The Death Shift

by Peter Elkind

  The numbers game became a theme of the early coverage: How many murdered babies were there? Even the best papers couldn’t decide. On one day (February 24), the New York Times’s, front-page headline read: TEXAS INQUIRY ON 47 BABY DEATHS. On the next, the paper reported: INVESTIGATION IN TEXAS FOCUSES ON 12 CHILD DEATHS. The second Times article made a distinction that the San Antonio papers obscured: Every death under investigation was not necessarily the result of hospital homicide. In fact, during the period under closest scrutiny—Jones’s last fifteen months in the ICU—a total of forty-three children had died. Horrifying as the details of this case were, no one in the DA’s office believed that all of them had been murdered.

  Although she had been charged with no wrongdoing, the media spotlight fell harshly on Genene Jones. By January, before the story broke, both Genene and Debbie Sultenfuss had left their jobs at the state school and gone to work at the Park Plaza Nursing Home in San Angelo. Genene trained nurses’ aides. On February 2, she and Kathy Holland had become defendants in a wrongful-death lawsuit filed by the parents of Chelsea McClellan. On being served with the legal papers in San Angelo, Genene flew into an angry funk. She called the Houston office of the McClellans’ attorney to scream that the malpractice claim was an outrage. When Dracos broke the story, the lawsuit, as a public document, gave newspapers an excuse to publish the names of Jones and Holland. With a little encouragement from the DA’s office, reporters soon began identifying Jones as the “central figure” in the case.

  Sam Millsap and Ron Sutton had signed a mutual-assistance pact to coordinate their separate investigations, which were proceeding in different counties. In February, they decided to summon their chief suspect before the Bexar County grand jury in San Antonio. Genene’s attorney, Bill Chenault, had complained of the media’s decision to publish her name but insisted his client had nothing to hide. And indeed, when subpoenaed, Genene seemed eager to appear for questioning. On February 24, a pack of national and local reporters staked out the third floor of the Bexar County courthouse for their first peek at the suspected baby-killer.

  Burly investigators from the DA’s office led Genene and Debbie Sultenfuss—suggestively identified the next day as Jones’s “roommate”—through the mob of reporters and cameramen in the hallway. “I have no comment, gentlemen,” shouted Jones, as she made her way to the witness room. Inside the closed grand jury chamber, however, Genene had plenty to say. Disregarding her attorney’s advice to take the Fifth and remain silent, she wove a tale of medical malpractice, caused not by nursing errors or misdeeds but by incompetent doctors who would lie to stay out of trouble. While there might have been five or six questionable deaths in San Antonio, Genene herself had done nothing wrong. During three hours of questioning, Ron Sutton asked the nurse about what had happened in Kerrville. Jones said she had just followed Dr. Holland’s orders; she had no idea who had used the opened bottle of succinylcholine.

  Eight days later, Genene Jones held a press conference in her attorney’s office to repeat her story to the public. “I didn’t kill any children,” she insisted to a pair of Texas newspaper reporters and a camera crew from NBC News. Genene attributed her problems to her abrasiveness, complaining that she had been singled out because “doctors don’t like to be told when they’ve done something wrong.” Complaining of media implications that she was a lesbian—and thus making the subject suitable for publication—Genene volunteered, “I am not a homosexual…I like men.” She complained that media sensationalism had destroyed her career and prompted threats against her life, and added—oblivious of the contradiction—that she was speaking out to clear her name. But as she spoke, Genene Jones did not appear besieged and beset. She seemed cool and collected, even cocky and a little jocular, as though she were enjoying the attention. And if she had truly hoped that a press conference would dim the spotlight in which she was cast, she would discover the next morning that it had precisely the opposite effect. The banner headline in the San Antonio Light was the biggest one yet. “I DIDN’T KILL THEM,” it read.

