By Sonika Khanal & Bob Aller
Posted on January 23, 2025
Patient Jessie Peterson
On April 6, 2024, Ms. Jessie Peterson, 31, experienced a severe diabetic exacerbation requiring hospitalization at Dignity’s Mercy Hospital. She had type 1 diabetes. According to medical records, two days later, on April 8, 2024, Ms. Peterson died at 4:27 PM. Her next of kin, her mother, was kept in the dark about her passing. The next day Dignity had Ms. Peterson’s remains transported to an off-site storage facility where her remains decomposed over 1 year. Due to advanced decomposition, no autopsy was possible. Dignity’s handling of Ms. Peterson’s remains was horrific. In addition, the manner in which Jessie Peterson’s family was treated afterward was appalling. Dignity chose to cover up the tragedy and would not explain to Ms. Peterson’s family how this happened. Dignity would not even offer a simple apology. Yet, Dignity Health claims “the dignity of persons requires reverence at every stage of life’s journey from conception to natural death.” The actions of Dignity administrators and staff reflected disrespect for the legacy of the hospital’s founding Sisters of Mercy.
A State Oversight Investigation Is Warranted
This case review submits that an investigation of this Dignity Hospital by the California Department of Public Health’s Licensing and Certification Program is duly warranted. Months have passed since this case and another related case became known. These cases involve shocking violations of sacrosanct state healthcare regulations that respect and protect human remains.
Incompetence Or Cover Up?
When Jessie’s mother, Ginger Congi, called the hospital on April 11th to check on Jessie, she was told there was “no one here by that name.” After asking more questions, Ms. Congi was informed her daughter “left against medical advice.” In fact, her daughter had died. During that phone conversation, hospital staff failed to reveal Jessie died three days earlier, on April 8th. The staff also failed to disclose that on April 9th Jessie’s remains were transported to an off-site storage facility, “Cremations Only”, and placed on Shelf Number Red 22 A, (to remain on that shelf for 1 year).
Family Searched For Jessie For One Year
Believing that Jessie was a missing person, Jessie’s mother and her sisters, Angie and Chandra, embarked on a year-long search. The family filed a missing person report with the Sacramento County Sheriff’s Office. Jessie’s information was posted on the Department of Justice website for missing persons. Jessie’s mother, a land surveyor supervisor at California’s Department of Transportation, reported that Jessie had struggled with addiction. Though her housing was unstable, she still had friends she stayed with. In addition, she always remained in contact with her family. The family firmly believed Jessie was somewhere in the Sacramento area. They showed her photo to many who were homeless. The family never stopped looking for Jessie during that year.
A Detective Contacted Jessie’s Mother!
Finally, on April 12, 2024, over a year after Jessie’s death, a Sacramento Sheriff’s detective phoned Jessie’s mother. Ms. Congi learned her daughter’s remains had been in a storage facility decomposing the entire time the family was searching for her. Ms. Congi and her daughters were shocked and dismayed.
Dignity Did Not Apologize To Jessie’s Family!
Dignity claims that “the dignity of persons requires reverence at every stage of life’s journey from conception to natural death.” Yet, Dignity failed to inform Jessie’s mother of her passing. Dignity covertly stored Jessie’s remains for one year while her remains decomposed. Finally, Dignity lacked the common decency to apologize to the family. It can reasonably be assumed that Dignity knew how this happened. However, hospital staff would not speak to the family about what happened. Dignity was silent. The family sought an attorney.
World-Wide Condemnation!
Four months later, on August 7, 2024, a lawsuit was filed. The case was reported in the NY Times, the Washington Post, the LA Times, USA Today, the Guardian, The Daily Mail, Reuters, the Hindu Times, and numerous other media outlets worldwide. Respect for the remains of the deceased is universal. The public response was outrage, expressed in literally thousands of posted comments. Here are just 3 comments.
Jessie’s Case Appeared In The Sacramento Bee & On Evening News Broadcasts
The California Health Facilities Licensing and Certification office is just 11 miles from the hospital. It would have been difficult for Health Facilities employees to miss Jessie’s story and miss recognizing the obvious violations of state regulations. The Health Facilities mission: “We ensure compliance with state licensing laws and federal certification regulations in our role as the state survey agency for the Centers for Medicare and Medicaid Services… But for some undisclosed reason, an investigation was not initiated. In an email, Hospital Watchdog asked Sacramento District Manager of Licensing and Certification, Daniel Schut, why a survey of Dignity’s Mercy hospital was not conducted. A reply came from Mark Smith in the California Department of Public Health Office of Communications: “…by law, we are unable to respond to them (our questions) or provide any further information.”
