Seabaugh, then 36, and his wife Sheri were walking along the shore that afternoon when he spotted a gray garbage bag in shallow water. Angered at the brazen act of littering, he planned to take the bag with them to deposit in the nearest trash can.

All these years later, he can remember everything about the moment. The bag tied with a knot, heavy, sagging as he lifted it. He felt the thin plastic, grasping for some clue to its mysterious contents.

His stomach climbed to his throat.

Oh my God, he thought. What is this?

Seabaugh’s discovery would spark a multi-agency investigation into one of the region’s most horrific crimes, the murder of 23-year-old Decatur mother Karyn Hearn Slover. Four years and thousands of tips later, authorities homed in on her suspected killers: ex-husband Michael Slover Jr., and his parents, Michael Slover Sr. and Jeannette Slover.

Macon County prosecutors built a case entirely on circumstantial evidence, some of it considered at the time to be cutting-edge forensics — dog hair DNA analysis and comparisons of concrete and cinder samples. In the end, they convinced a jury that the elder Slovers murdered their former daughter-in-law, with their son’s tacit approval, to stop her from taking her 3-year-old son and moving out of state.

In the two decades since the Slovers were sent to prison, the salacious details of their case have become fodder for the burgeoning true-crime entertainment industry. All the while, the Slovers have insisted they’re innocent and fought in court to clear their names.

For Michael Slover Sr., that fight ended with his death in prison in 2022. But his wife and son have continued to push for a new trial, aided by the Illinois Innocence Project, a nonprofit based at the University of Illinois at Springfield that works to overturn convictions in a state infamous for sending innocent people to prison.

Earlier this year, IIP attorneys launched what could be the best, and last, attempt at exonerating the Slovers. In a sweeping, nearly 2,000-page amended petition for post-conviction relief filed in February in Macon County court, attorneys say DNA testing previously unavailable during the initial trial “conclusively demonstrates the Slovers’ innocence.”

“Disturbingly,” attorneys wrote, authorities have not run the new DNA evidence through a federal database that could identify Karyn’s real killers, which, they added, could be three men whose names first surfaced as possible suspects days after Karyn disappeared.

The petition also mounts a detailed attack on the state’s evidence in the case, calling it a “junk science house of cards” that “completely collapses when subjected to scientific review and modern understandings of forensic science.” It goes on to accuse prosecutors of using false and misleading witness testimony to win a conviction.

Macon County State’s Attorney Scott Rueter did not respond to multiple messages seeking an interview for this story. Karyn’s family declined to be interviewed.

The question of whether the Slovers should receive a new trial now falls with 6th Judicial Circuit Associate Judge Rodney Forbes. The next status hearing is scheduled for July 11.

“The murder of Karyn Hearn Slover was a terrible tragedy,” IIP attorneys wrote in the petition. “This tragedy was further compounded by convicting three innocent people for a crime they did not commit.”

Part 1: The aspiring model goes missing

Friday, Sept. 27, 1996.

Two days before the Seabaughs’ lake trip.

Melany Jackson sat in the lunchroom inside the Decatur Herald & Review newspaper office, where she worked part time as a layout clerk. In two years, she had come to make friends with several co-workers, including an energetic and outgoing ad rep named Karyn.

At work, or while playing racquetball, the two shared stories from their lives. Jackson heard Karyn talk about her 3-year-old son Kolten, about her struggles with her ex-husband and former in-laws, and about her goal of becoming a model.

Karyn had professional headshots taken (photos that were widely circulated after her disappearance and murder), and had done some local jobs. But she wanted more.

A month or two earlier, Karyn applied to a company called Paris World International, based in Savannah, Georgia. For a yearly fee, the company offered opportunities as film extras or models in runway shows or catalogs.

Earlier that Friday, Karyn and her boyfriend, fellow newspaper employee David Swann, went to the post office and overnight-mailed a contract to the company, which, she excitedly told Jackson, had lined up a modeling job for her in Atlanta.

It wasn’t a permanent move, but, Jackson remembered, “it felt like a door was opening.”

Karyn left work around 5 p.m., driving Swann’s 1992 Pontiac Bonneville, which, he would later tell authorities, he let her borrow because her car needed an oil change and new brakes.

She had to pick up Kolten from her former in-laws and stop at the mall to buy a dress for a wedding she and Swann were attending the next day (there is debate as to which task she intended to do first). Eventually, she planned to swing by his place to pick up laundry she left there and then head home to make dinner for her son.

Swann, who had been at the wedding rehearsal that night, got home a little before 10 p.m. He spotted Karyn’s laundry bag in the same place she left it.

“It didn’t click right away,” he would later tell investigators.

Around the time Swann came home, a Piatt County sheriff’s deputy pulled over to investigate an abandoned Bonneville on the westbound shoulder along Interstate 72, about 40 miles northeast of Decatur.

The car was still running, its driver’s side door open, keys still in the ignition, dome light and tail lights and headlights still on.

There were no immediate signs of foul play.

The deputy ran the car’s unique license plate, CADS 7, and a dispatcher contacted its owner, Swann, who, upon learning there was no sign of Karyn or Kolten, called Karyn’s parents before hurrying to the stretch of interstate.

Karyn’s father, Larry Hearn, called the Slovers’ house in Mt. Zion to ask where Karyn and Michael Jr. were.

Junior’s at work, Jeannette Slover replied, and Karyn hadn’t come to pick up Kolten.

Hearing that Kolten was still with the Slovers, Larry Hearn broke down in tears.

Melany Jackson’s phone rang around 7 the next morning. A co-worker at the newspaper told her Karyn was missing, her car found near Champaign. Jackson hurried to the office, where several dozen colleagues made posters with Karyn’s picture and a photo of a similar Pontiac Bonneville. They split into search parties and fanned out in different directions.

The search continued through Saturday and into Sunday. By Monday, Jackson was at Richland Community College in Decatur, about to teach an English writing class. A student approached her in the bathroom. She knew Jackson worked at the newspaper and heard from a relative in law enforcement that authorities were soon to hold a news conference about a discovery made the previous day at Lake Shelbyville, about 30 miles south of Decatur and 50 miles south of where the Pontiac was found.

“No! It’s not her!” Jackson reflexively yelled. “Whatever they found is not her!”

Shocked at what they might have stumbled upon on that Sunday afternoon, Tracy and Sheri Seabaugh took their boat to the nearest marina. There, they convinced an employee to let them use the phone to call the Moultrie County sheriff.

Deputy Jeff Thomas was dispatched to the call. He followed the Seabaughs’ boat to the shoreline where they found the garbage bag. The couple was visibly shaken, Thomas remembered.

“It’s probably just a deer carcass dumped by a poacher,” he told them, and himself.

Not wanting to disturb any evidence, Thomas donned gloves and cut into the side of the bag with a knife. There looked to be a second gray garbage bag inside the first, this one sealed with duct tape. He cut it open too.

The color drained from Thomas’ face, and the 23-year veteran deputy nearly collapsed at the sight of blond hair draped over a human ear.

Part 2: The Slover task force

Authorities quickly descended on the lake. They pulled five other similar garbage bags from the water that week, containing hands and feet, an arm, a thigh and parts of a torso. Some body parts would never be found.

Dental records confirmed it was Karyn. An autopsy concluded she’d been shot seven times in the head with a .22-caliber handgun before being dismembered, likely with a power saw. Neither the gun nor the saw was ever located.

With a sprawling potential crime scene spanning multiple jurisdictions, authorities created a task force of local, state and federal investigators to catch Karyn’s killer or killers.

At the lake, they found cinders, grasses, weeds and broken concrete with her remains. A blood stain, later confirmed to be Karyn’s, and at least one fingerprint — both on the bridge spanning the lake near Findlay Marina — suggested that was the spot where the bags were dumped into the water.

Two more fingerprints were discovered inside the front passenger window of the Pontiac. None of those prints ended up identifying a suspect. Curiously, authorities never tested unknown material under Karyn’s fingernails on her left hand.

Task force members initially looked at the men in Karyn’s life.

Though Swann, then 31, had been friends with Karyn for months, the two only recently started dating before her murder. He also had a past arrest that raised red flags among investigators.

Five years earlier, Swann was arrested in nearby Coles County and charged with breaking into his estranged wife’s apartment, armed with a .22-caliber handgun. Inside, he hit his wife while threatening to kill her. Swann eventually pleaded guilty to aggravated battery, court records show, and was sentenced to probation.

Authorities questioned Swann about the incident and about his whereabouts the night Karyn disappeared.

He told investigators he had been at a Decatur restaurant until about 7:30 that night. Next, he stopped at a hardware store to copy keys for a joke he planned on his friend, the groom in the wedding he and Karyn were to attend that weekend. Then, he went to the church for the wedding rehearsal.

There was a roughly half-hour gap in his alibi that he couldn’t initially account for. He eventually told police he stopped at an ATM during that time. Bank records and footage from the ATM camera verified his story. To police, he was no longer a suspect.

Swann declined to be interviewed for this story.

Investigators also focused on Michael Slover Jr. He and Karyn attended the same community college and met through mutual friends. They married in 1993 and welcomed their son Kolten that same year. Karyn’s friends later testified to seeing him physically abuse his wife, though, defense attorneys argued, they only told authorities about the alleged abuse after the case was in the media.

By May 1996, the marriage had ended. Their divorce agreement named Karyn as Kolten’s primary custodian and gave Michael alternate weekends with his son. And, in a stipulation that would come to be a focus for police and prosecutors, it read that the boy’s grandmother Jeannette would continue to be his babysitter until he started kindergarten, or until the parties agreed otherwise.

Michael gave investigators a three-page handwritten account of his actions that Friday, from 12:30 p.m. when he started his first job as security at a grocery store, until 2 a.m. the next morning, when he finished his third job as a bar bouncer.

His alibi was airtight and detailed — almost too detailed, Thomas remembered.

“I believe he could tell us exactly the denomination of bills and change he got to buy a milkshake,” remembered Thomas, who eventually became Moultrie County sheriff before retiring in 2014. “Most people wouldn’t recall all those fine details. It was overkill.”

Two of Karyn’s ex-boyfriends were also questioned. Both had alibis that excluded them as suspects.

Amid unrelenting press coverage and a torrent of tips about possible suspects, pressure to solve Karyn’s murder mounted. Decatur’s roughly 82,000 residents, meanwhile, reeled from another grisly crime.

Two years before Karyn’s murder, 30-year-old realtor Sherry L. Lewis was found fatally beaten and strangled in a Decatur home she had an appointment to show. Her case remains unsolved.

Then, in September 1995, 3-year-old Sara Lynn Kramer vanished from her family’s Decatur home. Her body was found by a fisherman in the Sangamon River four days later. It would be another five years before police identified her uncle as her killer.

Detectives on the Slover task force looked closer at Karyn’s life and uncovered financial troubles they felt could provide clues. She struggled to pay rent and utilities. She’d been hit with hundreds of dollars in overdraft fees and returned check penalties. Her car was almost repossessed. She contemplated bankruptcy.

The month she was killed, Karyn pawned a diamond ring for $120 despite the pawnbroker telling her it was worth more. Still, the investigation was never able to tie her money problems to a suspect, and as the months went by, the case grew cold.

That’s when authorities looked closer at Karyn’s former in-laws.

Part 3: The unlikely suspects

Michael and Jeannette Slover were childhood sweethearts in suburban St. Louis, married just after high school in 1966. They eventually moved to Mt. Zion, a tiny village just south of Decatur. Jeannette stayed home to raise their two children, Michael Jr. and Mary, while Senior worked in a trade union. He sold used cars from home, at first, and eventually opened Miracle Motors used car lot on Illinois Route 121, a few minutes from home, which he ran on nights and weekends.

They were content to live a quiet life at home. They listened to NPR on weekends, took evening walks and shared ice cream cones at Dairy Queen.

Investigators questioned the couple multiple times. They said they last saw Karyn around 5:45 p.m. the day before she disappeared, when they met at a McDonald’s to pick up Kolten.

Senior said he went to work at a Clinton power plant the next day while Jeannette stayed home to watch Kolten and a friend’s 2-year-old. The friend came to collect her child around 3:30 p.m. and Senior returned home about an hour later. He said he had lunch and watched television while his wife took their grandson to Kmart to look for a toy.

Jeannette and Kolten returned sometime after 6 p.m., she said. By then, her husband had left for Miracle Motors.

Karyn typically picked up her son from the Slovers between 5 and 6 p.m. But, Jeannette told authorities, it was not uncommon for her former daughter-in-law to be late.

In her grand jury testimony, she said she once told Karyn: “Don’t worry if you’re late. If you get a chance to call, OK. If not, just don’t worry about it.”

Jeannette said she called Karyn’s apartment and got no answer, so she took Kolten to the car lot around 8 p.m. She and her husband planned to take their grandson to the McDonald’s playland but he fell asleep on the drive over, she said, so they went home instead.

There had been no one at the car lot that evening and no one who saw the couple and could corroborate their story. In essence, they were each other’s alibis.

Eighteen months after Karyn’s murder, a search warrant in hand, police descended on the Slovers’ used car lot. By then, the family’s names had been in the news as possible suspects. They planned to sell the business, Michael Sr. told police, because no one would buy a car from him.

The lot was blanketed in snow, so investigators brought in a machine normally used by road crews to melt asphalt. Once the snow was gone, they divided the lot into a grid and began excavating the ground, aided by a forensic geologist and former Canadian police constable, Richard Munroe.

After three days of searching, police left Miracle Motors with 60, five-gallon buckets of excavated ground. They took the buckets, uncovered, to a warehouse where teams spent weeks sifting through them like prospectors, searching for clues.

Authorities returned to the car lot, now under new ownership, in September 1999. This time, they brought a University of Illinois professor who they asked to search the property for specific plants — foxtail, nimble will and switchgrass — found with Karyn’s remains.

On Jan. 27, 2000, more than 1,200 days after the Seabaughs’ horrific discovery at the lake, a Macon County grand jury indicted Michael Slover Sr., his wife and their son on first-degree murder charges and, for the male Slovers, concealment of a homicide.

Part 4: The case against the Slovers

The closely watched trial began in April 2002, but not before a flurry of activity.

Prosecutors initially sought the death penalty (still an option at the time), which gave the Slovers access to a state fund designed to help pay for investigators and expert witnesses in capital cases.

Those extra resources were cut off when the state’s attorney took the death penalty off the table.

The two public defenders appointed to represent Michael Sr. and his son — Jeannette had the lone private defense attorney the family could afford — tried to have the case continued, saying the loss of investigators and their existing caseloads left them unable to adequately prepare for the trial.

The request was denied, as was a request by the defense to move the case out of Macon County, citing a jury pool they argued had been biased by extensive media coverage and public comments made by the state’s attorney.

The state built its case around the theory that Karyn’s plan to take Kolten and move out of state to pursue modeling had enraged the Slovers — especially Jeannette, whose attachment to her grandson, they argued, bordered on fixation.

And so, prosecutors said, Michael Jr. crafted an airtight alibi while his parents killed and dismembered Karyn when she came to pick up Kolten that Friday in September. They used concrete from the car lot to weigh down the bags, the state said, hoping her remains would sink to the bottom of Lake Shelbyville, never to be found.

The Slovers “staged” Karyn’s car along the interstate, one prosecutor said during the trial, to draw attention away from the crime scene at Miracle Motors, giving the family time to dispose of any evidence — witnesses testified to seeing Michael Jr. burning things and weed-whacking on the property shortly after Karyn disappeared.

Among the testimony presented during trial, jurors heard that the excavation at Miracle Motors uncovered jean rivets and a metal button. A state police forensic scientist testified that both appeared to match the type of buttons and rivets on the jeans Karyn was wearing when she died. The same forensic scientist said a burned cloth button from the lot was also similar to the cloth buttons on Karyn’s shirt.

Munroe, the Canadian geologist, testified that concrete and cinders at the lot were similar to those found with Karyn’s remains. The university professor who searched Miracle Motors for specific plants identified with Karyn’s body testified he located two of the three varieties at the car lot.

And, a little over a decade after human DNA analysis was first used in a criminal investigation, the state presented testimony from Dr. Joy Halverson, who said she analyzed DNA from a strand of dog hair stuck to the duct tape that sealed one of the bags containing Karyn’s remains and concluded it could have come from one of the Slovers’ dogs.

The defense team tried to poke holes in the state’s case, arguing, among other points, that the Slovers regularly burned discarded clothing or other belongings left in the cars they purchased at auction for resale, and that the city had issued a notice three days after Karyn’s disappearance to cut tall weeds.

Even if the hair belonged to the Slovers’ dog, defense attorneys argued, it could have been transferred from Kolten or Karyn at any time. And, during cross-examination, the university professor who testified about plants at the car lot also acknowledged that all three types found with Karyn’s remains also grew in his backyard.

The nearly five-week trial ended May 17, 2002, when the jury returned a unanimous verdict against the Slovers. All three received 60-year prison sentences for the murder; father and son were given an extra five years for concealing the crime.

Before sentencing, the family had a chance to make a statement. All three said they were innocent.

