University of Michigan President Mary Sue Coleman called the university's 6-month delay in reporting child porn to police "a serious failure" as the university released an internal review of the case Friday morning.

At least eight people, including the Deputy General Counsel (Health System Affairs) knew about the alleged crime by June 2, records show, but the child porn wasn't reported to police until November. No one has been fired, university spokesman Rick Fitzgerald said, noting that the report calls for corrective action for employees involved.

University of Michigan Hospital

"This was a serious failure on the part of our institution - there is simply no other way to describe it," Coleman said. "Findings indicate that an attorney in the Health Legal Office acted improperly when the incident was reported to her. A university attorney must not assume the lead role in investigating a potential crime of this nature. This is solely the responsibility of the police."

Records show university officials waited months to tell police after a resident physician found child porn May 23 on a thumb drive left in a locked lounge residents use in the Pediatric Emergency Department at U-M Hospital.

The internal review, completed by the U-M Office of University Audits, was released roughly a week after the Joint Commission, a hospital accreditation agency, confirmed it was investigating a complaint about the matter. The U.S. Department of Education also is looking into the case to determine whether there were violations of the federal Clery Act that requires universities to warn the campus community if a crime poses a threat.

To download a PDF of the internal review, click here.

Members of the Senate Advisory Committee on University Affairs said Monday that they wanted to see the internal review before deciding whether to recommend that the university ask for an external review.

In response to the review's findings, hospital management said that they will retain at least one "outside" expert by April 1 to "assess our safety and security culture and help us achieve needed change."

The review calls for improving communication between hospital security and the university's Department of Public Safety, including defining reportable criminal activity. It also suggests considering a DPS liaison office within the health system.

In her statement, Coleman said the attorney in charge of the case, whose name hasn't been released, was employed roughly three-and-a-half months, ending June 10. That attorney doesn't work for the university anymore, but her leaving didn't have to do with the child porn incident, Coleman said.

Coleman said the internal review revealed a "significant breakdown across a number of units responsible for the safety, security and well being of people on our campus."

"The review also shows poor judgment on the part of several employees who could have done more in May. And, there were some who thought they had correctly reported a potential crime, and confusion among others about the process for reporting potential criminal activity. There can be no delay in reporting wrongdoing. All of this is unacceptable, and we will address it immediately."

AnnArbor.com broke the news last week that university officials waited 6 months to report the child porn to university police. A resident physician found child porn on a thumb drive left in a hospital computer, suspected the drive belonged to another resident physician and told her supervisors, hospital security officials and the Office of the General Counsel, court records say.

The Office of the General Counsel took over the case, and the crime wasn't reported to police until a hospital security official came forward six months later. Another resident physician, 36-year-old Stephen Jenson, who worked at the hospital until late December, was charged with four counts of possessing child sexually abusive material and is scheduled to return to court Feb. 16 for a preliminary hearing.

The university acknowledged that the case wasn't handled properly and said Coleman requested the internal review on Dec. 3.

The report, which has been distributed to the Board of Regents and top university officials, says university management "accepts responsibility for the delay in reporting the crime" and the case should have been forwarded to police in May.

"We conclude that the assertion of improper control of the investigation by the attorney and reliance on her conclusions by others were the root cause" for the delay and improper handling of the report.

"Individual corrective action will be taken with the involved current employees to ensure greater clarity of their respective roles and the importance of vigilance when handling complaints of possible criminal activity or risk to patient safety," the report says. "This corrective action will be documented in the employees' personnel files and those employees will be held accountable for improvement through the established performance review process."

University timeline offers new details in case

In addition to a statement from Coleman and the 16-page report, the university released a timeline of the case Friday.

It offers new details about what transpired since a resident physician saw a photograph in May of a “nude adult lying” on a young child whose arms "were bound" and appeared to be tied to a bed frame, court records show.

A physician who knew about the child porn came forward last fall to risk management officials, in part, because of the Penn State University football child sex abuse scandal.

In addition, the timeline shows that a hospital security supervisor left a voicemail for a university police sergeant in May, two days after the child porn was found, asking whether police could provide "forensic assistance with images viewed on a computer from a USB thumb drive." That message wasn't returned.

The security supervisor told auditors he didn't complete a report to police after receiving an email from a health system attorney that "he believed meant he should stop" investigating.

The timeline also touches on a meeting June 2 between the lead attorney on the case and the resident physician who found the image. The report says that lead attorney had "significant experience investigating and prosecuting health care professionals" and asserted control over the investigation. An attorney who was assisting in the case couldn't make the meeting.

"The female resident leaves the interview crying," the timeline says. "The lead attorney tells the assisting attorney that the female resident was unsure of her story and what she saw."

"The attorneys call the Health System Chief Compliance Officer and relay that there is not sufficient evidence to move forward, that the Health System's Legal Office's assessment was that the female resident's story was shaky," the timeline says.

The lead attorney reported to the associate vice president and deputy general counsel "that there was no evidence and that the case would be closed," the timeline says. The resident physician texted another physician that the meeting didn't go well and the attorney told her "the investigation is complete and the claims are unfounded."

For months, nothing happened.

A physician comes forward

On Nov. 11, in the wake of the Penn State scandal, a physician who knew about the child porn called the Risk Management Top Executive who is part of the Office of Clinical Affairs in the health system and raised questions about the case, the timeline says. When she came forward, she knew the attorney who was in charge of the child porn case had left the university.

"The attending physician expressed concern about the treatment of the female resident and the outcome of the May case," the timeline says. "The Risk Management Top Executive tells her this is the first time he has heard of the allegations."

After meetings and discussions during the next week involving hospital officials and the resident physician who found the child porn, officials with the Office of Clinical Affairs and Health System Legal Office made a report to security, the timeline says. When they made the report Nov. 18, they were told security would report the case to police. Security called police and a formal police investigation was underway three days later.

Fitzgerald declined to identify the people referred to in the timeline who knew about the child porn and didn't tell police.

In her statement, Coleman apologized to the resident physician for "not properly investigating the allegations in May."

In responding to the auditors' review, hospital management said it accepts the recommendation to "to bring in external expertise" for a "full assessment of the working relationship and operational issues with HHC-Security, DPS, and the units with whom they interact regularly, in order to address significant cultural and management issues that have arisen in the course of this internal review."

U-M Health System CEO Ora Pescovitz wrote Friday on her blog "Medicine That Speaks" that the health system has "quite a bit of work to do to make sure our people, structures and processes are at their best."

"As an institution, we failed to make sure that this resident's concerns were investigated in a thorough and timely manner," she wrote. "We are committed to turning this failure into a lesson, and turning that lesson into actions that ensure that when someone does the right thing and reports a suspicion, we have a safeguarded system and appropriately trained personnel in place to make sure the matter is handled in a judicious and correct manner."

She wrote that the health system is cooperating with the Joint Commission's investigation into a complaint about the case.

"We are working diligently, along with campus leadership, to correct the shortcomings brought to light by this serious lapse. It is important to remember that it is both our individual and collective responsibility to make certain that the University of Michigan Health System promotes an environment of safety. We must never be complacent in this effort, and this means feeling safe to speak up and report concerns. It is up to all of us to ask why and seek a second opinion when something doesn't appear or feel right."

Lee Higgins is a reporter for AnnArbor.com. He can be reached by phone at (734) 623-2527 and email at leehiggins@annarbor.com.