WHO KILLED DR. JEROME LACKNER, M.D.?

                                Dr. Jerome Lackner, M.D.

                        Zelda Lackner-"Justice For My Dad"

Dr. Jerome Lackner, M.D. was a unique humanitarian first, a special breed of human being who dedicates their life to helping others less fortunate than themselves.

The fact that he was a gifted medical doctor and attorney, as well as a dedicated father of five children made him all the more of an inspiration in the manner in which he conducted his life by caring for others.

This man saved hundreds, perhaps thousands of lives during his lifetime. Personal dedications and descriptions from those whose lives he helped and saved can be found here by clicking on this link.

Jerome Lackner was the State of California, Director of Public Health during Gov. Jerry Brown’s first term. 

He also served as personal doctor to Cesar Chavez, and as a member of Martin Luther King Jr.’s medical staff. 

The purpose of today's Blog post is in memory of Dr. Jerome Lackner and to also point out once again, how dysfunctional the systems that are in place to protect human life, provide justice to victims families, failed to do anything productive in saving an innocent victim.

Instead of seeking the truth, they all "circled the wagons", protecting their own asses, their jobs, their incompetence by never taking accountability for another human life being stolen.

Their cowardice evidenced by not caring about finding the truth is the symbol of how cheap a human life is in America.

Much of the below are excerpts reproduced from the Charles Piller article, others are simply perceptions after reading the story.

It was the summer of 2010, and Jerome was languishing in hospice care at his Davis, California home. 

His primary caregivers: his second wife, Rebecca, then 72, from whom he was legally separated; and Joseph Poirier, a 51-year-old recovering addict who, friends and family would claim later, was having a clandestine affair with Rebecca.

In the final days of Jerome’s life, hospice records show, doctors would prescribe multiple vials of morphine. Joseph mixed drops of the bitter drug into Jerome’s beverages to "get him under control". 

The story of Jerome Lackner’s achievements and misfortunes, ended with the painful irony that while he helped protect so many people in life, he was unable to protect himself, or get protection from others when he needed it prior to his death.

The story of the extremely suspicious circumstances surrounding the death of Jerome Lackner are chronicled in a five part intensive professional Journalistic investigative report "An Unquiet Death", written by Charles Piller of the Sacramento Bee News, comprehensively and painstakingly reviewing over 50,000 pages of records.

On July 9, 2010, Jerome died. 

That began the usual "blame game" among the various care givers, public and private entities, law enforcement, legal systems, health systems, that are supposedly accountable to protect the lives of human beings.

The coroner’s pathologist blamed heart disease, with morphine toxicity as a secondary cause.

His daughters suspected darker forces at work, and within weeks Davis police launched a murder investigation.

 Gina Moya, chief deputy coroner of Yolo County "But caregivers, even against resistance, she said, if the patient is suffering certain conditions. “They know the person better than you and I sitting here … that’s why you choose your caregivers carefully.” (Me-go ahead, blame the dead victim).

Moya’s supervisor – whom she replaced after his resignation in 2013 – approved her report. “I’m not blaming him, but it was his responsibility to say … ‘you left this out, you left that out,’” she said. “When you are in this report every day, all day long, for a period of time, you can miss stuff.” (Me-Blame it on the supervisor, not yourself but say you are "not blaming him" for your own major errors).

Moya could not retrace her steps, because she destroyed her records. She said she did so to comply with office policy; federal and state regulators said coroners may retain such records.

How convenient, she destroyed the records because of her suddenly being such a thorough, competent professional Coroner.

A review of the coroner’s report also shows that Moya often failed to cite sources or resolve conflicts between witnesses and documents. Medical records didn’t corroborate some key health issues that Moya cited as proving Jerome was near death.

Later, a social worker with the Adult Protectice Services Agency (APS) would tell a Santa Cruz County deputy sheriff that the Lackner daughters had been making “unsubstantiated claims” for years against Becky, and that she had never found reason to suspect abuse. 

The Lackner children maintain this was their only contact with APS.

On the same day she buried her father, Zelda contacted Davis police Lt. Paul Doroshov with her suspicions. The coroner had already been in touch with the department. On July 22, the police launched an investigation of possible murder in hospice, a first for Davis as far back as records showed.

As detectives proceeded in their inquiry, they heard an interesting story from Jane Carpenter, another friend of Jerome and Becky’s. For 20 years, Becky had been Jane’s AA sponsor, a mentor for staying sober. Becky called her before the funeral, in need of a sympathetic ear. They talked over lunch.

“The first thing out of her mouth was, ‘I killed Doc,’” Jane said in an interview. “And I said, ‘What!?’”

“You know, I just really think we killed him. I just really think that Joseph and I killed him,” she said. They gave him too much morphine, Jane recalled Becky saying.

Trino Savala, a close friend,  said in an interview that Becky told him something similar just after Jerome died. “I think I killed Doc. I think I gave him too much morphine,” he recalled her saying. 

Morphine is often the drug of choice for hospice patients. It’s meant to blunt the pain, steady breathing, calm fears and gently help a person die in relative comfort. These are the goals of hospice. So powerful a drug requires great care.

The hospice record runs to 141 pages but is unclear about exactly when Joseph or Becky gave the morphine, or the amounts that Jerome received. It describes problems with the handling of the morphine that would form the basis for years of investigation into how Jerome died.

In the early days of hospice, Jerome didn’t seem to need morphine. Each time the nurses assessed his pain, they rated it as low.

The record doesn’t say how much Becky and Joseph gave him day by day, but by July 5, 10 milliliters had been used, the equivalent of 20 “moderate” doses. By July 6, Day 12, Jerome was described as anxious and anorexic. When the nurse asked if Jerome had pain, he said, “no I do not have any pain, go away, get out of here,” she wrote.

The Lackner family hired two leading experts to review the autopsy records: Bruce Goldberger, president of the American Board of Forensic Toxicology, the pre-eminent credentialing authority; and Marcella F. Fierro, formerly top medical examiner for Virginia. 

Zelda provided their comments to authorities.

“The circumstances of Dr. Lackner’s death are most disturbing and should inspire a serious homicide investigation to establish culpability,” Fierro said in a letter to Zelda.

“While morphine toxicity is a common finding in a patient treated by hospice, the dose and frequency of administration of morphine significantly contributed to his death,” Goldberger wrote.

Armed with the views of those authorities, the problems during hospice and her evidence of possible financial crimes, Zelda urged the Yolo County district attorney to prosecute.

Deputy DA Ryan J. Couzens, who had experience in elder abuse cases, reviewed Zelda’s evidence and that of the coroner. He had access to the complete police report, compiled over more than two years, which was never made public. After a few weeks, he decided not to file charges. He said, in general, he viewed the evidence as too thin to prove Becky committed any crime beyond a reasonable doubt.

Zelda Lackner said “I had such faith”when she described the systems in place.

Every layer of the ordeal “felt like a betrayal to my family, to my father, to my ideals as an attorney,” 

Zelda said. “I have been cured of my idealism …” 

This is the horrific real world of innocent dead victims and their grieving families.

There is no closure, no justice, no compassion, and the truth of what happened is not important to anyone but us.

The fate of victims and their families is to have their lives erased by those "in charge", but for victim advocates such as Zelda, others, and myself, we will remember our loved ones forever, never to be forgotten.