Law Dean Linda L. Ammons
today presented a list of 68 recommendations, ranging from proposed changes in state law to more public accountability for the people who investigate misconduct claims against physicians, as she shared the findings of her independent review with Gov. Jack Markell.
Markell tapped Ammons Jan. 13
to undertake the review after the arrest of Dr. Earl Bradley, the Lewes pediatrician accused of sexually assaulting more than 100 children in his care. Prosecutors allege Bradley filmed many of the assaults.
Markell asked the dean to probe Delaware statutory and administrative procedures governing child abuse and exploitation to explain how alleged criminal behavior at such a massive scale could go undetected for so long. Prosecutors allege the abuse dates back decades. Working on a pro bono basis, Ammons spoke with nearly 70 people around the country in an exhaustive examination of the facts and circumstances.
The dean completed her report late yesterday and presented it to the governor this morning. He began briefing leadership of both political parties from both legislative chambers after their meeting.
Ammons called the criminal case against Bradley on charges of rape and molestation “perhaps the pedophilia case of the century,” in her report. She wrote that no one mandated by Delaware law to report child abuse had forwarded information about Bradley to state agencies in the manner required by current law.
She found that only two people – Lt. Kenneth Brown of the Milford Police Department and Lynda Barnes, Bradley’s sister and former office manager – had attempted to call attention to concerns and suspicions about Bradley’s behavior. Instead, the pediatrician was able to continue practicing despite complaints about his behavior first raised in Pennsylvania in the 1990s through a combination of Bradley’s cunning, carelessness and inattention to detail by the Medical Society of Delaware and Beebe Medical Center, communication breakdowns and a lack of action by a medical regulatory board with a reputation for protecting the very individuals it is meant to police, according to her report.
“A mass tragedy of this magnitude may have been pre-empted if the individuals directly involved had been alert, less willing to give Bradley the benefit of the doubt, and if they had scrupulously followed the law,” Ammons concluded. “Systems were in place to catch a perpetrator, but, they were either not properly assessed, or when called upon, human and mechanical error prevented the appropriate actions from being taken.”
Among her findings:
- A nurse at Beebe Medical Center told hospital officials in November 1996 that she had concerns about Bradley taking photos of patients in his office without their guardians’ knowledge. She also complained to her supervisors about excessive kissing of patients and inappropriate remarks about females, and questioned his medical practices involving young female patients. The nurse remembered giving the hospital names of complaining patients and offered to provide many more, but the hospital declined the offer. Ammons found the hospital did not report the information to authorities, including the state medical board.
- An apparent fax machine transmission error caused a letter by Barnes, airing concerns about her brother’s unprofessional behavior, to cut off one of its two pages en route to the Delaware Medical Society. The affected copy included a section noting parents had complained about Bradley improperly touching their daughters. However, enough of the letter did transmit to warrant a formal referral to the Board of Medical Practice, which licenses and regulates Delaware doctors and is authorized to conduct investigations. Ammons found that was not done – and the lack of action was inconsistent with what the law would require.
- Multiple entities reported different and sometimes conflicting stories on who they thought was taking responsibility for alerting the Board of Medical Practice to the complaints and allegations against Bradley. The board did not log a complaint until after the allegations were publicized by the media in 2009, despite the law requiring six classes of people to have done so years before in a matter like this. Ammons found specifically that the Department of Justice should have communicated directly and in writing to the board about allegations against Bradley as early as 2005, noting others who would have reported to the board refrained from doing so, instead apparently relying on the Justice Department’s representation that it would.
Markell also asked the dean to provide recommendations that would foster a child-protection community of collaboration and accountability to better protect children from predators. She responded with 68 recommendations, including these 14:For the Board of Medical Practice:
1.) Open the board's hearings to the public and communicate hearing outcomes through easily accessible public records.
2.) Add public and other professional members to the board, now made up of medical experts, to enhance objectivity.
3.) Professionalize the hearing process by hiring administrative law judges to conduct the hearings and make findings of fact for the board.For the executive branch:
4.) Establish clear internal administrative disciplinary sanctions for agencies that fail to meet their responsibilities for reporting child abuse.
5.) Establish a central repository for reports of all accusations by name of alleged victim and accused perpetrator, accessible to all law enforcement, medical and child welfare agencies.For the Department of Justice:
6.) Establish internal protocol to ensure deputies and staff report vital information to the requisite agencies about suspected abusers.
7.) Evaluate whether deputy attorneys general are too risk-averse in taking hard cases.
8.) Invest in a comprehensive case-management system accessible to all deputy attorneys general to track every civil and criminal case.For the General Assembly:
9.) Consider whether a sexually violent or dangerous predatory statute, which requires civil commitment of those who are a threat to the public but cannot be successfully prosecuted, should be adopted. Twenty states have such a provision.
10.) Amend Delaware law to make it clear when and if law enforcement agencies are exempt from reporting to the medical board.
11.) Ensure that licensing boards have access to any criminal report.
12.) Increase penalties for those who violate the law’s reporting mandates.For hospitals:
13.) Have consistent protocol guidelines as to how they will investigate, and keep records concerning all medical personnel if allegations of sexual exploitation are raised.For the Delaware Medical Society:
14.) Keep more thorough records of what is discussed with the state Board of Medical Practice.
The full report can be found on the governor’s homepage at governor.delaware.gov