“I just hope that someday the truth comes out,” Michael Sr. said in his statement, “and that somehow everyone knows that we had nothing to do with this.”

Melany Jackson did not attend the trial. She didn’t need to. In her mind, she knew who killed Karyn the minute she learned her friend and co-worker was dead.

All these years later, she can’t remember where she was when the verdict came down, or how she found out the Slovers had been convicted. She just remembers her first thought when she heard the news.

Finally.

Part 5: The IL Innocence Project

In the spring of 2002, as the Slover trial was about to begin, a student at the University of Illinois at Springfield pitched a project idea for her legal studies class.

Her husband, a Champaign defense attorney, heard about the case, she told the professor. And it appeared to them to be little, if any, hard evidence of the family’s guilt.

Her professor was Larry Golden. About a year earlier, inspired by a conference organized by the attorneys behind the Innocence Project, Golden and two others started a similar effort, then called the Downstate Illinois Innocence Project.

One of the founders, Springfield private investigator Bill Clutter, was familiar with the Slover case, having briefly worked for the defense team when it had access to capital defense funds.

The student eventually presented her report to Golden’s class at the end of the semester, after the trial had ended. Her assessment was that the family was innocent, Golden, 80, recalled, “or at a minimum should never have been found guilty.”

“In our minds, we knew this case wasn’t right,” said Golden, who remains the project’s founding director on its leadership team.

At the start, students in Golden’s class worked with the family’s appellate attorney on a motion for post-conviction relief. And as the project grew and added staff, its attorneys eventually took on the Slovers’ case.

Along the way, the family’s efforts met resistance in the courts.

In 2009, for example, the Slovers asked for new testing on the fingerprint found near Karyn’s blood on the bridge guardrail at Lake Shelbyville, and on a print left on a fast-food bag in her car. The state opposed the testing; an appeals court agreed.

The state also fought the Slovers’ request for DNA testing.

“Generally,” Golden said, “prosecutors and judges at the local level tend to be extremely resistant to admission of error, reopening cases and, in some cases like the Slovers, any belief that there was a wrong committed and that the people could be innocent.”

Part 6: The Slovers’ defense

By 2014, a Macon County judge cleared the way for the family’s attorneys to pursue DNA testing.

A partial DNA profile found on a piece of duct tape that sealed one of the bags containing Karyn’s remains excludes all three Slovers, IIP attorneys said in the court filing. Instead, the profile points to at least two unknown people, one of whom is male.

Other pieces of evidence tested at the family’s request revealed DNA profiles that exclude Jeannette and her son, the petition reads. One of those profiles appears to belong to at least three unknown males.

Analysts were unable to extract a suitable profile from a piece of hair submitted by Michael Sr. for comparison to the additional DNA samples. Still, attorneys argued in court filings that the DNA results are enough to exonerate the Slovers.

And yet, the family’s petition goes further, attempting to pick apart, at length, key pieces of evidence used against the family: dog hair DNA analysis, comparisons of cinders and concrete, grasses, buttons and rivets.

“In the early 2000s, this so-called evidence was presented as new and novel scientific evidence,” IIP attorneys wrote in court filings. “Now, more than two decades later, this ‘evidence’ could only be considered new or novel because it was not, in fact, based on any real or existing science.”

IIP attorneys asked an Elgin-based laboratory to review Munroe’s work on the case, which the lab’s scientists concluded was flawed at “every level of the scientific process.”

“Peaks in X-ray diffraction” used by the Canadian geologists to match concrete samples from the Slovers car lot to concrete found with Karyn’s remains were, the lab’s scientists wrote in a report, “just peaks of some of the most common minerals used in concrete in Illinois.”

A research geneticist commissioned by the IIP examined case files from Halverson’s DNA testing of dog hair found with Karyn’s remains and concluded that her analysis linking that hair to hair from one of the Slovers’ dogs “appears to be plagued by several problems.”

“Even two decades ago,” the geneticist wrote, “several major issues with (Halverson’s) analysis should have prevented the admission of her canine DNA evidence.”

Halverson’s work in three other criminal cases faced similar criticism, IIP attorneys noted.

Munroe could not be reached for comment. Halverson, 69 and retired, said her lab used the best available resources for what was then the nascent field of animal DNA testing.

To criticize her work all these years later, she said, is akin to criticizing NASA for once sending astronauts to space without modern computers.

“Do I stand by my results? Absolutely,” she said. “But if they want to impugn them because of the lack of bells and whistles, so be it.”

The IIP petition also accused Macon County prosecutors of using false testimony and inflammatory closing arguments to convict the family; similar allegations led to new trials in two other Macon County criminal cases a year earlier.

During the Slover trial, the defense team tried to poke holes in the state’s theory that Karyn was killed at the Slovers’ car lot. To do so, they called more than one person who testified to seeing the Pontiac and its unique CADS 7 plate between 5:25 p.m. and 9:30 p.m. the Friday she disappeared, in locations miles east of Miracle Motors.

But those witnesses said the car they saw had lightly tinted windows. And the state put Swann on the stand to testify, more than once, that his car’s windows were clear.

Two IIP volunteers later tracked down the car’s current owner and records from General Motors, both of which confirmed that the Pontiac did have lightly tinted windows, just as witnesses testified.

Another piece of Swann’s trial testimony drew the ire of IIP attorneys. He told the court he first learned that Karyn’s purse was found in his Pontiac when he got to the stretch of interstate where it had been abandoned that Friday night and, he added, he was unable to share that information with Karyn’s parents.

And yet, after Michael Jr. spoke by phone to his mom that same night, he told a bar co-worker that Karyn was missing and her purse was left in the abandoned car.

How could the younger Slover have known about the purse, the state asked, unless his parents killed her?

But, a phone transcript included with the family’s petition shows that Swann was told about the purse when a Piatt County dispatcher first called him to say his car was found.

Additional phone records filed with the petition reveal that he and Karyn’s parents exchanged two separate phone calls less than 30 minutes after Swann spoke to the dispatcher, followed quickly by a third call from the bar where Michael Jr. worked to Karyn’s parents.

“This evidence is critical in explaining how Michael Slover Jr. would know that Karyn’s purse had been found with the car,” IIP attorneys wrote.

The state’s closing arguments, alone, merit a new trial, IIP attorneys said. At one point, prosecutor Richard Current compared the dog hair DNA analysis with the DNA testing done eight months earlier to identify 9/11 terrorist attack victims. He also suggested that Karyn could not have been killed by a stranger because there was no evidence of a sexual assault and she was “a very attractive lady.”

Part 7: The alternative suspects

There is also a question in the minds of IIP attorneys about what the jury did not hear during the trial.

Around 4:30 a.m. on the day Karyn’s remains were found in Lake Shelbyville, a police officer in the tiny village of Grant Park, about 20 miles northeast of Kankakee, pulled over a Ford Mustang with three people inside, records included in the family’s petition show.

The officer stood near the driver’s side door and spoke with the driver. Meanwhile, a Suzuki that had been traveling with the Ford continued down the street for a block, then turned back toward the officer, sped across the lane divider and struck the officer before smashing into his squad car.

Both the officer and the Suzuki’s driver were taken to the hospital. Authorities learned the Ford had been reported stolen three days earlier in Effingham, about 60 miles south of Decatur.

There had been a second man in the Suzuki who, authorities were later told, grabbed his gun from under the passenger seat and bailed before the car hit the officer.

Three days after the Grant Park crash, the names of the Suzuki’s two occupants would surface in a tip about Karyn’s murder.

A police officer in Charleston, 55 miles southeast of Decatur, met with a source who had been told that the Suzuki’s two occupants and a third man stole a car from the Charleston area and drove to Decatur because one of them knew Karyn and wanted to see her. The man who knew Karyn raped her while the other two held her down and then shot her in the head, the source told the officer. The three dismembered her body, put her remains in garbage bags and dumped them in a lake because they noted how long it took authorities to find an Eastern Illinois University student who had recently drowned.

Records in the IIP court filing show that investigators received at least two similar tips identifying the Suzuki’s two occupants as being two of the three men responsible for Karyn’s murder.

Investigators searched both cars involved in the Grant Park incident, collecting hairs and fibers from the Ford. They also searched a Champaign motel room that the men reportedly rented for two nights, Sept. 26 and 27 — the last two days Karyn was seen alive. They found no evidence connecting them to her murder, and the fingerprint found on the Lake Shelbyville bridge was not left by either man.

Four years after the Slovers were found guilty, the man tipsters said fired the shots that killed Karyn was convicted in Tennessee on three counts of statutory rape of a 14-year-old.

That means his DNA could be in the national Combined DNA Index System (CODIS for short), an FBI-maintained database that contains more than 20 million DNA profiles.

But, IIP attorneys said, authorities have not entered the new DNA evidence from the Slover case into that database for any matches.

Part 8: ‘Who would do this?’

Michael Slover Jr. walked out of Robinson Correctional Center on March 15 of this year, paroled after 24 years behind bars. His mother’s projected parole date is in three more years.

About three weeks after Michael Jr.’s release, IIP attorneys filed into a Macon County courtroom for the first of what will likely be many hearings in their effort to overturn the family’s conviction. Before the next court date in July, they expect to have more DNA testing results they said would further prove the Slovers’ innocence.

“This would be almost the culmination of my career work with the project, with a belief that this injustice had been done,” Golden said. “I actually hope that I will be around to see some remedy to this.”

As for Kolten, the 3-year-old who became the crux of the prosecution’s case against his father and grandparents would eventually find himself at the center of another bitter court battle, this one a custody dispute between his aunt, Mary Slover, who legally adopted her nephew months before her family’s arrests, and Karyn’s parents, Larry and Donna Hearn.

In the end, the Hearns were awarded custody of Kolten, who is now approaching his 31st birthday.

Melany Jackson, Karyn’s friend and colleague, remains certain of the Slovers’ guilt. Now living in Colorado Springs, she said she did not intend to read the family’s latest court filing.

“Whatever evidence they’re going to put forth, I already know in my heart what happened,” she said. “I’m not interested in any efforts for them to be exonerated.”

Thomas, the former sheriff who took part in the initial investigation, said the evidence against the Slovers remains “overwhelming.”

“If not the Slovers,” he asked, “then who would do this?”

“Stalled Justice,” led by Tribune reporters Joe Mahr and Megan Crepeau, investigated why Cook County murder cases take so long to reach a resolution. The defendants in these cases are routinely locked up for years — sometimes up to a decade or more — without a trial. That’s longer than in any other major American city reporters could study.

Defendants and victims’ families both described feeling confused and hopeless as they wait year after year for closure. Reporters found frequent breakdowns at every phase of a criminal case, failures that have become so common that courthouse insiders barely register them as problems. Judges have the power to strike a better balance between fairness and efficiency but rarely exercise it.

The Tribune also found Cook County courts have ignored their own case management standards for years, as well as repeatedly disregarding recommendations for reform. The result is a justice system that has failed in its fundamental duties of fairness and competency.

To reach their findings, Tribune reporters observed hundreds of court hearings, interviewed victims’ families as well as defendants, analyzed millions of lines of raw data, and reviewed five decades’ worth of studies chronicling Cook County court delays.

“The presumption of innocence in our criminal justice system tends to be more myth than reality. But the Chicago Tribune treats the presumption seriously in this exceptional series on the impact of stunning delays in the Cook County courts,” said Taylor judge Ken Armstrong. “The series accounts for all the people hurt by the court system’s failures, be they a relative of a murder victim or a defendant awaiting trial. This could have been a laborious read, full of procedural jargon. It’s anything but. The reporting is deep and thoughtful, the writing clean and clear.”

The Taylor award recognizes work from across the country that exemplifies fairness in news coverage. It is administered by the Nieman Foundation for Journalism at Harvard University.

“The Chicago Tribune’s ‘Stalled Justice’ series represents the best in local journalism. The series had a very clear mandate, based on principles of fairness, and the reporters went to great lengths to seek out sources from all sides — from defendants to relatives to prosecutors to judges and administrators,” said another Taylor judge, Wonbo Woo. “They further took steps to ensure those sources were well-informed about their participation and were thoughtful in their approach to covering very sensitive issues.”

The team named as this year’s winner also includes Tribune photojournalist Brian Cassella and editors Jeff Coen and Kaarin Tisue.

The Tribune won 2017’s Taylor award for an investigation that exposed Cook County’s unfair property tax assessment practices, with ProPublica Illinois contributing. In past years, the Taylor award also has recognized the Tribune for reporting on Chicago’s corrupt red-light camera program, for a series on toxic flame-retardant chemicals, for exposing a clout-filled admissions process at the University of Illinois and for coverage of race issues in America.

The licensed practical nurse watches the doctor. Every few seconds, she looks at the patient’s face, searching for signs of distress.

As a chaperone in the Women’s Health Clinic at Edward Hines Jr. VA Hospital, Hill is present for sensitive procedures including Pap smears, breast exams and pelvic exams, acting as a witness and helping to protect both patients and doctors.

“As a chaperone, we have to ensure patient and provider comfort — for safety, privacy and dignity,” said Hill, who serves in that role in addition to her regular duties.

Preventing patient sexual abuse is an issue that’s gained national attention amid the fallout from scandals such as Dr. Larry Nassar’s abuse of female athletes; the hundreds of allegations leveled at former University of Southern California gynecologist George Tyndall; and Columbia University’s acknowledged failures regarding gynecologist Robert Hadden, also accused of sexually abusing hundreds of patients.

In Illinois, the Tribune recently exposed how several large Illinois health systems allowed health care workers who were accused of sexually abusing patients to continue working, sometimes leading to additional harm.

In one of the most egregious local cases, at least 30 patients have accused gynecologist Fabio Ortega of sexually assaulting them. Several women alleged in lawsuits he assaulted them after NorthShore University HealthSystem – now known as Endeavor Health – already knew he was under police investigation. Ortega pleaded guilty in 2021 to sexually abusing two former patients and was sentenced to three years in prison; his medical license was permanently revoked. Endeavor has settled 21 civil lawsuits related to Ortega.

The Tribune found that Endeavor and other health systems have faced few consequences from state or federal regulators for allowing providers accused of sexually abusing patients to continue working. Sometimes, all regulators required was a plan to do better in the future. The Tribune also found that the state agency that regulates many medical licensees can be slow to take disciplinary action, and providers who worked outside of hospitals sometimes practiced for months while police investigated allegations against them, because of loopholes in state law.

In addition to addressing those issues, some medical experts and survivors of sexual abuse say broader use of chaperones may be one way to prevent misconduct.

“I would like to see rules put in place where this can’t occur to any other women,” said Victoria, one of the women who has sued Ortega and Endeavor, alleging the doctor sexually assaulted her during an exam in 2017. The Tribune is using a pseudonym for Victoria because the Tribune generally does not identify survivors of sexual abuse or assault without their permission.

Victoria told the Tribune she doesn’t know why a chaperone wasn’t in the room with her and Ortega, especially given that he was under police investigation at the time because of another patient’s abuse complaint. She contends in her lawsuit that she asked if her partner could be in the exam room with her and was told no.

Endeavor now has signs in at least some of its doctors’ offices telling patients they can request medical chaperones. In response to Tribune questions, Endeavor said in a statement that it offers chaperones for sensitive exams, such as those involving the breasts or genitals. Endeavor also said it requires any provider accused of abuse to work with a chaperone or be removed from care pending the outcome of an investigation.

Endeavor declined to comment on specific allegations from Victoria and other patients, citing patient privacy and pending litigation. It also would not say whether Ortega was removed from care or required to work with a chaperone after women complained about his behavior, and did not answer questions about when it began offering chaperones for sensitive appointments or whether the policy is related to Ortega.

In a separate statement, Endeavor said it had “enhanced and evolved” its processes and policies to support the reporting of abuse allegations in the years since Ortega worked for the organization. “We have absolutely no tolerance for abuse of any kind,” Endeavor said.

Protecting patients, doctors

In the past, the American College of Obstetricians and Gynecologists recommended that chaperones be used when patients or doctors requested them. But in late 2019, the college changed its position, recommending that chaperones be present for all breast, genital and rectal exams with a few exceptions, such as during medical emergencies. Often, nurses or medical assistants serve as chaperones in addition to their other duties.

“Given the profoundly negative effect of sexual misconduct on patients and the medical profession and the association between misconduct and the absence of a chaperone, ACOG now believes that the routine use of chaperones is needed for the protection of patients and obstetrician-gynecologists,” the college wrote in 2019.

The same document also provided a list of unacceptable behavior during exams, including watching patients undress, asking unnecessary questions about sexual history or sexual desires, and touching patients’ genitals with ungloved hands.

Administrative rules in Oregon and Alabama require chaperones be present, or at least offered, during many exams of intimate parts of the body. Georgia’s administrative rules state that not having a chaperone present during certain types of exams is considered unprofessional conduct, unless the patient specifically refuses a chaperone.

Illinois has no law requiring chaperones at sensitive medical appointments, but the Illinois Department of Financial and Professional Regulation, the state agency responsible for oversight of doctors and many other licensed health care workers, can mandate in some circumstances that providers use chaperones.

