Samuel Cole Hartman
May 28, 2005 – August 4, 2013
Samuel Cole Hartman, known as Cole Hartman, was an eight-year-old boy from Castaic, California. He had Fragile X syndrome. He was the son of Jeremy Hartman. His mother died in 2009.
Incident and hospitalization
On July 31, 2013, Hartman’s stepmother found him head down in a top-loading washing machine filled with water and clothes. He was resuscitated at Henry Mayo Hospital. The Los Angeles County Sheriff’s Department homicide unit was assigned to the case because the injury appeared suspicious. The following day, he was transferred to Ronald Reagan UCLA Medical Center. His pupils became reactive, and he was minimally responsive. He did not meet the criteria for brain death and was placed on the donation after circulatory death (DCD) track.
Death
On August 4, 2013, Hartman was taken to an operating room at Ronald Reagan UCLA Medical Center. His intensive care physician also served on UCLA’s liver transplant team and acted as the anesthesiologist for the organ recovery, roles that are typically held by separate individuals. Hartman was on a continuous morphine drip. When the ventilator was removed, he continued to breathe. The physician administered 500 micrograms of fentanyl. Hartman weighed 21 kilograms and had no prior history of opioid use. He was pronounced dead at 11:03 a.m.
The fentanyl dose was not entered into the medication record. It was handwritten on a slip of paper and scanned into the chart. Pharmacy logs subpoenaed by investigators showed that one vial of 250 micrograms had been checked out for Hartman. The source of the second 250 micrograms was never established.
Investigation and autopsy findings
Blood drawn in the operating room was couriered to the coroner by OneLegacy, an organ procurement organization. That sample showed morphine but no fentanyl. Denise Bertone, the pediatric death investigator assigned to the case, requested that the pathologist also draw blood from the body at autopsy. That sample remained untested for seven months. When it was analyzed in March 2014, it showed morphine and a lethal level of fentanyl.
The case was initially closed in October 2013, with the cause of death listed as sequelae of near drowning and the manner of death undetermined. It was reopened in November 2016. A pediatric toxicologist determined that the fentanyl level was inconsistent with a therapeutic dose, and the death certificate was amended to include fentanyl toxicity. In June 2017, the chief of anesthesiology at the University of Southern California reviewed the records and found the dose to be 250 to 300 micrograms above a safe level for Hartman. The manner of death was changed to homicide. No criminal charges were filed. The deputy district attorney assigned to the case did not issue a written rejection notice explaining why prosecution was declined. Bertone stated that Hartman’s family was told the fentanyl administration was comfort care.
UCLA Health declined to comment on the case, citing patient privacy law, and stated that “potential organ and tissue donations are not a consideration in decisions about life-sustaining care.”
Whistleblower lawsuit
Bertone sued Los Angeles County, alleging that she was pushed out of her position for pursuing the investigation. Dr. Lakshmanan Sathyavagiswaran, the chief medical examiner, testified at trial that the coroner’s office received $140,000 to $150,000 per year from OneLegacy, which he described as cost recovery for staff time spent on organ and tissue procurement. He stated that the office operated on a budget of approximately $40 million per year. He acknowledged having served on the board of OneLegacy before returning as interim chief medical examiner. He denied that anyone retaliated against Bertone. Bertone testified that OneLegacy had also assisted Sathyavagiswaran’s son-in-law in obtaining a job.
On December 17, 2021, a jury found in favor of Bertone after 90 minutes of deliberation. Following the verdict, Bertone stated that no further action was taken in relation to the case.
OneLegacy stated that California law authorizes coroners to enter agreements with organ procurement organizations, and noted that Los Angeles County has an ordinance requiring such an agreement. OneLegacy holds similar arrangements in all seven counties it serves.
