Larry and Cheryle Blake were the proud parents of Allied News' first baby of the year in 1995. Brady was born Jan. 1 in United Community Hospital, Pine Township.
(Allied News file photo)
Published Friday, April 23, 1999
"Brady Blake died as a result of a combination of errors made by those who had a legal obligation to provide competent medical care and protection to him"p align=right> attorney and investigator Richard A. Peterson
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Larry and Cheryle Blake were the proud parents of Allied News' first baby of the year in 1995. Brady was born Jan. 1 in United Community Hospital, Pine Township.
(Allied News file photo)
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"Brady Blake died as a result of a combination of errors made by those who had a legal obligation to provide competent medical care and protection to him," according to a report written by Richard A. Peterson, who oversaw the investigation.
Mercer County Commissioners, who launched the investigation in March 1997, washed their hands of any liability when they released the report Thursday and did not vouch for its accuracy.
Peterson -- a lawyer, not a doctor -- wrote the report and a former state police trooper conducted the investigation.
The determination that the baby died due to a "failure to thrive caused by his environment" was not substantiated by the medical record, the report says.
According to the report, the "most likely" cause of death was "failure to recognize and treat organic failure to thrive syndrome," which is a weight-growth failure due to a physical problem. The report says Brady's condition may have been aggravated by the "inappropriate use" of a steroid diaper-rash medicine prescribed by physicians.
"Only a complete scientific review and evaluation of the medical records and/or examination of the remains of Brady Blake could prove or disprove this suspicion," the report says.
The report recommends criminal investigation of two doctors; the home health agency contracted by the county at the time and personnel of Mercer County Children and Youth Services.
Additionally, the statute of limitations expired the day after commissioners solicited the investigation, said District Attorney James P. Epstein.
Epstein said Thursday he determined in 1995 that "there was no criminal liability that went beyond the two people charged" but he will be reviewing the case.
Charges previously were filed against the baby's parents, Larry and Cheryle Blake. Officials had said Brady died because his parents failed to provide physical attention, nourishment and medical attention.
The Blakes, who were 21 and 16 at the time of the baby's death, pleaded guilty to endangering the welfare of a child.
The criminal cases against the Blakes should be re-evaluated and "their eligibility for pardon" considered because the young parents relied on the expertise of CYS and medical personnel, the report says.
Brady died March 25, 1995, after his parents twice took him to hospitals, according to police reports. His parents told hospital personnel, that Brady would not eat and often vomited, the report says.
According to the report:
After both hospital visits and after consulting with doctors and the home health agency, CYS assigned a home-health care worker to visit the Blake home several times a week. A CYS caseworker was to visit the home daily after the second hospital visit.
From the beginning the agency failed to recognize its primary obligation to the child, the report concludes. The caseworker had no experience with children and she did not perceive her role as protector of the child; instead, she overemphasized keeping the family together, according to the report.
The agency also grossly misunderstood and overestimated the services contracted through the home health agency, the report said.
Even at biweekly hospital visits with the family physician, the parents reported that the child frequently vomited, the report says. According to the report, the medical records show that the nurse and doctor listed significant discrepancies in the child's weight, yet on more than one occasion the child was sent home with the parents and the doctors continued to prescribe the steroid-containing diaper rash cream.
The report says despite reports that Brady was vomiting frequently, the doctor did not order adequate tests to determine the cause. The report does not specify which tests should have been ordered.
The doctor initially prescribed the diaper rash cream that likely could put Brady at a greater risk of a fatal drug-induced complication to failure to thrive, the report says. The typical side effects from toxic exposure to such steroids include weight loss or inability to gain weight, vomiting and damage to the immune system, the report says.
The cream puts a child with failure to thrive at a greater risk, the report says, adding that the doctor called an abuse hot line about the child yet signed the paper to have him discharged to his parents. The report says the doctor also would not testify, something that he denies.
The report does note that the doctor recommended Brady be placed in foster care and that should have alerted CYS to the fact that Brady was at risk.
The doctor "knew returning the child to the Blake home placed the child at risk and elected to ignore that risk," the report says.
The child's inability to hold down food was not necessarily related to the lack of care provided by the mother, the report says, noting that Brady vomited and continued to lose weight in the hospital and under the care of home-health care workers. Those developments, under the supposed supervision of the CYS caseworker, should have been noticed by the treating physician, home health agency staff and CYS personnel, the report says.
It also criticizes Eugene Montone, the CYS director at the time, for not conducting an investigation into the Blake case. Montone called reports by concerned medical professionals "a hysterical nuisance" and he seemed to feel the same about calls in the Blake case, the report says.
Montone could not be reached for comment.
According to the report, the family doctors' services were "woefully inadequate" and "he admitted his negligence." The doctor "carelessly" weighed the baby and continued the use of the cream containing steroids, the report says.
The doctor's records show that on two occasions the child's weight varied greatly and his body temperature was rising, the report notes. A low-grade fever also is also a symptom of corticosteroid toxicity.
According to the report, the doctor admitted that he was negligent in failing to adequately monitor the child's condition, especially his lack of weight gain.
The report harshly criticizes the doctor's care of the infant, including his continued prescription of the steroid-containing rash medication that may have subjected Brady to greater risk.
Epstein, who with Judge Francis Fornelli reviewed the report prior to giving it to the commissioners, said he plans to review the criminal investigation of the incidents and the parents and the investigation that took place for the report. He said he will also look at his decision to prosecute the Blakes.
"My responsibility will be to see that a just result occurred," he said. "In 1995, I had no evidence to prosecute anyone else and I haven't seen anything that should change my mind, but some things in the report were from documents I did not have access to."
The investigation, which was requested by Fornelli and Epstein after the prosecution of the Blakes, was to review the practices and procedures of CYS to determine if there was a problem, and if so, how to correct it.
The report cost the county about $50,000, said Commissioner Chairman Richard Stevenson.
"The board is aware that the report is totally inconclusive on some material items and there may be records in existence that do not corroborate all of the findings and conclusions," the commissioners said in a news release.