What state laws appear to have been violated?
Legal Issue #1: Why Didn’t The Dignity Doctor Complete A Mandatory Death Certificate Within 15 Hours?
A California healthcare regulation required the attending physician, Nadeem Mukhtar, DO, to complete the death certificate within 15 hours of Jessie’s death. (Health and Safety Code § 102825). But it took Dr. Mukhtar a year before he completed the Certificate of Death. On April 4, 2024, 362 days after Jessie died, the death certificate was completed by Dr. Mukhtar. But no explanation was provided by Dignity or by Dr. Mukhtar for his inexplicable, unlawful delay in completing the death certificate.
Legal Issue #2: Why Didn’t Dignity Make Sure The Hospital Filed A Death Certificate With 8 Days?
In addition to Dr. Mukhtar’s failure to complete the death certificate, Dignity’s Mercy San Juan Medical Center failed to file a death certificate with the local registrar within eight days of the death. (Cal. Health & Safety Code § 102775).
Legal Issue #3: Did Dignity or Cremations Only Obtain A Required Permit To Move & Store Ms. Peterson’s Remains For 1 Year?
For each death, the state must give a Disposition Permit for the Disposition of Human Remains (also called a “Burial Permit” or “Disposition Permit”). Under California Health and Safety Code §103070 a permit is needed when a body is going to be buried, cremated, or moved. It appears highly unlikely a permit was issued to move and store human remains for one year, during which advanced decomposition would occur.
Legal Issue #4: Why Didn’t Dignity Notify Jessie’s Mother Of Her Death?
California Code of Regulations, Title 22, Section 70707 mandates that ”family requests for information, including a patient’s condition or death, should be addressed promptly and reasonably.” Jessie’s mother was listed as her next of kin. She had contact with the hospital during Jessie’s previous hospitalizations. Yet, she was never informed of her daughter’s death. In addition to violating a state regulation, Dignity violated federal regulation 42 CFR §482.13. Hospitals must inform a patient’s family or representative of significant changes in the patient’s condition, including death, promptly.
Legal Issue #5: Why Didn’t Dignity Transfer Jessie’s Remains To Her Mother As Required By Law?
California Health and Safety Code § 7100 establishes that control of a deceased’s remains is vested with “the surviving competent parent or parents of the decedent.” Dignity violated this regulation by covertly storing Jessie’s remains for one year, rather than vesting the remains with Jessie’s mother.
Dignity’s Mishandling Of Human Remains Goes Beyond Jessie Peterson’s Case!
Investigative reporter Lycee Mitri, of the NBC affiliate KRCA, revealed another case where human remains went missing at Dignity’s San Juan Medical Center. After the death of Michael Gray at Dignity, his remains disappeared. Like Jessie Peterson, Mr. Gray also experienced housing instability or homelessness, but he also stayed in close contact with his family. Mr. Gray’s mother, Valerie Gray, reported him missing in August 2021. A detective made the discovery of his whereabouts by tracking his credit card and discovering that after making a purchase at a 711, he went outside and collapsed. An ambulance took him to Dignity, where his death had been unreported for an entire month.
It may be significant that both Jessie Peterson and Michael Gray were experiencing homelessness at the time of their hospitalizations at Mercy.
Conclusion: Dignity Health’s Handling Of Two Deceased Patients Warrants A State Investigation!
In the case of Jessie Peterson, Dignity Hospital violated state and federal healthcare regulations. Those regulations were designed to respect the remains of the deceased. In addition to the Jessie Peterson case, the case of Michael Gray is also pertinent. It’s abundantly clear there are systemic human remains problems at Dignity Health’s San Juan Medical Center. These issues should be fully addressed by the Health Facilities Licensing and Certification Program. Over 19,000 patients are admitted to Mercy Hospital each year. These folks deserve an assurance that if they die in this hospital, their remains will be treated with respect and reverence. Dignity has not provided that assurance!
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