DSHS investigating 2 deaths

The state Department of Social and Health Services (DSHS) has hired an independent forensic expert to review the deaths of two female patients who died unexpectedly at a state-run institution for the developmentally disabled.

Bremerton Police Department started an investigation earlier this month, three days after the second patient death in three months at the Frances Haddon Morgan Center in Bremerton. The U.S. Department of Justice, which has been investigating patient-care issues at the institution since 1998, also was alerted by the institution's superintendent, Carol Kirk.

DSHS hired its own forensic investigator after disagreeing with the Kitsap County coroner over the cause of the first death, Kirk said.

The coroner ruled that Kristina M. Shannon, 29, died July 2 of an acute overdose of an antihistamine, but the "medical information we have just doesn't jibe with that report," Kirk said. She said she could not elaborate because of patient-confidentiality laws.

Dennis Shannon said his daughter, who had lived at Frances Haddon Morgan Center for 20 years, died after ingesting 5-½ times the normal dose of the antihistamine chlorpheniramine, which can cause drowsiness and seizures if misused.

His daughter was autistic, deaf and had the mental capacity of an 18-month-old, and she was unlikely to have taken the drug on her own because she disliked pills, he said.

"If someone intentionally gave it to Krissy, maybe because they wanted to get her to sleep a while longer, that to me is homicide," said Shannon, who has retained a lawyer. "If it was left out and Krissy got into it, that's unintentional homicide."

DSHS policy requires unexplained or suspicious deaths at its facilities to be reported to police, but Shannon's death was not reported until early September, when the second patient, Jenny A. Jessup, 27, died, said Bremerton Police Det. Jason Vertefeuille.

Shannon's death was not reported because it was not considered unexplained or suspicious until Jessup's death, Kirk said.

Kitsap County Coroner Greg Sandstrom said Jessup's cause of death is still under investigation, pending toxicology-lab results. But she appeared to have died of natural causes, he said. The deaths are the first at the institution since 1998, Sandstrom said.

Frances Haddon Morgan, one of five state institutions for the developmentally disabled, opened in 1972 as an institution for autistic children. A virtual freeze on new admissions has caused its average patient age to climb to 31.

In 1998, the U.S. Department of Justice's (DOJ) civil-rights division opened an investigation of patient care at the 56-bed institution. While the investigators did not find problems worthy of closing the institution, a highly-critical DOJ report in 1999 cited Frances Haddon Morgan for over-medicating patients to control their behaviors; for a lack of expertise in treating autism; and for failing to prevent and investigate cases of self-abuse by patients.

DOJ continued the investigation and monitoring, which is nearly finished, and found no problems with medication management, Kirk said.

Over the past five years, Frances Haddon Morgan and its sister institutions have been the subject of a heated debate between disability advocates who consider the facilities dinosaurs of a bygone era and parents or guardians of the institutions' residents who defend the institution's quality of care for their loved ones.

Lobbyist Dave Wood, who has represented pro-institution groups for 15 years, said he quit last week because he could no longer advocate the facility open. While the other four institutions are "wonderful resources," the deaths at the Bremerton institution "should raise a very high level of alarm," Wood said.

Jonathan Martin: 206-464-2605 or jmartin@seattletimes.com