An elderly Alaskan died alone of hypothermia in the spring of 2021 even though concerned neighbors had reported the elder’s worsening condition multiple times to state social services personnel.
That’s according to a report out Thursday from the state ombudsman.
“We found multiple opportunities to actually help the vulnerable adult that were missed,” Alaska State Ombudsman Kate Burkhart said.
A nearly three-year investigation by Burkhart’s office, which is tasked with investigating administrative complaints against state agencies, found that Adult Protective Services acted unreasonably and inefficiently by deprioritizing the elder’s case and failing to follow through with help before their death.
According to the report, which only notes that the elder lived in an Alaska community that gets cold in the winter, this is what happened:
In January 2020, neighbors were getting worried the elder did not have heat at home, and they hadn’t seen them for a few days.
An animal rescue organization was paying the elder’s electric bill. Though the elder could no longer drive, their car still served one useful purpose: a source of heat.
The neighbor submitted a report to Adult Protective Services. The screener who took the report classified it as Priority 3 out of 4, requiring a response within 10 business days.
A month later, the elder was too weak to walk. Their electricity had been disconnected. There was no running water. Their home was piled high with belongings. The stench of animal waste was inescapable.
The neighbor reached out to Adult Protective Services again.
It would be another month – March 2020 – before a state caseworker knocked on the door and yet another month before a report of the visit made it into the agency’s records.
About a year later, the elder would be dead of hypothermia.
The issues identified at Adult Protective Services raise larger questions about the ability of Alaska’s state government to provide for the state’s elders, said Burkhart, the state ombudsman. Those questions will grow more pressing in the years to come, she said.
As of 2022, about a fifth of Alaska’s population is over 60. The population over 70 has nearly doubled since 2010. By 2050, the population of Alaskans 65 and older is forecast to grow by 30%. The working-age population is expected to grow just 2%.
“We’ve talked a lot about, you know, ‘Our population is aging. Let’s plan for that,’” Burkhart said. “Are we able to meet their needs? I don’t know.”
And beyond the state’s capacity, the aging population presents a question of values, she said: In a place where personal autonomy is a core part of residents’ identity, when should the state step in to protect someone from themselves?
A state website for the Adult Protective Services program puts it like this: “Freedom is more important than safety. The person can choose to live in harm or even self-destructively provided that he or she has the capacity to choose, does not harm others and commits no crime.”
According to the ombudsman’s report, when the caseworker visited in March, the electricity and heat were on, though the house was filthy and filled with animal feces. Local cab companies refused to transport the elder because of the smell.
The caseworker asked if the elder would consider moving into an assisted living facility. The elder declined, at least at that time. They didn’t want to leave their animals. But the elder said they would consider selling their property.
Adult Protective Services outlines its principles in its policy manual, saying the office “provides supportive and protective services to Alaskans within the philosophy of respect for the individual’s right to refuse services and to exercise self-determination in the receipt of services.”
As a result, adults who caseworkers believe have the power to make decisions for themselves – and understand the consequences of those choices – must consent before caseworkers can serve them. And if adults aren’t able to make decisions for themselves, Adult Protective Services is directed to choose the least restrictive solution, such as a power of attorney rather than a court-appointed guardian or conservator.
Though the caseworker found enough evidence that the elder was suffering from “self-neglect,” as the report notes, the caseworker concluded the elder didn’t fit the criteria for more intensive help without consent. After all, they were used to asking for help from local organizations and neighbors. The caseworker closed the investigation.
By October 2020, the roof was caving in. A door was missing. There was no heat or running water. The house had sold, but the elder was still living there.
A neighbor contacted Adult Protective Services again, worried the elder might freeze to death. The screener again classified the report as Priority 3.
“Again, APS classified a report of a disabled elder at risk of freezing as a low priority,” the report states.
A caseworker called about a week later. The elder told the caseworker they had access to food and had purchased some new heaters. The elder explained that though the property had been sold, they didn’t have money for a new place to live and had fallen victim to an internet scam.
According to the report, the caseworker did not recall whether the scam was reported to police, though the worker’s notes “indicated that they had encouraged the adult to report the scam to Facebook.”
Later, during a conference call with a caseworker and the real estate agent who had helped sell the property, the elder mentioned they might give their Permanent Fund dividend to a family member. “The APS Worker documented that they thought this may be connected to another internet scam,” the report says.