So-called chaperone orders must be issued for individual medical providers, including nurses and doctors, if they have been charged with certain crimes, including sexual offenses. Chris Slaby, a spokesperson with the agency, said the orders are one of its “strongest tools.”

The agency has in at least one instance required that a health care provider utilize an attendant while his license is on probation, state records show.

In the absence of criminal charges and a state-issued chaperone order, it’s up to individual health systems in Illinois to decide whether to offer chaperones, and their practices vary.

Veterans Affairs hospitals across the country require chaperones during certain types of appointments, though patients can decline a chaperone if they wish.

Sinai Chicago requires chaperones for all of its gynecological appointments, according to spokesperson Dan Regan. Representatives for Cook County Health and Rush University Medical Center said those institutions also use chaperones for sensitive gynecological appointments.

Other systems in Illinois offer patients the option. Obstetricians and gynecologists who work for Ascension Illinois have signs in their offices telling patients they can request chaperones. At Advocate Health Care and Northwestern Medicine, chaperones are available to patients upon request, spokespeople said.

The American Medical Association recommends that physicians have chaperones available to patients upon request and make sure patients are aware of the option.

The use of chaperones can present challenges for medical practices and health systems, according to the American College of Obstetricians and Gynecologists. Using chaperones might mean a health system has to hire more people or treat fewer patients.

Dr. Kavita Arora, an OB-GYN and recent past chair of the ethics committee for the American College of Obstetricians and Gynecologists, estimates that she sees about 20% fewer patients in a day when using chaperones than she could otherwise. But she thinks it’s worth it.

“It definitely impacts flow,” Arora said. “However, I think it’s really hard to put a price tag on the ethical and legal issues surrounding misconduct and boundary violations.”

Not a perfect solution

Some physicians and patients resist the idea of a third person being in the room during invasive exams.

Dr. Christine Ko, a dermatologist and professor at Yale University in Connecticut, said she was not allowed to refuse a chaperone when she went to Yale Health for a gynecology appointment in 2022. Yale Health requires chaperones at all sensitive appointments, including those involving breasts and genitals.

Ko said she thinks chaperones should be allowed but not required; she wrote an article about the topic last year for MedPage Today.

“It’s uncomfortable enough to be naked in front of one person,” Ko said. “To me, it changes the dynamic if I’m naked or exposed in front of two people.”

As a physician, she said, she also knows that patients sometimes confide important personal information to their doctors that they might not feel comfortable disclosing with another person in the room.

In addition, Ko said the hierarchical nature of medicine makes it hard for her to imagine a chaperone calling out a physician for inappropriate behavior in the middle of an exam.

The American College of Obstetricians and Gynecologists says chaperones should be “empowered to report concerning behavior through a process independent of the health care provider being chaperoned.”

Red flags during sensitive exams

The American College of Obstetricians and Gynecologists lists examples of inappropriate conduct during exams that include:

• Watching patients undress
• Failing to drape patients for privacy
• Failing to obtain consent for sensitive exams, whether or not medical students are present
• Touching a patient’s genitals with ungloved hands
• Inquiring unnecessarily about details of a patient’s sexual history or sexual desires
• Touching a patient’s genitals orally

The organization acknowledges that “although chaperones may deter or discourage sexual misconduct by physicians, sexual misconduct still can occur in their presence.”

That’s what Pamela Harris says happened to her. Harris, who gave the Tribune permission to use her name, filed a lawsuit in 2022 alleging that Dr. Ala Albazzaz fondled her breast during an in-home exam in January 2020, even though an attendant was present.

“I was in tears. I couldn’t believe that happened,” Harris said in a Tribune interview.

State records show that the Illinois Department of Financial and Professional Regulation suspended Albazzaz’s license in 1997 after the agency heard testimony from six former patients who alleged sexual misconduct.

Earlier, prosecutors had filed dozens of charges accusing Albazzaz of touching women inappropriately during exams, according to Tribune reporting at the time. He was acquitted of criminal charges in 1990 related to one patient’s complaint and acquitted again in 1995 following a jury trial based on four women’s allegations, after which prosecutors dropped the remaining charges, the Tribune reported.

The state agency restored Albazzaz’s license to probationary status in 2008 and has required him to work with a female attendant when treating female patients ever since, according to state records.

Harris told Wheeling police in January 2020 that an attendant was in the room when Albazzaz examined her but the attendant’s back was turned when the doctor touched her inappropriately, according to Harris’ lawsuit.

“She should have been an active participant,” Harris told the Tribune. “She should have been facing me, watching what he’s doing and assisting, and she did nothing.”

Police closed the case in September 2020, records show; no criminal charges were brought against Albazzaz.

Albazzaz did not respond directly to the Tribune’s requests for comment on Harris’ allegations. In a letter to a Tribune attorney, a lawyer for Albazzaz described those allegations as “false”; he also stated that the female medical assistant was “observing and assisting Dr. Albazzaz, for the entirety of his examination of the patient.”

Training varies

None of the documents obtained by the Tribune address what training the woman at Harris’ exam might have had to be an attendant.

The American College of Obstetricians and Gynecologists says chaperones should be trained “in the requirements of best clinical practices.”

Health systems contacted by the Tribune take varying approaches to training chaperones. A spokesperson for Rush said it requires all newly hired nurses, medical assistants and certified nursing assistants to participate in training that covers medical chaperoning.

Sinai Chicago and Cook County Health said they don’t require any chaperone-specific training.

The Hines VA, which requires chaperones during certain types of appointments, is developing a policy about chaperones, based on existing VA requirements, that will include additional training on what to look for and the importance of intervention, said Krystal Gilewski, who managed the Hines VA’s Women Veterans Program until December 2022, and still works for the organization.

Cheryl Stevenson, a licensed practical nurse who often chaperones appointments at the Hines VA, said serving as a chaperone is “something you learn, you pick up being a nurse.”

During a chaperoned exam, Stevenson said, she stands where she can see the patient’s face. If the patient looks distressed or uncomfortable, she’ll ask the patient if she’s OK, after which the doctor will typically pause.

Stevenson, who’s worked at the Women’s Health Clinic at Hines since 2015, said she’s never witnessed a physician do anything inappropriate. But if a doctor did cross a line she wouldn’t hesitate to speak up, she said.

“It’s not an issue where you feel uncomfortable or can’t say anything,” Stevenson said. “That’s not the case.”

One local doctor with Endeavor wrote about the increased push for chaperones in an op-ed for the Tribune that was published shortly after Columbia University and its affiliated hospitals announced a multimillion-dollar settlement based on patients’ complaints against former gynecologist Hadden.

Dr. Emmet Hirsch, an OB-GYN, wrote in the October 2022 piece that he couldn’t think of a better way to protect patients undergoing sensitive exams than by using chaperones. Yet he expressed concern that having a chaperone in the room might signal to patients that their doctors cannot be trusted. Hirsch is director of the OB hospitalist program at Endeavor in Evanston.

“And yet, the fact is that our patients need a level of protection we have not previously provided,” Hirsch wrote. “I accept the necessity of having chaperones in my exam room — but I do so with sadness. Sadness that my practice has changed and sadness that my colleagues and I can no longer be relied upon to do no harm to the people who have entrusted themselves to our care.”

Hirsch did not respond to a request for comment, and Endeavor Health would not make him available for an interview.

DePaul University student Samantha Moilanen contributed to this story.

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As Victoria stepped into Dr. Fabio Ortega’s exam room in the summer of 2017, she had no idea the gynecologist’s career was hurtling toward destruction.

She didn’t know that an angry husband had called more than five months earlier to complain about Ortega’s treatment of his wife at a NorthShore University HealthSystem office in Skokie. The woman said the doctor had asked if it felt good when his fingers were inside her vagina, had conducted an ungloved breast exam, and had inquired about her sexual fantasies.

NorthShore, now called Endeavor Health, did not tell Victoria that Ortega was under police investigation as a result of that woman’s allegations, according to a lawsuit Victoria later filed. The Skokie Police Department had already gone back and forth with Endeavor about Ortega over a span of several months, police records show.

Nor was Victoria aware of Ortega’s previous history, including a patient who public records show had complained to Endeavor back in 2012, contending he had behaved inappropriately during an appointment.

Had Victoria known those things, she never would have agreed to see Ortega at his Lincolnwood office, she said in an interview. Instead, she wound up in a room with a gynecologist who would later serve prison time for sexually abusing patients.

“That’s what angers me the most, is NorthShore knew,” she said. “They could have done something.” The Tribune is using a pseudonym for Victoria because the Tribune generally does not name people who report being sexually assaulted or abused without their permission.

At least 30 women, including Victoria, have filed lawsuits alleging that Ortega sexually assaulted them during appointments over a span of three decades at various Endeavor locations and, before that, at Swedish Hospital in Chicago, formerly Swedish Covenant. Most of the lawsuits allege that Endeavor and Swedish either knew or should have known that Ortega was a danger to patients. They contend the health system failed to protect them.

Now a Tribune investigation has pieced together the fullest picture yet of Ortega’s troubled history with patients and Endeavor’s pivotal role in keeping the doctor in place, with access to vulnerable female patients, despite multiple complaints.

In court records, patient after patient described how Ortega had inquired about their sex lives while his fingers were inside them. They recalled the doctor’s attempts to sexually stimulate them and the vaginal and breast examinations they now believe were not medically necessary.

At Victoria’s appointment, she contends in her lawsuit, the doctor touched her thigh without medical gloves, joked about her boyfriend’s penis size and tried to stimulate her while stating he was touching her “G spot.” She left the appointment in tears, she told the Tribune.

Tamara Holder, an attorney who is representing nearly all of the women who have sued Ortega, Endeavor and Swedish, said an additional 123 of Ortega’s former patients have retained her and her co-counsels, Johanna Raimond and Stephan Blandin, to represent them.

Ortega pleaded guilty in October 2021 to sexually abusing two former patients, including the woman whose husband called the Skokie medical office, and was sentenced to three years in prison.

Ortega and Endeavor have settled 21 lawsuits in the last five years, according to court records. Ortega and Swedish Hospital, which Endeavor acquired in 2020, have settled an additional two lawsuits, and six lawsuits against the doctor, Endeavor and/or Swedish are still pending.

The terms of the settlements are confidential, and Endeavor has never publicly admitted any wrongdoing or error in its handling of Ortega and the allegations against him.

By contrast, after ProPublica reported last year that Columbia University had protected gynecologist Robert Hadden, who faced allegations from hundreds of women, leaders of Columbia and Columbia University Irving Medical Center said in a November news release that they were “deeply sorry” that “Columbia failed these survivors.”

The release said Columbia would notify nearly 6,500 patients of Hadden’s crimes and establish a $100 million survivors’ settlement fund. It also said the university would commit to an external investigation to examine the failures that allowed Hadden to abuse patients and work with outside experts to review the hospital’s patient safety policies and procedures.

Endeavor Health did not answer numerous written questions from the Tribune about the allegations and lawsuits against Endeavor, Ortega and Swedish, saying in statements that it was unable to comment on pending claims or litigation but that “Endeavor Health has absolutely no tolerance for abuse of any kind.”

“The past events reported are incredibly upsetting and concerning, and we recognize the tremendous strength and courage it takes for survivors of abuse to come forward,” Endeavor said in a statement. The statement said Endeavor is committed to “meaningful review and response to each patient impacted.”

In the time since Ortega last worked there, Endeavor has “enhanced and evolved” its processes and policies to support the reporting of abuse allegations, the statement said. “Our policies require we investigate all allegations of abuse that are reported to us, (and) take prompt action in all matters, including removal from care or chaperoning for providers during investigation,” it said. “We also support patients in reporting allegations, and fully cooperate with law enforcement.”

The health system offers chaperones for sensitive exams and has implemented sensitivity training for providers, another Endeavor statement said.

Ortega did not respond to requests for comment for this story. But at the court hearing where he pleaded guilty to sexual abuse, he denied that he ever meant to harm his patients.

Endeavor is a large health system with nine hospitals, including in affluent northern and western suburbs, and has a total of about 300 locations providing care. The health system had more than $5.3 billion in revenue in 2022.

Some of Ortega’s patients say they wish Endeavor had devoted more of its resources to protecting them.

‘Something is very, very wrong’

Elena kept what happened buried within her for more than a decade.

Elena (also a pseudonym) began seeing Ortega at Swedish Hospital in 2001, amid the excitement of her first pregnancy. Elena, who typically brought her husband or mother to appointments, told the Tribune she found Ortega to be trustworthy at the time.

The doctor, who is from Colombia, spoke to her and her mother in Spanish, which provided additional comfort, Elena said. She remembers her mother saying he seemed like a great doctor.

When Elena became pregnant again two years later, she didn’t hesitate to turn to Ortega. But for this pregnancy, she went to most of the appointments by herself.

The appointments seemed different this time, she said. It seemed as if Ortega often wanted to do a vaginal exam, even during appointments where she thought she was there only to check on the baby’s heartbeat, she said.

The vaginal exams were rough and painful, according to the lawsuit she later filed. At one point, when she complained about the pain, Ortega made a comment about the size of her husband’s penis, she contended in the suit.

“The look on his face, at times, I had to just turn away because there was just something gross,” she told the Tribune.

Still, she stuck with him throughout the pregnancy. “You’re in this state of confusion, you’re like: ‘I know this guy. He helped deliver my first child.’”

She couldn’t wait until the pregnancy was over, so she wouldn’t have to see him anymore. She didn’t say anything to anyone at the time, she said — she worried she wouldn’t be believed.

Once her daughter was born, Elena tried to move on with her life but experienced anxiety and depression, she said. She could no longer stomach seeing male doctors, she said.

One day, more than 15 years later, Elena was scrolling through Facebook on her phone when she saw a headline about Ortega being arrested on a charge that he had sexually assaulted a patient.

“In that moment, my heart sank to my stomach; everything just went pitch black,” Elena said. “That’s when reality set in, like, OK, wait a minute, something is very, very wrong.”

She also, however, felt some relief. Now that Ortega had been arrested, and others had come forward, she felt safe talking about her own experience and she filed her lawsuit in December 2019. She withdrew the lawsuit in June 2023 so her attorneys could focus on an Endeavor case that was set for trial, but said she intends to file again in coming months.

“I’m hoping the fact that women like me, that have decided to come forward, even if it’s 20-plus years later, it can inspire somebody to say, ‘Hey, it’s not too late,’” Elena said.

Women who have sued Ortega told the Tribune they felt uncomfortable during his examinations but didn’t report the incidents earlier out of fear, disbelief or because they trusted that a doctor would do them no harm. In their lawsuits, the women said it wasn’t until they learned of Ortega’s criminal charges that they realized his behavior reflected something more sinister.

Jennifer, a patient who saw Ortega for an appointment in March 2016, told the Tribune: “I drove home and I remember thinking to myself: ‘No, that didn’t happen. You’re overreacting. He’s a doctor. A doctor would never ever do that.’”

Jennifer – also a pseudonym – alleged that as her feet were in stirrups, Ortega began asking her questions about her husband and sex life. As he questioned her, he stroked her vagina in a rhythmic motion, explaining that he was rubbing her G-spot, prosecutors said at the hearing at which Ortega pleaded guilty.

She tried to squirm away from him, she said, but she couldn’t move much.

During the breast exam, Ortega rubbed and groped Jennifer’s breasts, according to prosecutors. She told the Tribune she started counting the little holes in the ceiling tiles to take her mind off of what was happening.

Finally, he finished. He told her to get dressed, she said, and to come back for another appointment. She left and never returned.

Continuing to practice

Even before Skokie police began asking Endeavor Health questions about Ortega in 2017, there were signs that something was amiss with the doctor’s behavior.

One woman told police after Ortega was charged criminally that in 2006 or 2007 she had requested a chaperone during her appointments with Ortega after one exam left her in tears. She continued seeing the doctor until she got health insurance and was able to see another physician, according to a 2018 Skokie police report obtained by the Tribune.

Endeavor officials told police at the time that they had no records indicating the woman was ever a patient of Ortega’s, but also acknowledged that records from the time period may have been purged, the police report states.

In addition, a patient told Endeavor in 2012 that Ortega had asked inappropriate questions and touched her inappropriately during an exam, according to a court transcript.

Leaders of obstetrics and gynecology at Endeavor met with Ortega and presented him with the patient’s complaint, according to a 2012 note from the health system’s obstetrics director that a Cook County judge described last year at a hearing related to another patient’s lawsuit.

It’s not clear from court documents how Ortega responded at the time, but he said last year, in response to written questions from Jennifer’s lawyers, that it was “determined that my questions and exam were not inappropriate.”

According to the judge’s description of the note, the patient ended up apologizing for her “misconception” about Ortega’s actions.

A 2019 lawsuit filed against Ortega and Endeavor by another patient alleges that she told Endeavor staff on multiple occasions that she was refusing to see Ortega because she did not feel comfortable with him. In a 2016 Yelp post about the Lincolnwood clinic that is quoted in her lawsuit, the patient wrote that “while most of the doctors are wonderful, I had a bad experience with one particular (Ortega) and I feel like my problem is being dismissed and like they don’t care. I have told multiple people I do not feel comfortable with him, and I basically got told too bad.”

