Coroner's officials in 10 of the state's largest counties said they can't recall ever receiving a call from the Office of the Inspector General for the Illinois Department of Human Services after a disabled adult who lived at home died.

The News-Democrat surveyed the state's largest coroner's offices, including the Cook County Medical Examiner, after reporting that the OIG does not investigate the deaths of disabled adults who allegedly were the victims of neglect or abuse.

Madison County Coroner Steve Nonn, president of the Illinois Coroner's Association, said his office has never received a call from the OIG but has received calls from other agencies about the deaths of children and the elderly.

"I think the whole thing is about communication," he said. "Why is someone dropping the ball and not notifying the proper authorities?"

The OIG is mandated by law to immediately report deaths to coroners if they believe a disabled adult died "as the result of abuse, neglect or exploitation."

Coroners receiving information about possible abuse and neglect of disabled adults when they die could order autopsies and preserve evidence that may lead to criminal charges, Nonn said, even if the abuse or neglect didn't directly cause the death.

"The coroner works as the point man for law enforcement when there is a death," Nonn said.

Januari Smith Trader, a spokeswoman for the Department of Human Services, said in a prepared statement late Tuesday, "The OIG has written evidence that many of these cases were referred to local law enforcement and/or the medical examiner/coroner. In other cases, contact was made but not documented by OIG staff or the receiving entity. This is unacceptable and the OIG recognizes this issue and has swiftly taken steps to strengthen policies and procedures to ensure referrals/notifications are properly documented."

The Department of Human Service's directive to the OIG regarding referrals to local law enforcement changed June 15 -- just days after News-Democrat reporters inquired about whether any of 53 death cases were referred to police.

The OIG initiated a "review and re-evaluation of its practices, policies and role under state law" after the News-Democrat reported that the agency failed to investigate the deaths of 53 disabled adults who lived at home from 2003-2012, despite receiving calls on a state abuse hotline the agency operates.

The OIG interprets state law to mean that when a disabled person dies, they are "ineligible for services." The agency closes the case without investigating whether abuse or neglect contributed to their deaths.

Gov. Pat Quinn said Saturday he was "disturbed" and "disappointed" after he read the newspaper's stories.

"We immediately initiated a top-to-bottom review. We have been meeting with the top officials in DHS. We are looking at the facts and we expect to take action promptly," said Brooke Anderson, a Quinn spokeswoman.

State Rep. Greg Harris, D-Chicago, chairman of the House Human Services Committee that oversees the Department of Human Services, said Tuesday he plans to convene a meeting of the committee to discuss the OIG issues.

State Sen. William Haine, D-Alton, said he was working with Harris to convene the meeting and may hold it in the metro-east.

"The goal is a change. There is a major failure," Haine said. "The key to this is to have a clear understanding of how to investigate, especially suspicious deaths."

Haine said "stakeholders," including county coroners and state's attorneys, should be a part of the committee meeting, which may be convened later this month or in August.

The counties surveyed were Cook, DuPage, Lake, Kane, Winnebago, McHenry, Madison, St. Clair, Sangamon and Champaign. Their combined population is more than 8 million -- or two-thirds of the state's total population of about 12.8 million.

At least 16 of the 53 deaths reported by the News-Democrat occurred in Cook County. There were two each in Winnebago and Sangamon counties.

Mary Paleologos, a spokeswoman for the Cook County Medical Examiner's Office, said Tony Brucci, the office's chief of investigations for 23 years, "can't remember them ever calling."

St. Clair County Coroner Rick Stone agreed.

"They never called us about any of that. If they would have, we would have acted on it. It borders on criminal," Stone said. "They certainly need to review their procedures. Even though they say they are doing that now, that doesn't help the people who have already slipped through the cracks."

Nonn, the Madison County coroner and head of state coroners association, said the group's executive committee will discuss the OIG's duties at a meeting in August.

"It's pretty clear what they are supposed to do," Nonn said.

"I have never heard of it either until now," McHenry County Coroner Marlene Lantz said. "It amazes me that they have a $5 million budget and 53 people and they aren't doing squat."

In one case, the OIG received a hotline call on June 8, 2011, alleging that a caretaker abused and neglected Mary Smith, 52, of Carmi, who suffered from chronic obstructive pulmonary disease. The caller further alleged that the caregiver failed to provide adequate medical care, according to a hotline call summary obtained by the News-Democrat.

Police were called to the trailer on July 27. The temperature inside the trailer was more than 100 degrees. Tables were covered with tobacco and pill bottles. Roaches were everywhere. Relatives found Smith dead in a chair, her oxygen tube still in her nose, according to a police report.

A week after Smith's death, a juvenile relative said she saw the caregiver slip something into Smith's drink, according to an OIG hotline call summary and a police report.

Neither White County Coroner Carl McVey nor Carmi police knew about the June allegation to the OIG hotline. McVey never ordered an autopsy or directed that blood be drawn for a toxicological screening, he said.

Carmi Police Chief Randy Hamblin said the investigation into Smith's death is "open but inactive at this time." Carmi police investigated the allegation that Smith was poisoned, Hamblin said, but discounted it.

Under the Department of Human Service's new referral directive, cases now must be referred to police when there is a serious injury or death associated with an allegation of abuse or neglect, or whenever abuse or neglect complaints "rise to the level of criminal conduct."

Contact reporters George Pawlaczyk at 239-2625 or gpawlaczyk@bnd.com and Beth Hundsdorfer at 239-2570 or bhundsdorfer@bnd.com.