  Genene Jones was not the only one protesting her innocence. Following the public disclosure of the investigation, those in charge at Medical Center Hospital professed ignorance. “We have not had any evidence of wrongdoing in this institution,” declared William Thornton, the dentist who served as chairman of the hospital district’s board of managers. Informed that the DA was investigating multiple deaths at the hospital, Thornton told a reporter: “I’m totally shocked and stunned.” In fact, the hospital board chairman had been told about allegations of wrongdoing more than a year earlier. On January 26, 1982—the day after the summit meeting that had prompted the Conn investigation—B. H. Corum, executive director of the hospital district, had briefed Thornton on the ICU’s problems. Yet in an interview with a local paper, Thornton actually waxed indignant, attacking medical examiner DiMaio for asserting that there had been suspicious deaths. “What is motivating him to go public with such serious accusations and then not provide the details or documentation?” Thornton asked. “If he had known all along about some questionable deaths, why in heaven’s name hadn’t he told us at the hospital district?”

  B. H. Corum was equally disingenuous. At a February 22 hospital board meeting, Corum was asked about reports that the hospital had conducted an internal investigation of unexplained deaths in the pediatric ICU. Corum responded that he knew nothing about it. “I do not believe personally that there was any wrongdoing,” he told reporters. “…We hope whatever the truth is, it comes out.” Corum, in fact, had not merely known about the Mangos report but authorized it. And it was with the knowledge of the executive director, the very man who proclaimed his interest in getting out the truth, that the Pediatric ICU Committee had set hospital policy toward the unfolding investigation in Kerrville—the policy of “judicious silence.”

  On March 16, Dr. Mangos sent Corum and Marvin Dunn an addendum to his committee’s report on care in the pediatric ICU. The document included a breakdown of deaths by nursing shift. Of thirty-five children who had expired during 1981 in the ICU, twenty-five had died during the 3–11 shift. The next day, Dr. McFee convened another meeting of the Pediatric ICU Committee. In the absence of the anesthesiology department chairman, Dr. Malcolm Orr was sitting in. For almost an hour over lunch, the group discussed fund-raising to finance new equipment and recruitment of pediatric faculty. McFee reported on plans to restore the unit back to an eight-bed capacity by June. The committee ended its meeting by turning to the messy events under criminal investigation, with talk not of remorse but of revenge. “Dr. Orr raised a final issue regarding the possibility of redress for the hospital district regarding the appalling publicity that has been circulated as a result of the grand jury investigation,” McFee’s minutes state. “In general, it was the view of the committee that redress should be sought, but not until after the investigations of the grand jury are terminated.”

  For the presumed target of such redress, the “appalling publicity” was having precisely the desired effect. Within days after the story broke, Sam Millsap’s office began receiving a flood of unsolicited calls. Many were from crackpots, but others came from residents, nurses, and parents who had known Genene Jones. And the flow didn’t let up; each new leak produced a fresh stack of phone messages. To Millsap, the response had vindicated his strategy of leaning on the medical school and hospital through leaks to the press. It had also given the DA pleasure. The baby-deaths case had made Millsap the talk of the Texas legal community. Crowds of reporters were appearing in his office for press conferences every day. People were responding to his pronouncements, even thousands of miles away; Millsap’s disclosure of the investigation had prompted Moody’s, the Wall Street firm, to suspend the hospital district’s bond rating. Those under the DA’s scrutiny didn’t merely respect him; they feared him. It was political jujitsu at its best—the very definition of power, the ambitious officeholder’s dream.

  The hospital district and the medical schoo
l had pledged total cooperation, but Millsap sensed a need to maintain the heat. When doctors and administrators seemed to be holding back or dragging their feet, Millsap lobbed a media grenade in the direction of the medical center. “I want to impress how absolutely essential it is that we have the full cooperation of the Bexar County Hospital District,” Millsap would tell reporters. “In some cases, we have been disappointed and that is a source of real concern.”

  Assembling a criminal case in San Antonio required sifting through dozens of incidents and scrutinizing thousands of pages of documents. As the stacks of subpoenaed records and lists of witnesses to interview began to multiply, it became clear to the DA that uncovering the truth would take months. In early March, Millsap placed his top gun, Nick Rothe, in charge of the investigation. Rothe felt familiar with the territory. His father, a doctor, was director of the San Antonio Metropolitan Health District. Rothe’s great-grandfather had once chaired the county hospital’s board; his portrait hung at Medical Center Hospital. After securing $30,000 extra funding from the county commissioners, Millsap expanded the baby-deaths task force: Rothe’s team would include a second full-time attorney, Joe Galenski; a pair of staff investigators; and as much extra legal and secretarial help as he required. Needing extra room, tight security, and an out-of-the-way place to interview witnesses, the group moved from the courthouse into the old Bexar County jail. The drafty stone building had been vacant for years; to the best of oldtimers’ knowledge, no one had ever broken in.

