Inclusion Daily Express -- November Death Of Institution Resident Came To Light In March

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November Death Of Institution Resident Came To Light In March
By Dave Reynolds, Inclusion Daily Express
April 10, 2006

ST. LOUIS, MISSOURI--Michael Pallme died last November 8.

Doctors said the 24-year-old man died because his bowel was ruptured by part of an ink pen he had swallowed. A few days earlier, they had found in his digestive tract parts of the pen, along with a piece of twine, a plastic flower, some plastic or tape, and a bottle dispenser pump.

Pallme had been diagnosed with mental retardation and a condition called "pica" in which the person wants to eat non-food items. Because of this, Pallme was supposed to be supervised closely at Northwest Habilitation Center, with a worker assigned to be within arm's length at all times.

Even so, investigators from the Missouri Department of Mental Health said they could not conclude that Pallme had been neglected, because they could not determine exactly when he had swallowed the items or who was supposed to be with him at the time.

That is also the reason the department gave for not reporting Pallme's death to the federally mandated Missouri Protection and Advocacy Services (MO P&A) for more than four months. The department has an agreement with the watchdog agency to notify it immediately of such cases, the St. Louis Post-Dispatch reported.

In fact, the department did not report the details of Pallme's death until after it was revealed that another Northwest resident, Rutherford "Rudy" Wallace, died on March 16. Wallace -- who was partially paralyzed and had intellectual disabilities -- died after he received second and third degree burns when scalded in a tub or shower six days earlier.

MO P&A learned about Wallace's death when a reporter phoned to ask questions nearly a week later. It learned about Pallme's November death just a week and a half ago, from a private attorney.

Dr. John Constantino, chair of the board of commissioners that oversees the Department of Mental Health, said last Wednesday that they are launching an investigation into both deaths at the 80-bed facility.

"If (Pallme) was to have one-on-one care, it should never have happened," Constantino said.

Two workers were fired over the Wallace incident. None have lost their jobs over Pallme's death.

Related:
"State investigating two deaths at center" (St. Louis Post-Dispatch)
http://www.inclusiondaily.com/news/06/red/0410c.htm

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