Killed by the System

Killed by the System: Death at the Army’s Hands
by Mark Thompson, TIME

Left, Cassidy during his tour of Iraq in 2006

Iraqi insurgents wounded Gerald Cassidy in the deafening blast of a roadside bomb just outside Baghdad on Aug. 28, 2006. But it took more than a year for him to die from neglect by the Army that had sent him off to war. When Cassidy returned to the U.S. last April, the Army shipped him to a hospital in Fort Knox, Ky., to get treatment for the excruciating headaches that had accompanied him home. For five months, he made the rounds of Army medical personnel, who couldn’t cure a pain that grew steadily worse. Unable to make room for him in a pain-management clinic, the Army increasingly plied him with drugs to dull the torment. 

At summer’s end, the headaches had grown so intense that Cassidy pleaded once more for help, and his doctor prescribed methadone, a powerful narcotic. The next day, calls to Cassidy’s cell phone from his wife Melissa went unanswered. After two more days without word from her husband, she frantically called the Army and urged that someone check on him. Nine hours later, two soldiers finally unlocked the door to his room. They found Cassidy slumped in his chair, dead, his laptop and cold takeout chicken wings on his desk…

The "manner of death" was summed up at the end of the 12-page autopsy: "Accident." But when he died, Cassidy had the contents of a locked medicine cabinet coursing through his body, powerful narcotics and other drugs like citalopram, hydromorphine, morphine and oxycodone, as well as methadone. The drugs–both the levels that Cassidy took and "their combined, synergistic actions," in the medical examiner’s words–killed him.

Horrifyingly, it appears that Cassidy lived for up to two days after falling into a stupor. Forgotten and alone, he sat in his room until he died. "My God, he was there for three days, and no one even found him. That’s a huge scandal," says Dr. William Kearney, Cassidy’s Army psychiatrist. Regulations that require a soldier to show up for formation three times a day or be tracked down were widely ignored, say soldiers who stayed at Fort Knox. "You could easily linger for two days in a coma," Kearney says, "and if anybody had opened his door, they would have found him unconscious and they would have called 911."

Soldiers fall through the cracks in every war. But the death of Sergeant Gerald (GJ) Cassidy, a cheerful 31-year-old husband and father of two, highlights the tragic and persistent shortcomings of Army medicine. The same Army that spends $160 billion on tomorrow’s fighting machines is shortchanging the shell-shocked troops coming home from war in need of healing. Cassidy was promised world-class health care. But he didn’t get the simple help–quick treatment, pain-management classes, knowledge of his whereabouts or even a roommate–that could have saved his life.

Combat Trauma

Cassidy grew up playing army games with cousins and re-creating Civil War battles on a Ping-Pong table covered with fake grass and tiny trees in the basement of his Carmel, Ind., home. He joined the Army Reserve in 1992, and the Indiana National Guard in 2003, intending to serve 20 years, get a pension and then retire to teach junior-high history. He served in Bosnia in 2004. And in April 2006, when the Army called, Cassidy left his landscaping job for Iraq. "Some guys had gone to Iraq three times at that point, and he hadn’t gone," Melissa says. "He felt if he volunteered, someone else would get to stay home."

In Iraq, Cassidy’s job was to protect the serpentine convoys that carry food, fuel and mail to and from Kuwait. On a routine mission in August 2006, a roadside bomb blew up 10 yds. (9 m) from his armored humvee. There was no apparent damage to the humvee or the four men in it. But for two to three minutes after the attack, Cassidy lost his hearing, and he quickly developed a bad headache. The next day medics diagnosed a minor concussion. "Since that time," he wrote in a January 2007 statement, "I have been plagued with migraine headaches every seven to 10 days."

Melissa was grateful when Cassidy finally came home. "I felt like I could breathe again," she says. But because of the continuing head pain, the Army decided to send him to Fort Knox, 150 miles (240 km) from his home in Indiana. It was a strange choice. Cassidy was apparently suffering from traumatic brain injury (TBI) compounded by posttraumatic stress disorder (PTSD), which should have required treatment by neurologists. But there are none at Fort Knox’s Ireland Army Community Hospital.

Just as the Pentagon failed to anticipate the duration and cost of the Iraq war, it has been woefully unprepared for the waves of wounded who return home needing care. Earnest, hardworking medical personnel haven’t been able to handle the deluge. At Fort Knox, Cassidy and more than 200 other soldiers were placed in a newly created Warrior Transition Unit (WTU). The Army is spending $500 million this year on such units, in which troops operate as a military detachment and continue to be paid. After a 2007 Washington Post series focused attention on poor conditions at the service’s flagship Walter Reed hospital in Washington, the Army created the units to streamline the care of Army outpatients. There are currently 8,300 soldiers in 35 WTUS. One in 5 suffers from TBI, PTSD or both.

Mild TBI is the "signature wound" of the Iraq war, afflicting up to 250,000 troops. It nearly doubles the chance of developing PTSD, according to a recent study in the New England Journal of Medicine. While severe TBI cases are easily identified by bloodied and broken craniums, disorders in which brains are rattled inside intact skulls by IEDS (improvised explosive devices) are harder, and sometimes impossible, to diagnose.

During his first month at Fort Knox, an MRI of Cassidy’s brain revealed no "hemorrhage, edema, mass effect or midline shift" that would clearly indicate TBI. Nonetheless, his case manager made a note in his file that "headaches are gradually worsening." Cassidy tried a slew of prescription pain relievers without success. Because there was no physical evidence of an injury, a civilian neurologist working for the Army who examined Cassidy in late April concluded that the headaches were most likely "posttraumatic migraines." The doctor prescribed two more kinds of drugs. It was the soldier’s lone visit to a neurologist during his 13 months of headaches.

