A citizens panel that oversees the Office of the Inspector General for the Department of Human Services -- the state agency responsible for protecting disabled adults -- was told to keep quiet about a beating death at a Charleston group home.
During the meeting on April 23, 2009, at which former Inspector General William M. Davis was present, the group learned about the death of Dustin Higgins, a 22-year-old mentally impaired patient who died in 2008, according to the meeting minutes. The panel was told, "Please keep this confidential." It's not clear who said it.
Two years after agreeing to keep Higgins' death confidential, Paul McCann, another mentally disabled adult, was beaten to death at another group home in Charleston, according to court records.
The homes were operated by the now defunct Graywood Foundation, which was the recipient of more than 50 complaints of abuse and neglect of patients at its facilities.
The failure of the Quality Care Board to warn the public about the dangerous conditions encountered by Higgins and McCann is one of the issues being addressed by an administrative overhaul of the OIG ordered by Gov. Pat Quinn.
In July, Quinn ordered a "top to bottom" review of the OIG after the Belleville News-Democrat reported that the agency failed to investigate 53 calls to its abuse hotline that resulted in death. The agency's policy at the time was that the dead are ineligible for services.
The final reorganization of the OIG ordered by Quinn, which a spokeswoman said may be announced as early as Friday or next week, includes a major revision of the membership of the Quality Care Board, a little-known citizens panel that was supposed to act as a watchdog for the agency.
Last week, the board's outgoing chairwoman, Rita Burke, said the panel was still trying to learn what it is supposed to do.
"The Quality Care Board has requested, as it has in the past, a review of its role and authority," said Burke, one of four members on the six member panel who were replaced last week by Quinn. Burke declined further comment.
Two of the new members are from the metro east: Cathy Contarino, the executive director of the Independent Living Center in Alton, and Untress Quinn, no relation to the governor, a Belleville attorney. They joined the board on Sept. 28.
The BND's six month investigation showed that many of the disabled adults who lived at home suffered neglect and abuse. The newspaper also reported that 534 or 41 percent of 1,289 calls for help to the hotline in fiscal 2011 were not investigated after they were deemed to be "non-reportable" by hotline operators. The stories led to Davis' resignation on Aug. 1.
A review of the board's meeting minutes for the last five years showed that its members were unaware or failed to act on issues critical to the health and safety of the disabled.
There is no mention of the OIG's failure to investigate the 53 deaths. Board members have said they were unaware of the "dead are ineligible for services" policy, which has since been scrapped. And there was no talk of Higgin's death until McCann was killed in January 2011.
The attorney for McCann's family said a warning to parents of the death of Higgins could have saved their loved one.
Spokeswoman Brooke Anderson said the governor is determined to "take this board in a new direction," but added that details of its new role won't be announced until Mike McCotter, a former chief of detectives for the Chicago Police Department appointed by Quinn, finished his review of the OIG's investigative processes.
Quinn issued an executive order in July calling for a thorough outside investigation of how the agency handles reports of injury and death involving homebound disabled adults. The order requires that all 53 deaths reported by the newspaper be investigated.
"The Quality Care Board needed to do more, and that's why we are re-evaluating their mission, role and responsibilities," Anderson said. "That's also why we appointed new members last week, to take this board in a new direction," Anderson said.
"Everything is under consideration as we work to reform this office (OIG) and ensure clear and effective oversight, more transparency and results-oriented operations," she said.
The governor's office will work with state legislators to possibly revise the 2000 statute that governs the protection and care of the disabled -- the Abuse of Adults with Disabilities Intervention Act, Anderson said.
"Special investigator Michael McCotter has informed us that he will soon be issuing an official report following his thorough investigation," Anderson said. "Once we receive the report, the governor's office will move quickly -- working with the legislature and advocates -- to enact a comprehensive solution."
Shawn Collins, a Naperville attorney who represents the McCann family in a lawsuit alleging negligence in the death of Paul McCann, said, "The Quality Control Board had completely lost sight of its mission. When it failed to take seriously the death of Dustin Higgins, the board forfeited its reason to exist."
Collins said, "In fact, it would have been better that there were no board at all, because its very existence gave people comfort -- false comfort -- that someone at DHS actually cared about the quality of service given to people like Paul McCann at places like Graywood. The board should have sounded a loud alarm with the death of Mr. Higgins."