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    Hospital deaths draw attention of officials

    The scrutiny follows several deaths among patients at a facility for the mentally retarded.


    © St. Petersburg Times, published April 19, 2001

    FORT MYERS -- State officials are reviewing several recent deaths at an institution for profoundly mentally retarded people, after a 49-year-old man died in January when he swallowed a latex glove.

    The Department of Children and Families, which operates the institution, stressed that the review does not necessarily indicate problems with the other deaths at Gulf Coast Center, east of Fort Myers.

    But the agency already has agreed to tighten its procedures because of the January death. The man who died habitually swallowed inedible objects including the latex gloves commonly worn by medical workers.

    DCF District Administrator Mike Murphy also has asked a medical consultant with the agency's Tallahassee office to visit Gulf Coast Center and review the previous deaths. And he has assigned one of his own employees to prepare a second report on whether the facility's staff acted properly in the most recent incident.

    Murphy said he wanted his own extra report on the matter because the other reviews "often don't tell us if staff was negligent or not."

    Gulf Coast Center is a home for about 300 profoundly mentally retarded people, whose IQs are generally 20 or below. The average resident has been there 22 years.

    One of those was Carl Stine, who had lived 40 of his 49 years at Gulf Coast Center, according to his mother Mary Stine. Mrs. Stine, 81, who lives in Longwood in Central Florida, said her son could not talk, but was able to feed himself and walk.

    He also suffered from "pica," a disorder in people who repeatedly put inedible objects into their mouths.

    His tendency to swallow things was well-known to staff at Gulf Coast, according to a report from the Agency for Health Care Administration, which investigated the case. The report does not mention Stine by name.

    The report said Stine had swallowed paper, latex gloves, a screw and and other materials. Last April he was found coughing, and staff removed a latex glove from his mouth. In October, the staff noticed a latex glove had passed through in a bowel movement.

    When he was discovered unresponsive in the bathroom on the night of Jan. 14, the staff discovered a glove in his throat. In a later investigation, the medical examiner "retrieved another latex glove and paper towel (from) the resident's stomach."

    AHCA's report also says that a day or two after Stine's death, gloves were found where residents have access to them in the cottage where he lived. "Both staff (members) that were assigned to the resident on the evening when he died were aware of his pica behavior," the report said.

    Mary Stine said "I couldn't put any blame on anybody," for her son's death. "I think that these children, the problems they have, it's easy for something like that to happen."

    The department has agreed to keep latex gloves locked away and carefully disposed of after use; lock trash containers; produce a staff video training video on controlling and disposing of gloves; and other measures designed to increase awareness of how to protect residents who suffer from pica.

    Recently, an anonymous letter was sent to parents of Gulf Coast's residents alleging that there had been an unusual number of deaths there. State officials said they are reviewing the letter.

    DCF spokeswoman Debbie Webb said the January death of the resident -- identified in a death certificate as Stine -- was one of three this year at Gulf Coast. The other two were from "expected" causes, meaning known medical conditions.

    Last year there were four deaths. Two were "unexpected," meaning they were not from ongoing, previously diagnosed medical problems, but they were from natural causes nonetheless, Webb said. In 1999 there were five deaths, of which one was unexpected. She did not elaborate on that case. No deaths were recorded in 1998.

    Gulf Coast Center has scheduled a meeting for Sunday for parents of residents. A main topic of that meeting is another controversial issue: The center is about to admit eight or more people who have been accused of violent crimes but have not been found guilty because they were considered incompetent to stand trial.

    "I'm so aggravated with it because I have a son there and my son has an IQ of about a 2-year-old and they have to have a place for this type of child," said Thelma Weaver of Fort Myers.

    - Times Staff Writer Curtis Krueger can be reached at or by calling (727) 893-8232. Thomas C. Tobin can be reached at or by calling (727) 893-8923.

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