Dying Under the Army's Care

(2 of 2)

At Fort Knox, Cassidy spent most of his time alone in his room with his laptop computer and Xbox video game. "While he was at Fort Knox," his wife says, "he was actually getting worse." He met with his case manager weekly but saw Kearney, his psychiatrist and only regular doctor, barely once a month. Their first visit was on May 30, 2007, nearly two months after he arrived at Fort Knox. "Alert and smiles throughout the interview, is anxious," Kearney typed into Cassidy's file. "He was under fire and under constant stress and was mortared frequently." Kearney prescribed Valium and another medication in addition to the other drugs the soldier was already taking.

But while the pills sometimes worked, they didn't keep the headaches at bay. "We kept asking, 'What's the treatment plan here?'" his wife recalls. "There was never an answer for that." After a terrible headache drove Cassidy to Fort Knox's emergency room, Kearney prescribed methadone for the first time on Sept. 13.

Cassidy's final day of Army medical care began early on Tuesday, Sept. 18. That morning the Fort Knox medical clinic noted that he was "awake, alert, oriented to time, place and person, well developed, well nourished, well hydrated, healthy appearing, in no acute distress." A short time later, Cassidy met with Kearney, who observed in his file that "the methadone worked for the headache...used 40 mg without difficulty or too much sedation." So Kearney wrote a prescription for 16 more 10-mg methadone tablets "for severe pain" after discussing "potential side effects with patient who indicated understanding." Cassidy showed no suicidal inclinations, Kearney added.

About lunchtime, Cassidy spoke by telephone with his mother Kay McMullen. "Mom, there's a lift dropping huge bundles of shingles on top of the roof," she says he told her. "It seems like I'm back in Iraq again--my head is pounding." But around dinnertime he had an upbeat conversation with Melissa. He talked happily about visiting home the next weekend. Two weeks after that, he was to return for good and continue treatment at a civilian hospital.

Melissa was unable to reach her husband on his cell phone later that night or the next day. By Thursday, she became anxious after he had failed to respond to her four messages. On Friday morning, she called and found his voice mail was full. Moments later, her apprehension turned into panic when she dialed into his cell-phone messages and found he hadn't listened to any of them, including her good-night call on Tuesday.

She immediately dialed Kearney and her husband's platoon sergeant, but they didn't answer. She reached a soldier at his barracks who promised to hunt him down. When Melissa hadn't heard anything by mid-afternoon, she called the barracks again and spoke to Sergeant Rory Martin, another outpatient. She asked him to check to see whether her husband had applied on Wednesday, as required, for his weekend pass. When they spoke again four hours later, Martin told Melissa that Cassidy had not applied for a weekend pass and that a knock on his door had gotten no response.

Martin promised he would find her husband, but when she hadn't heard from him by 6:45, Melissa placed another call to Martin's cell phone. "I haven't got in yet, I haven't got in yet," Martin told her, voice shaking. "Let me call you back, sweetie." Then he hung up. "I knew," Melissa says quietly, "something was terribly wrong."

After another hour, Colonel Rhonda Earls, the hospital commander, got on the phone to give Melissa the news. "Mrs. Cassidy, I regret to inform you that we found your husband in the barracks, and he is dead." A military chaplain and casualty-assistance officer arrived at the house at about midnight.

Killed by the System

Martin, who found Cassidy's body, can still recall his horror but says he understands how it happened. "Nobody there had accountability for nobody," he says. Sergeant Jim Hunt, who lived in the Fort Knox barracks from January to July 2007, says only about half of those who were supposed to show up for mandatory formations--at 7 a.m., 1 p.m. and 4:30 p.m.--actually did.

Five days after Cassidy's death, the Government Accountability Office told Congress that more than half the WTUS had "significant shortfalls" in key positions. At Fort Knox, more than half the squad-leader positions--those most responsible for Cassidy's well-being--were unfilled. An Army report on TBI released in January also offered a grim assessment, finding "no specific standards" for dealing with the TBI problem, "major gaps" in coordinating care and "no medical-provider core competencies." Now the Army is rushing to catch up, setting up screening tools and treatment plans to deal with TBI and a "center of excellence" dedicated to the challenge.

A month after Cassidy's death, the Army removed from command the three soldiers most responsible for his well-being. The Army suspended Kearney on Jan. 11 after an aide to Indiana Senator Evan Bayh, who has been probing the circumstances surrounding Cassidy's death, complained that he was still seeing patients. (Kearney says he did nothing wrong and is a victim of political pressure.) "The enemy could not kill him, but our own government did," Bayh said of Cassidy. The Senator has succeeded in requiring the Army to make sure wounded soldiers are sent to the "most appropriate" facility for care and to set time limits on delivery of that care.

But for some, such reforms come too late. Cassidy's death was the first in a string of at least three that led to urgent meetings at the Pentagon earlier this month on how to prevent them. They included soldiers who died in late January at WTUS in New York and Texas. Lieut. General Eric Schoomaker, the Army's top doctor, told TIME that easy access to drugs and lack of accountability played key roles in Cassidy's death. "If there's any good to come of this at all," Schoomaker said, "it's that we will work as hard as we possibly can to prevent any recurrence." But moments later, he conceded that while Cassidy is the first such death, he's "not an isolated case. We know of several others at this point." Once again, Sergeant Cassidy is leading soldiers in a war not of his making.