The caseworker discussed money management with the elder but declined to pursue appointing a guardian or conservator against their will, maintaining the elder had the capacity to decide for themselves. Instead, the caseworker started looking for a family member to take power of attorney, a less restrictive arrangement.
It took nearly four months before the adult gave the caseworker the right phone number, according to the report, but the family member quickly agreed.
Later in March, a food delivery service called for a welfare check, saying the elder hadn’t picked up their food in three days. Speaking to state troopers before the welfare check, the caseworker “expressed concern that the adult may be at risk for suicide,” according to the report. The trooper found the elder at home, determined the elder was not in imminent danger, and asked them to call their caseworker. The elder did not.
Two days later, a family member told the caseworker the elder wasn’t answering their phone. The family member said they were concerned the elder wouldn’t consent to the power of attorney arrangement.
The caseworker contacted their supervisor and a senior assistant attorney general, telling them they planned to file for an emergency conservatorship, which could be evaluated by the court within 72 hours.
But the caseworker never followed up. They told the ombudsman’s office “they had a large caseload for the region and did not receive overtime,” according to the report, though investigators did not find evidence the caseworker had requested overtime.
A community volunteer found the elder dead on March 31, 2021. The State Medical Examiner identified the cause of death as hypothermia.
The case was closed eight days later. Though the adult had died alone, of hypothermia, in a home with a collapsing roof and what a state trooper described as trash piled four feet high, Adult Protective Services maintained that the elder, before their death, had the capacity to seek help and was thus not a “vulnerable” adult.
Burkhart’s report issued eight recommendations, from caps on caseloads to new staff.
The Department of Health’s Division of Senior and Disabilities Services, which runs Adult Protective Services, has fully accepted six of the eight recommendations. Among them, it agreed to offer more intensive training to its screeners and caseworkers and create “multidisciplinary teams” of experts to review complex cases, an approach that has shown promise in other settings, according to studies cited in the report. The report also recommended clearer guidelines for reporting suspected crimes to law enforcement.
The ombudsman’s report also recommends three new positions: an administrative assistant and a quality assurance manager to free up time for senior staff, plus an additional supervisor.
But as the state continues to reckon with the fallout of an ongoing staff shortage, state officials say it’s difficult or impossible to act on all of the report’s prescriptions.
The division pushed back on the ombudsman’s recommendation to determine and stick to a reasonable limit for the number of cases assigned to each worker.
In 2022, management estimated that each caseworker carried 50 to 70 cases, a figure slightly higher than the 26- to 50-case range found in a majority of other states, according to the ombudsman’s report. The head of Senior and Disabilities Services told the ombudsman that implementing that recommendation would be difficult.
“Since 2020, APS has had a 50% turnover rate yearly, leading to staff shortages. Currently three positions in the unit are vacant. Given these challenges, limiting the number of case assignments to workers would not be feasible,” division director Anthony Newman wrote to the ombudsman. “We are unsure when we will be fully staffed and when we will see a stabilization in staffing.”
Given the difficulty in hiring, Newman said his division would consider reassigning one existing staffer to fulfill the recommendation for a new supervisor.
In a statement to Alaska Public Media, the division’s deputy director, Lynne Keilman-Cruz, said she was unable to discuss the specifics of the report but said the division takes the recommendations seriously.
“APS acknowledges the findings and is working to implement changes to address any deficiencies found in regard to the oversight of investigation processes. Adult Protective Services takes seriously all reports of harm and works diligently to ensure the health, safety, and welfare of Alaska’s most vulnerable individuals,” she said in an email.
One of the recommendations is much broader than new staff or training: that Adult Protective Services rethink its mission.
“The agency prioritizes personal independence, and that’s a value many of us have. Another value we have is taking care of our elders, and there was tension between those values in this situation,” said Burkhart, the ombudsman.
She says the agency’s approach – prioritizing independence over health and wellbeing – meant the elder’s self-neglect and hoarding were treated as a choice, rather than a symptom of serious mental health issues.
“Personal independence and freedom from unnecessary and unwarranted government intrusion are values held by Alaskans. Certainly, state government agencies should not limit or infringe on the rights of individuals unless absolutely necessary to protect them from harming themselves or others,” the recommendation reads. “However, as the population ages and incidence of severe self-neglect continue to present difficult cases for APS, it may be time to revisit when and how the State protects vulnerable elders from dying the way this adult did.”