< Previous page

According to the federal report, Jones took the entire bottle within minutes of being left alone. He was rushed to nearby Wayne Memorial Hospital and treated.

Two days later, however, he was returned to Cherry. Though he soon started complaining of chest pain and shortness of breath, Jones was not examined by a doctor.

A physician assistant who examined Jones failed to take his vital signs or listen to his heart, according to McMillen's review of her son's medical records. The staff member determined he was just seeking attention.

A known side effect of an Elavil overdose is an irregular heartbeat. Still, the staff member gave Jones an antipsychotic drug, Geodon, that the FDA warns should not be given to anyone with an irregular heartbeat.

"He had every symptom of acute coronary syndrome that is in any textbook," McMillen said. "I am livid at the medical care he did not receive. These are symptoms we are well educated on."

Hospital staff later found Jones unconscious. He was transferred to Pitt Memorial Hospital, where he lay in a coma until he died. His organs were harvested for transplant.

Overdose omitted

A doctor from Pitt called the local medical examiner and reported that Jones had died of a heart attack, making no mention of the overdose, said Butts, the chief medical examiner.

Though Cherry Hospital filed a written report within DHHS that said Jones' death was the result of an Elavil overdose, that document was never shared with the medical examiner.

In August 2006, federal regulators cited Cherry Hospital for allowing Jones access to the pills that led to his death. That report, however, was also not shared with the medical examiner's office or Jones' family.

Butts said his office would have likely assumed jurisdiction over the case two years ago had it been told about the overdose or received either written report.

"We're always at the mercy of someone who reports the death to us," Butts said.

John Rittelmeyer, the director of legal services for the advocacy group Disability Rights North Carolina, said Jones' death shows why the current standard of making oral reports to the medical examiner is insufficient. A new law is needed, he said.

"If there is any question a failure of care caused or contributed to a death of a person who was in the custody of the state, then an autopsy must be conducted," Rittelmeyer said.

< Previous page

Get $150+ in coupons in every Sunday N&O. Click here for convenient home delivery.