PEMBROKE – The family of a 20-year-old woman who died at Pembroke Hospital last August is questioning whether the psychiatric hospital’s decision to transport her body to South Shore Hospital interfered with finding out what really happened to her.

Pembroke Hospital instructed town paramedics to transport Amber Mace to South Shore Hospital, even though she was in full rigor mortis, according to an investigation by the state mental health agency.



State law requires notifying the Office of Chief Medical Examiner when a body is discovered in certain circumstances including a death “in any mental health or mental retardation institution” or “death associated with diagnostic or therapeutic procedures.”



Mace’s uncle argued that police and medical examiners should have investigated the scene before his niece’s body was moved.



“Why move her? It seems like they didn’t want her to be found on the property,” said Mark Savio, who lives in Lynn. “Honestly, it’s a crime scene. They may not see it that way but to me it’s a cover-up. The attending doctor should have pronounced her dead on the scene.”



Pembroke Fire Chief Michael Hill said that paramedics questioned the directive from a Pembroke Hospital physician but ultimately complied after consulting by telephone with a physician at South Shore Hospital.



“It’s illegal for us to move a dead body,” Hill said. “It’s more complex than I can discuss. We were told she was breathing 15 minutes prior.”



Judith Merel, a spokeswoman for the 120-bed psychiatric hospital, denied any wrongdoing.



“Pembroke Hospital has a policy in place regarding transfer to nearby acute care hospitals in the instance of a patient medical emergency,” Merel wrote Friday in an e-mailed statement. “Any notification to the medical examiner would only occur after a patient has been pronounced dead by appropriate medical personnel.”



Pembroke Hospital physician Dr. Konrad Mark was on duty the morning of Aug. 30 when Mace’s body was found in her room at about 5 a.m., her limbs and jaw already stiffened into full rigor mortis, according to an investigation into Mace’s death by the State Department of Mental Health completed last November.



The state’s investigation revealed a different timeline than what the fire chief says hospital staff told emergency workers. According to the state probe, the Pembroke Fire Department arrived at Pembroke Hospital at 5:11 a.m. and was told by hospital staff that Mace had been observed breathing at 4:15 a.m. The state’s investigation later determined that Pembroke Hospital staff had failed to conduct a proper well-being check of Mace.



The state’s review of fire department records showed Mark “requesting transport to SSH (South Shore Hospital.)”



Mace’s body arrived at the Weymouth hospital at 5:54 a.m. where Dr. Mark Toyer pronounced her dead.



The Plymouth County District Attorney’s Office declined to comment Friday on the incident and whether anyone involved in transporting Mace’s body violated state law.



The State Department of Mental Health determined last fall that the hospital created “dangerous and inhumane” conditions for Mace.



“Had checks been conducted in accordance with policy, it is likely that the patient’s condition could have been discovered much sooner,” Janet Ross, the director of licensing for the State Department of Mental Health, wrote in November. “(The) failure of safety checks constituted a dangerous condition, which may have delayed treatment for a medical condition beyond the point where intervention could be effective.”



The state medical examiner determined that Mace probably died from an inflammation of her heart that could have followed a viral infection.



In Ross’ report, the state criticized Pembroke Hospital for recording pulse rates of 106 and 113 for Mace as stable vital signs.



“(They) are not considered to be stable vital signs for a young woman of 20 years old,” Ross stated.



Another investigation completed in March by the state Department of Public Health for the Centers for Medicare and Medicaid found that Pembroke Hospital failed to follow its own policy by not completing a comprehensive assessment of Mace. However, the investigation concluded that Pembroke Hospital still met Medicare requirements.



Mace’s mother, Tammy Mace, also questioned the drugs that Amber Mace was prescribed and the possible interactions and complications they might have caused.



In April and March, the state health inspectors made six surprise inspections of Pembroke Hospital and flagged violations related to understaffing, simultaneously restraining and isolating a patient and unclear criteria for evaluating a patient’s risk for aggressive behavior.



The state uncovered “urgent patient care and life safety violations” at Pembroke Hospital and ordered the hospital’s parent company, Arbour Health System, to take immediate steps to correct the violations or risk having to close to new patient admissions.



Arbour Health System is owned by the for-profit Universal Health Services, a publicly-traded company and largest provider of mental health services care in the U.S.



