Doug Fraser
Cape Cod Times, Hyannis, Mass.
ORLEANS, Mass. — The family of an Orleans man who died of a heart attack in September 2016 filed a wrongful death lawsuit against the town in Barnstable Superior Court last week.
The suit alleges that Orleans rescue personnel prematurely terminated lifesaving efforts on Duane Mead, and then attempted to cover it up with false statements on documents and in verbal correspondence with hospital personnel.
The suit also claims the town failed to conduct a review of the Priority One call and take corrective measures as required under state Department of Public Health regulations and Cape & Islands Emergency Medical Services System guidelines.
Chief Geof Deering, who was not the chief at the time of the incident, said he could not comment on ongoing litigation. Town Administrator John Kelly did not return an email requesting comment. Dr. Bryan Canterbury, a consultant hired by the town to conduct a review of the paperwork from the incident found that rescue personnel had “acted within the standard of care appropriate for the emergency.”
The lawsuit filed on behalf of James Mead, Duane Mead’s father and executor of his estate, asks the court to award an unspecified amount of monetary damages, along with costs and fees.
Family attorney Jon Cowen said that what was more important to the family was their request in the lawsuit that the court order the town to undertake an investigation into the incident, to identify what went wrong, take action against both the paramedics and/or management, and implement policies and procedures to prevent this from happening again. They want the court to require that the results of the investigation be made public.
“I am so appalled that my town, the town where I have practiced medicine for over 25 years, knows that critical errors occurred and is still denying it,” said Dr. Kimberely Mead-Walters, Duane Mead’s sister. “How will we avoid these errors in the future if we don’t acknowledge them and become educated on how to avoid them?”
A dreaded early morning call
There’s an undercurrent of dread when the phone rings in the pre-dawn hours.
When Mead-Walters answered her phone at around 4:30 a.m. on Sept. 16, 2016, her sister said their brother Duane had collapsed at his Orleans home, and that his girlfriend, Inger Landers Montgomery, called 911. Orleans EMTs were at the scene, she said, and they were taking him to the emergency room at Cape Cod Hospital.
Soon after, the three women sat together in the ER’s family waiting room and were told by Dr. Peter Bosco, the attending physician, that Duane, who was only 52 years old, was dead. Bosco said he had granted a request from Orleans paramedics to cease resuscitative efforts while the ambulance was en route to the hospital.
But the physician also asked Montgomery to tell him what had happened. She told him the same story she’d related to the family and to dispatchers on her 911 call.
Mead, who had been diagnosed with pneumonia the previous day, was sleeping fitfully and got out of bed in the early morning to use the bathroom. He walked the dozen feet from the bed into the bathroom, when he collapsed at approximately 4:10 a.m.
Hearing the crash, Montgomery immediately got out of bed and found him face down on the floor, bleeding from a head injury, and wedged between the toilet and the vanity.
Mead was alive, but mumbling incoherently, Montgomery told the ER physician, according to Mead-Walters and Bosco’s own ER notes. At over 6-feet tall and 250 pounds, Mead was too heavy for Montgomery to move, and she dialed 911 for help.
Orleans Police were the first to arrive and they were able to lift him from between the toilet and vanity and place him on his back. In their report, police said they didn’t find a pulse, but that he was warm to the touch.
Rescue personnel arrived shortly after, around 4:30 a.m. according to the EMS report (although the Mead family believes it was slightly later according to the ambulance call log), and took over CPR from police. The paramedics’ report notes that Mead wasn’t breathing and that they didn’t find an electric signal from the heart required to use the defibrillator.
EMTs did not use epinephrine on Mead
In cases where emergency responders can’t determine the cause, state Department of Public Health protocols requires the use of epinephrine by paramedics for persistent Asystole cardiac arrest, in other words, when there is no discernible electric signal from the heart. Epinephrine increases blood pressure and blood flow in the coronary artery and also strengthens muscle contractions.
In the EMS incident form filled out by Orleans Fire Department Capt. Chester Burge, Orleans paramedics did not use epinephrine on Mead. According to the ambulance call log, they administered Narcan (a standard procedure even if an overdose is not suspected) with no result.
Although state Department of Public Health EMS protocols requires at least 20 minutes of resuscitation, paramedics called Cape Cod Hospital and spoke to Bosco at 4:45 a.m. with their request to terminate lifesaving efforts.
William Ozga, a consultant hired by the Mead family, reviewed Orleans paramedic reports, call logs from police and fire departments, ER notes and other relevant paperwork and found that resuscitation had only been administered for 17 minutes (the lawsuit says 16 minutes).
Ozga, an EMT-Cardiac Instructor from Rhode Island, concluded that both epinephrine and a saline solution should have been administered. He said Orleans paramedics also should have used a specialized device that measures whether chest compressions are being done adequately.
“In my opinion, Mr. Mead did not receive the expected and required care by the Orleans Fire and Rescue paramedics,” Ozga concluded.