"He Was Getting Worse" 

At Fort Knox, Cassidy spent most of his time alone in his room with his laptop computer and Xbox video game. "While he was at Fort Knox," his wife says, "he was actually getting worse." He met with his case manager weekly but saw Kearney, his psychiatrist and only regular doctor, barely once a month. Their first visit was on May 30, 2007, nearly two months after he arrived at Fort Knox. "Alert and smiles throughout the interview, is anxious," Kearney typed into Cassidy’s file. "He was under fire and under constant stress and was mortared frequently." Kearney prescribed Valium and another medication in addition to the other drugs the soldier was already taking. 

But while the pills sometimes worked, they didn’t keep the headaches at bay. "We kept asking, ‘What’s the treatment plan here?’" his wife recalls. "There was never an answer for that." After a terrible headache drove Cassidy to Fort Knox’s emergency room, Kearney prescribed methadone for the first time on Sept. 13.

Cassidy’s final day of Army medical care began early on Tuesday, Sept. 18. That morning the Fort Knox medical clinic noted that he was "awake, alert, oriented to time, place and person, well developed, well nourished, well hydrated, healthy appearing, in no acute distress." A short time later, Cassidy met with Kearney, who observed in his file that "the methadone worked for the headache…used 40 mg without difficulty or too much sedation." So Kearney wrote a prescription for 16 more 10-mg methadone tablets "for severe pain" after discussing "potential side effects with patient who indicated understanding." Cassidy showed no suicidal inclinations, Kearney added.

About lunchtime, Cassidy spoke by telephone with his mother Kay McMullen. "Mom, there’s a lift dropping huge bundles of shingles on top of the roof," she says he told her. "It seems like I’m back in Iraq again–my head is pounding." But around dinnertime he had an upbeat conversation with Melissa. He talked happily about visiting home the next weekend. Two weeks after that, he was to return for good and continue treatment at a civilian hospital.

Melissa was unable to reach her husband on his cell phone later that night or the next day. By Thursday, she became anxious after he had failed to respond to her four messages. On Friday morning, she called and found his voice mail was full. Moments later, her apprehension turned into panic when she dialed into his cell-phone messages and found he hadn’t listened to any of them, including her good-night call on Tuesday.

She immediately dialed Kearney and her husband’s platoon sergeant, but they didn’t answer. She reached a soldier at his barracks who promised to hunt him down. When Melissa hadn’t heard anything by mid-afternoon, she called the barracks again and spoke to Sergeant Rory Martin, another outpatient. She asked him to check to see whether her husband had applied on Wednesday, as required, for his weekend pass. When they spoke again four hours later, Martin told Melissa that Cassidy had not applied for a weekend pass and that a knock on his door had gotten no response.

Martin promised he would find her husband, but when she hadn’t heard from him by 6:45, Melissa placed another call to Martin’s cell phone. "I haven’t got in yet, I haven’t got in yet," Martin told her, voice shaking. "Let me call you back, sweetie." Then he hung up. "I knew," Melissa says quietly, "something was terribly wrong."

After another hour, Colonel Rhonda Earls, the hospital commander, got on the phone to give Melissa the news. "Mrs. Cassidy, I regret to inform you that we found your husband in the barracks, and he is dead." A military chaplain and casualty-assistance officer arrived at the house at about midnight.

Killed by the System

Martin, who found Cassidy’s body, can still recall his horror but says he understands how it happened. "Nobody there had accountability for nobody," he says. Sergeant Jim Hunt, who lived in the Fort Knox barracks from January to July 2007, says only about half of those who were supposed to show up for mandatory formations–at 7 a.m., 1 p.m. and 4:30 p.m.–actually did.

Five days after Cassidy’s death, the Government Accountability Office told Congress that more than half the WTUS had "significant shortfalls" in key positions. At Fort Knox, more than half the squad-leader positions–those most responsible for Cassidy’s well-being–were unfilled. An Army report on TBI released in January also offered a grim assessment, finding "no specific standards" for dealing with the TBI problem, "major gaps" in coordinating care and "no medical-provider core competencies." Now the Army is rushing to catch up, setting up screening tools and treatment plans to deal with TBI and a "center of excellence" dedicated to the challenge.

A month after Cassidy’s death, the Army removed from command the three soldiers most responsible for his well-being. The Army suspended Kearney on Jan. 11 after an aide to Indiana Senator Evan Bayh, who has been probing the circumstances surrounding Cassidy’s death, complained that he was still seeing patients. (Kearney says he did nothing wrong and is a victim of political pressure.) "The enemy could not kill him, but our own government did," Bayh said of Cassidy. The Senator has succeeded in requiring the Army to make sure wounded soldiers are sent to the "most appropriate" facility for care and to set time limits on delivery of that care.

But for some, such reforms come too late. Cassidy’s death was the first in a string of at least three that led to urgent meetings at the Pentagon earlier this month on how to prevent them. They included soldiers who died in late January at WTUS in New York and Texas. Lieut. General Eric Schoomaker, the Army’s top doctor, told TIME that easy access to drugs and lack of accountability played key roles in Cassidy’s death. "If there’s any good to come of this at all," Schoomaker said, "it’s that we will work as hard as we possibly can to prevent any recurrence." But moments later, he conceded that while Cassidy is the first such death, he’s "not an isolated case. We know of several others at this point." Once again, Sergeant Cassidy is leading soldiers in a war not of his making.