Three patient deaths at Peoria State Hospital; a report to the Illinois General Assembly

              Dr. Ante's recall of the time of this transaction must be questioned.
According to his account, he was notified of Roe's injury at 5:30, and examined him some time between 5:35 and 5:45. However, at one hour previous to the alleged time of the examination, Roe was still in the cafeteria. Furthermore, Ray stated that the injection was given at about 5:15 p.m. Therefore, Roe would have been under the influence of the drug for only 20 or 30 minutes at the alleged time of the examination.
Later that evening, at approximately 10:00 p.m., Sunderland was going to change Roe's clothing when she noticed that his bladder was severely distended. She contacted Ray, who in turn telephoned for Dr. Ante. Ante arrived shortly thereafter and catheterized Roe. In his memorandum, Ante stated that at that time Roe's vital signs were "good." He then left the ward, after being present there for approximately 20 minutes. After Ante left, Sunderland allegedly wrote a note to Eldred Davis, the Ward Chief, expressing her concern over the treatment rendered by Dr. Ante and questioning whether another staff physician could be contacted for additional medical care.
At approximately 11:00 p.m., aides Marjorie Engstrom and Lois Kingsland reported for duty on Ward D-1. They recounted that they found Roe still on the day room floor, his eyes open and fixed and his pupils dilated. In their opinion he was apparently unconscious.
At 12:30 a.m. on June 20, 1972, David Rawling, the Supervising Nurse on Ward D-1 during the late shift, found Roe to be in very grave condition. Roe was comatose with widely dilated pupils, and dried blood was noticed in Roe's left ear. He telephoned Dr. Ante, who subsequently ordered that Roe be taken to the acute care hospital on the premises for skull x-rays. The transfer was effected at approximately 1:00 a.m. Following the x-rays, Dr. Ante stated that he then learned that a displacement of a previous craniotomy had taken place, apparently due to the injury Roe sustained when he struck his head on the floor during his seizure. Dr. Ante then sought the approval of Dr. Staras to transfer Roe to St. Francis Hospital in Peoria, where more complete facilities were available. The transfer to St. Francis was effected at approximately 2:30 a.m. when Roe was taken by ambulance to the St. Francis Emergency Room.
Roe's Death
Upon his admission, Roe was examined by Dr. D. J. Garwacki, an attending physician at St. Francis. Roe was still comatose. He was admitted to a hospital room at 5:00 a.m. and expired at 11:55 a.m. that same day, June 20, 1972. An autopsy was performed on that day at 3:30 p.m. by Dr. R. V. Kowalski. He diagnosed the cause of death to be a severe intra-cerebral and suborachnoid hemorrhage.
A coroner's inquest into the death of Bernard Roe was held on July 5, 1972. The coroner's jury heard testimony on the fact that Roe had fallen twice in the day room and had struck his head violently in each instance. Nevertheless, the jury found that the injuries which caused Roe's death came about when he "fell from a chair following an altercation, when he was struck by a chair that was thrown at him
21