A woman who sued Ortega and Endeavor in 2021 said in an affidavit that starting in April 2014 she told Endeavor schedulers on several occasions that she would not see Ortega.

Then came the patient whose angry husband called the Skokie medical office demanding to speak to Ortega after her appointment with the doctor in late January 2017. The woman also went to Skokie police, who first contacted Endeavor about a week after the incident, a police report states.

Endeavor allowed Ortega to see patients after police contacted the health system, court records show. Endeavor would not answer questions from the Tribune about whether it put Ortega on leave or at all restricted his duties in the months after the patient contacted police.

Officers spent more than a month going back and forth with an Endeavor office manager, an Endeavor attorney and the human resources department before they were able to question a medical worker and the physician who took the husband’s phone call, according to the police report.

At one point in the investigation, the report states, police received a call back from the human resources director only after police attempted to call Ortega and instead reached his wife.

During the same period that police were beginning to investigate the woman’s complaint, Endeavor was discussing the patient’s allegation with Ortega and the other doctor, according to police and state disciplinary documents.

Endeavor would not answer the Tribune’s questions about how it investigated the woman’s allegation. A complaint brought against Ortega by the Illinois Department of Financial and Professional Regulation in 2018 states that Endeavor discussed the allegation with Ortega on Feb. 10, 11 days after the woman’s husband contacted the medical group — and three days after being contacted by police.

The gynecologist who spoke to the patient’s husband told police in mid-March of 2017 that he had already been interviewed by the human resources director and another Endeavor manager, in the presence of two attorneys, according to the police report.

Police interviewed Ortega about six months after the patient went to police. Records show they also talked to him about another patient whose husband had reported the doctor to the Department of Financial and Professional Regulation in 2014, alleging inappropriate conduct. Police learned from the department, which oversees doctors’ licenses, that it had closed the complaint because it couldn’t reach the man or his wife for follow-up.

A civil attorney representing Endeavor was present when the police interviewed Ortega, along with the doctor’s criminal attorney, according to a police report. Yet Ortega went back to work the next day, according to a lawsuit filed by a former patient who alleged Ortega sexually assaulted her on Aug. 12, the day after police questioned him. Endeavor agreed to a settlement in that lawsuit, court records show.

Ortega went on leave Aug. 14, 2017, and resigned from Endeavor about a year later, Ortega said in response to questions raised in one of the lawsuits against him. The resignation came around the time he was indicted in 2018 on one charge of criminal sexual assault, related to the woman who went to police in early 2017.

Shortly after Ortega was indicted, the Department of Financial and Professional Regulation temporarily suspended his license. He was no longer allowed to practice medicine.

Connecting the dots

Jennifer said she was standing in her kitchen washing dishes when she saw a story on the news about Ortega that noted his arrest. She dropped the dish she was holding and ran to her bedroom, where she fell to the floor.

In the years since her appointment, Jennifer had felt depressed and experienced debilitating migraines. She said she had panic attacks so severe they sent her to the emergency room.

“It feels like you’re failing your children, you’re failing your husband, you’re failing yourself because you can’t figure out what’s wrong with you,” Jennifer told the Tribune.

It wasn’t until she saw his photograph on her television screen that it all started to make sense.

“I never would have connected the dots,” she said. “It was almost like a sense of relief. I wasn’t crazy.”

She then went to Lincolnwood police. Jennifer and her husband also filed a lawsuit against Ortega and Endeavor that was settled in July 2023. The amount of the settlement is confidential, and Jennifer spoke with the Tribune before the case was settled.

Carrie Ward, CEO of the Illinois Coalition Against Sexual Assault, said women who experience sexual abuse often don’t come forward right away.

Women may worry they’ll be blamed or won’t be believed over a doctor, Ward said. And when assault occurs at the hands of a medical provider, she said, it sometimes can take a while for the victim to sort out what was and wasn’t appropriate about the encounter.

“They’re expecting to be safe,” Ward said. “I think that does contribute to confusion for folks harmed in that setting.”

About 14 months after Ortega’s 2018 arrest, he was charged with a second count of criminal sexual assault related to Jennifer’s allegations.

At the 2021 hearing where he submitted his guilty pleas to charges of aggravated criminal sexual abuse, he tearfully told the courtroom: “As a physician … I had never intended to hurt anyone. Never, never. I sincerely apologize to the women who felt that I acted inappropriately.”

Jennifer’s attorneys asked Ortega in written questions, as part of her civil case, if he had sexually assaulted Jennifer.

“No,” Ortega answered last year. “I plead guilty to the charge based on advice of my attorney.”

He is now out of prison, and his medical license has been permanently revoked.

Silence and settlements

According to the Department of Financial and Professional Regulation, there have been 21 out-of-court settlements related to medical malpractice claims involving Ortega between December 2019 and March 2021 totaling more than $4.8 million.

Separately, in court, Endeavor and Ortega have reached settlement agreements in 21 lawsuits brought by women over the last five years, court records show. The settlement amounts have not been made public, and Endeavor’s recent financial statements make no mention of them.

Meanwhile, the Tribune found no records to indicate that Endeavor has been disciplined by the state or other regulators for its handling of the allegations against him.

That may be partly because of a loophole in Illinois law.

If a hospital worker or staff member has “reasonable cause to believe” a patient may have been abused at the hospital, the worker is required by law to report it to a hospital administrator. The hospital is then supposed to report the allegation of abuse to the Illinois Department of Public Health, and the hospital must take steps to protect patients, such as by “removing suspected violators from further patient contact” while hospital officials conduct a review. Hospitals may be required to come up with a corrective plan if the department’s investigation finds problems.

But the allegation brought to police in 2017 involved an appointment with Ortega at an Endeavor clinic — not at a hospital. And state law does not require clinics and independent doctors’ offices to report allegations of abuse to the public health department.

The federal Centers for Medicare & Medicaid Services requires many medical facilities — including the two clinics where Ortega mostly practiced — to protect patients from abuse, and facilities can be cited for failing to do so. Federal records do not show any patient abuse citations against Endeavor related to Ortega.

The federal agency did cite Endeavor late last year after a woman alleged sexually inappropriate conduct by a patient care technician at Evanston Hospital. An investigation by the state health department found in October that the hospital did not have a written system in place for handling sexual abuse allegations. Endeavor submitted a corrective plan that included enhanced training and a new policy on how to handle sexual abuse allegations.

In a statement to the Tribune, Endeavor said its hospitals already had written policies and processes on how to handle abuse allegations. “Nevertheless, we did update our policy to add specific information in the written policy for escalating allegations of ‘sexual abuse,’” the statement said.

Endeavor has never publicly announced changes in its policies or procedures related to what happened with Ortega. And in addition to the confidential settlements reached with his patients, the Tribune found attorneys for Endeavor have also sought to control what information about lawsuits is accessible to the public before they are settled.

Court records show that, at a May 2023 court hearing related to the civil cases, a lawyer for Endeavor raised concerns about former patients of Ortega’s having “been to the media.” The judge then issued a verbal protective order that “prohibits any dissemination” of discovery documents in the case except to the attorneys and certain others involved.

One of the pending cases the judge and attorneys continue to discuss is Victoria’s — the woman who alleges Ortega assaulted her in July 2017, months after Endeavor became aware the doctor was under police investigation.

Victoria was uncomfortable about going to that July appointment, she said in an interview. At an appointment with Ortega eight months earlier, she contends in her lawsuit, he asked her questions about her orgasms and sexual history while touching her intimately.

But by July she needed to visit a gynecologist urgently, she told the Tribune. In her lawsuit, Victoria alleges that she asked if her partner could go into the exam room with her but was told no.

“​​The least they could have done was have someone in the room with me,” Victoria told the Tribune. “Protect him or protect me, but take a stance and have a chaperone there. I don’t think that’s asking too much.”

When Victoria learned in April 2023 that Ortega had pleaded guilty to sexual abuse, she understood that she too had been harmed by him, according to her lawsuit.

Victoria realized she wasn’t alone, she told the Tribune — she wasn’t the only one who felt victimized by Ortega and Endeavor. She decided to reach out to Holder, the attorney, and file a lawsuit.

Her lawsuit is, at the moment, the only pending lawsuit against Endeavor and Ortega, after 21 others settled. Five lawsuits against Ortega and/or Swedish Hospital are also still pending.

Two of the settled lawsuits were filed by women who, like Victoria, alleged that Ortega sexually assaulted them at Endeavor facilities while he was under police investigation in 2017.

“I would like to see (Endeavor) held accountable since they knew, and did nothing about it to protect me,” Victoria said. “It’s an abuse of power. It’s looking the other way.”

Help the Chicago Tribune report on medical misconduct

The Tribune hopes to continue reporting on how hospitals and other medical institutions respond when patients report instances of sexual misconduct by health care providers.

If you have information to share, please fill out this form. Responses will not be published without your permission.

And while some medical systems in other states have reckoned publicly with their failures, Illinois health care providers have quietly settled lawsuits, entered into confidentiality agreements with patients and often refused to acknowledge wrongdoing.

“You would hope that a hospital organization or health care provider organization would be more invested in rooting out bad apples,” said one state legislator. “As we’ve seen in the priesthood and school systems and police departments, it’s easier to just hide bad behavior and hope it goes away.”

The Tribune also found efforts by state government to hold providers accountable have fallen short, largely leaving hospital systems to decide on their own how to balance patient safety with their reputations and financial interests.

Patients reported sexual abuse by medical providers. Health care systems let them keep working.

Failures by health systems to respond adequately to abuse allegations had devastating consequences for victims, who felt betrayed by institutions they had trusted with their health and safety.

The daughter of one woman who was victimized at age 76 by nurse David Giurgiu said her mother was devastated when she learned Giurgiu had allegedly abused another patient at Glenbrook Hospital. It wasn’t until the second allegation that the hospital fired him.

“That made everything worse,” the daughter said. “She was like, ‘If they just would have believed me, this wouldn’t have happened to another woman.’” Read part one of our investigation.

Failure to protect: Flawed state oversight lets doctors accused of abuse continue to see patients

Doctors and other health care providers accused by patients of sexual misconduct kept practicing – sometimes for years – because of gaps in Illinois laws and a licensing agency that can be slow to take disciplinary action, part two of a Tribune investigation found.

The providers went on to harm additional patients, in some cases, as their licenses remained in good standing with the Illinois Department of Financial and Professional Regulation.

Illinois law requires hospital officials who learn of abuse allegations to take action to protect patients, but the Tribune found that some medical providers who work outside those settings were left to operate largely unchecked until they were charged with a crime. Read part two of our investigation.

Former patients of Fabio Ortega say Endeavor Health failed to protect them from an abusive doctor

At least 30 women have filed lawsuits alleging that Dr. Fabio Ortega sexually assaulted them during appointments over a span of three decades at various Endeavor Health locations and, before that, at Swedish Hospital in Chicago. Most of the lawsuits allege that Endeavor and Swedish either knew or should have known that Ortega was a danger to patients and failed to protect them.

Now a Tribune investigation has pieced together the fullest picture yet of Ortega’s troubled history with patients and Endeavor’s pivotal role in keeping the doctor in place, with access to vulnerable female patients, despite multiple complaints.

Endeavor, formerly NorthShore University HealthSystem, has never publicly admitted any wrongdoing or error in its handling of Ortega and the allegations against him. Read part three of our investigation.

Chaperones may offer one solution to sexual abuse of patients by medical providers

Some medical experts and survivors of sexual abuse say broader use of chaperones may be one way to prevent misconduct.

In the past, the American College of Obstetricians and Gynecologists recommended that chaperones be used when patients or doctors requested them. But in late 2019, the college changed its position, recommending that chaperones be present for all breast, genital and rectal exams with a few exceptions, such as during medical emergencies. Often, nurses or medical assistants serve as chaperones in addition to their other duties.

“Given the profoundly negative effect of sexual misconduct on patients and the medical profession and the association between misconduct and the absence of a chaperone, ACOG now believes that the routine use of chaperones is needed for the protection of patients and obstetrician-gynecologists,” the college wrote in 2019. Read part four of our investigation.

Help the Chicago Tribune report on medical misconduct

The Tribune hopes to continue reporting on how hospitals and other medical institutions respond when patients report instances of sexual misconduct by health care providers. If you have information to share, please fill out this form. Responses will not be published without your permission.

Doctors and other health care providers accused by patients of sexual misconduct kept practicing – sometimes for years – because of gaps in Illinois laws and a licensing agency that can be slow to take disciplinary action, a Tribune investigation has found.

The providers went on to harm additional patients, in some cases, as their licenses remained in good standing with the Illinois Department of Financial and Professional Regulation.

Though Illinois law requires hospital officials who learn of abuse allegations to take action to protect patients, the Tribune found that some medical providers who work outside those settings were left to operate largely unchecked until they were charged with a crime.

In one case, an independent doctor continued seeing patients for two and a half years as several patients complained to police about his behavior. State law does not require police or prosecutors to notify the licensing agency of investigations into health care providers, only of certain criminal charges.

The Illinois Department of Financial and Professional Regulation, meanwhile, sometimes took years to discipline medical providers accused of sexual misconduct.

The agency did not take action against a nurse’s license for more than two years after learning he had been fired from a hospital over allegations of sexually inappropriate behavior. The nurse went on to face criminal sexual abuse charges after a woman alleged he sexually assaulted her while providing in-home care.

The agency did not suspend the license of a chiropractor until more than two years after he was found guilty of battery stemming from sexual contact with a patient. When it did finally act, the agency blamed the delay in part on the practitioner for failing to notify the agency of the outcome of his criminal case.

Illinois law does not require medical providers to tell patients they are under police investigation or, in many cases, that they have faced discipline from the state, making it difficult for patients to make informed decisions about whom to entrust with their care. Although the agency maintains a website where patients can look up the status of a provider’s license, it is often not clear why the person was disciplined.

The site sometimes fails to disclose the full extent of the allegations against doctors, using euphemistic phrases such as “inappropriate conduct” and “boundary violations” to describe their actions. The reasons for discipline are often described in a line or two. Some other states post full disciplinary reports online and require doctors who are on probation to inform patients, which is not the case in Illinois.

In California, a 2019 law requires doctors to notify patients if their license is on probation for sexual misconduct, a move fueled in part by the #MeToo movement and media coverage of Dr. George Tyndall’s decades of alleged abuse at the University of Southern California. In Kentucky and Iowa, the medical licensing boards post disciplinary documents online that spell out accusations against health care professionals.

“I think that there needs to be more transparency,” said state Sen. Karina Villa, D-West Chicago, who chairs the Senate Public Health Committee. “It seems like there have been too many loopholes that really need to be tightened up to protect people.”

The Tribune reported last Sunday that several well-known health care systems failed to remove providers from patient care after learning of sexual misconduct allegations, and that those institutions faced few meaningful consequences from the state for their actions. One 2005 law that would help document and track abuse allegations and other problems at hospitals has yet to be implemented.

“When we fail to examine the full story arc of an issue, that’s how we end up with these holes,” said Illinois Rep. Kelly Cassidy, D-Chicago, who is now working with the Illinois Department of Public Health on legislation to require doctors offices and satellite clinics to report patient abuse allegations to the state under the same rules that apply to hospitals. “What you just described to me is a patchwork where the patchwork itself has holes in it.”

A spokesperson for the Illinois Department of Financial and Professional Regulation, Chris Slaby, said in a statement that actions in many of the cases identified by the Tribune took place under prior administrations and the agency is “committed to protecting the public from professionals who have sexually assaulted patients.”

He said the agency has expanded resources to investigate complaints in recent years, including by adding four attorneys to the health and medical prosecutions teams. Camile Lindsay, the new acting director of the department’s Division of Professional Regulation, has expedited temporary suspensions in some cases by allowing rulings based on documented evidence instead of requiring a trial proceeding, he wrote.

Slaby said that although prosecutors are supposed to notify the department when medical providers are indicted on sexual assault charges, “they often fail to do so.” Slaby ​​acknowledged that the agency does not have to wait for criminal charges to take disciplinary action but noted that law enforcement often does not choose to notify the state about investigations still in progress. Lindsay is reaching out to law enforcement to encourage more reporting, Slaby said.

The agency is also pursuing legislation, Slaby said, that would require health care facilities to report allegations of sexual assault or misconduct to the agency within 24 hours, as well as requiring hospitals to report to the agency more quickly when they fire licensed health care workers or change their duties for certain reasons, such as when the person was found to have threatened patient care.

Under investigation, still providing care

One patient was so upset after her appointment with Dr. Haohua Yang that she vomited outside her car after talking about it with a Yorkville police officer.

She had made the October 2012 appointment because of lower back pain and brought along her 2-year-old son. As the little boy slept nearby, the doctor touched her vaginal area with an ungloved hand, she told police.

