A Bitter End, part 3: The overdose

In print, this story was split across more than one issue because of its length. Online, we've split it into six chapters: 

1. The very old man who wanted to die
2. The hospice
3. The overdose
4. The pro-life coroner
5. The strange prosecution of Barbara Mancini
6. The legal land mine, undefused

Or you can read the story as a single page. 

Part 3: The overdose

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The night before Joseph Yourshaw’s overdose, Mancini says, her mother called in tears. Yourshaw had fallen that morning, and now as they were trying to put him to bed “was in so much pain they couldn’t even get his clothes off.” He was wearing one of his old button-down shirts from when he was 50 pounds heavier, but even unbuttoning it and trying to ease the loose-fitting shirt off his shoulder was too painful for him. “My mother and my brother felt like they were breaking his arms.” (Postmortem records would later show that Yourshaw’s arthritis was particularly bad in his shoulders.)

“I drove up that morning from Philly and he was sleeping when I got there,” says Mancini. Her mom stepped out to get lunch and do some shopping, leaving them alone in the house. “After a while, he woke up and asked for a little orange juice. He told me he was in a lot of pain, he asked me to bring his medicine to him, which I did. I had the dosing syringe in my hand, I handed him the medicine, because he always opened the medicine for my mom, it had one of those child-proof caps on it that she could never get open. So I let him open it like he did for her. And he drank it. That’s what happened.”

Afterward, she says, “I sat there and held his hand and we talked for a while about a number of things … how he loved my mother and how he loved us. He talked about the war. Talked about some friends of his,” says Mancini. “Then he got sleepy, so he stopped talking and I just sat there and held his hand.”

Nobody disputes that Joseph Yourshaw wanted to die. He might have been able to do so in peace that day instead of in anguish at the hospital four days later if a hospice nurse hadn’t called about an hour later asking if she could drop in for an unscheduled visit.

The disagreement about the death of Joseph Yourshaw starts when nurse Barbara Cattermole comes by the house about an hour and a half after he drank his morphine. Since, again, HCP declined to comment on the part of all its employees, everything from hospice employees has been taken from her testimony at Mancini’s preliminary hearing.

It all seems to start with the word “give.” A major point in the Commonwealth’s case against Mancini was multiple accounts that she’d said she “gave” her father the morphine. Mancini insists she meant “handed.” Cattermole understood it as “administered.” Everyone who heard Cattermole’s account of what happened before they heard Mancini’s understood it to mean “administered,” too — and that includes the hospital, the coroner, the pathologist and the police. For example, see this cross-examination of responding officer Captain Steven Durkin by defense counsel Fred Fanelli:

A. [S]he told me she gave him his morphine.

Q. And by “give,” she handed him the bottle. That's what we're talking about, just for clarity. There's a lot of difference.

A. If you want to take it that way.

Q. Like if I hand you my cell phone or my pen, that's a lot different than actually administering something to you.

A. Yes, that would be different.

Q. So she never admitted or made any statements to you that she did anything other than hand the bottle when he asked for the bottle; is that correct?

A. She indicated that he wanted to die, so she gave him his morphine.

That last one is the second semantic trouble spot. Mancini says that two things she said to Cattermole and Durkin — that she had given him the bottle of morphine and that he should not be taken to the hospital because he wanted to die — got lumped together to make another key part of the case against her: She gave him his morphine so he would die.

For example, in the Commonewealth’s brief opposing habeas corpus: "The Defendant admitted to giving him the whole bottle of morphine” and “She said several times that she gave him the morphine so he could die.” (Mancini argues that she never said it.)

Another thing was that Cattermole testified that Mancini had asked her to do something: “To get more morphine because her father had not died yet.” In hospice records, Cattermole wrote that Mancini had told her upon her arrival, “I gave my father the bottle of morphine to drink, all of it, and I need more morphine.” Cattermole also told the ER doctors the same thing, and they recorded in their records that Mancini “actually wanted to have more Roxanol provided,” and it’s in the records of the coroner and police.

Mancini says that she never said anything like that. “Complete perjury. It’s a bald-faced lie.”

Why would she say that? Mancini has no idea. “[Cattermole] was the nurse who withheld those medications when my father was enrolled in hospice. I don’t know what was in her brain when she said it.” Again, regardless of what was actually said, which is one person’s word against another, this was used as a key part of the Commonwealth’s case: “Your Honor, the most compelling evidence from Nurse Cattermole when the bottle didn't do the trick, she wanted Nurse Cattermole to get more morphine to do the trick.”

