CLEARWATER, Fla. — In January of 2022, the ABC Action News I-Team reported how Jimmy Johnston was involuntarily committed, placed in guardianship and spent more than a year in Morton Plant Hospital as his family fought to get him out.
He died in the hospital, and a toxicology report showed high levels of drugs were in his system when he passed.
Since then, I-Team investigator Adam Walser has been following his family’s ongoing search for answers and accountability.
“You can imagine the sadness here”
“The first thing I did was call Clearwater police,” said Kathleen Johnston, writing with a marker on a poster board.
She documented the many twists and turns in her family’s search for answers about her brother Jimmy Johnston’s death.
“This is just a small sample of the papers and the hoops we’ve been going through to get some justice for Jimmy,” Kathleen said, pointing to files of documents related to contacts she had with local and state governments.
Jimmy, a U.S. Navy veteran who struggled with schizophrenia, died alone after spending a year in Morton Plant Hospital while his family fought in court for his release.
“You can imagine the sadness here of us having to do this,” Kathleen said.
Kathleen’s sister Patty and brother Tommy share in the sadness.
The siblings all live in Indiana and can’t sue the hospital because Jimmy didn’t have a wife or any children.
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“That’s not the issue. The issue is, why did they do this to him?” said Tommy.
Kathleen has used her professional skills to try to come up with answers.
She is the founding director of an investigative journalism center at Indiana University.
“I was a senior investigative producer for CNN, I worked at CBS News, I worked in newspapers. I’ve had a long career in this business,” she said. “The system is not working.”
A year in the hospital under a Baker Act and guardianship
Jimmy and his sisters signed a form at Morton Plant Hospital in January 2020 designating Kathleen and Patty, his healthcare surrogates, to make decisions if he couldn’t.
“They insisted that we sign it,” Patty Johnston said.
But when Jimmy returned to Morton Plant for a mental health episode three months later, the hospital went to court without contacting his family and had him involuntarily committed for six months under Florida’s Baker Act, saying “the patient requires a highly structured setting for safety and cannot be maintained safely outside of a hospital setting."
A lawyer working for the hospital then obtained guardianship without informing the judge that Jimmy’s sisters were his surrogates.
A guardian paid by the hospital was put in complete control of his care.
Kathleen hired a lawyer, went to court and was eventually appointed his guardian, but Jimmy's doctors refused to release him.
“I’ve helped people all my life in my career, and I couldn’t save my own little brother’s life. It’s gut-wrenching, it’s gut-wrenching,” Kathleen said.
Toxicology report shows high levels of drugs
Jimmy died on March 21, 2021, three days before a hearing to determine if his family could move him out. His death certificate listed natural causes.
But a toxicology report from a private autopsy his family paid for raised concerns about the level of drugs in his body.
“The cause of death of this gentleman is most probably a result of overdoses of medicine as obtained in the toxicology report,” Kathleen read from the private autopsy report.
Forensic psychiatrist Dr. Craig Beach reviewed the findings for the I-Team.
“The Clozapine level was around 20 times higher than the upper limit of that usual blood level range for Clozapine. And the Haloperidol level was around 50 times higher,” Beach said.
A hospital spokesperson said in an email, “While we cannot comment directly on any patient’s toxicology results, we do know that blood levels for some pharmaceuticals are significantly higher when drawn postmortem.”
“Those levels aren’t normal. There’s no way to pretend that they are,” Beach said.
“The only place he was getting the drugs was the hospital. They were administering it to him,” Tommy Johnston said.
Kathleen sent the autopsy and toxicology reports to multiple local and state agencies, but none followed up with the pathologist.
“Not the health department, not the prosecutor, not the police,” Kathleen said.
State agencies don’t provide answers
The Agency for Healthcare Administration, which oversees hospital safety in Florida, investigated 16 months after receiving the complaint and closed the case after a single visit.
“At the time of the inspection, they did not find the facility was violating any laws,” Kathleen read from a letter in which AHCA closed the case.
Kathleen filed complaints with the Florida Board of Medicine.
“They lost one of the complaints against one of the doctors,” Kathleen said.
Then there was another issue.
“They said the expert is unable to read the records because the hospital sent them over jumbled,” Kathleen said.
Jimmy had more than 24,000 medical records at the time of his death.
A hospital spokesperson denies that there was a problem with how they were turned over to the board, saying in a statement, “The hospital turned over a single digital file with records in chronological order.”
In a closed meeting, a committee heard the case and found the doctors did not violate standards of care.
“It’s closed door. I can’t be in there,” Kathleen said.
“Somebody needs to be accountable”
A Clearwater Police spokesperson told us the investigator Kathleen spoke with had died, and they couldn’t locate records on the case.
Kathleen sent all the records she had to Assistant State’s Attorney Rene Bauer, including autopsy report, the toxicology report and a 1,500 page abstract she obtained from the hospital after a legal battle.
“She said I’ve decided with the evidence I have, there’s not a crime here,” Kathleen said.
Bauer told the I-Team she thoroughly reviewed the documents, but there was not enough evidence to prove to a jury that a crime had been committed and who was responsible.
Jimmy’s siblings said they’re not giving up.
“Somebody needs to be accountable,” Tommy said.
We contacted the Florida Board of Medicine and AHCA about their investigations but did not receive any additional information.
The family has also contacted federal agencies, who they say are looking into different aspects of the case.
They contacted Indiana Sen. Mike Braun's office and he brought Jimmy's story to the floor of a U.S. Senate committee hearing about problems with court-ordered guardianship earlier this year.
"I heard from the sister of Navy veteran Jimmy Johnston who said that a court ordered guardianship ultimately led to her brother’s death," Braun said.
"After Jimmy’s death, his family received a hospital bill of nearly $1.2 million. Nearly all of it was billed to Medicare. That’s unacceptable," he said.
If you have a story you think the I-Team should investigate, email us at adam@abcactionnews.com