The woman wasn’t the first patient to contact the police about Yang, an internist who ran his own practice out of an office in suburban Yorkville. Several months earlier, another patient experiencing back pain had told police the doctor touched her inappropriately during an appointment and had an erection she could feel and see.

If Yang worked at a hospital, officials there who learned of a patient’s abuse allegation would be required by law to report it to the Illinois Department of Public Health, triggering an investigation. That requirement didn’t apply, however, to Yang’s independent practice.

And although a report of abuse can lead to action by the licensing agency, Slaby said there were no records to indicate the Illinois Department of Financial and Professional Regulation knew at the time about the patients’ allegations.

If the agency is notified of certain criminal charges against a provider, it is supposed to require the provider to use a chaperone while caring for patients until the case is resolved. Patients should also be notified that there are criminal charges and must acknowledge the chaperone requirement in writing.

But with no charges filed against Yang after the first two reports to police, the doctor continued to see patients alone in exam rooms, police records show.

In January 2014, a third patient complained about Yang. Police talked to the doctor in May of that year, but he kept seeing patients until he was arrested in mid-December, records show. One day before Kendall County prosecutors issued formal charges against Yang – eight counts of criminal sexual abuse and criminal sexual assault – Yorkville police notified the Illinois Department of Financial and Professional Regulation.

More charges would follow. In total, prosecutors brought charges of criminal sexual abuse and criminal sexual assault stemming from appointments with 17 patients, most of which occurred after the first patient reported the incident to law enforcement.

In January 2017, a judge acquitted Yang of sexually assaulting the woman who got sick after talking to police about her appointment. The judge ruled that he had not found beyond a reasonable doubt that sexual penetration occurred, which he said was required for a sexual assault conviction.

That November, Yang pleaded guilty to three counts of felony aggravated battery involving three other patients, and prosecutors dismissed the remaining charges against him. He was sentenced to 180 days in jail and a year of probation.

The Illinois Department of Financial and Professional Regulation temporarily suspended Yang’s license on Dec. 17, 2014, a day after formal charges were filed. Yorkville police had notified the agency of the imminent charges two days earlier, on Dec. 15, according to a police report.

It was a short delay, but swifter action on Yang’s license might have made a difference for at least one patient.

During the two days before Yang turned himself in to police on Dec. 17 to face the criminal charges, a grandmother took a minor patient to see him for a required school sports physical, she later told police.

The grandmother, who was present for the exam, told police that Yang had her granddaughter lie on a table, placed his hands under the girl’s underwear to feel for an artery and blocked the grandmother’s view partway through the examination, records show.

Among the many criminal charges filed against Yang was one count of predatory criminal sexual assault related to the allegation involving this girl, according to police records. The charge was one of those dismissed after Yang’s guilty plea.

Slaby said the Illinois Department of Financial and Professional Regulation is required to have sufficient evidence to prove an allegation before it can summarily suspend a medical provider’s license, and achieving that “isn’t feasible” in a two-day period. A chaperone order – which requires a provider to be monitored during patient care – is one of the department’s “strongest tools,” Slaby said, but it can be issued only after a license holder is criminally charged.

Yang’s license was revoked after his conviction. “I’m completely innocent,” Yang said when contacted by the Tribune. He declined to comment further.

One of Yang’s former patients, 59-year-old Lisa Eller, said the doctor’s actions left a lasting mark on her life. The Tribune is using her name with her consent.

Eller said she received what she considered to be great care from Yang – at first. But over time, she noticed some odd things about the way the doctor behaved. Yang was fond of giving hugs, she said. He’d tell her she was beautiful. Sometimes, he’d rest a hand on her thigh while he listened to her breathe during checkups, Eller said. She let it go because she trusted him, she said.

After seeing that Yang had been arrested, Eller decided to go to police. Among her allegations was that Yang put his mouth on her nipples during a 2013 breast exam, a police report shows. Three of the charges against Yang, including criminal sexual assault and abuse, were related to his treatment of Eller, according to police records. Those charges were ultimately dismissed as a result of his plea agreement.

Now Eller has advanced emphysema, she said. Every breath she takes hurts. But what she experienced with Yang has made her suspicious of doctors, interfering with her medical care.

“Now that I really need them, with my health being so bad, I can’t trust them,” Eller said. “I can’t stand for any doctor to touch me.”

Delays in action

Unlike Yang, registered nurse Thomas Trunk was working for a hospital when a patient complained that he had talked to her about sex toys and begun to expose himself to her, according to a police report.

Rush University Medical Center fired Trunk in August 2016 and reported the firing to the Illinois Department of Financial and Professional Regulation on Sept. 13, according to Rush spokesperson Charlie Jolie.

But the agency took no public action at that point against Trunk’s license, and within about three months of his termination he began working at a new job with Advocate Health Care’s home care division.

Trunk told Advocate he left Rush because of a family emergency, according to court records. Advocate said in a court document that it checked the status of Trunk’s license before hiring him and did not find any discipline on his record, and that it used a background check company to verify Trunk’s prior employment at Rush.

Trouble followed the nurse at his new job. In early 2018, Trunk propositioned a patient over a text message, according to a lawsuit she later filed. She rebuffed the request, sending a message stating: “NO that would not be appropriate. I’m really a very happily married woman.” Trunk apologized, later adding that he had crossed a line and it would not happen again, according to court records.

Not long afterward, Trunk came to the patient’s home for an appointment in April 2018, according to the lawsuit. The patient later said in a deposition that the nurse forcibly stuck his tongue in her mouth, exposed his penis and made her touch him after administering medicine that made her begin to slip out of consciousness.

“I actually was scared,” the woman said in a 2021 deposition. “After he administered the Benadryl, and he knew that I would not be able to scream out or shout out for my husband, he approached the bed. … I couldn’t push him off. I couldn’t fight him off.”

According to court records, the patient’s husband told Advocate there had been “some serious issues,” without describing what happened, and Trunk was not to return to their home. Police records obtained by the Tribune also show that a different patient told Advocate that Trunk had made romantic advances while providing in-home care. Advocate was not required to report these allegations to the state health department because the alleged incidents did not occur within hospital walls.

In a statement sent to the Tribune, Advocate said it suspended Trunk immediately after being notified of the patient’s lawsuit in August 2018 and learning details of her allegations; it fired him the following month. The lawsuit, which alleges Advocate should have known Trunk was being untruthful about his reasons for leaving Rush, is still pending.

“Patient safety is our top priority, and our providers and teammates must adhere to a code of conduct that guides ethical and professional behavior,” Advocate said in a statement. “When we’re made aware of an accusation of misconduct, we act quickly to investigate and take appropriate action, including suspending or firing a teammate when appropriate.”

Meanwhile, the Illinois Department of Financial and Professional Regulation did not file a complaint against Trunk related to his conduct at Rush until October 2018, more than two years after Rush reported firing him. The agency didn’t take disciplinary action against Trunk’s nursing license until August 2019 when it issued a reprimand “due to unprofessional conduct.”

During this period, Trunk began working at Northwestern Medicine, spokesperson Christopher King confirmed in a statement. When it hired Trunk in November 2018, Northwestern was “unaware of any previous allegations,” the statement said. King said no allegations of wrongdoing were associated with Trunk’s employment at Northwestern, which ended in December 2019 for reasons King would not discuss.

Trunk was charged in November 2019 with criminal sexual abuse. The state agency issued a chaperone order, and it went on to permanently revoke his nursing license after he was convicted in late 2020 of misdemeanor battery. Trunk received a sentence of probation.

Trunk did not respond to requests for comment made through his attorneys.

In a statement, Slaby said the case was delayed at the agency “due to being mishandled by a staff member who resigned before disciplinary action could be taken” against the staff member.

The agency was also slow to discipline Arlington Heights chiropractor Michael Davenport, who was charged with misdemeanor battery in June 2018 after a patient – who also worked for Davenport’s practice – complained that Davenport had touched and put his mouth on the patient’s genitals during chiropractic treatment, according to state disciplinary records.

The chiropractor was found guilty and sentenced in December 2018 under conditions that allowed him to avoid a conviction if he completed a term of court supervision.

But Davenport, who had continued to operate his practice and treat patients, was not disciplined by the licensing agency until May 2021, when it temporarily suspended his license. The agency, which acknowledged receiving a complaint against Davenport in 2018, said it didn’t learn until later about the outcome of his criminal case.

Davenport requested that the agency drop the temporary suspension, noting that the decision was based on allegations the Illinois Department of Financial and Professional Regulation became aware of three years prior and that no action was taken in the interim.

“Three years after the incident they say I’m an immediate threat,” Davenport said in a Tribune interview. “How can you do that when nothing has happened?”

In response to Davenport’s request, the agency noted that he had failed to notify the state of the outcome of his criminal case and ultimately denied his appeal. State laws require doctors and nurses to report any adverse action taken against them by any health care institution or law enforcement agency.

Davenport “should not be rewarded for failing to notify the Department of the criminal finding of guilt against him especially since the victim was a patient and his crime was directly related to his practice,” the department wrote.

Records show the state agency referred Davenport’s case to its investigations unit after learning of a civil settlement involving Davenport in 2019. Slaby would not discuss details of the case but said civil settlements can complicate investigations in part because they sometimes include confidentiality clauses. Slaby said the department “moved quickly” after learning what happened in the criminal case.

The agency suspended Davenport’s license for a minimum of 18 months “due to a sexual boundary violation with a patient of his practice.”

Davenport told the Tribune the incident with the patient was “not sexual misconduct” and that he has paid his dues and wants to move on. In an email to the Tribune, an attorney for Davenport stated the case was “exceptionally complicated” and “would be difficult to describe fairly in a newspaper article.”

Davenport’s license remains suspended.

Transparency failings

Patients can, in theory, look up any medical provider on the Illinois Department of Financial and Professional Regulation’s website to see if the agency has taken disciplinary action on their license, and why.

But the brief reasons provided for the state’s disciplinary actions often fail to paint a clear picture of the allegations against health care providers. To obtain additional information about allegations that led to discipline, reporters had to file public records requests with the state agency and various police departments.

Take Dr. Pavan Bejgum, a physician from downstate Metropolis whose license shows up as being suspended for a minimum of four years based on “inappropriate conduct with a patient of his practice.”

That’s the only description on the Illinois agency’s website. But according to documents posted online by the Board of Medical Licensure in Kentucky, where Bejgum was also licensed to practice, the Illinois agency disciplined him in November 2021 after hearing testimony from a former patient who alleged he kissed her neck and put an ungloved finger on her vagina during an appointment three years earlier. The Illinois agency also learned that Bejgum had agreed to a two-year civil no-contact order the patient sought in court.

Bejgum did not respond to a request for comment the Tribune sent to his attorney.

In the case of Dr. Ala Albazzaz, the public can see on the agency’s website that he was fined $30,000 and suspended from practicing medicine between December 1997 and June 2008 for “fondling female patients during examinations” and that his license remains on probationary status.

What the website doesn’t say is that the suspension of his license came after the agency heard testimony from six patients who said he engaged in sexual behavior during their pelvic, rectal or vaginal exams, leaving them “embarrassed, shocked, stunned, degraded and/or humiliated as a result,” according to state records obtained by the Tribune through a public records request.

Cook County prosecutors filed dozens of charges accusing Albazzaz of touching 38 women inappropriately during exams from the late 1980s into the early 1990s, according to Tribune reporting at the time. The doctor was acquitted in 1990 after a bench trial related to one patient’s complaint and acquitted again in 1995 after a jury trial based on four women’s allegations. Prosecutors then dismissed the remaining charges, the Tribune reported.

In 1997, the Illinois Department of Financial and Professional Regulation suspended Albazzaz’s license. Although a criminal conviction requires a finding of guilt beyond a reasonable doubt, the agency needs to prove at a disciplinary hearing only that there was “clear and convincing evidence” that a violation occurred, Slaby said.

Before the department agreed to end the suspension in 2008, a psychiatrist recommended that the agency bar Albazzaz from doing OB-GYN examinations as he found that Albazzaz, “while remorseful, did minimize his role as a misunderstanding despite the magnitude of evidence against him,” according to state records. Another psychiatrist opined that Albazzaz could return to practicing medicine with “no danger or threat to society.” When Albazzaz’s license was restored, the department did not restrict him from doing OB-GYN exams.

His license remains on probation, and the agency requires that a female attendant monitor his exams with female patients, state records show.

Albazzaz is now facing a new lawsuit alleging sexual misconduct. The plaintiff, Pamela Harris, contends in her 2022 suit that the doctor fondled her breast during an in-home appointment two years earlier.

Harris, who agreed to be identified by name in this story, said in an interview that she doesn’t understand why the state didn’t revoke the doctor’s license.

“He shouldn’t have been allowed to practice,” said Harris, who told the Tribune she has multiple health conditions, including congestive heart failure. She said she believes “he shouldn’t be allowed to have any female patients at all.”

Harris went to Wheeling police with her allegation in January 2020. Police closed the case that September, records show; Albazzaz was not criminally charged.

Albazzaz did not respond directly to requests for comment for this story. In a letter to a Tribune attorney, a lawyer for Albazzaz did not address the disciplinary action taken on Albazzaz’s medical license but said Albazzaz had been cleared of criminal conduct and described allegations by patients against Albazzaz as “false.”

In a statement sent to the Tribune, Slaby said the Illinois Department of Financial and Professional Regulation can permanently revoke a doctor’s license only after certain types of criminal convictions, and Albazzaz was never convicted of a crime.

What the agency’s website says now about Albazzaz’s probationary status is hard to parse. It states that Albazzaz is currently on probation “due to allegations that an Integrity Agreement Respondent entered into with the Department of Healthcare and Family Services constitutes an adverse action by a State Agency.”

Left unsaid is that the Illinois Department of Healthcare and Family Services, which provides health care coverage to residents who qualify for Medicaid, had reached an agreement with Albazzaz in 2012 that allowed him to resume caring for patients in the Illinois Medical Assistance Program as long as he did not treat any women for two years. Albazzaz’s license remained on probation partly because he did not notify the licensing agency of the terms of that agreement, state records show.

The lack of detailed information on the department’s license lookup seems to protect providers who were disciplined more than the patients who allege they were abused, said Carrie Ward, CEO of the Illinois Coalition Against Sexual Assault.

Members of the public might not take the extra step of filing a public records request for a disciplinary report, or even know they can, she said.

“More information is always better, and more easily accessible information, so folks can make informed decisions about who they might want to interact with,” Ward said.

Slaby said that the short summaries available on the website are based on the law or rule that was violated or are sometimes negotiated if a medical professional enters into an agreed order, and that the department “readily provides” disciplinary reports upon request.

“Unfortunately, due to technology system constraints IDFPR does not currently have the capability of linking a disciplinary order to an entry on its License Lookup tool,” he wrote.

DePaul University student Samantha Moilanen contributed to this report.

Help the Chicago Tribune report on medical misconduct

The Tribune hopes to continue reporting on how hospitals and other medical institutions respond when patients report instances of sexual misconduct by health care providers.

If you have information to share, please fill out this form. Responses will not be published without your permission.

“What have you been doing?” the judge asked.

“Playing basketball,” the defendant replied to laughs around the room, amending that he has also participated in programming through community services organizations in the hopes of completing the court program that would allow his charges to be dismissed.

The experimental court is one of three restorative justice courts in Cook County which divert defendants from the traditional justice system in the hopes of reducing crime and creating a more equitable system. Now, a new study is advising the county to take on a series of reforms before expanding such neighborhood courts, raising concerns about structural problems that it said diminish the overall impact of the program.

The report by the Chicago Appleseed Center for Fair Courts and the Chicago Council of Lawyers is the first external study of Cook County’s restorative justice courts, which have generated excitement for their potential but have thus far largely been unstudied outside of the court system’s own evaluations.

The appraisal indicates that the county has work ahead to create a system that fully reaches its goal of better outcomes for defendants, victims and the community than they would find in the traditional criminal justice system.

The chief judge’s office in a statement said it is “open to collaboration with our criminal justice and community partners on additional alternatives to the traditional court process to the extent the law allows.” The office highlighted an internal study that showed the programs reduced recidivism and said they are open to working with the report’s researchers “in the future on a more rigorous evaluation.”

“I think they right now are serving an important role in reducing the harm of the legal system on people … these courts aren’t perfect but they have a huge, incredible impact on preventing felony convictions for these first time low-level offenses for young folks,” said Naomi Johnson, one of the report’s researchers and authors. “But there does need to be considerable reform undertaken in order to be better aligned with restorative justice, if the court wants to call itself restorative justice community court.”

The courts — located in neighborhood settings away from the bustling Leighton Criminal Court Building on the Southwest Side — seek to focus not on punishment but on trying to help the defendant atone for the harm they have done to people or the community. Upon successful completion of the program, participants have their charges dismissed and arrest expunged.

The Tribune spent time observing the courts last summer, noting a more casual atmosphere where judges built relationships with defendants and checked on progress, though the level of engagement from the participants varied.

In the six years since the county opened the first community court in North Lawndale in 2017 under the watchful eyes of stakeholders, it has added two more, in Englewood and Avondale, accepting young adult participants accused of low-level, nonviolent crimes.

