commonly used for the use of medications such as opioids or sedatives to
ease pain, experts said.
Medical experts said it is difficult to
know for sure whether patients such as Cole in vegetative states are
experiencing pain, but physicians prefer to err on the side of caution
when withdrawing life support.
“It’s generally thought you give
enough medication to reassure everyone that the patient is comfortable,
but not so much that it is actually the primary cause of death,” said
anesthesiologist Nicholas Sadovnikoff, co-director of the surgical
intensive care unit and co-chair of the ethics committee at Brigham and
Women’s Hospital in Boston.
UCLA’s policy for DCD allows the use
of opioids “in doses that are clinically appropriate to prevent
discomfort.” Under the policy, “interventions intended to preserve organ
function, but which may hasten death, are prohibited.”
Cole’s
heart stopped at 10:59 a.m. and Brill declared death four minutes later,
according to Brill’s chart entry. Transplant surgeons removed Cole’s
kidneys and liver, according to coroner’s records. The nonprofit that
oversees organ donation in the L.A. region, OneLegacy, said in a
statement that its transplant teams have no role in the care of living
patients.
At the coroner’s office, Cole’s case was assigned to
Bertone, the only full-time pediatric death investigator. A registered
nurse, Bertone had investigated more than 2,500 cases, including
numerous child abuse cases. Law enforcement officers across the county
called on her frequently to interpret crime scenes and help interview
distraught parents. Reviewing the medical records, Bertone said she had
concerns about giving a boy who weighed 47 pounds that quantity of
fentanyl.
Dispute inside coroner’s office
Bertone
told Dr. Mark Fajardo, then-chief medical examiner-coroner, she thought
Cole died from fentanyl – making his death, in her estimation, a
possible murder or manslaughter – and urged him to test a sample of the
boy’s blood, she alleges in the lawsuit.
Fajardo declined and
ruled the cause of death was near-drowning. Fragile X syndrome was
listed as another significant cause, according to coroner’s records.
Bertone
continued complaining to supervisors in person and in emails. Fajardo
eventually ordered a blood test that showed fentanyl in Cole’s system.
Bertone pressed him to change the cause of Cole’s death, but according
to her lawsuit, Fajardo refused.
Fajardo, now Riverside County’s
chief forensic pathologist, said in an interview that Bertone’s
allegations left him “speechless,” but he declined to comment further,
citing the ongoing litigation.
After Fajardo left office last
year, Bertone approached the then-interim chief medical examiner, Dr.
Lakshmanan Sathyavagiswaran, who agreed to reopen the case. A pediatric
toxicologist brought in as an expert by the coroner’s office found that
the fentanyl “was responsible for the death of this patient” and that
the dose was “not consistent with a therapeutic dose for the management
of pain and discomfort,” according to excerpts of his findings quoted in
a coroner’s report.
As a result, Sathyavagiswaran changed Cole’s
death certificate in December to add fentanyl toxicity to the list of
causes of death and asked for a law enforcement investigation. The
manner of death – whether it was an accident or a homicide – remains
listed as “undetermined” pending the outcome of the investigation.
In
what was believed to be the first organ donation prosecution in the
United States, the San Luis Obispo County district attorney accused a
transplant doctor in 2007 of giving a DCD donor with a devastating
neurological disease excessive amounts of morphine and a sedative in a
bid to induce death within a half-hour window. The man continued
breathing for seven hours, and the transplant was called off. A jury
ultimately acquitted the physician, Dr. Hootan Roozrokh, of wrongdoing.
‘An exemplary career’
Bertone
is no longer assigned full time to pediatric cases. In her lawsuit, she
contends supervisors removed her from the work she loved in retaliation
for challenging the handling of Cole’s case. She is suing the county
for damages that include the loss of overtime, on-call pay and a
take-home car.
The county has yet to respond to the suit in court.
A coroner’s official said no one at the office would speak about Cole’s
case because of the suit and the ongoing police investigation.
Those who know Brill say she is deeply troubled by the accusations.
“This
is someone who has really had an exemplary career,” said Dr. Jean Lake,
a pediatric neurologist at Miller Children’s Hospital in Long Beach.
She is “just so concerned that her ability, her skills, her intentions
would be called into question.”

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