New Jersey Department of Health and Senior Services

The New Jersey Department of Health and Senior Services was the state agency to which hospitals were required to report events threatening patient health and safety. Its role in the Somerset Medical Center case began amid unexplained, potentially criminal patient poisonings and became entangled with the hospital’s preference to investigate internally before reporting. The department reviewed the incidents, but its response also illustrates how a warning can move through several levels of authority without producing immediate, unified action.

Reporting authority and the Somerset dispute

State regulations required hospitals to report patient-safety events to the department immediately; hospitals did not have to know the cause before making a report. Somerset Medical Center nevertheless told New Jersey Poison Control Center that it would wait to notify either the department or police until it had completed a thorough internal investigation. That position put the timing of external scrutiny at the center of the dispute: the hospital treated a settled explanation as a precondition for reporting, while the reporting rule did not.

New Jersey Poison Control Center director Steven Marcus warned Somerset administrators that they were already out of compliance with their reporting obligations. On a conference call, Marcus said that suspected poisonings implicated patient safety and the police, and told the administrators he would report the matter to the department himself if Somerset did not act. The call was recorded. Marcus had already contacted state epidemiologist and assistant commissioner Eddy Bresnitz, describing a cluster of illnesses that might result from a criminal act, and had sent assistant commissioner Amie Thornton an email summarizing four adverse clinical events and Somerset’s refusal to report them before finishing its own investigation.

After that confrontation, Somerset risk manager Mary Lund reported four incidents to the department by fax and email. The patients included Reverend Florian Gall and Jin Kyung Han, whose incidents involved digoxin, as well as patients affected by insulin. Somerset described steps it had taken to test ordinary explanations: it checked for manufacturer recalls and adverse drug interactions, confirmed that IV equipment and bedside monitors were functioning, and repeated laboratory tests to exclude lab error. It had also tightened controls on digoxin after previously strengthening controls on insulin. These measures documented the hospital’s inquiries, but the underlying incidents remained unexplained.

Review at the hospital

The department sent Edward Harbet, a registered nurse and complaints investigator with Health Care Systems Analysis, to Somerset Medical Center. On July 11 and 14, he reviewed records for the reported patients, the hospital’s internal-investigation summary, relevant policies and staffing assignments, and met with administrators. He could not identify a specific finding that explained the abnormal laboratory values. He told the hospital that others in his department would review the charts, and he did not advise an additional external-agency report.

Two department clinical laboratory evaluators also examined Somerset’s laboratory services, focusing on testing procedures and facilities used to validate the abnormal results. They found no deficiencies in the laboratory process. The hospital’s executive report characterized the reviewers as satisfied that appropriate steps were being taken to identify the cause. That initial review did not resolve whether the incidents were connected or establish their cause; the agency’s inability to identify a laboratory explanation was not itself proof of criminal conduct.

The department’s investigation did not immediately give Somerset County investigators the records they wanted. When detective Danny Baldwin later sought information from the department, his calls passed among investigators Edward Harbet and Kathey Demarkey and assistant director Alma Clark. He learned that the department had identified issues at Somerset, but was told that further information could not be provided without a subpoena. The state investigation had also been transferred to the Center for Medicare/Medicaid and Social Service, which Baldwin understood as a licensing matter rather than a homicide inquiry. The separation between regulatory review and police investigation therefore shaped what investigators could obtain and how quickly they could obtain it.

Escalation and missed warnings

The agency’s internal correspondence shows that its assessment changed as further information arrived. On September 26, a senior staff member reported that Somerset had disclosed a fourth incident a month after it occurred, despite having been explicitly warned to report any additional cases. Marilyn Dahl, a senior assistant commissioner, discussed the matter with Alison Gibson and Amie Thornton. They agreed that there might be sufficient reason to suspect foul play and regarded the month-long delay in reporting the fourth event as irresponsible at best. That day the department contacted the Attorney General’s office about a possible referral.

The concern at the department level had not been consistent from the outset. Commissioner Cliff Lacey had previously considered suspicion of foul play premature, citing his experience with the drugs and as a senior medical officer at a large hospital. He proposed explanations that did not involve foul play and declined an earlier suggestion to refer the matter to the Attorney General. By September, however, staff were confronting both the accumulating incidents and Somerset’s delay in disclosing one of them. The department’s escalation thus emerged through reconsideration within the agency, rather than from a single settled judgment at the first report.

The sequence also complicated the public account of who initiated outside action. The department reached out to the Attorney General’s office before Somerset Medical Center contacted the Somerset County Prosecutor’s Office. Somerset contacted the prosecutor seven days after the department’s September 26 approach. The state’s intervention therefore preceded the hospital’s referral to local police, even though Somerset later presented itself as having notified the department. In a later email, Thornton credited Marcus’s earlier call as the grain of sand that brought the situation to light; Bresnitz later remarked that Somerset’s notification had followed Marcus’s warning that he would report the matter himself.

Significance in the investigation

The department occupied a boundary between hospital oversight and criminal investigation. Its staff could review patient charts, laboratory procedures, policies, and staffing documents, while the Somerset County investigators were trying to establish whether the deaths and abnormal results constituted crimes. The delay in access to state records and the transfer of the review to a program understood by investigators as concerned with licensing made those different purposes consequential. The record does not depict the department as a substitute for police investigation; it shows how regulatory review and criminal inquiry depended on timely reporting and cooperation across institutional lines.

Its involvement also made the difference between an unexplained medical pattern and an issue formally escalated beyond the hospital. The initial laboratory review found no process deficiencies but could not account for the patients’ abnormal results. Subsequent concern focused not only on what had happened to patients, but on Somerset’s handling of the information and its failure to report a later incident promptly. The department’s eventual approach to the Attorney General’s office marked a shift from reviewing incidents submitted by the hospital toward questioning the hospital’s conduct and seeking higher-level legal review.

The department’s record is therefore neither a simple account of immediate intervention nor of complete inaction. State rules called for immediate reporting regardless of whether the cause was known; Marcus pressed that requirement before Somerset complied, and the department later pursued escalation as the incident count and reporting delay sharpened concern. At the same time, the commissioner initially resisted a criminal referral, and the first review did not prompt additional external reporting. The unfolding case shows how authority, evidence, and responsibility were distributed across the hospital, health officials, and law enforcement—and how the time taken to connect those roles mattered.