In order to fully conform with the tenets of restorative justice, the report found, the courts should be subject to community oversight rather than primarily under the supervision of judges and prosecutors.

Among other concerns raised by the report:

• Onerous requirements that at times made it difficult for participants to fulfill other work and life obligations
• Inconsistent training for court administrators and officials
• Significant discretion by prosecutors to determine who can participate in the program, even among defendants who meet eligibility criteria
• Program participants who are mostly charged with offenses typically considered victimless, despite a core principle of restorative justice being making amends to a victim
• A lack of community participation, in part due to opaqueness about the programs, with little information available about court calls

The report laid out a series of long- and short-term recommendations the courts should undertake before expanding the program, though the county has already announced one new location in south suburban Sauk Village.

“I think that when implementing restorative justice in the criminal legal system, there are going to be inherent conflicts that arise and in order to mitigate conflicts, it is critical that it is community led, not just community based or located in the community,” said Johnson, director of research and program management at the Chicago Appleseed Center for Fair Courts. “I am absolutely interested in a model that has less involvement from the court system.”

External review

The organizations launched the study to observe ways in which Cook County’s courts “align with and/or depart from” general restorative justice principles.

The report’s release comes months after the chief judge’s office released an internal study that showed participants of the restorative justice courts were charged with a new offense less often that their peers charged with similar offenses in the regular court system.

About 13% of participants who had been released from the program for at least a year were charged with a new offense, compared with about 65% in a peer control group of defendants with similar characteristics and charges.

While promising, the courts would likely need further studies to draw broad and enduring conclusions. The report from Appleseed and Chicago Council of Lawyers notes that there is limited research nationally on outcomes of restorative justice practices in courts, and frames its own study as exploratory rather than a fully comprehensive evaluation. Still, it called the recidivism results from the internal study one of the “major benefits” of the program.

For this study, the researchers recorded data from observing court sessions from January through March 2023 and interviewed stakeholders across the system.

The report notes that they struggled to interview many participants, a shortcoming of the undertaking, overall.

“Our research aimed to understand how community members and stakeholders feel about how these courts operate and where they may be able to improve,” the report said.

‘Different than a regular court’

The courts seek to provide a gentler version of justice, one that forces defendants to acknowledge the harm their actions have caused, while also providing social services and dismissing the case if the program is completed. Officials hope the courts reduce recidivism and tackle entrenched systemic problems that contribute to the city’s gun violence.

Participants attend peace circles, a confidential forum where they talk about the crime, the impact on the victim or community and how to repair the harm. They discuss progress toward establishing housing, education or jobs during court calls, and sometimes display art projects or letters to family members or people hurt by their actions.

“This court is a lot different than regular court,” Judge Beatriz Santiago told participants during a court call last May in Avondale.

Individual hearings were sometimes productive, with the defendant relaying progress in finding a job or housing, or enrolling in drug treatment or educational opportunities. Other times, judges and court staff prodded participants for not answering their phones or missing appointments.

The court calls sometimes started late, or were moved or canceled without notice to the public, though the court delays are found across the court system and not unique to the restorative justice courts.

The Appleseed report noted that the courts stand out for its more humane treatment of defendants, in contrast to hearings in the traditional courts.

“Here is where the RJCCs are remarkable: Their flexibility and recognition of participants, who are largely young Black and brown men, as human beings unlike many criminal proceedings at other Cook County criminal courts,” the report said.

Reforms needed

While noting where the system had a positive impact on defendants, the study highlighted weaknesses in the programs that it recommended the county address before taking on a wide expansion.

A critical flaw in the system, the report found, is the lack of involvement from the community, noting that court calls, though open to the public, are not publicized and difficult to find information about online.

Traditional restorative justice principles provide that defendants engage with the victims, but many of the cases diverted to the courts are gun possession cases with no identifiable victim. The report recommended that in the long term, the courts should expand eligibility to people who are accused of offenses considered violent.

“Interestingly, at no point in its history has the RJCC worked primarily, or even substantially, with cases involving a personal victim,” the report said.

The report recommends that the court implement a system of community oversight, which would offer checks and balances on the involvement of judges and prosecutors.

“We posit that absolute community oversight of the RJCCs is necessary for the court to be both a restorative justice court and a community court,” the report said. “Without community oversight, these are simply neighborhood-based courts that implement some restorative practices.”

The report also criticized the courts for an at times long and arduous process, at odds with the program’s mission of setting defendants on a better path when long and inflexible court calls interfered with their ability to work.

The court calls were often subject to delays when administrative work that preceded the call ran over time. The calls themselves, also ran long.

“Participants, who often work full time or have family obligations, struggle to attend RJCC court calls and the time taken out of their day can have a negative impact on their employment or other responsibilities,” the report said.

The report also recommended that court staff receive “ongoing, rigorous, community-led restorative justice training,” finding while studying the program that some actions and behaviors in court were inconsistent with the principles of restorative justice.

When a woman came to the Illinois Bone & Joint Institute complaining of hip and groin pain, X-ray technician Karol Ruszczyk put his hand between her legs, touching her vaginal area over her clothes.

At Glenbrook Hospital in Glenview, nurse David Giurgiu had a heavily medicated, 76-year-old patient perform oral sex on him from her hospital bed.

At Chicago’s Jackson Park Hospital and Medical Center, a patient reported that worker Titus Snelling had rolled her wheelchair into an elevator and, when they were alone, began kissing her up and down her neck.

All three of the victims complained to the hospitals and health care systems that employed the workers. All three of those systems allowed the employees to continue working. And all three workers were later charged with abusing additional patients.

Over the course of a yearlong investigation, the Tribune found that well-known Illinois health systems have allowed workers accused of abusing patients to keep providing care.

The failures to respond adequately to abuse allegations had devastating consequences for the victims, who felt betrayed by medical systems they had trusted with their health and safety.

While some medical systems in other states have reckoned publicly with their failures, Illinois health care providers have quietly settled lawsuits, entered into confidentiality agreements with patients and often refused to acknowledge wrongdoing.

Efforts by state government to hold providers accountable have fallen short, largely leaving hospital systems to decide on their own how to balance patient safety with their reputations and financial interests. Loopholes in state laws leave many providers without meaningful oversight, other laws lack teeth, and one law that would help document and track adverse events at hospitals has yet to be implemented 16 years later.

Illinois law does require hospitals to report allegations of patient abuse to state health officials, but those that fail to do so face few consequences, even in cases where the health care worker went on to face abuse allegations from additional patients. In many cases, the only real consequences health systems appeared to face came from lawsuits filed by victims.

Tribune reporters identified allegations of patient sexual abuse in Illinois by obtaining and reviewing thousands of pages of medical board disciplinary findings, arrest records, police reports, Illinois Department of Public Health investigations, civil and criminal court documents and by analyzing state data. The Tribune filed 50 Freedom of Information Act requests and conducted more than three dozen interviews.

In all, the Tribune identified 52 health care workers accused of sexual misconduct with patients in Illinois over the last decade. At least 27 of those workers faced allegations from multiple patients in recent years, the Tribune found. The true numbers are almost certainly higher, since many allegations are not reported to law enforcement or to the state.

In one of the most egregious cases, dozens of women have alleged that former NorthShore University HealthSystem gynecologist Dr. Fabio Ortega sexually assaulted them during exams over three decades. According to police and court records, NorthShore — now known as Endeavor Health — allowed him to continue working after receiving complaints from patients and even after it knew police were investigating him. Ortega eventually pleaded guilty to sexually abusing two patients, and he has been sued — along with Endeavor and his former employer, Swedish Hospital in Chicago — by at least 30 women. The hospital, formerly known as Swedish Covenant, is now part of Endeavor.

Women told the Tribune they suffered for years after they were abused by medical providers.

The patient who was assaulted by emergency department nurse Giurgiu at Glenbrook Hospital — also part of Endeavor Health — was afraid of being in any room alone after the abuse, according to her daughter. She wouldn’t sleep in her own bed.

The Tribune is using the pseudonyms Mary and Susan for the two women because the Tribune generally does not identify victims of sexual abuse or assault without their permission.

“She was a very strong-willed person who just started crumbling,” Susan said of her mother.

Mary, who died in 2022, was devastated again when she learned that Giurgiu had allegedly abused another patient about nine months later. It wasn’t until the second allegation that Glenbrook fired him.

“That made everything worse,” Susan said. “She was like, ‘If they just would have believed me, this wouldn’t have happened to another woman.’”

Representatives of Endeavor Health, the Illinois Bone & Joint Institute and Jackson Park Hospital would not answer questions from the Tribune about their handling of patients’ specific allegations. Endeavor and Illinois Bone & Joint both stressed their commitment to patient safety.

“The past events you discuss are incredibly upsetting and heartbreaking,” Endeavor said in a statement, adding that the hospital system continues to improve its processes to support the reporting of abuse allegations. “We acknowledge trust is earned and will always look for opportunities to demonstrate our commitment to the highest standards of safety and quality in our care.”

‘I just want to die, I just want to die’

Mary’s nightmare began on Thanksgiving night in 2018, when she took a spill that landed her in the Glenbrook Hospital emergency department with a broken femur, court and medical records show. Susan stayed with Mary until early the next day, when her mother finally persuaded her to go home and rest, Susan said.

Between 4:30 and 5:50 a.m., according to a state investigation, the injured woman was visited three times by Giurgiu, a 25-year-old registered nurse. The visits ranged in length from eight to 20 minutes.

Later that day, Mary was transferred to Skokie Hospital for surgery. Susan said she noticed a change in her mother after the operation; Mary was refusing to eat and crying uncontrollably, she said.

The nurses at the hospital noticed too. Days after the surgery, a nurse wrote in Mary’s chart that the patient began “shaking and crying” when talking about an earlier incident. Several hours later another nurse wrote that Mary was “weepy throughout the day” and that the elderly woman had “reported an alleged event” at Glenbrook Hospital.

In a later police interview, Mary recalled telling hospital staff, “I just want to die, I just want to die,” and “I don’t want to live anymore,” court records show. The hospital put her on suicide watch.

Susan would soon learn what was causing her mother such agony: The nurse had assaulted Mary while she was alone and in pain, engaging her in oral sex when she was unable to consent.

Glenbrook Hospital officials launched a brief internal investigation into Mary’s allegation, led by the hospital’s vice president of nursing and clinical operations, according to the state’s investigation. Susan also went to the police.

Endeavor Health did not answer Tribune questions about what its investigation into Giurgiu consisted of, nor whether Giurgiu worked with patients during that time. But state records show that two days after Mary reported the abuse, hospital officials told Mary and her family that the hospital had found the allegation was not substantiated.

The hospital found that no other patient had ever complained about Giurgiu, and other staff had not witnessed anything inappropriate, according to state records.

Police also suspended their investigation after running out of leads, police records show.

With the police investigation at a dead end, and Glenbrook Hospital moving on from Mary’s allegation, Giurgiu continued working with patients.

About nine months later, another woman came forward with a disturbingly similar account of being sexually abused by the nurse after receiving pain medication in the emergency department, according to police and court records.

This time, the hospital fired Giurgiu, a police report states. Hospital officials also alerted the police and the Illinois Department of Public Health.

Giurgiu initially denied the allegations to police. Then police told Giurgiu they had taken clothing samples from the patient and planned to test them for Giurgiu’s semen, according to a police report. At that point, police noticed a change in Giurgiu’s demeanor. He soon admitted to both incidents, the report states, and said he’d engaged in sexual activity with a third patient, also after the interaction with Mary. He told police the activity was all consensual.

In September 2019, Giurgiu was charged in the incident involving Mary and the one that occurred nine months later. He was convicted in September 2022 on one count of aggravated criminal sexual assault and three counts of aggravated criminal sexual abuse in the attack on Mary. Prosecutors dismissed the charges involving the other known victim after Giurgiu was convicted and sentenced. Giurgiu is now in prison, sentenced to decades behind bars.

Giurgiu did not respond to a request for comment.

The state health department investigated Endeavor’s response to the allegations and found the hospital had failed to report Mary’s allegations to the state within 24 hours and had not adequately investigated Mary’s claims, according to a state report the Tribune obtained through a public records request.

The agency noted in its findings that the hospital investigation had focused on one interaction between Mary and the nurse when others were present — a catheter insertion — but failed to take into account the three times Giurgiu was seen on hallway surveillance video entering and exiting Mary’s room alone. It also found the hospital had not offered Mary the opportunity for a sexual assault examination.

Maria Knecht, who was vice president of nursing and clinical operations at the time of the investigation, has since been promoted and took over as Glenbrook Hospital president this year. Endeavor Health did not make Knecht available for an interview and would not answer questions about Giurgiu, including whether the hospital ever put him on leave or restricted his duties after the allegations by Mary.

In a plan of correction submitted to the state, Endeavor detailed measures it planned to take at Glenbrook, such as updating “processes to ensure compliance with reporting of sexual abuse allegations to the state,” addressing “gaps” in the investigation process by establishing an oversight committee, and developing a checklist for reviewing patient assault allegations. But the corrective plan “does not constitute an admission that a deficiency exists or that one was cited correctly,” Endeavor wrote.

Responding to Tribune questions, Endeavor said in a January statement that it thoroughly reviews sexual abuse allegations and that providers are required to have a chaperone present or be removed from care if an investigation is underway. Endeavor did not answer questions about when the chaperone policy started and whether a chaperone accompanied Giurgiu while the hospital was investigating Mary’s allegations.

“The provider’s alleged conduct is a fundamental betrayal of our mission and our patients’ trust,” Endeavor said.

After allegations, more harm

When a patient reports sexual abuse by a hospital employee or medical staff member, several things are supposed to happen under Illinois law.

For one, the hospital should report the allegation to the Illinois Department of Public Health within 24 hours so state officials can investigate. It should also take prompt action to ensure the patient’s safety, which can include “removing suspected violators from further patient contact” while hospital officials conduct an internal review.

Yet the Tribune identified at least 10 instances in the last decade where a patient had alleged sexual misconduct at a hospital but the incident does not appear in the state’s database for abuse allegations reported by hospitals.

For example, when Rush University Medical Center fired nurse Thomas Trunk in 2016 after a patient alleged sexually inappropriate conduct, it notified the state agency that had the power to take action against the nurse’s license. But the hospital did not notify the Illinois Department of Public Health, the agency that could have investigated Rush’s response to the allegations. Trunk was later convicted of battery after a home health care patient accused him of sexual abuse, in a separate incident.

A Rush spokesperson would not say why the hospital did not contact the health department, saying Rush could not “speak to details that led to a decision in a personnel matter.” Trunk did not respond to requests for comment sent to his attorneys.

In the case of nurse technician Titus Snelling, court records show that a female patient alleged in October 2016 that he began flirting with her and kissing her neck while he was supposed to be wheeling her to her room.

The patient immediately told other hospital workers what had happened, Cook County prosecutors later said. But Jackson Park did not report the allegation to the Department of Public Health, state officials confirmed, and Snelling continued to work with patients.

About four months after that incident, in February 2017, Snelling was supposed to transport another patient to her room. Instead, he rolled her to a dark room in an unused part of the hospital, inappropriately touched her under her gown and put his mouth on her toes, prosecutors said.

Only after receiving that complaint did Jackson Park Hospital fire Snelling. As Chicago police investigated, hospital officials acknowledged that another patient had also previously made an allegation against Snelling.

Snelling later received a 10-year prison sentence related to the most recent incident after a Cook County judge found him guilty of aggravated kidnapping in 2019 following a bench trial.

From the Western Illinois Correctional Center, Snelling told the Tribune that Jackson Park Hospital investigated the October patient’s complaint and cleared him to return to work about three days later. After the February complaint, the hospital’s nursing director spoke with Snelling again, referenced some security video, and fired him, according to Snelling. He denied he abused any patients and said he is working to overturn his conviction.

Jackson Park Hospital, which also did not report the February incident to the state, did not answer the Tribune’s questions about its failures to report, whether it changed Snelling’s duties after the first patient spoke out, and whether and how it investigated Snelling.

Margo Brooks, the hospital’s vice president of development, said the hospital would not comment “due to patient privacy and hospital policy against commenting on pending or past litigation.” The patient from the February incident reached a settlement in 2021 for an undisclosed amount after filing a lawsuit contending the hospital had failed to protect her from abuse by Snelling.

In most cases, there’s no reason a hospital can’t fire a worker after a single complaint as long as the worker is an at-will employee, said Bill Tarnow, a Chicago-based partner and chair of the labor and employment group at law firm Neal, Gerber & Eisenberg.

That’s the case even if the hospital can’t prove definitively that the worker acted inappropriately, he said. The hospital also is free to change a worker’s duties in almost all cases, such as by requiring them to work with a chaperone or prohibiting them from working with female patients, pending further investigation and review.

Illinois Rep. Kelly Cassidy, D-Chicago, said patients at hospital-based practices in particular have an expectation that the infrastructure is designed to help and support them and that hospitals operate with strong oversight. When that accountability is lacking, she said, it is “doubly disappointing.”