Orleans officials kept Cape & Islands EMS investigation findings secret
A mandatory review of the Priority One response by Cape & Islands Emergency Medical Services in October 2016, and submitted to the town, found a “critical treatment and procedural error,” that the ambulance crew had not applied full advanced lifesaving services for the required 20 minutes before requesting termination of resuscitation and should have used epinephrine.
None of this was known to the Mead family in September 2016. Facts only began to emerge in 2019 and 2020, after Cowen filed records requests with the town and other agencies.
As the responses came in — a recording of the 911 call, the Orleans Fire Department call log for the ambulance, the incident form filled out by the ambulance crew, notes on the exchange between the ambulance crew and the ER, Bosco’s ER report, and other records — discrepancies emerged between the incident report filed by Burge, Montgomery’s statements, and the timeline laid out in the 911 tape.
On the day of Duane Mead’s death in 2016, the family suspected something wasn’t right. They immediately requested that the state medical examiner’s office do an autopsy, but that was denied. ER doctor Bosco supported the family’s autopsy request.
“I expressed concern over the discrepancies and the evidence of head injury,” Bosco wrote in his ER report.
In that report, Bosco included what appear to be two conflicting accounts of what had happened. He said that in their request to terminate lifesaving efforts, Orleans paramedics told him Mead was last seen alert by Montgomery at midnight and that she found him unresponsive in the bathroom hours later. But he also notes a different timeline, Montgomery’s statement to him that she heard him fall, responded immediately, and then called 911.
In asking to terminate lifesaving efforts paramedics also told Bosco, according to his ER report, that they had observed dependent lividity, pooling of the blood in tissues consistent with someone who had been dead and in one position for an hour or more.
It’s a condition that is used by physicians to determine death and would have precluded the continued use of Advanced Life Support, including epinephrine, according to Canterbury’s analysis.
Canterbury, an emergency room physician at Newton-Wellesley Hospital and medical director for Action Ambulance in Wilmington, was hired by Orleans last year after the family notified the town about their concerns about the case.
What lividity tells us about Mead’s death
Canterbury said lividity would have been present because, according to the timeline provided by Orleans paramedics, “his heart had not pumped for at least two hours.”
But that time frame was contradicted by Inger Montgomery’s statement that she’d heard Mead fall at approximately 4:10 a.m. and called 911 immediately.
In his analysis, Canterbury cited the timeline provided by Orleans paramedics and dismissed Montgomery’s version. He cited the EMT report that they had found dependent lividity and that Mead had not been seen alive after midnight in finding that Mead had been dead for a long time and that there was nothing EMTs could have done to save him.
According to Bosco’s notes, Orleans paramedics told him they’d found dependent lividity on the back of Mead’s head, chest and shoulders, but Mead-Walters said that it was documented by Montgomery and Orleans police that her brother had fallen face down and was only turned onto his back by police when they arrived.
If he was in that face-down position for hours, Mead-Walters said, the dependent lividity should have been on the front of his body, not the back.
Bosco did observe dependent lividity on Mead’s back when he arrived at the ER, but it had been over an hour since Mead collapsed, time enough for that to occur. The EMS incident report signed by Burge does not mention dependent lividity.
The lawsuit notes other inconsistencies in the Orleans EMS report: the claim that there was no bystander CPR, although police had administered CPR; that there had been a prolonged extrication when police said they removed Mead from where he fell and placed him on the floor; that they listed the time of the heart attack as unknown and the last time he was seen alert as bedtime, even though Montgomery said she’d heard him fall that morning and that he was conscious enough to be talking.
“In their rush to terminate resuscitative efforts, the Town’s EMS personnel made numerous misstatements to Bosco that they knew, or reasonably should have known, were false,” the lawsuit charges.
“I think he had a cardiac event. He is a patient who would have benefitted from a clot buster (medication) or a trip to the Cath lab. That might have happened if the EMS had managed to do CPR properly and got Duane to the hospital alive,” Mead-Walters said.
The Mead family presented a wrongful death claim to selectmen in February 2020. The town denied the claim in August 2020. In making that decision, the town hired Caterbury, who reached the conclusion that the “overall prognosis for Mr. Mead was poor; any interventions by the EMTs would not have changed the outcome.”
Family upset Orleans officials ignored Cape & Islands EMS report
The Mead family was particularly upset at the response by the town. Even though the review by Cape & Islands EMS citing a critical error was submitted to the town in October 2016, Orleans officials said in December 2020, in response to Cowen’s public records request, that it had no records of any investigation or review of the emergency call for Duane Mead, according to the complaint in the lawsuit.
The complaint asserts that the town failed to submit a written report to the state Department of Public Health on the incident after the regional EMS review determined there was a critical procedural error by EMTs. The lawsuit alleges that the town also failed to conduct an investigation as required by the state Department of Public Health and present a plan for correction and prevention that would have included Cape Cod Hospital, and included training and other corrective measures for personnel involved in the incident.
“The town ( Orleans) could have owned it, but instead they did the opposite. They went out and found an attorney and a doctor willing to support a demonstrably false narrative,” Mead-Walters said.
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