Coroner's Inquest
Dean Paul English
On September 26, 2002 a Coroner's Inquest was held in Woodland Park, CO to determine the Manner of Death of Dean Paul English. English (DOB 3-20-69), died February 23, 2000 of a single gunshot wound to the head from a 0.22 caliber revolver. The Coroner was not called to the scene immediately, and when she arrived on scene ~3 � hours after shots were fired, much of the evidence at the scene had been moved or destroyed and witnesses were unavailable for questioning. From 2nd, 3rd, and 4th hand accounts of investigators, the evidence initially appeared consistent with a verdict of suicide.
In Fall 2001, the English family declared their intention of filing a civil suit. Such a trial would require testimony based on photos of an untainted scene, but it took 5-6 months and 3 subpoenas to obtain these photos from the Sheriff's Office. The photos revealed more serious problems with the case than had initially been identified. Bloody fingerprints on a wall 18-20 feet from where the deceased had been shot and died were clearly visible in the photos. However, these prints had NOT been present at the time of the Coroner's arrival on scene. Likewise, the deceased's gunshot wound was the only bleeding injury of a person who had reportedly been at the scene.
Other evidence was equally problematic. Both the deceased and his live-in girlfriend showed signs of exposure to gunshot residue, the Sheriff's Entry/Exit log had disappeared from evidence, crucial evidence had not been collected or processed, and there were numerous instances where witness statements contradicted scene evidence, their previous statements, another witness' statements, or violated basic common sense.
A jury of 6 Teller County residents participated in incisively questioning the witnesses, and determined the correct manner of death to be "HOMICIDE, by person or persons unknown." The jurors were awesome in their questioning, honing in on inconsistencies in the testimony, claims that defied common sense and human nature, credibility gaps in the witness statements, and procedural difficulties.
Larry James Harper
Member of the 'Texas 7'
In a spectacularly successful venture jointly led by the FBI, Federal Marshals, and ATF, with support from WPPD, CSP, EPCSO, TCSO, and CCPD, 4 of the Texas 7 were apprehended without incident in Woodland Park January 22, 2001. The sole casualty in the recapture of the 7 fugitives that ended in Colorado Springs in the early hours of January 24 was Larry James Harper who took his own life when cornered in the RV at the Coachlight RV Park where the escapees had been living. Sadly, Harold Harper, father of the deceased, only learned several hours after Larry Harper ended his life with 2 gunshots through his heart that his son had asked to speak with him. After receiving the news of his son's imminent recapture, Mr. Harper turned on the TV to hear the latest, only to learn the request had come far too late for them to have that final father-son talk.
Wayne Brown Tease
14 years is a painfully long time to fight the bureaucratic red tape of county, state, and federal government agencies. 14 years is a dreadfully long time to wait for the State of Colorado to acknowledge that your son is dead. 14 years is an agonizingly long time to wait for closure.
Just ask Janet and Ted Kunz, formerly of Oreland, Pennsylvania and presently of Page, Arizona. On April 27, 1986, their son, Wayne Brown Tease, fell to his death in the derelict Mary McKinney Mine shaft located off Hwy. 67 about 3 miles south of Cripple Creek. After numerous fruitless attempts to recover the 23-year-old's remains, the efforts were abandoned lest other lives be lost.
Little did the Kunzes know, their struggles were only just beginning. Despite video film footage showing Wayne Tease's body in the mine shaft, the grieving parents were denied their very reasonable request for a Death Certificate because the body could not be recovered. Efforts to seal the mine shaft to prevent any future such accidents also ran into a snarl of red tape involving the Historical Society and the District Attorney who sought to prevent dirt from covering the remains.
Slowly but surely the red tape was eliminated and the mine shaft was filled, with a bronze plaque denoting the tragic secret of the Mary McKinney Mine. Yet, there was that one final piece of paper preventing total closure for the family, and it stung like a slap in the face. In the intervening years Teller County Coroners repeatedly refused to help the Kunz family in their efforts to obtain a Death Certificate. Without that document, it was as though the State of Colorado was denying Wayne Tease his right to rest in peace.
