February 13, 2012 - 1:36am
Coleman critical of investigation as University releases internal report on child porn incident
BY ADAM RUBENFIRE
The results of an internal investigation examining why the University of Michigan Health System waited six months to appropriately alert the Department of Public Safety that former medical resident Stephen Jenson was in possession of child pornography were released to the public Friday.
In a letter to the campus community, University President Mary Sue Coleman wrote that University officials acknowledge that the situation was handled improperly and hope he incident will serve as a catalyst for strengthening campus security protocol in the future. The report highlights information not previously known to the public, including a report that UMHS security asked the University’s Department of Public Safety to use forensic resources to examine a flash drive containing the pornography, but DPS did not return the voicemail.
Last May, a UMHS medical resident found a flash drive containing images of child pornography plugged into a hospital computer in the residents’ lounge. The report notes she opened files on the drive to determine who owned it, and found Jenson’s name. She left work without reporting the incident, and found the flash drive gone the next day. She then notified her supervisor, the attending physician, who notified the chair of the Medical School Department Compliance Officers.
On Dec. 3, Coleman was notified of the issue, and asked the University’s audit office to conduct an internal review. Regent Katherine White (D–Ann Arbor), chair of the University’s Board of Regents Finance, Audit, and Investment Committee was also notified.
In the letter released Friday, Coleman commended the medical resident who reported the flash drive to hospital security, noting that she reported the incident “not once, but twice,” a fact that was previously not known.
“I want to apologize to her for not properly investigating the allegations in May,” Coleman wrote. “It took an act of courage to come forward again, and it is because of her that the case is now moving forward in the legal system.”
Coleman also wrote that though the Jenson case has been challenging, it will allow officials to strengthen protocol in the future.
“I believe this experience, painful as it has been, will enable all of us to properly address the seriousness of these issues with any and all future reports and investigations,” Coleman said. “As a community, we must and will be constantly vigilant.”
The University will review its current procedures regarding “police and security reporting lines and organizational structures” and ensure they are up to par with other universities, according to the report. DPS and hospital security leaders will provide an “action plan” regarding the recommendations within 90 days, and a benchmarking report will also be completed in six months.
The report also notes that starting in June the University Audit Office will conduct quarterly follow-up reviews of the incident “until all noted risks are appropriately mitigated.”
In an e-mail to the UMHS community on Friday, Ora Pescovitz, the University’s executive vice president for medical affairs, wrote that the health system is cooperating with a review by the Joint Commission, a national healthcare accreditor, of UMHS’ reporting system and infrastructure.
“We are working diligently, along with campus leadership, to correct the shortcomings brought to light by this serious lapse,” Pescovitz wrote. “It is important to remember that it is both our individual and collective responsibility to make certain that the University of Michigan Health System promotes an environment of safety.”
A second report
The report notes that police were only involved after the resident who reported the crime alerted the Attending Physician that the Health System Legal Office did not intend to pursue the case. He re-reported the case in November to the Office of Clinical Affairs.
“Upon a second review, sufficient evidence was discovered that led to the termination and arrest of a suspect in the case,” according to the report.
According to the audit, on the evening of Nov. 11, the attending physician called the top executive in the Risk Management Office, prompted by the apparent absence of the attorney handling the case and the allegations made at Pennsylvania State University that Jerry Sandusky, a former assistant football coach, raped several young children. The executive told the attending physician that it was the first time he had been made aware of the case, and he proceeded to interview the reporting resident the next day.
The next day, Nov. 12, Chief Medical Officer Darrell Campbell Jr. was briefed by the University’s Risk Management Services regarding the incident. After conferring with Valerie Castle, chair of the Department of Pediatrics and Communicable Diseases and a supervisor of Jenson in the medicine-pediatrics residency program, he determined that Jenson would be “carefully supervised until appropriate action including precautionary suspension under the Medical Staff Bylaws can take place.”
According to the report, Hilary M. Haftel, director of pediatric education, and another Health System Legal Office attorney then met with the resident who reported the crime in May. They found her report “convincing,” and made an additional report to UMHS security officials, assuming they would make an immediate report to DPS.
Even as late as Dec. 2, Jenson was not yet alerted that he was under investigation. The report notes DPS asked staff involved to keep Jenson on the job, as he would most likely destroy any evidence if he knew of the ongoing investigation.
From Nov. 21 to Dec. 2, a DPS detective conducted an investigation regarding the incident, and reviewed the case with a Washtenaw County prosecutor — most likely attorney Brian Mackie, who will now be prosecuting the case in Washtenaw County trial court. A search warrant was executed Dec. 2, and that same day, Campbell and John Carethers, chair of internal medicine, issued Jenson a “precautionary” suspension. Following these events, Jenson was arrested on Dec. 9.