  Fifty-one-year-old investigator Art Brogley quickly emerged as the probe’s most valuable asset. Brogley was a veteran of twenty-one years in the army, the father of six children, and one-hundred-percent business. He had served a tour in Korea and two more in Vietnam, where his duties included investigating atrocities against civilians. Six foot four and balding, perpetually troubled by an ulcer, the potato-faced Brogley had the hard-bitten manner of a Mickey Spillane gumshoe. Pretty girls were “dollies” and “dames”; bad guys were “scumbags.” He hung out at Dunkin’ Donuts and ate in coffee shops and cafeterias where the waitresses knew his name. Brogley was suspicious of money and power in all its forms, but his heart bled at every dumb slob’s misfortune. His dogged compulsiveness suited him perfectly for an investigation that would rest on a foundation of detail. Millsap had assigned Brogley to the case after asking his chief investigator for a man who would lie awake in bed at night, worrying about what remained undone.

  A few weeks after starting on the case, Brogley returned a call from Cathy Ferguson, who had taken up residence at the Buckner Baptist Maternity Home for unwed mothers in San Antonio. The investigator knew nothing about the woman who had baby-sat for Genene’s children. When Ferguson informed Brogley she had much to tell him about Genene Jones, Brogley arranged to meet her at a Dairy Queen near the home. Arriving with a fellow investigator, Brogley found a young woman in a ripe stage of pregnancy—and eager to talk. As she munched on french fries, Cathy explained that she had met Genene in San Antonio, lived with her at the house on Nixon Lane in Kerrville, and accompanied her to San Angelo. Around Christmas, Cathy had decided to leave; she explained that she wanted to give birth to her baby in San Antonio. Ferguson was so big, Brogley worried that might happen at any moment.

  Cathy then startled the investigators. She said she had been in the crash room of Dr. Holland’s clinic on about five occasions when Genene had taken a bottle of clear liquid from a drawer in the examining table, drawn some of its contents into a syringe, and injected children with the liquid. In each case, said Ferguson, the child began seizing a few moments later. The exam-room table drawer was where Genene had told Dr. Holland she had found the missing bottle of succinylcholine. Ferguson was offering an eyewitness account of unauthorized injections—precisely the link needed for prosecution of Jones in Kerrville. As Cathy gobbled down more french fries, Brogley began writing out a statement of her comments in longhand. The young woman’s tale was vivid and detailed, but the investigator immediately wondered about her credibility. Tall and fresh-scrubbed, Ferguson had no apparent ax to grind. But she also possessed a curiously benign affect. Brogley had a rule: He never believed anyone the first time around. Besides, how could you buy the story of someone you’d met in a Dairy Queen? After three hours of conversation, Brogley, with his fellow investigator, drove Ferguson back to the Baptist Home. He had struck up an easy rapport with this curious young woman. As he escorted Cathy to her dormitory, Brogley offered a word of fatherly advice: He told the expectant mother to lay off the greasy food.

  In the days that followed, much about the meeting troubled the investigator. Why had Cathy Ferguson suddenly turned on Genene Jones, spinning a tale that could send her longtime benefactor to prison? In her grand jury appearance, Genene had said that Cathy was mentally retarded. Brogley did not believe that; troubled seemed more like it. But Brogley soon learned that Cathy had spent time in a state mental hospital. It was not the sort of background that inspired faith in a witness. He would need to speak with Cathy again. Time would tell if she would stick by her story.

  But less than two weeks later, Cathy Ferguson disappeared. A caseworker at the Baptist Home reported that Ferguson had met Genene Jones on March 3 at a local supermarket and returned with the happy news that Genene had asked Cathy to rejoin her. Cathy resurfaced in San Angelo on March 6, when she gave birth to a healthy baby boy at Angelo Community Hospital. When released from the hospital, Ferguson took her infant back to the South Concho Trailer Park and resumed living with Genene—the woman whose willful efforts to harm children she had recently detailed for investigators. Ferguson’s behavior was as inexplicable as it was irrational; she seemed to have fallen back under Jones’s spell. Cathy even named her son Travis, making him a living memorial to Genene’s beloved baby brother, who had blown himself up with a bomb sixteen years earlier.