The final hurdle has been surpassed, and at last Janet and Ted Kunz and their children -- one of which is Wayne's identical twin, can heave a sigh of relief that the agonizing wait is over. They have their Death Certificate, they have their closure, and finally, they have the blessing of the State of Colorado that indeed Wayne Tease can rest in peace in the wild and splendid countryside that so intrigued him and lured him to his death.
Hilltop Nursing Home Investigation, Phase Two
State Board of Nursing Home Administrators
and Phase Three: State Board of Nurses
Jackie Webb, has been found guilty of violating C.R.S. 12-39-111(1)(d) and (e) and Rule 3(1)(a),(b),(d),(e), and (g) of Standards for Licensure. By virtue of these admissions, Ms. Webb has agreed to the term of license suspension (to at least July 6, 2000) and such formal monitoring (3 years), upon reinstatement by the Board to the extent the Board believes such monitoring is necessary to protect the public health, safety and welfare. On September 13, 2000, a former Hilltop nurse under investigation by the State Regulatory Agency also had her license suspended.
Ethel M. Pedrie, Teller County Registrar, died in Memorial Hospital ICU on December 18, 1999. She will be sorely missed by all who knew her.
Hilltop Nursing Home Investigation, Phase One
Deficiencies Found By
Colorado Department of Public Health & Environment
During the campaign of 1998 multiple complaints from constituents regarding health care problems in Teller County were brought to my attention. Without exception every one of these concerns involved Hilltop Nursing Home (AKA Cripple Creek Rehab & Wellness Center). Shortly after taking office in January 1999 I began researching these complaints. Some were beyond the scope of the Coroner's authority, and others were quickly dismissed as being without foundation. Nevertheless, several incidents were so exceedingly troubling that according to
C.R.S. 26-3.1-102 they necessitated action on my part. Consequently, formal inquiries regarding these concerns were forwarded to the Colorado Dept. of Public Health & Environment as well as to the Dept. of Regulatory Agencies, eventually spawning multiple investigations into the health care practices at Hilltop.
Several investigators involved in these inquiries have stated that the allegations were of such a serious nature, were so well-justified, and that my concerns were so well-documented by entries from the resident's files and medical records, that the authorities have acted with unprecedented speed and severity to remedy the problems. The findings of the Complaint Investigator (CDPH&E) looking into the allegations against the Nursing Home have just been released, and several deficiencies were found to exist.
CASE #1
Roxanol (morphine) was prescribed for a Hospice patient and Hilltop resident on 3-19-99, as follows:
"10-40 mg every 6 hours, as needed for pain"
All of the doses given after the 1645 dose on 3-20-99 were given sooner than the frequency of 6 hours ordered by the physician who had not been contacted to authorize a change in orders. The intervals between doses given after this time were as short as 30 minutes, and never exceeded 1 hour 45 minutes. The resident died at 10:15 AM on 3-21-99. Overdosing of this resident could not be substantiated. However, since the resident received Roxanol more frequently than every 6 hours, contrary to the order, this created the potential for the resident to receive more medication than intended. A deficiency was written concerning giving the medication at a greater frequency than ordered by the physician.
CASE #2
On 12-10-98 the Hilltop van made a sudden stop in traffic causing a resident to slide forward out of his seat, striking a guard pole in the van, and landing on his buttocks. He did not complain of any injuries at that time. Because the resident denied injuries, the van driver did not report the accident to the nursing staff until the next day. 2 days after the accident, records indicate the resident was "in bed all day due to pain in ribs from hurting self Thursday" (day of the accident). 3 days after the accident, the resident was transported to the hospital because of severe pain. He was treated with narcotic analgesics and released. The 4th morning following the accident, the resident was vomiting, cold, clammy, pale, his abdomen hard and distended, with rapid, shallow respiration, and he was complaining of "unbearable" pain. He was returned to the hospital and admitted to ICU where he died the next day (12-15-98).
Autopsy revealed he died of aspiration pneumonia. A liver laceration found at autopsy may have been caused by the accident, but could possibly have resulted from some other behavior pattern. Therefore, it could not be substantiated that the accident contributed to the death of this resident. Seatbelts and wheelchair anchors, not available at the time of this accident, have since been installed in the Hilltop van.