“You would hope that a hospital organization or health care provider organization would be more invested in rooting out bad apples,” Cassidy said. “As we’ve seen in the priesthood and school systems and police departments, it’s easier to just hide bad behavior and hope it goes away.”

In response to the Tribune’s investigation, the state health department said it is now working with Cassidy on legislation that would “create financial penalties for hospitals that fail to report sexual abuse cases by staff” to the department. The legislation would also require doctors offices and satellite clinics to report abuse allegations involving health care workers to the state under the same rules that now apply to hospitals.

The department has also said it will review hospitals’ abuse reporting policies to ensure they align with state regulations, and is following up with the hospitals that did not report allegations, as identified by the Tribune, “to seek more information regarding the allegations of patient abuse occurring in those facilities.”

Poor transparency, little accountability

In 2005, Illinois legislators handily passed a bill meant to improve the health care system by addressing so-called never events: unthinkable incidents such as leaving an item inside the body during surgery — or the sexual abuse of a patient.

The law directed the Illinois Department of Public Health to create a reporting system in which hospitals and surgery centers would report these events, discuss the root causes of the incidents and outline how they would be prevented in the future.

The system was supposed to be operational by 2008 and accompanied by annual reports summarizing the events, causes and solutions. Facilities that didn’t comply could be sanctioned.

But this important attempt to improve transparency has floundered for nearly two decades. The state hasn’t created the reporting system, and has not published any of the required reports.

By contrast, the Minnesota Department of Health has been publishing an annual public report on adverse events, including sexual assaults, in hospitals since 2005. Members of the public can also look up adverse events, by hospital, on the department’s website.

Mike Claffey, a state health department spokesperson, said a lack of funding initially delayed the law’s implementation, followed by unsuccessful requests for proposals to build the reporting system. The COVID-19 pandemic also delayed the process, he said, but the department is now preparing a new request for proposals to establish the online reporting system and database.

Sen. Karina Villa, who leads the Illinois Senate Public Health Committee, called it “devastating” to hear that the 2005 law has yet to be implemented.

“This is a top priority,” said Villa, D-West Chicago. “We need to make sure we’re protecting people in the state when they’re going in for care. … We need to make sure we’re addressing this issue with the department and if funds are needed … the General Assembly needs to have a clear understanding as to what kinds of funds they’re needing.”

Even when the state found a hospital had failed to protect patients, Tribune reporting showed there was sometimes little required beyond a promise from the hospital that it would do better next time.

Early last year, the Illinois Department of Public Health found that Ascension Mercy hospital in Aurora had failed to protect its patients from abuse. The agency’s investigation involved a case in which three adolescent girls reported to hospital staff that a doctor had touched them inappropriately.

A hospital committee quickly held a hearing and decided to take the doctor out of the behavioral health unit, where the girls were being treated, and put him into the hospital’s nursery to care for younger patients, state records show. The doctor went on a leave of absence roughly a month after the hospital learned of the first patient’s allegations, according to the health department’s investigation.

The hospital’s vice president of patient safety and quality later told the state health department: “Retrospectively, (the doctor) should’ve been removed from service at the hospital, including the nursery, during the investigation.”

Yet the hospital faced few significant consequences for the error. Although the state health department placed Ascension Mercy hospital in “immediate jeopardy,” a distinction that had the potential to cost the hospital millions in lost Medicare dollars, the sanction lasted only one day.

The agency dropped the jeopardy ruling after the hospital developed a plan to promptly remove providers from patient care following allegations in the future.

Ascension Illinois spokesperson Tim Nelson said in a statement that Ascension takes “all allegations seriously, following state and regulatory guidelines to address and investigate.” Nelson would not answer specific questions about the hospital’s response to the patient allegations.

“We can assure the patients and communities we serve they can expect the safest and highest quality care possible,” the Ascension statement said.

The Illinois Department of Public Health said in a statement that if a hospital’s plan of correction did not include removing alleged abusers from patient care, the plan would not be accepted and the hospital could lose federal funding.

“To be clear: no health care worker who is accused of sexually abusing a patient should be allowed near patients unless and until they have been cleared of such allegations,” the department said in a statement.

Less oversight outside hospitals

Health care systems and providers that are not hospitals are subject to even less state oversight.

A woman had been a patient for two decades at the Illinois Bone & Joint Institute, a large orthopedic group practice, when she went to an institute facility in Morton Grove to be seen for a knee injury in March 2018.

During her appointment, X-ray technician Karol Ruszczyk began rubbing the inside of her thigh and touched the outside of her vagina, she told police.

While Morton Grove police were investigating, they discovered from Ruszczyk’s personnel file that he had been accused of a similar incident 16 days earlier.

Police contacted the previous patient, who said she had gone to an Illinois Bone & Joint Institute office in Des Plaines for help with hip and groin pain when Ruszczyk began touching her inappropriately.

Ruszczyk would go on to plead guilty in 2019 to aggravated criminal sexual abuse of both patients and was sentenced to 24 months of probation. Efforts to reach Ruszczyk for comment were unsuccessful.

The Illinois Bone & Joint Institute and Ruszczyk reached a settlement with the second patient, who contended in a lawsuit that the institute had failed to prevent her abuse because it took no action in response to the earlier allegation other than making a note in Ruszczyk’s file.

But the state health department never investigated the institute’s handling of these incidents — it is not responsible for doing so. The institute is not a hospital, so it was not required to report either patient’s allegation to the state health department, a loophole that also applies to places such as independent clinics and doctors offices.

An attorney for Illinois Bone & Joint would not answer any questions about the incidents involving Ruszczyk, citing patient privacy laws and a need to “preserve confidentiality.”

“IBJI is committed to provide an environment safe for its patients and its staff,” the attorney said in an October statement.

Owners of medical corporations and other types of health care companies can theoretically lose their ability to operate if they fail to quickly remove an employee who has engaged in unethical professional conduct. But if an employee is fired for abusing a patient, there is no requirement that they work to understand how the misconduct was able to occur or how to prevent similar situations in the future, according to the laws that govern those businesses.

In 2016, a longtime patient of Dr. Sheldon Levine arrived at the MedPlus S.C. clinic offices in Hazel Crest for an appointment. The doctor began conducting a breast exam where he aggressively rubbed the patient’s nipples and exposed his penis to the patient before she fled from the exam room, according to court records.

A day later, records show, the patient told police what happened. The doctor was charged, he was indefinitely suspended from the practice, and he then resigned. A Cook County judge later found Levine guilty of battery and public indecency.

The patient also sued the medical practice, alleging it failed to protect her from the abuse. Testimony showed that another patient had reported to police that Levine had touched her inappropriately about six months earlier.

MedPlus administrator John Saldanha acknowledged in a deposition that the clinic made little effort to understand how the incidents were able to happen, aside from asking staff whether anyone else had been in the room during the appointment that led to the criminal conviction and whether the patient had complained.

“Whatever happened is not my problem,” Saldanha testified after being asked whether he had questioned the doctor about the allegations. He said he did not contact the victim either, stating that “there was no reason for me to interfere, to call after what happened. It’s not my duty, it’s not my job to do.”

Saldhana died in early 2023, and his wife — the owner of the medical corporation — did not respond to a request for comment. Levine reached a settlement with the patient and has also since died.

“As employers, we have a responsibility to respond to sexual assault in our workplaces,” said Carrie Ward, CEO of the Illinois Coalition Against Sexual Assault. “If that doesn’t happen, how are we protecting the future survivors of sexual violence?

“We want reporting mechanisms, internal policies and procedures about who someone goes to when something has happened to them,” Ward said. “We want intervention to happen at the earliest possible level, and we want investigations to be serious and sincere.”

Irreparable damage

Mary, who was assaulted by Giurgiu at Glenbrook Hospital, didn’t live to see him sentenced to prison time for assault and abuse. But two months before her death in 2022, Mary was able to testify in court about what happened to her.

“She was a brave soul and she did what she needed to do,” Susan said. That day, Susan told her mom she was a superhero. Her mom requested a strawberry milkshake after leaving court.

Testifying felt like a small victory amid years of torment. In some ways, Mary blamed herself for the second assault, Susan said. If only she had been able to convince hospital officials and police that she’d been attacked, maybe the second incident wouldn’t have happened, Mary thought.

“Knowing what she was living with, she couldn’t bear the thought of anyone else experiencing the same fate. This reality caused her to withdraw from life even further,” Susan wrote in a statement she read at Giurgiu’s sentencing. “The damage caused by her abuser and the struggle to be believed, was irreparable. She was gone.”

Meanwhile, though Glenbrook Hospital submitted a plan of correction to the state that detailed new processes for handling abuse allegations, it’s unclear whether the other seven traditional hospitals under Endeavor implemented similar systems.

In 2022 a patient at a different Endeavor facility, Highland Park Hospital, alleged that a male nurse had touched her inappropriately following a breast reduction surgery, according to police records.

That patient reported the incident to police and the hospital, police records show. But the hospital did not report the complaint to the state health department within 24 hours, or at all, state officials confirmed.

According to a police report, Highland Park Hospital conducted a 24-hour investigation on the nurse’s day off before determining the allegations were “unsubstantiated.” A hospital official told police the nurse was doing a head-to-toe skin assessment and the nurse had said that if he made contact near her vaginal area, it was accidental, according to the police report.

Police forwarded the case to the Lake County state’s attorney’s office. In January 2023, the office told police they had decided not to pursue charges because of insufficient evidence.

Endeavor Health did not answer the Tribune’s questions about how the hospital handled this specific allegation, including why Highland Park didn’t report the allegation to the state health department. According to police records, hospital officials determined the incident “did not meet the definition of abuse in the Hospital Licensing Act,” the law that requires the disclosure of patient abuse allegations to the state.

In an emailed statement, Endeavor said it is required to report “only substantiated reasonable allegations of abuse” to the state’s health department and it relies on police investigators’ determinations of whether allegations are “unfounded.”

Under state law, a hospital employee who has “reasonable cause to believe that any patient with whom he or she has direct contact has been subjected to abuse in the hospital” must report those allegations to a designated administrator, who then is required to notify the state. The law does not require that allegations first be substantiated.

The patient who came forward about the Highland Park Hospital nurse said she remains haunted by the incident. “Is this how my life is going to be for the rest of my life, that I don’t trust anyone?” she wonders.

She’s also frustrated that Endeavor didn’t do more to protect her and other patients.

“It’s sad and ridiculous that it has to take so many victims before they’ll believe them,” she said.

DePaul University student Samantha Moilanen contributed to this report.

Read part two: 

Failure to protect: Flawed state oversight lets doctors accused of abuse continue to see patients

Help the Chicago Tribune report on medical misconduct

The Tribune hopes to continue reporting on how hospitals and other medical institutions respond when patients report instances of sexual misconduct by health care providers.

If you have information to share, please fill out this form. Responses will not be published without your permission.

The Tribune identified 52 medical providers accused of sexual misconduct with patients in Illinois over the last decade. More than half of those providers faced allegations from multiple patients in recent years. The true numbers are almost certainly higher, since many allegations are not reported to law enforcement or to the state.

The Tribune hopes to continue reporting on how hospitals and other medical institutions respond when patients report instances of sexual misconduct by health care providers.

If you have information to share, please fill out this form. Responses will not be published without your permission.

Harris spent 33 years in prison, convicted of murder. During his decades of incarceration, he obtained a college associate degree, volunteered in prison ministries and directed gospel choirs, all while trying to prove his innocence.

Eight months before his death last Thanksgiving at age 68, the Chicago man finally won back his freedom.

When he started serving time he was a young married father from Cabrini-Green who had helped organize youth athletic programs and anti-violence events and worked with prominent figures such as Mayor Jane Byrne and Jesse White, then a state representative.

Harris also was a self-admitted hustler and petty thief on parole for burglary. When police arrested him in the 1989 murder of a promising young graduate student, they cited his shifting stories. He would later say he’d been foolish – naively repeating what police told him to say with an eye on collecting a $25,000 reward.

“I ain’t no angel,” he told the Tribune that year. “But I don’t hurt no one. I’m a thief, but I never been violent in my life.”

The crime was horrific. Armed assailants had abducted 24-year-old Dana Feitler from the lobby of her Gold Coast apartment building, forced her to withdraw money from an automated teller machine and left her unconscious in a nearby alley with a bullet wound in her head.

It would be years before the case against Harris finally unraveled, as allegations of police misconduct, mistaken witness identification, an unreliable jailhouse snitch and other constitutional violations surfaced. A defining moment in his legal battle came when Harris became friends with a cellmate who later made it his life’s work to help clear him.

Last March, a judge finally vacated Harris’ conviction and sentence, and prosecutors declined to try him again. He was out. Cook County State’s Attorney Kim Foxx said her office “had determined that Harris didn’t in fact do this” and was “likely actually innocent.”

But, as one struggle ended, another began.

Harris returned to a much-changed city that seemed foreign to him. His former home, Cabrini-Green – a public housing complex once infamous as a symbol of crime and urban blight – had been gradually demolished and replaced by new retail and sleek condos.

Foxx, who spent part of her childhood in Cabrini, told the Tribune she met Harris at an event in early October and sensed a heaviness to his spirit. Though thankful to be free, he was tearful and anxious, she said.

“I couldn’t imagine anything scarier, to me, than prison. But he was scared of a world that was foreign to him,” she said. Foxx said the two swapped stories about “a home that was no longer there.”

She said, “I tried, in that moment, to assure him that he would be OK.”

Relatives and friends say Harris did indeed adapt. He had recently filed a federal lawsuit against the city and several police officers who he alleged framed him. He had big plans for his future.

But fate decided otherwise. Hours after posing for a Thanksgiving Day photo while carving a plump turkey, he was found dead in his niece’s home. Harris died of natural causes, according to his family.

In the wake of his death, the family of the slain woman – the victim of a crime that may never be solved – pledged to continue their anti-violence work and hopes Feitler will be “celebrated and not forgotten.”

The ex-cellmate who became a longtime friend to Harris said the two had so much more they wanted to accomplish together. They planned to share their story with students with the hope of inspiring others.

And Harris’ only son, Jermaine, is reckoning with losing his father for the second time. The first was one day before his 7th birthday, when police arrested the elder Harris.

“The plan was for him to be around a long time,” said Jermaine Harris, now 41.

To him, his father’s main legacy is one of perseverance through a decadeslong ordeal.

“It didn’t break him,” he said.

From informant to suspect

Raised by a single mother who cleaned houses and collected public aid to support her five sons, Lee Harris grew up surrounded by the gangs and drugs that permeated the densely populated public housing complex he called home.

Mildred Harris is described in interviews and court records as a strict but loving mother who kept a tight rein on her boys, providing as much structure as she could with the help of her church. His dad, a cab mechanic with a drinking problem who fathered two of the woman’s sons, did not live with the family or help out much financially.

Lee Harris sang in his church choir and, at his mother’s urging, had part-time jobs as young as age 12 with a paper route and, at 14 in 1969, working for Ronald Hollis’ maintenance company.

Hollis employed Harris for the next 20 years with steady jobs such as window washing and refurbishing buildings, including downtown high rises. Hollis told the Tribune that Harris was “a mischievous kid who ran his mouth,” but one who worked hard and steered clear of serious trouble.

Much of Harris’ early life is documented in a lengthy 1992 sentencing court report. He did not have a juvenile criminal record but struggled in school, dropping out in eleventh grade. In 1979, when Harris was in his 20s, his mother committed suicide by jumping in front of a CTA train. Other family tragedies included his father’s death from cirrhosis of the liver four years later and a younger brother’s murder in 1987.

As a young man, Harris was active in his community. He organized girls’ softball games through an athletic club he co-founded and was instrumental with helping the YMCA bring the Black Olympics to Cabrini-Green. His activism included political canvassing for local Democrats who relied on Harris to collect signatures in Cabrini.

In early 1981, according to court records and interviews, Harris got to know then-Mayor Jane Byrne and her husband during the couple’s three-week stay in the neighborhood to call attention to its violent conditions. Hollis said Harris introduced him to Byrne, White and Cook County Commissioner George Dunne, among others.

“He was for the people,” Hollis said. “He was really trying to bring a different life over there by giving (young people) something better to do, because when you get that many poor people all living together, and ain’t nobody making more than $10,000 a year, you’re going to have nothing but chaos.”

Harris didn’t escape that chaos unscathed. He had a handful of adult criminal convictions beginning at 19, including theft, possession of marijuana and a 1987 burglary. He received a three-year prison sentence for that crime but was paroled after about 16 months, in late May 1989.

Three weeks later, in the predawn hours of June 18, armed assailants abducted Feitler as she returned to her Near North Side apartment building.

Feitler, who was to start graduate school at the University of Chicago the next day, was forced at gunpoint to walk to an ATM. She made two withdrawals totaling $400.

Shortly afterward, a passerby spotted her unconscious body in an alley. Shot once in the back of her head, Feitler languished in a coma for three weeks before dying on July 9.