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Opiates like heroin and morphine kill people by essentially relaxing the central nervous system so much that the brain forgets to tell the lungs to keep breathing, called “respiratory arrest.” Guides for how to identify and handle opiate overdoses always say to check for slowed breathing, which is cited variously as between 8-12 breaths per minute. (The eventual hospital plan of care for Yourshaw was to give another dose of IV Narcan if his respiration dropped below six, which it never did.)

Roxanol, the brand-name oral form of morphine Yourshaw had been prescribed, reaches its peak effect after an hour and continues to work for 2-4 hours. Cattermole arrived about an hour and a half after Yourshaw ingested the Roxanol at 11:30 a.m. She testified that Mancini was upset when she told her she would need to call 911, and wouldn't let her near her father; Cattermole convinced Mancini to let her do Reiki on Yourshaw (which Mancini says she thought was weird enough to be harmless) and used that to surrpetitiously check his vitals.

She wrote in hospice records that during her chakra spread, Yourshaw’s respiration had been 16 breaths per minute. His respiration had also been recorded at 16 the last time a nurse had seen him two days earlier, which had not been noted as a cause for concern.

When Yourshaw arrived at the hospital at 1:50 p.m., it had been more than two hours since he’d ingested the Roxanol. He was out of it, but his respiration was again recorded at 16, though “shallow.”

With all this put together, it’s not surprising that the hospital, while keeping a close eye on the situation, was not treating this as an all-hands-on-deck urgent situation, and didn’t immediately move to treat him until they were able to contact his wife.

At 2:35, it’s noted that a hospice nurse (Cattermole) is present, and records reflect that she filled in the hospital staff with her version of events:

Hospice worker to me stated … that the daughter had given the Roxanol. Do not wish her to be involved and actually wanted to have more Roxanol provided and then asked the Hospice worker to leave.

Around this time, three hours after he’d swallowed the morphine, Yourshaw’s respiration was recorded at 20.

At 2:45, more than three hours since he’d swallowed the morphine, Yourshaw’s charts note:

WIFE AND DAUGHTER AT BEDSIDE PT SNORING AT THIS TIME

Marguerite Yourshaw had come home from lunch “to find police in her home,” note the hospice records, continuing: “She was upset that she had not said goodbye to him because he was sleeping when she left.” The DAUGHTER was actually a daughter-in-law; Mancini was still at the police station.

At 3:00, three and a half hours after he’d swallowed the morphine, Yourshaw’s respiration was recorded at 22.

Around that time, Mancini got a call on her cell phone. “I was in the police station sitting next to the guy who arrested me, and my mom calls my cell phone and says, ‘They want me to sign a consent for treatment, what should I do?’” says Mancini. Captain Durkin “overhears this and says, ‘Let me talk to the ER doctor.’ He takes the phone and says to the ER doctor, ‘If he dies now, it’s going to go worse for her.’”

“That was my mother’s choice, if you want to call that a choice: Honor my dad’s wishes, or try to help me.” Marguerite signed the permission to treat her husband, and he was given a dose of Narcan at 3:40, more than four hours after he’d drunk the morphine. From hospice records:

After patient received dose of narcan he awoke and was calling out for his daughter Barbara. “Don’t let anyone hurt Barbara” He kept repeating this over and over. He also became agitated and began pulling the pulse ox off and the leads that were monitoring his vital signs.

At 3:50, Yourshaw's respiration was recorded at 20.

Around 4 p.m., more hospice staff shows up — supervisors Deb Hornberger and Barbara Woods, who had spoken to Mancini on the phone. From hospice records:

We proceeded to [Yourshaw’s] room and upon entry, he stated, “Get those foreigners out of here”. His wife stated “they are not foreigners, they are hospice staff”. The patient stated, “I don’t know them so they are foreigners.”

Hospital records:

patient belligerent when spoken to. States “get the hell out of here” and “your hurting me”

Hospice records:

DIL [daughter-in-law] followed us out into the hallway and stated that patient has always been very stubborn. She stated that if he said the sky was green, then the sky was green. The family is very concerned for Barbara.

“The hospice people showed up to fill in the ER on my dad’s history,” says Mancini, and “suddenly it appears that my father has a history of dementia and depression. Which he did not, ever.”