CASE #3
A man in his 70s was admitted to Hilltop on 11-12-98 with rehab potential noted as 'Good.' The records indicate he was "subjected to numerous medication errors."
2 conflicting orders for the same anti-psychotic were ordered within 30 minutes of one another. Nursing staff did not question the physician with regard to these orders, but instead administered both doses. Nearly a month later the resident was given two-times the prescribed dose of yet another anti-psychotic for a period of 2 days.
Narcotic analgesics were incorrectly administered to the resident from 12-17-98 through 12-22-98. Orders state, "Vicodin 1 tab until current dosepak done, then Oxycontin 10 mg, orally twice a day." On occasion during this time period, the resident was given twice the prescribed dose of Vicodin with simultaneous administration of Oxycontin. Records disclose no physician orders either to increase the resident's Vicodin or to start the resident on Oxycontin before the last prescribed dose of Vicodin was given.
On 2-12-99 an order was written instructing staff to "follow protocol for management of anxiety/agitation and pain management (Hospice and facility policy)." Dietary memo of 2-19-99 states, "Resident is currently in Hospice and is declining in health. Did inform nurse aides that being Hospice we do not need to weigh him anymore."
Roxanol (morphine) was prescribed to combat "severe pain" but chart entries show this medication was often given for "complaints of general discomfort" or when the patient was "unresponsive." Likewise, doses were increased in increments that greatly exceeded the prescription order.
Haldol and Ativan were prescribed to combat extreme agitation, i.e. behavior which "constitutes an emergent or semi-emergent situation where disruptive behavior is not conducive to the general well-being of the patient or others." Frequent physician contact and close documentation of patient status are necessary. From 2-12-99 through 2-22-99 the resident was given Haldol and Ativan because of "complaints of agitation", "restless", "yelling", or calling for help, but without indications that the resident might cause harm to himself or others.
On several occasions, Roxanol, Haldol, and Ativan were all given at or about the same time. These same 3 medications, alone or in combination, were sometimes given even when the resident was unresponsive. When he was unresponsive, his routine medications and meals were NOT given. Records disclosed that administration of medications on 5 occasions rendered this resident unresponsive to verbal stimuli for an extended period of time.
Medical records for this patient are sometimes inconsistent:
2-13-99 -- 7:30 PM: Medication Administration Record indicates resident was "Hollering help very restless." Roxanol was given for pain.
2-13-99 -- 7:30 PM: Nursing note states "resident resting in bed quietly."
2-20-99 -- 10:45 AM: Resident was "resting" and his agitation had decreased. 20 mg Roxanol given.
2-22-99 -- 4:30 PM: 40 mg Roxanol given.
2-22-99 -- 5:30 PM: Resident "quiet"; 40 mg Roxanol given.
The resident died at 11:45 PM on 2-22-99.
Findings revealed that the resident was improperly administered several medications. Furthermore, the facility's protocol for pain and anxiety management was not adhered to. Specifically, the documentation was inadequate to justify the medications given for pain and agitation, coordination of the two protocols was not evident, and the facility did not communicate the resident's condition to the physician as per protocol to ensure medical evaluation of the medication regime. These failures created the potential for the resident to receive more medication than intended and necessary to meet his needs, and created the potential for the resident to receive multiple medications.
Hilltop is not licensed to provide Hospice care without collaboration from Prospect Home Care Hospice that was not involved in this resident's care. However, as the 2-12-99 entry in the patient's chart to follow 'Hospice policy' could not be proven to be a 'change in status' for this resident, the allegation that Hilltop violated licensing laws in this instance could not be substantiated. Overdosing of this resident could not be substantiated. However, because medication discrepancies were found, the allegation concerning his multiple medications was substantiated and a deficiency was written concerning giving medication inconsistent with physician's orders and inconsistent with standards for nursing practice.
While not all concerns could be substantiated, the Complaint Investigator from the CDPH&E stresses that an unsubstantiated complaint does NOT necessarily mean that what was heard or seen did not occur, but rather that the SUBSTANTIAL evidence required to confirm regulations were violated could not be found. In the case of the deficiencies at Hilltop, the facility is required to submit a Plan of Correction to address the issues cited. Anyone interested in reading the full 20 page report detailing the investigation can click here to access the Summary for Public Viewing.