The case attracted national media attention, and police faced mounting pressure as months passed without an arrest. Feitler’s family offered a $25,000 reward.

Detectives initially had few clues. Surveillance footage from the bank showed only Feitler, not her assailants. But a few witnesses soon stepped forward in response to media coverage.

One man said he saw three Black men that night acting suspiciously in a white car parked near the site of the crime. A woman reported seeing someone she believed was Feitler walking with three Black men that night. The witness, who was walking her dog at the time, said Feitler had made lingering eye contact with her. One of the men had a limp, she said.

Police showed photos and a live lineup of suspects to the dog-walking witness. She identified the same man both times, but he denied involvement and his girlfriend provided him with an alibi. He was never charged, though he did have a distinctive gait, thanks to an earlier shooting injury, that was similar to the limp the witness had described.

With the two witness descriptions, detectives focused their search for suspects on the nearby Cabrini-Green neighborhood where Harris lived. At the time, he was friendly with two police officers assigned to Cabrini who used him as an occasional informant. And so, Harris has said, he thought nothing of it when the patrol officers spoke to him about the attack on Feitler.

Harris would have more than 20 conversations with police over the next few months. Initially, he implicated other men. But in mid-September 1989, prosecutors refused to approve charges against the police’s main suspect based solely on Harris’ statements. According to his attorneys, Harris himself then became the target of the police investigation.

Hollis, more than a decade older than Harris, had looked out for him for 20 years. He attended school events when Harris needed a parent and stood up as Harris’ best man at his wedding. He said Harris was a petty thief at worst who made up stories to please others or appear important.

Hollis said he recalls Harris bragging at the time about reward money, but he had no idea what a dangerous game Harris had been playing with police.

Beyond a reasonable doubt?

Four months after Feitler’s murder, prosecutors charged Harris with aggravated kidnapping, armed robbery and first-degree murder. No one else was ever charged.

Jermaine Harris said that while he can’t recall the circumstances of his dad’s arrest, he does remember that his parents, especially his mother, protected him from what was happening.

At the time, he did not live with his father, who in 1989 was married to another woman. “My mom did a great job of not letting this be too much for me,” Harris said. “She’d say, ‘Go be a 7-year-old kid. These are adult problems.’”

One day after Lee Harris’ arrest, police called the dog-walking witness back into the station to view a lineup that included Harris. The witness said she was almost certain, but not positive, that one of the men she saw with Feitler was Harris.

The other witness – the man who reported seeing the white car – testified that he did not identify Harris in a police lineup.

A key prosecution witness was a jailhouse snitch named David Toles, who testified that Harris admitted he was the triggerman while Toles and Harris were playing cards.

Defense attorneys challenged the convicted felon’s credibility and noted prosecutors had reduced his felony burglary charges to misdemeanors after he told authorities about the alleged confession.

The version of events that Toles said Harris provided, in which the victim was shot in a car, did not fit Harris’ statements to police or the female witness’s account.

Authorities never recovered the murder weapon and had no physical evidence linking Harris to the crime. Their strongest evidence against him was his own words, collected over the few months he was talking to police.

Harris initially told them he witnessed three men run out of the alley as he sat in a coffee shop near the crime scene. After police noted that it was impossible to see the alley from that location, Harris said he was actually outside.

In his final statement to police, Harris said he happened upon Feitler and her abductors on the street and followed them into the alley in hopes of getting some robbery money.

During his trial, prosecutors told the jury Harris provided police with details only the killer would know, including the exact location of the alley where a wounded Feitler was found.

His defense team noted the inconsistencies in his statements. They argued police coached him about key details and Harris repeated what they wanted him to say – in part to try to get the reward money but also because they had been financially supporting him for months.

Several officers testified they had provided housing, food, cash and other assistance to protect their informant from possible retaliation in Cabrini because of his cooperation with police.

A jury convicted Harris of all charges in March 1992, after about four hours of deliberations. Prosecutors sought the death penalty, but a judge instead meted out a 90-year prison term.

Harris did not testify at his trial. At his sentencing, his attorneys read a statement from him in which he said he was sorry for the Feitler family’s “tragic loss” but that he “had no part of it.”

Feitler, who grew up in a Milwaukee suburb, was unafraid of city life, her relatives said at the time. Her family later became active in anti-gun violence advocacy work in her memory.

“We will always miss Dana,” her dad told reporters after the verdict. “We will always have this loss.”

An unlikely friendship

Nearly a decade into his incarceration, Lee Harris got a new cellmate at Joliet Correctional Center, a now-closed maximum-security prison about 50 miles southwest of Chicago.

The two had little in common. Robert Chattler was more than 20 years younger than Harris. A white kid in his 20s who grew up in a Jewish family in an affluent suburb, Chattler’s crimes – burglary and drug possession – were not of a violent nature. His stint in prison would be brief.

Harris, who didn’t smoke but kept cigarettes as currency, offered his new cellmate one and then eventually the whole pack. Chattler didn’t have many privileges, and so Harris arranged it so the younger man could phone his family and get snacks and other items from the commissary.

Chattler said Harris’ outgoing personality made him popular among inmates and prison guards. “He looked out for me,” Chattler said.

But the two didn’t room together long. Chattler admits his chain smoking and taste in music “annoyed the hell” out of Harris, who Chattler suspects complained and got him moved into a nearby cell where smoking was permitted. But Harris continued to check in on him, especially when Chattler’s sister died unexpectedly from viral encephalitis.

“He was a people person,” he said of Harris. “He’d always get involved if someone was down or needed something.”

One of the few times Chattler can recall Harris in a bad mood was the first time the two spoke about his conviction. Harris accused police of framing him.

“Being who I am, this suburban Jewish kid who had nothing but proper interactions with the police, including the one I was arrested for, I was like, ‘Yeah, right. That doesn’t happen. It’s impossible,’” Chattler said.

He didn’t share his doubts with Harris. Instead, Chattler promised to try to help some day. A short time later, state corrections officials moved Chattler to a minimum-security prison to serve out the remaining months of his sentence. As he left the Joliet prison, Chattler said, he stopped by Harris’ cell to say goodbye. He repeated his promise.

He was released in December 2001. With family support, Chattler said he did well. He worked his way up in his father’s advertising business and never returned to the college drug habit that had landed him in prison.

One day, about a year after his release, Chattler began thinking about his old cellmate and the promise he had made. He wrote Harris a letter asking: “Where do I start?”

Harris wrote back quickly. One of the first things Chattler did was find Toles, the jailhouse snitch with a long criminal record who had testified at Harris’ trial. A television journalist helped him track down the man at a Wisconsin jail. Chattler wrote to him, and to his surprise the man wrote back, he said. The two began communicating and Toles, though often cryptic in his responses, which were not dated or signed, was apologetic about Harris.

Chattler said he began to believe Harris might be innocent.

“I felt a responsibility to help him,” Chattler said. “It became my life’s project.”

A long road

In March 2004, Toles reported to the FBI that he had testified falsely against Harris, according to court documents. During a May interview with the Cook County state’s attorney’s office, which took place in a Wisconsin jail, Toles admitted Harris never confessed and that he had lied on the stand at the behest of police.

His recantation was not enough alone to clear Harris, but it did help persuade prosecutors in Foxx’s conviction integrity unit – now called the conviction review unit – to grant Harris’ long-stalled request for forensic testing on the sweatshirt of the man with the odd gait.

The testing, which focused on blood spatter evidence, failed to yield conclusive results linking him to Feitler’s murder.

Chattler, then living in Texas, continued to try to free his friend. He and Harris talked two or three times a week and exchanged letters. Chattler dug into his own pocket to help Harris pay for the calls, special meals on holidays and for his legal needs.

In 2016, attorney Jennifer Blagg agreed to represent Harris. Chattler also had started an online campaign, including a Facebook page and petition drive, to raise awareness and money.

By then, a 2015 investigation published by The Guardian had detailed how Richard Zuley – the lead detective in Feitler’s murder case – had been accused of coercing false confessions through unorthodox and sometimes violent interrogations. It noted that Zuley later worked a stint at Guantanamo Bay, where his interrogation tactics were included in a scathing 2008 Senate investigation into allegations of military torture.

Prosecutors agreed in 2013 to dismiss another high-profile murder conviction that Zuley had been involved in because of constitutional issues raised by the man’s defense. Other police officers involved in Harris’ arrest also were later involved in wrongful conviction cases, sustained complaint investigations and lawsuits, court records show.

A lengthy 2018 feature by the Marshall Project, a non-profit newsroom focused on criminal justice, highlighted Chattler’s efforts and the allegations of police misconduct. Foxx’s conviction integrity unit had again started to investigate Harris’ case as well.

Among the allegations raised in Blagg’s court filings was that police falsified some reports to fit facts in the case. Blagg noted instances when the detectives’ general progress reports differed from official versions. In some cases, she said, a new detail emerged with suspicious timing.

One example concerned the victim’s Tiffany watch. Months after the murder, Feitler’s mother called police to report the family had noticed her daughter’s watch was missing. Blagg said police shortly thereafter indicated for the first time in reports that Harris had mentioned the watch, saying one of the assailants had taken it during the robbery.

Issues also arose related to the lineup where the woman walking her dog had tentatively identified Harris as one of the assailants. That witness told the conviction integrity unit in 2018 that she’d seen a Black man at the police station a couple of times back in 1989. Harris’ attorneys argued that it was Harris, who’d been cooperating with police, and that the lineup was therefore tainted.

Police made Harris their “sacrificial lamb” after prosecutors declined to approve charges against a man Harris had implicated, Blagg argued.

“It also defies reason that Harris would go from being the prosecution’s star witness, being compensated for his meals and housing, to being the only person charged with the crime after (prosecutors) refused to charge CPD’s target,” Blagg said. “The only answer to how this happened is that there was a complete and total failure of our justice system.”

Blagg has suggested the man with the odd gait is the real killer, but he has never been fully investigated. Forensic testing on that man’s sweatshirt in more recent years showed evidence of gunshot powder residue, according to court documents.

The Chicago Police Department declined to comment for this story, citing Harris’ pending lawsuit. Zuley’s attorneys did not answer a Tribune request for comment. In a response to the lawsuit, filed Thursday in federal court, attorneys representing the city and the individual officers denied wrongdoing and said Harris’ arrest was based on “police department reports, court documents and (Harris’) oral statements.”

Finding a way

Jermaine Harris said his dad remained a constant presence despite his incarceration, through phone calls, letters, cards and prison visits.

“I would talk to him on the phone four or five times a week,” he said. “My dad would help me with my homework. I got a birthday card every year of my entire life. He would always find a way.”

He said he never doubted his father’s innocence.

“Not once,” he said. “I know he wasn’t always a saint. He told me how he did dumb stuff when he was young.” His father admitted he lied to get the reward money, Jermaine said.

“He told me (police) hung X amount of dollars over his head and he thought that’s the fastest way he could get us all out of the projects,” he said. “He said he trusted these people and it came back and backfired on me.”

He said his father never gave up hope he would one day be free, and so neither did he.

Lee Harris finally won his freedom March 16, 2023. His son brought T-shirts featuring a photo showing the two of them hugging, taken when the younger Harris was in middle school. The shirts read: “Together again.”

Standing before reporters, Harris thanked his supporters – especially Chattler, who flew in from Texas.

“If everyone had a friend like this,” Harris said, “this world would be such a better place.”

Hollis, who said he had sent Harris up to $40 a month for three decades of incarceration, also greeted his old friend. They all celebrated that night at Manzo’s Burger in Morgan Park.

Feitler’s family shared a statement with the media upon Harris’ release. They said members had learned of the development only two days prior. The family noted Harris’ criminal history, confession and the jury’s guilty verdict. The statement said the family is “heartbroken that this epidemic of gun violence remains a horrific plague” decades after their loss.

After leaving Stateville Correctional Center, Lee Harris got busy living. The sports enthusiast attended several Chicago Bulls, Bears and White Sox games. He watched his son play softball. He reconnected with friends, attended concerts and traveled to Arizona, Florida, Mexico and Las Vegas.

Harris stayed with Chattler for about a month at his Texas farm, where Chattler cares for a host of rescue animals. The two went fishing, something Harris had talked about wanting to do if he ever got free. Back in Chicago, Harris lived with a niece on the city’s South Side and volunteered at church, relatives and friends said.

But his re-entry wasn’t easy. At times he slept on the floor because his mattress, compared with his prison bed, was too soft. He struggled with public transportation and once ended up at an airport rather than the sports store he was trying to reach.

And, according to his loved ones, he was afraid of the police and struggled with trust. Harris had health problems, including heart issues, high blood pressure, diabetes and chronic obstructive pulmonary disease. His son said Harris was repeatedly hospitalized after his release from prison.

In July, he began dating Rhodena Arnold, whom he met through his niece. She said he shared his life story with her during their first date at Navy Pier.

“I loved Lee,” she said. “If you knew Lee, you would have loved him too. There was never a dull moment being with him. He never wanted to disappoint anyone.”

But Arnold also noticed the times Harris was struggling.

“When I met Lee, he didn’t know what to do with himself,” she said. “He would sit across the street at the church on this bench, and, in his words, he’d say, ‘I have a church behind me and a funeral home facing me.’ He was kind of lost.”

Harris got some help from GRO Community, a mental health center that serves Black and brown boys and men in low-income, high-crime neighborhoods. Harris took part in a 16-week re-entry program that offers individual and group therapy. He also worked a temporary, paid job through the program.

Harris impressed the staff, including when he gave up his spot for subsidized housing to someone else in the program. Kiana Nash, a GRO program manager, said Harris did so well, they were working out the logistics of hiring him to work part time at GRO.

“He always brought a positive perspective to everything,” Nash said, adding: “He was one of our success stories. He wanted to do public speaking. He wanted to inspire youth and others.”

Harris graduated Nov. 6. Weeks earlier, in late September, he had filed a federal lawsuit against the city, naming nearly a dozen Chicago police officers and seeking compensation for his incarceration.

He dreamed of owning a downtown home with a balcony view of the lakefront or moving somewhere warm, like Arizona.

Lee Harris’ first grandchild, Amena Jiraya Harris, nicknamed “A.J.,” was born Dec. 5. They never had a chance to meet.

A final goodbye

Harris celebrated his first Thanksgiving out of prison in Chicago with Arnold. She said she noticed he had labored breathing and was sweating. But he was in his usual good spirits, albeit more subdued.

Hours later, she drove him home so he could get a good night’s sleep. She was so busy cleaning up after her holiday party that she didn’t notice he had failed to call to make sure she had arrived home safely.

Early the next morning, when her phone rang as she was leaving for work, she assumed it was Harris. He phoned her each morning with a trademark, “Rise and shine. It’s time to get up!”

Instead, it was Harris’ niece. She had found his body.

Though heartbroken, Arnold said, “I’m also thankful and grateful that he didn’t die in prison and that he was able to come home for a short period of time to see his family.”

Foxx said she felt “gutted” by Harris’ death. Foxx said she still thinks about the day the two met and swapped stories about Cabrini-Green – and how Harris, with tears in his eyes, hugged Foxx and thanked her.

“Inasmuch as we do this work around wrongful convictions and celebrate people coming home, what Lee’s case reminded me of is how difficult that journey can be,” Foxx said. “His description of how scary the world is shook me because here I was thinking it would be glorious to be out. It made me appreciate that we have a lot to do to make sure that outside feels as free as it should.”

For Chattler, the loss of his friend reverberates still. For decades, he has saved their letters, documenting Harris’ journey to exoneration. They had hoped to share their story of friendship and perseverance in public schools and college criminal justice classes.

“He was my best friend,” Chattler said. “I loved Lee. Next to my mom, I don’t think there’s anybody that cared or loved me as much as he did.”

In a recent statement to the Tribune, members of Feitler’s family pledged to continue their anti-violence advocacy work “so that no family ever has to endure the horror that we have experienced since Dana’s murder, as well as the wounds that continue to resurface when victims and their families are forgotten in the national narrative.”

They said Feitler was a two-sport college athlete who was about to embark on her MBA and dreamed of becoming a hospital administrator.

“We’d like to remember who Dana was and ask that she be celebrated and not forgotten,” the statement read. “Not a day has gone by where the memory of Dana, our beautiful 24-year-old sister, daughter, aunt, and friend, has not been present in our family’s lives. Dana was just beginning her life. She was thoughtful and adventurous – with a real zest and excitement for her future.”

Harris died before he could apply for an official certificate of innocence. As for his lawsuit, it’s unclear how his death will impact its outcome. His son is the executor of his father’s estate.

Jermaine Harris said more than 150 mourners packed his father’s memorial services over two days and dozens more called to offer their condolences.

Wearing his “Together Again” T-shirt, Harris told the crowd he will “forever be proud” to be his father’s son.

“He promised me one thing” while incarcerated, Jermaine Harris told mourners at his father’s Dec. 1 funeral. “He said, ‘They will not carry me out of here.’

“Even days where he couldn’t see the end of the tunnel, he saw the light. It’s that perseverance I want everyone to leave here with. Never give up.”

cmgutowski@chicagotribune.com