A 60-year-old Black man committed to Lemuel Shattuck Hospital’s psychiatric ward died a “painful, untimely death” due in part to the state’s failure to provide adequate health care, according to a report released Monday.
Haywood Earl, residing at the public hospital in Jamaica Plain, likely would have survived his bout with skin cancer if he’d received a timely diagnosis and appropriate medical treatment, the nonprofit Disability Law Center concluded in a 28-page report.
Instead, Earl was a victim of neglect, the organization said. He died in 2020, about three years after being seen by a hospital dermatologist to evaluate a mole on his nose that turned out to be cancerous, all while living at the Shattuck, surrounded by mental health and medical personnel.
Earl’s sister Beverly Goodridge, his legal guardian, told GBH News that the center’s conclusions brought her both satisfaction and sadness. The 65-year-old Randolph woman said she asked the Disability Law Center to investigate Earl’s death, concerned he had been failed by the system.
“I felt like, wow, if he had gotten the proper care, he could possibly still be here,” Goodridge said during an interview at a Dorchester cemetery where Earl is buried. “His life was worth something.”
The authors of the report concluded that the Shattuck failed to biopsy a lesion on Earl’s nose when he was first seen by a dermatologist in 2017; failed to adequately communicate with Goodridge, his legal guardian; and waited almost a year after determining he needed surgery to get him medical help.
Tatum Pritchard, the center’s litigation director, said Earl’s case reveals systemic issues in the 250-bed state hospital.
“This gentleman was in the hospital the entire time,” Pritchard said. “So the fact that he experienced medical neglect that led to his death from cancer is incredibly shocking.”
State officials released a written statment late Friday calling Earl's death "tragic." They said since 2020, the hospital has made major changes, including the hiring of an "entirely new executive team," recruitment of new doctors and improvement of communication between guardians and their health care teams. They say they “traditionally” review unexpected deaths but plan to set up a process to review all deaths at the hospital by July.
"Following the tragic death of this patient, DPH has made significant improvements at LSH and the other three public health hospitals since 2020," said Ann Scales, a Department of Public Health spokesperson. "The Massachusetts Department of Public Health is committed to the health and safety of every patient at Lemuel Shattuck Hospital and ensuring they are treated with dignity and respect."
The Shattuck treats some of the poorest patients in Massachusetts, including prisoners, the unhoused and people with mental illness. Findings in Earl’s case, the center’s authors write, “raise concerns about access to medical treatment for persons with mental health disabilities.” The hospital made changes to how it operates last year after the Disability Law Center first shared its findings with officials, but the report’s authors believe more should be done to make patients are treated in a timely way and without bias.
Earl’s case is coming to light nearly two months after an investigation by the GBH News Center for Investigative Reporting revealed a history of problems at the hospital, documented by patients, prisoners and former employees.
March’s GBH News story centered on one particular Shattuck doctor, Adriana Carrillo, who has been sued by prisoners 20 times alleging medical malpractice and other issues. The orthopedic surgeon said through an attorney that she has done nothing wrong and has never lost a legal case. But critics say that medical malpractice cases are notoriously hard to win, especially for prisoners filing lawsuits without attorneys — and that allegations of medical mistreatment are emblematic of wider problems of oversight and poor care at the public hospital.
State Sen. Jamie Eldridge, a Democrat from Marlborough who leads the Criminal Justice Reform Caucus and sits as the Senate Chair of the Judiciary Committee, said he was concerned about GBH News’ findings. He joined a group of state lawmakers last week to tour the Shattuck.
“I came away from the whole visit with a lot of unanswered questions,” he said. “We’re going to dig deeper.”
Earl’s final years
Goodridge described her brother as a sweet and beloved member of her family who was diagnosed with schizoaffective disorder. The middle of three children, Earl graduated from English High School in Boston and studied photography at Emerson College before dropping out. Over the years, she says, her brother lived on his own and in a series of state and private hospitals.
His last stop in 2017 was the Shattuck’s Metro Boston Mental Health Units.
Goodridge says she begged health officials not to send her brother to the hospital, which state officials consider a “safety net” for patients who have nowhere else to go.
“I had literally objected, did all I could, just as a common citizen: please do not send my brother there,” she said. “I just sensed it would be downhill for him.”
Goodridge said she visited her brother weekly at the psychiatric ward, where depending on his mental state, he lived in a room by himself or shared with others. She said the cleanliness of bathrooms was deplorable and other patients would come up to her often and say they wished they had a sister like her to watch out for them. She said she'd take him away for weekends when he was able, and he often wouldn't want to return.
