MIDLOTHIAN, Ill. — Rajubhai Desai was sick.

His kidneys had stopped working because of severe diabetes. He spent hours each week hooked up to a machine that filtered toxins from his blood.

But it was a foot bath that killed him.

On March 12, 2007, the 59-year-old Desai went to South Suburban Hospital near Chicago because he was bleeding at a stent in his arm used to connect him to a dialysis machine. He returned home about 2 p.m.

His regular home health-care worker showed up a couple hours later. The worker gave Desai a sponge bath, then put his patient's feet into a tub of water to clean off dried blood that had dripped from the stent, according to a police investigation report.

Desai's wife, Deuyaniben, went to make tea. When she returned she found her husband's feet were bleeding and the skin was peeling away.

Desai had slumped into a chair, unconscious.

As a severe diabetic, he had lost the ability in his feet to discern hot or cold and had left his feet in what a medical examiner would eventually rule was scalding hot water.

The caregiver wrapped Desai's feet in a towel, put him on the bed and took the medical treatment sheet -- normally left at the house -- with him.

He told Desai's wife that her husband would be OK and if he's wasn't to call 911.

"He just left," said Sid Desai, the couple's son. "He didn't even call his supervisor."

The details were contained in a report of an investigation by the Midlothian Police Department that went awry, with police saying the Cook County State's Attorney's office failed to file charges and the prosecutors saying police never filed a case seeking prosecution.

The caregiver was not charged.

A week after the scalding, surgeons grafted skin onto Desai's feet where he suffered third-degree burns, but he lapsed into a coma and was placed on a respirator.

A Loyola University Hospital social worker called a hotline operated by the Office of the Inspector General for the Illinois Department of Human Services to report alleged neglect. The social worker told the hotline operator that Desai wasn't expected to live.

When Desai died March 31, 2007, the OIG closed the case without contacting police or conducting its own investigation.

Sid Desai called the Midlothian Police on April 2, 2007.

The police investigative report that resulted lists the offense as "homicide."

Five years after Desai's death, police and prosecutors still cannot agree on what happened to the case.

Police still insist that prosecutors didn't want to charge the health-care worker, while prosecutors maintain police never presented a case.

"We did consult with Midlothian police during the investigation and they never requested that it be reviewed for felony charges," said Andy Conklin, a spokesman for the Cook County State's Attorney's office.

"They don't know what they are talking about over there," said Police Chief David Burke, who was not the chief when Desai died.

What is clear is that neither the Cook County State's Attorney's office nor the Midlothian Police Department ever spoke to the OIG regarding Desai's case. Spokesmen for the prosecutor and the police were adamant about that.

'Ineligible for services'

The OIG is the state's main agency dedicated to investigating neglect and abuse of disabled adults who live at home.

The agency ruled that because Desai died soon after the alleged neglect, he was "ineligible for services."

That meant it did not investigate whether he died because of neglect or abuse.

Because it closed the case without an investigation, the OIG was unaware that the criminal investigation had stalled until June 3, 2008, more than a year after Desai's death. That's when Midlothian Deputy Chief Steve Zamiar, the police investigator in the case, reclassified Desai's death as "accidental."

In his report, Zamiar noted that he asked the caregiver to come in for an interview. Zamiar stated he received a phone call from an attorney for the private health-care company, who said he would not allow the worker to be interviewed by police.

Zamiar tested the water temperature at the Desai home at the request of the state's attorney's office.

The hot water tap was between 122.5 and 123.1 degrees Fahrenheit on June 6, 2008, he reported.

Zamiar's report lists no further police investigation.

"I have no idea why the nurse wasn't charged after what happened, except the state's attorney refused to file a charge," said Burke, the police chief.

The death certificate signed by the Cook County medical examiner's office on July 9, 2007, listed the cause of Desai's death as hypertensive cardiovascular disorder, scalding and diabetes mellitus.

The manner of death is undetermined, according to the medical examiner's report.

Desai's former caregiver remains listed on the Illinois Healthcare Worker Registry, an Illinois Department of Public Health website where employers can make sure they are hiring medical personnel who have not been substantiated for egregious neglect, sexual or physical abuse.

He continues to hold his certified nurse's aide license and another as an emergency medical technician, or EMT.

"No administrative findings," stated the website regarding the health-care worker's status.

After leaving the agency that provided care to Desai, the caregiver went to work for an organization that provides care for veterans. His current employment status could not be determined.

The OIG did not notify the Illinois Department of Public Health, the agency that issues licenses and oversees discipline for nurse's aides and emergency medical technicians, said Melanie Arnold, a spokeswoman for the Public Health Department.

"If we had known this, it is something we would have investigated," Arnold said.

Contact reporter Beth Hundsdorfer at bhundsdorfer@bnd.com or 239-2570.