Joseph Shepter died in January 2007 at age 76. On Shepter's death certificate, the nursing home's chief medical officer, explained that the cause was heart failure brought on by clogged arteries.
Shepter's family had no reason to doubt it. The local coroner never looked into the death. Shepter's body was interred in a local cemetery.
A tip from a nursing-home staffer would later prompt state officials to re-examine the case and reach a very different conclusion.
When investigators reviewed Shepter's medical records, they determined that he had actually died of a combination of ailments often related to poor care, including an infected ulcer, pneumonia, dehydration and sepsis.
Investigators also concluded that Shepter's demise was hastened by the inappropriate administration of powerful antipsychotic drugs, which can have potentially lethal side effects for seniors.
Prosecutors in 2009 charged two former colleagues with killing Shepter and two other elderly residents. They've pleaded not guilty. The criminal case is ongoing.
Gone Without a Case: Suspicious Elder Deaths Rarely Investigated - ProPublica
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