Three months after his arrival, Earl went to see a hospital dermatologist, Shahla Asvadi, about the lesion on his nose, the report said. Suspecting a particular form of skin cancer, Asvadi prescribed a lotion and told Earl to come back in two months. He returned for follow-ups, but she didn’t order a biopsy to confirm her diagnosis. Several months later, Asvadi recommended surgery to treat the “lesion — now nodular and bleeding occasionally,” according to the report.
Even then, it took another 11 months before Earl was sent to a surgical consult at an outside hospital, the report said. In August of 2019, more than two years after he first saw Asvadi, Earl underwent surgery at Boston Medical Center where doctors removed part of his nose. “Due to the extent of the tumor, the wound on his face could not be completely closed,” the report said.
But the cancer spread, and Earl died about a year later.
"I hope that people will take [this] as a cautionary tale of why we have to do better."Tatum Pritchard, Disability Law Center’s litigation director
A medical expert hired by the Disability Law Center to review Earl’s records determined that he “would have had a high chance for survival at initial presentation if treated promptly, despite any challenges associated with his mental health condition.”
Asvadi, reached by phone in her office last week, said that she hadn’t even known about the Disability Law Center investigation into Earl’s death until a GBH News reporter called her.
“I did nothing wrong,” she said. “I know that I am a good physician.”
Asvadi says she works out of her Framingham office and also has a contract to provide care at the Shattuck. She says she is board qualified as a dermatologist, but not board certified. Asvadi invited a GBH News reporter to meet her at the hospital to discuss further last week, but when the reporter arrived, she was escorted out of the building by hospital officials.
Asvadi is also facing a wrongful death suit in Suffolk Superior Court with similar allegations to those detailed by the Disability Law Center. In the complaint, filed by the mother of a former state prisoner, Asvadi allegedly failed to order a biopsy of a mole on the prisoner’s right cheek despite “clear risk factors suggesting a malignant growth.” The man, Micah Gibson, died in 2018 at the age of 41.
Asvadi says she had requested that the Department of Correction send Gibson back to the hospital a few weeks after her first in-person visit with him, but he wasn’t brought back for months. At that point, he was diagnosed with malignant melanoma. She said she didn’t want to cast blame, but stated she couldn’t control when he’d be brought back from prison.
“He should never have died at that age,” she said.
State officials said they couldn't comment on a case in litigation. Jonathan Shapiro, the attorney for Gibson’s mother, claims both Asvadi and the prison health care system failed them.
“There was no biopsy, and even though Dr. Asvadi asked that he be returned for a follow-up in six weeks, the prison health care people failed to do that,” he said.
The Disability Law Center report found a series of violations of medical “standard of care” related to Haywood Earl’s death. More than a year ago, the center shared its findings with Shattuck officials for the first time.
The Shattuck has since made changes to how it operates, including standardizing the use of photos to document lesions, improving internal communication and requiring biopsies on lesions before starting treatments, according to the state health department and the report. State officials say the hospital has found “no support” that any mistakes were caused by bias.
The Disability Law Center believes more needs to be done. Earl’s case, the report’s authors write, is a “saddening and disturbing example” of unequal care that people with disabilities, especially people of color, receive across the nation. Studies show people with mental disabilities have poor health outcomes, partly because some people can’t communicate with their health practitioners, or their doctors are biased against them.
“I hope that people will take [this] as a cautionary tale of why we have to do better,” Pritchard said.
Among its recommendations, the center wants the state to provide board-certified doctors when making speciality referrals. It also says the hospital should take another look at whether bias contributed to Earl’s death.
And the authors said the state should do a better job investigating deaths — because if it hadn’t been for Beverly Goodridge bringing his case to the center, no one might ever have known about what happened to Earl.
State officials told GBH News they found no evidence that bias affected Earl's care; nevertheless they will continue to "address implicit biases" through training.
They said that while the hospital prefers board certification for physicians, they can't guarantee all physicians will be certified, partly because of their availability.
"It is important to also recognize that lack of board certification does not impugn a provider’s care," Scales, the department's spokesperson, said. "Providers forgo board certification for many reasons including monetary."
On a recent spring day, Goodridge placed flowers at Earl’s gravesite in Dorchester. She says she misses her brother and worries about other patients still residing at the hospital with no one to advocate for them.
“They’re in a specialized care hospital that not only has the services to treat them for mental illness, but also the services to treat them for the medical, but yet they do not get adequate treatment,” she said. “Treat them like human beings.”