For those who are unfamiliar with Hilltop, it is a 54-bed in-patient facility with a resident population comprised of approximately 50% geriatric and 50% rehab patients. It is Teller County's only in-patient nursing facility. A number of other investigations regarding Hilltop are ongoing, and hopefully will be resolved within the next few months.
MT. PISGAH SKELETAL REMAINS IDENTIFIED
Skeletal remains discovered in March 1999 on the slopes of
Mt. Pisgah in Teller County have been positively identified as being
those of Richard Dean Holmes who had been reported missing April
23, 1997 by his roommate. Positive identification was made by
comparison of an antemortem CT scan of the head with a comparable
CT scan of the skull. This case is of particular scientific significance
in that it is believed to be one of the very first reported instances where
a postmortem CT scan has been performed on skeletal remains to
confirm identity.
The identification process was more complicated than initially
expected in that bones from more than one individual were recovered
by the Necrosearch team. Identification of the remaining bones has
not been made.
The skeletal remains possess three distinguishing features,
namely a healed fracture of the left ankle, a healed fracture of a left rib,
and the skull. The Teller County Sheriff's Office was informed June
21 that while the remains provided a reasonable match with
antemortem x-rays of the ankle, the rib could NOT be that of Richard
Holmes. At that point in time, no skull data had been obtained for a
comparison. Despite this, the TCSO refused to consider the
possibility that the remains were those of someone other than Mr.
Holmes, or that more than one deceased could be represented.
Instead, the Sheriff's Office was adamant that because all the
circumstantial evidence fit, the remains must be those of Richard
Holmes, regardless of the discrepancies in forensic evidence.
On July 12 the Teller County Sheriff's Office closed their case and finally provided the Coroner's office with a name
and telephone number of Mr. Holmes' mother. One telephone call to
the next-of-kin changed the course of the investigation. Although
starting from the point where the Sheriff's Office had begun their
investigation nearly 4 months earlier, in 6 weeks it was possible to
retrace the steps the TCSO had taken, locating much additional
information that permitted identification of Mr. Holmes' remains.
Acting on a tip from Don Heer, Morgan County Coroner, Lisa
Miller, a former roommate of Richard Holmes was located. This led
to the dentist in North Carolina who had made Mr. Holmes' dentures,
and ultimately to a dentist in Virginia Beach who had bought the dental
practice where Mr. Holmes had been treated. This in turn led to a
clinic and hospital in Norfolk, VA, a Veterans' Hospital in Fort
Meade, SD, as well as Penrose Hospital in Colorado Springs where
Mr. Holmes had been a patient shortly before he disappeared. These
latter records were indeed the key ones that provided the comparison
scans for identification of the skull, and which also proved that the
skeletal remains represent more than one person.
Ironically, the Teller County Sheriff's Office case file on
Richard Dean Holmes had held the key to the ultimate solution of the
identification of the remains in the form of information from Richard
Holmes' former roommate, Patricia Hartfiel, that described a stay at
Penrose Hospital nine days before his disappearance. Tests performed during that stay included the CT scan of the head and a chest x-ray that proved the fractured rib could not belong to Richard Holmes. One point to
the TCSO's credit was that they did enlist the aid of Necrosearch in locating additional remains in mid-June.
The successful identification of Richard Holmes' remains
could not have occurred without the help of many individuals. Some of the key players involved forensic anthropologist and Colorado College Professor Dr. Mike Hoffman, radiologist Dr. Keith Limbird and the Penrad Imaging team of Steve Kruzich and Diane Doty, Morgan County Coroner Don Heer, Jefferson County Chief Deputy Coroner Triena Harper, Necrosearch, forensic odontologist Dr. Joe Gentile, and the El Paso County Coroner's Office.
Links
Teller County Burial Sites
Colorado Coroners Association
Fingerprints and Paws
Flower Icons Site
The Banner Generator
Gini's Over the Rainbow
Backgrounds by Marie
Resource to locate the interments of friends and relatives
Teller County, Colorado
Health Information
Survivor's Assistance and Grief Counseling
In Memorium-1999
In Memorium-2000
In Memorium-2001
In Memorium-2002
In Memorium-2003
Webmaster: Debbie Smith