The lead attorney
The report cites the Health System Legal Office as a major contributor to the delay, noting that it “should be available for legal advice but should not take ownership of an investigation.” It appears as though the legal office was aware of the case as early as May 25, just days after it was reported to Hospital Security, though it wasn’t reported to police until December.
In her letter, Coleman also wrote one of the most significant findings of the audit cites a UMHS attorney in the Health Legal Office for “acting improperly when the incident was reported to her.”
“A University attorney must not assume the lead role in investigating a potential crime of this nature,” Coleman wrote, but later notes that the incident cannot be blamed on one singe individual.
This individual, the lead attorney on the case, is cited several times as a major contributor to the delay, and the audit further suggests that she he acted inappropriately, even noting that the resident who reported the incident left an interview crying.
“The resident who reported the crime described the lead attorney who interviewed her as intimidating and threatening, causing distress and a feeling that she should not have come forward with the report,” the audit noted.
The attorney told the resident her claims were “unfounded,” according to the report. The report also suggests that the attorney delayed other UMHS departments, like hospital security, in their investigation efforts because of inappropriate control of the case.
“We conclude that the assertion of improper control of the investigation by the attorney and reliance on her conclusions by others were the root cause for the delay and improper handling of the initial report,” the reported stated.
The audit criticizes the Health System Legal Office for relying on the single opinion of the lead attorney, and further notes that the Office of Clinical Affairs or the Health System Risk Management Office should have been notified in order to protect patients or employees involved, “even in the absence of a criminal investigation.”
As part of the investigation, UMHS security interviewed the resident and other employees involved, and a technician from the Medical Center Information Technology reviewed the flash drive and computer in question. The report notes MCIT did not have the capability to uncover certain information that was embedded on the computer.
“The review of the computer by Health System personnel was insufficient and would have been enhanced if law enforcement had been involved to lead the investigation,” the audit states.
Data in the report further alleges that the hospital security supervisor who received the resident’s complaint left a voicemail for a sergeant at DPS to provide forensic assistance with the USB thumb drive. The voicemail was not returned.
It wasn’t previously known that hospital security reached out to DPS, and it contradicts earlier reports that almost entirely blame Hospital Security for not communicating the case to DPS via incident logs.
The security supervisor reportedly told University auditors he didn’t follow up with DPS due to an e-mail he received from an attorney from the Health Legal Office noting that his work was “confidential and under attorney client privilege,” which he interpreted to mean that he should cease communication with DPS regarding the matter.
“Please do not disclose to anyone, without our prior written permission, the nature or content of any oral or written communication with us in the course of this engagement,” The e-mail stated. “We ask that you communicate only with attorneys in the OGC about substantive issues, the results of your activities, or any questions that you may have.”
The report further notes that the lead attorney told the assisting attorney who received the report that the resident who reported the case was “unsure of her story and what she saw.”
On or around June 2, the lead attorney reported to Maragret Marchak, associate vice president and deputy general council at UMHS, that there was “no evidence” and that the case would be closed. Seven days later, on June 9, the lead attorney departed her job at UMHS for what the report noted as “unrelated” reasons.
The report suggests that employees who wrongly acted in this case will be reprimanded.
“Individual corrective action will be taken with the involved current employees to ensure greater clarity of their respective roles and the importance of vigilance when handling complaints of possible criminal activity or risk to patient safety,” the reported stated.
Report recommends actions moving foward
Several investigative results already released were also included in the report, including information that several employees believed they were speaking with University Police when they were actually speaking with hospital security officers, who aren’t responsible for criminal investigations. The report notes that those officers should clearly identify themselves as “security and not law enforcement.”
The report also highlights that 911 calls made inside UMHS buildings are routed to UMHS security, which can cause further difficulties for reporting individuals who may believe they are talking to law enforcement. The report recommends that DPS and hospital security develop formal dispatch detailing regarding the responsibilities of each department in triage.
The report further suggests that DPS should consider placing a liaison within the health system, and criticizes the department for not having a “consistent presence.”
“There is no consistent DPS presence within the Health System,” the report reads. “DPS officers are only interacting with hospital faculty and staff when there is a criminal investigation or an emergent situation. This contributes to tense working relationships and miscommunication.”
The report also recommends the development of “cross-functional teams” to ensure security officers and police understand how to respond to particular issues.
“Safety and security teams should be defined by incident type, and will ensure that the right skill sets are matched to respond to the particular issue,” the audit stated. “Teams should meet regularly in non-crisis mode to further develop understanding and trust.”
The report and related documents can be read here.
Jenson’s preliminary exam is scheduled for Feb. 16.
—This is a developing story. Check back to michigandaily.com for updates.
Correction Appended: A previous version misidentified the individual who reported the case a second time.
