Regarding Allegations Made
by the New York State Commission on the Quality of Care for the Mentally
It is the responsibility of the Medical Examiner, as an official independent
"watch dog", to objectively report its' findings as to causation so that
needless deaths may be prevented. Unfortunately, relating the truth is not
always an easy road to travel, as rudely discovered by the Rockland County
Medical Examiner in July, 1978. The Medical Examiner's Office opined that based
upon autopsy findings and a statistical review, it appeared that a contributing
factor in a large percentage of aspiration deaths at the two state psychiatric
facilities located in Rockland County was the use of psychotropic and/or
sedative drugs. This opinion was met by relentless and inordinate political
pressures resulting in a barrage of formal hearings, distortions, character
assassination, credibility undermining, harassment, and false accusations.
Nevertheless, the Medical Examiner fervently stood by its findings and after
nearly a year and a half, the Office was vindicated.
Now, 20 years later, and although the
association between psychotropic drugs and aspiration deaths is universally
accepted, the Commission persists in spreading
its professionally discredited
position...and thus the reason
for this page.
allegations were made by the Office of the Medical Examiner, County of Rockland
leading to a report issued by the N.Y. State Commission on the Quality of Care
for the Mentally Disabled entitled, "The Case of Joel G." followed by a
second report entitled "Allegations Without Substantiation"?
In response to queries made by a
reporter regarding the Levitt report, the Chief Medical Examiner stated that the
Medical Examiner's Office had observed over the preceding years that a
contributing factor in an alarming number of deaths investigated at Letchworth
Village Developmental Center and the Rockland Psychiatric Center was the use of
tranquilizing and sedative drugs. It was opined that this correlation was,
perhaps, endemic to all mental institutions. These two psychiatric facilities
located in Rockland County operate under the auspices of the New York State
Office of Mental Retardation and Developmental Disabilities (OMRDD). A review of
all data compiled during a specified time period revealed that 110 cases were
accepted for autopsy from the Rockland Psychiatric Center and 93 cases from
Letchworth Village. Of the 110 Letchworth Village cases, 33 cases or about
30% were aspiration deaths and of the 93 Rockland Psychiatric
cases, 35 cases or about 38% were aspiration deaths. This was
in striking contrast to aspiration deaths outside these institutions that
constituted approximately 2% of Medical Examiner cases.
Aspiration deaths result from the sucking of vomitus,
food or foreign bodies into the airways causing suffocation. The only apparent
common denominator in the institution cases was the use of psychotropic and
2. What was the substance of the
commission's first report entitled "In the Matter of Joel G., Deceased, A
Resident of Rockland State Psychiatric Center"?
The Commission charged that:
(a) an autopsy report was not provided to the Mental Hygiene Medical
review Board until November of 1977 despite a Supreme Court Order.
This was FALSE!
Nancy Roth, Esq., Office of Counsel, Department of
Mental Hygiene, named in the petition, signed for and received a copy of the
autopsy report on August 8, 1977, the same date of the court order.
(b) the family of Joel G. was compelled to
wait nearly 18 months to learn the cause of death. This
was also FALSE! The cause of death was known to the family
on July 5, 1977, approximately one month and 9 days after the autopsy. At
that time, the father's attorney personally signed for and received a copy
of the autopsy report. A copy of the signed receipt was provided to the
Commission, yet, they, nevertheless, persisted in the dissemination of this
knowingly false statement
(c) Dr. Zugibe, the Chief Medical Examiner
signed the death certificate although Dr. So, a pathologist performed the
autopsy. Again, the allegation
was patently FALSE! Both the
original and the amended death certificates were signed by Dr. So.
(d) the family's request for a special autopsy
to determine the organic nature, if any, of their son's disability was refused
by an Assistant Medical Examiner. This
was FALSE! No representative of the Medical Examiner's Office was
ever even contacted. It was later learned that a request was made to personnel
at Nyack Hospital who incorrectly informed them that such an autopsy would not
Myriad other unfounded and insolent charges were
made that were, likewise, proven to be specious. For instance, the commission
challenged the cause of death attributing the death to an epileptic attack. The
clinical findings prior to his demise was most consistent with iatrogenic
ventricular fibrillation and subsequent aspiration of gastric contents and
inconsistent with epileptic seizure. It was the conclusion of the Medical
Examiner that the investigation into the death of Joel G. by the State
Commission on the Quality of Care for the Mentally Disabled and the Mental
Hygiene Medical Review Board was based on incorrect facts, blatant
misinterpretation of data and unfounded allegations.
3. What was the substance of their
second report entitled "Allegations Without Substantiation"?
The Commission charged that the Medical Examiner's
allegations regarding the correlation between the use of psychotropic drugs and
the remarkably high incidence of aspiration deaths at state psychiatric
facilities were without substantiation.
4. Were the facts in the
State's Report accurate?
The facts related in the State report were fraught
with willful inaccuracies. This agency resorted to egregious political tactics
based on erroneous facts, distortion of critical data and groundless
5. Was there a formal reply to the
Yes, a 75 page report entitled "Death is an
Unacceptable Side Effect" was immediately issued by the Medical Examiner's
Office answering each allegation and exposing the fallacy of the Commission's
politically motivated allegations. Each answer was supported with official
documents, scientific publications and the opinions of renowned scientists.
