Man died in jail for lack of his medication

By DEBORAH O'NEIL

© St. Petersburg Times, published April 19, 2000

In the nine days Daniel Cory spent at the Pinellas County Jail, at least 11 nurses and two doctors were charged with caring for him.

Not one of them gave the mentally disabled man who suffered from Addison's disease medicine that would have saved his life -- even though nurses had been given a list of seven drugs Cory needed every day.

On the 10th day after the young man with the mind of a 6-year-old was arrested for waving a butter knife at a teenager, Cory was dead.

A ruling from the Pinellas County Medical Examiner's Office, released Tuesday along with records of the Sheriff's Office investigation into Cory's death, shows he died because he did not receive medications needed to treat Addison's disease. The medical examiner ruled his death accidental.

More than 150 pages of reports on the case released by the Sheriff's Office paint a disturbing picture of the medical care Cory received at the jail from Sept. 30 to Oct. 10, when he died. Cory was there on charges of aggravated assault and criminal mischief after he waved a knife at a teenager and threw rocks at the teen's car at a Safety Harbor park.

"He had Addison's disease and he should have been given the medications and he wasn't," Sheriff Everett Rice said. "This death never should have happened."

Medical care at the jail was provided by Correctional Physicians Services, a private company hired by the Sheriff's Office for $5-million a year. Shortly after Cory's death, Sheriff Everett Rice's office took control of medical services at the jail.

CPS conducted an internal investigation of Cory's death and 11 nurses were disciplined with either verbal or written counseling or suspensions. Neither doctor who saw Cory was disciplined. The Sheriff's Office has hired seven of those nurses to continue to provide care at the jail, and one of the doctors still works at the jail.

According to the reports, a nurse received a written list of seven of the eight medications Cory needed. The list included what doctors say is the most crucial, hydrocortisone, but did not specify its form or why it was included. The list also did not include a related medicine, Florinef, that should have been on it.

The nurse who got the list failed to verify its contents with the Safety Harbor group home where Cory lived and did not ensure he got the medicines. A doctor who later saw the list didn't know what the medications were for, so he did not administer them to Cory, reports say.

In the meantime, Cory became more ill, as he would have, experts say, without those medications.

He stopped eating.

He became frail and unstable on his feet.

In his childlike and garbled way, he told a corrections officer, "It hurts."

"I can't fathom that they wouldn't know the importance of this medication . . . that they would just not give it," said his mother, Dotty Cory, a nurse at Codee River Elementary School in Pasco County. "It's unforgivable."

Mrs. Cory has filed written notice that she intends to sue the Sheriff's Office for wrongful death.

Cory suffered from cerebral palsy and epilepsy. He drooled and his slurred speech was difficult to understand. But it was the Addison's disease that needed vigilance. The disease robs the body of the hormone cortisol, said Dr. M. Hamed Farooqi of Morton Plant Hospital in Clearwater. Cortisol is needed to maintain the body's sodium level, which stabilizes blood pressure and balances the body's blood sugar.

Two of the medications Cory never received at the jail stabilized his disease by replacing the missing cortisol in his body. Without the medication, a person's body can shut down, said Dr. Wendy Bailey, a pediatric endocrinologist at the Naval Medical Center in San Diego.

"Your blood pressure drops, you can go into shock, you just kind of collapse," Bailey said. "He could have had a seizure and not woken up. His electrolytes would go wacky. It's of major league importance to take the medications."

Bailey and Farooqi -- neither of whom was involved in Cory's care -- said that when an Addison's patient is under stress, the standard recommendation is to double or triple his doses.

An internal investigation by sheriff's Detective Rob Snipes found no criminal activity by either the Sheriff's Office or the medical staff. Rice said the mistakes the medical staff made did not rise to the level of a crime -- they just failed to recognize Cory's medical needs.

"I don't think the medical staff was ever told directly he had Addison's disease," Rice said.

"To prove criminal negligence in failing to give medicine, one of the problems was proving where the negligence was," Rice said. "Which person is in jeopardy of criminal culpable negligence? That's the problem."

Staff writers Jane Meinhardt, Edie Gross, Chris Cosdon and Sebastian Dortch contributed to this report.

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