  Travis Ferguson was to suffer a brush with a similar fate. On March 13, the newborn was rushed from the mobile home to a local hospital. Genene Jones, identifying herself as Travis’s grandmother, took the baby to the emergency room. She explained that the child had suffered a sudden episode of breathing problems.

  Twenty-Two

  It was impossible for Petti McClellan not to feel guilt over her daughter’s death. Day after day, she replayed the horrible events in her mind, torturing herself with thoughts of how she might have interrupted the unfolding nightmare. Why hadn’t she suspected something after Chelsea’s first arrest in Dr. Holland’s office? Why had she brought Chelsea back and handed her to Genene Jones? Why, as the nurse prepared to stick the deadly needles into her daughter’s thighs, why hadn’t she grabbed Chelsea and run, taken her someplace far away, someplace where her baby would still be alive? Petti rolled the nightmare back even further. Why had she brought Chelsea to a doctor she didn’t even know?

  For a month after Chelsea’s death, Petti had stumbled about the family trailer home in a fog, unable to accept that her daughter was gone. Every few days, she changed the sheets on Chelsea’s bed, as if her little girl were still sleeping in it every night. When Petti stumbled across one of Chelsea’s socks while cleaning the house, she sat and stared at it mindlessly, tears streaming down her cheeks. Reid had sent his wife to a psychiatrist, who had prescribed powerful sedatives and antidepressants, which seemed only to thicken Petti’s daze. Shay and Cameron, nine and four, were bewildered by their mother’s behavior; she screamed at them every time they ran out of her sight. One night, Reid grabbed Petti and shook her until her teeth rattled. “Either you accept what’s going on, or I will go someplace else!” he shouted. “Look what you’re doing to the boys. Look what you’re doing to me. You’re either going to face it, or I’m out of here!” They cried together for hours. The next morning, Petti threw away the pills she’d been taking; she soon reclaimed her grip on reality.

  The McClellans read books about coping with the loss of a child and waited for their passions to fade. But there was no outlet for their guilt and anger, and everywher
e there were reminders of what had happened. People gawked at them at the grocery store. “Those are the parents,” folks would whisper. In January, Petti had run into Gwen Grantner at the Kerrville Kmart, and Dr. Holland’s receptionist had lit into her, telling her she had no right to be angry at Holland, that the doctor had done everything she could to save Chelsea—even that the McClellans ought to take Cameron back to her for his medical care. An assistant store manager had been forced to separate the two women. When Shay developed tonsillitis, his little brother was terrified. “Is he going to the same hospital where Chelsea went?” asked Cameron. Petti and Reid said that he was. “Shay’s going to die!” screamed the four-year-old. No, Petti and Reid explained, Shay was going to be fine. Cameron shook his head. “That’s what you said with Chelsea.” A month after her daughter’s death, anxious to fill the void, Petti had visited her gynecologist to ask if it was possible to reverse her tubal ligation. They could try, but the procedure was tricky, the doctor told her; the odds were only fair that she would ever conceive another child. Petti and Reid decided she should not attempt the operation.

  After learning from Ron Sutton that their daughter’s death might have resulted from murder, the McClellans had retained Jim Perdue, a prominent Houston attorney who specialized in medical malpractice cases. Perdue filed a wrongful-death suit against Holland and Jones in Kerr County. When news of the baby-deaths case broke a few days later, reporters began appearing in the McClellans’ front yard and calling their house at all hours of the day and night. Petti and Reid described their lawsuit as a search for answers, a chance to find out who was ultimately responsible for what had happened to Chelsea. They felt certain that Dr. Holland either knew Genene was harming children or should have known. And as they learned that similar events had taken place in San Antonio, they wondered why Medical Center Hospital hadn’t warned anyone about Jones. Petti and Reid wanted answers. But they also sought a measure of simple human revenge—a salve for their fury at the doctor and the nurse whom they had trusted with Chelsea’s life. “I want them to suffer for a long period of time,” Reid told me one day. “I want them to suffer like they caused my daughter to suffer.”