6. Was there a statistical
relationship between the use of these drugs and the deaths?
Yes, The Medical Examiner equated the link between
these deaths and the psychotropic drugs to that of the scientific connection
between cancer and cigarette smoking proclaimed by the U.S. Surgeon General's
Office and numerous research studies. However, the Chairman of the Mental
Hygiene Medical Review Board, Dr. Sheldon Sommers not only disputed the
drug/aspiration relationship but also dismissed the tobacco/cancer connection
which, as everyone knows, is currently accepted even by the tobacco companies
themselves. It should be noted that at the same time that Dr. Sommers
Chaired the Medical Hygiene Medical Review Board, he was Chairman of the
industry financed Scientific Advisory Committee of the Council for Tobacco
Research, a defender of the tobacco industry against the government's efforts to
prevent lung cancer by restricting smoking!
7. How do you answer the
Commission's accusation that not a single case was identified (as conceded by
Dr. Zugibe) where it could be unequivocally concluded that the aspiration death
was precipitated by the use of a psychotropic drug.
Their objection places environmental medicine on
trial, in essence questioning the well known statistical relationships between
estrogens and endometrial cancer, cigarettes and lung cancer, thalidomide and
birth defects and so forth. Of course, no individual autopsy will reveal a
definitive cause and effect relationship. The finding of lung cancer in a person
smoking 5 packs of cigarettes daily for years in no way confirms that the
cigarettes definitively caused the cancer in that individual since there is no
analytical method that can demonstrate that cigarette smoking did, indeed, cause
the cancer in any individual case. Moreover, the cause and effect relationships
are clearly recognized by drug manufacturers in the
Physicians Desk Reference and package inserts on the
basis of experimental studies and clinical observations.
8. Did you present any of your
findings before any credible scientific body?
Yes, the results of the Medical Examiner's
investigation were presented by invitation before the Forensic Pathology Section
of the American Academy of Forensic Sciences in Atlanta, Georgia and was
attended by medical examiners from throughout the United States and Canada. The
paper, entitled "Psychotropic and/or Sedative Drug Related Deaths" was well
accepted. This was followed by an invitation to write a definitive chapter
for the book, Legal Medicine 1980 edited by Cyril Wecht
(Appleton-Century-Crofts) entitled "Sudden Death Related to the Use of
9. In the State Report, was
the Rockland County Legislature requested by the Commission on the Quality of
Care to determine whether the Rockland County Medical Examiner's Office was
being operated in a manner consistent with the public interest?
Yes, they formed a Special Committee that conducted
months of hearings. This Special Legislative Committee embarked on a complete
investigation into every aspect of the Medical Examiner's Office and concluded
that the Office was operating in a manner consistent with the public interest.
A report that had been conducted by the Rockland County
Department of Audit and Control was introduced. This report stated:
"Our study indicated the uniqueness of the
Medical Examiner's Office. Due to the nature of the work, a special dedication
and responsibility was particularly noted in the study. Standards were found in
areas such as immediate response, timely work and high quality of work. To
effectively meet these standards, it was found that the staff worked together
closely in terms of 24-hour, 7 day availability with no compromises in work
quality. To assist them, policies and procedures were finely organized in
manuals, forms were clearly produced and outstanding files were maintained so
that data is easily retrieved. The quality of management on the part of the
medical examiner promoted a cooperative spirit on the part of the entire staff.
The entire operation indicated effective organization and management to achieve
objectives in an extremely sensitive area of work."
10. Was the Medical Examiner
recognized for his efforts?
Rockland County Legislature presented the Chief Medical Examiner, Dr. Zugibe
with the County of Rockland Distinguished Service Award and declared by official
proclamation the week of February 16-22, 1980 as Frederick T. Zugibe Week. A
testimonial in honor of the Chief Medical Examiner was sponsored by the Police
Chief's Association and attended by several hundred prominent citizens,
government officials, politicians and friends. Dr. Zugibe was presented with
numerous awards and commendations by the District Attorney, County Legislature,
Governor, U.S. Senators and Congressmen, County officials, PBA, Fire Divisions,
etc. Also, Phoenix Rising ( Montreal, Canada) awarded the prestigious Phoenix
Pheather " for honesty and courage in speaking out against
the numerous health risks in the face of severe criticism."
Interestingly, a publication entitled "Manual of
Psychotherapeutic Drugs and Epileptic Drugs" was authored by the State of New
York Office of Mental Retardation and Developmental Disabilities (OMRDD) in
April, 1979 for the purpose of guiding physicians in "the very specialized use
of psychotropic and epileptic drugs, as well as possible adverse reactions and
undesirable interactions" by setting the "standard of prescribing behavior for
medical staff caring for developmentally disabled persons of all ages".
The manual , thereafter, proceeds to warn and instruct that a "MAJOR
ADVERSE EFFECT" of certain psychotherapeutic drugs is,
indeed, the "SUPPRESSION OF THE COUGH REFLEX". Although the
Medical Examiner's observations relative to the correlation between psychotropic
drugs and aspiration deaths is now universally recognized by pathologists and
mental health professionals, including the New York State OMRDD, the Commission
persists in its politically expedient, yet professionally discredited position
by the recent re-publication of their findings on the internet.
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