Reviewing her father’s hospital records, Mancini was confused about where this information originated, because he hadn’t been diagnosed with either. “I asked my mother about it, and she said ‘I never said anything like that!’ He’d never been hospitalized there before” and so wouldn’t have an existing record. The ER admission staff, she knew, wouldn’t have just assumed dementia from the circumstances. “You’re supposed to have a physician diagnose dementia,” says Mancini. “You can’t just write it down.”

The attending physician, Dr. Timothy Henninger, writes that the information had come from Cattermole: "According to [her] statement to me, states that the daughter had given him a bottle of Roxanol … He also has a history [sic] dementia” and that when he’d enrolled in hospice had “seemed a little depressed, but was not suicidal.”

Until that point, HCP hadn’t been acting as if Yourshaw had dementia or clinical depression, nor writing it down on his charts. There are notes that he has some memory problems, that he sometimes seems “sad/depressed” and that he’s often grumpy and negative; there’s far more consistent notes that say he’s alert and has his judgment and insight intact. And in the areas where it’s important, he’s treated as competent. He signed his own forms admitting him into hospice, and his physician’s plan of care states “patient may self-administer medications.” Nurse Cattermole allowed him to refuse the e-kit containing all his medicines without consulting with his family, which wouldn’t have been a responsible thing to do with a patient who wasn’t in his right mind.

Mancini says after HCP employees spoke with Dr. Henninger, “suddenly dementia appears on that ER record, and then on the hospital records — because what one doctor writes down, the rest write it down afterwards.”

Mancini suspects the reason the records start stressing dementia and depression only after her father’s overdose is that the hospice was trying to cover its ass. “They realized they’d failed my dad, and I believe that they wanted to divert scrutiny away from their failure and onto me.” HCP, again, declined to answer questions.

The hospital didn’t have much opportunity to observe Yourshaw’s mental status, anyway — his hour of post-Narcan fury was the storm before the calm. By 6:20, when he was moved from the ER to a patient room and Mancini was allowed to visit, but he was unresponsive and she wasn’t sure if he could hear her or not.

By the next morning, Yourshaw’s charts note that he’s semi-comatose and has the beginnings of bedsores. The morning after, he’s developed rhonchi (rattling, snore-like sounds) and wheezes in both his lungs, and the beginnings of a rash around where he’d been catheterized.

All of these conditions worsened over the next three days. By Feb. 9, he doesn’t respond to pain stimuli — Mancini hopes that he wasn’t able to feel the rash that had spread down his penis to his scrotum and tailbone, because it would have been extremely painful. In the overview, his attending doctor wrote Yourshaw "was stable and then subsequently spiked a temperature … then developed worsening respiratory distress.” He was put on an antibiotic.

On the morning of Feb. 11, Yourshaw’s condition worsened even more. His blood was found to be very acidic (his kidneys had gone from stage III to stage IV), and a chest X-ray revealed that his lungs, which had been clear when he was admitted, were now full of gunk. He was put on a respirator.

The attending doctor records telling the family that Yourshaw was not going to make it “because of the respiratory failure and probable aspiration pneumonia.” Attempts to fix Yourshaw were stopped at 8 a.m. At 8:39, he “was given morphine for any respiratory distress,” though at a very low dosage. After four days in the hospital, Joseph Yourshaw died at 4:42 that afternoon.

The hospital didn’t list an official cause of death; the field was left blank. Dr. Kimberly A. Hashin’s discharge diagnosis:

1. Respiratory failure.
2. Aspiration pneumonia.
3. Drug overdose.
4. Acute on chronic kidney disease.
5. Diabetes mellitus type 2 uncontrolled.
6. Failure to thrive.

It seemed very clear to Mancini that her father had died of pneumonia. At the time of his death, she says, he’d been out of the danger zone for morphine toxicity for days. “You develop pneumonia very quickly in the hospital. He had a high fever, he had a rapid heart rate, junky-sounding lungs,” and other symptoms that signaled pneumonia. “The way a narcotic overdose kills you is you stop breathing. He didn’t! He didn’t stop breathing!”

As of 6 p.m., about an hour after Yourshaw’s death, records show that Schuylkill County Coroner Dr. David Moylan had already arrived at the hospital, spoken to the family and viewed the body. He got full autopsy and toxicology reports done, so it was mid-June by the time the final coroner’s report and death certificate were issued.

Cause of death: morphine toxicity complicating hypertensive atherosclerotic cardiovascular disease. Manner of death: homicide.

“When I found out what that death certificate said, I remember saying to my husband, ‘I’m screwed. They’re using me for politics,’” says Mancini.

>>> Continue to part 4: The pro-life coroner.