Nearly two years after a mentally retarded woman died following a car accident, the state’s oversight agency found “the circumstances of this death …did not suggest any deficiencies in the care provided.”

Mabel Speanburg, a 60-year-old mentally retarded woman who lived in a New Visions group home, died on Nov. 8, 2006, two days after suffering an accident in a New Visions van. She was on her way from the New Visions day facility on Krumkill Road to a group home on Rapp Road in Guilderland.

“It remains undetermined as to how Ms. Speanburg’s seatbelt became unfastened,” according to an Aug. 25, 2008 letter sent by René L. Paluba, an investigator with the state’s Commission on Quality of Care and Advocacy for Persons with Disabilities, to Andrew F. McKenzie, executive director of New Visions.

McKenzie did not return calls from The Enterprise this week.

“It is our understanding that, following this misfortune, Van Safety Assessments were implemented for inclusion in consumer’s Individual Plans of Protective Oversight,” the letter goes on. “Additionally, a new safety form identifying any changes in consumer’s functioning, behavior or health continues to be completed on all transports. These actions appear appropriate given the circumstances.”

The letter also says the commission’s investigation consisted of a review of records from the Western Turnpike Rescue Squad, St. Peter’s Hospital, and New Visions. It notes the cause of death on the autopsy as cardiorespiratory arrest due to neurologic brain death as a consequence of a motor vehicle accident. “The manner was determined to be accidental,” it says.

The letter was obtained by The Enterprise through a Freedom of Information Law Request filed nearly two years ago.

Gary W. Masline, assistant counsel for the state’s Commission on Quality of Care and Advocacy for Persons with Disabilities, told The Enterprise this week that the 14-sentence letter serves as the commission’s report.

“The letter of findings serves as a report,” he said. “Beyond that, we don’t release our investigative files and there’s good reason for that. If we did, we wouldn’t get the level of cooperation we do from the field.”

Speanburg suffered two van crashes

The Bethlehem Police issued a report on the Nov. 6 accident in December of 2006 after The Enterprise broke the story of Speanburg’s death; police had not written a report earlier, Bethlehem Lieutenant Thomas Heffernan said at the time, because they did not know she had died and the New Visions van did not collide with another vehicle or go off the road.

The police report says that at 3:21 p.m. on Nov. 6, 2006, Speanburg was riding in a New Visions van eastbound from the Krumkill Road day facility to her group home on Rapp Road in Guilderland. An unidentified vehicle coming from Beldale Road cut off the line of traffic in front of the van, causing it to “stop abruptly to avoid a collision,” the report says. The sudden stop caused Speanburg to “fall forward,” it says.

“When the operator of the van stopped abruptly, Mabel was thrown forward, hitting her head,” Heffernan told The Enterprise in 2006.

She was treated at the scene and transported to St. Peter’s Hospital in Albany by the Western Turnpike Rescue Squad.

The van’s driver, the police report said, checked the wheelchair locks and seat-belt restraints for all five passengers before leaving New Visions and said all the restraints were secure; she also said that “Speanburg was physically capable of releasing or unhooking the seat belt and must have,” according to the report.

The police report also says a hospital worker stated “she received information from the Western Turnpike Ambulance personnel that Speanburg was not restrained properly and that it was not the first time this had happened with New Visions’ vans.”

A former New Visions employee, who worked at the group home on Rosemont Street in Albany, told The Enterprise two years ago, that Speanburg, who used to live there, was in a similar accident on Krumkill Road in early 2005. Speanburg was traveling to the day program when a car turned in front of the New Visions vehicle and, the worker told The Enterprise, “The driver slammed on the brakes…Mabel and the staff member went flying.”

Speanburg, received “a gash on her eyebrow and went to St. Peter’s [Hospital] where she was bandaged,” the worker said.

Speanburg, who had been wearing a seat belt, should have been in the front seat or seated next to a staff member, the worker said. “Knowing Mabel,” the worker said, that would have been a wise precaution. She described Speanburg as “very mischievous at times and fun-loving…very playful.”

That worker said that New Visions needed more staff to run its programs properly. Other workers, after the Nov. 6, 2006 accident, said that Speanburg did not have her seat belt on; they said that, with just one staff member on the van, clients cannot be properly maintained.

McKenzie responded in 2006 that New Visions had adequate and competent staffing. At the time, it had about 450 employees to serve a little over 600 clients in 22 group homes and 30 apartments as well as in a day facility; clients then were transported in 68 company vehicles.

McKenzie also said after the 2006 accident that seat-belt use at New Visions is strictly enforced and seat-belt enforcement rules were in place well before the accident.

“The Albany County Association for Retarded Citizens’ mission is to serve, advocate and offer opportunities to persons with differing abilities and their families,” says New Visions’ mission statement.

“Universe of possibilities”

The Enterprise asked Masline this week if other accidents or staffing issues at New Visions had been investigated.

“We don’t go into the file and answer questions beyond the letter of finding,” said Masline.

The Enterprise also asked if investigators had considered, since Speanburg had had a similar accident earlier and could release her own seat belt, if she should have been more closely supervised or had a device that would have locked her belt.

“We’re not going to go into the file and see which things we looked at or how we looked at them,” Masline said.

Asked if Speanburg might still be alive if she had had her seat belt fastened, Masline replied, “We do say it remains undetermined how it became unfastened. The laws of physics say…that’s not something we would draw a conclusion on unless we had some indication there were some impropriety.”

He went on, “We did have a recommendation even though we didn’t site a deficiency because, again, we couldn’t determine how the seat belt became unfastened so we can’t connect dots that there was somehow some deficiency in this case.

“It’s possible — again, it’s just possible within the universe of possibilities — that the deceased did something to cause the belt to become undone and the staff had done everything they should have done.”

Asked if precautions shouldn’t have been taken since Speanburg had had a similar accident before, Masline said, “People ask me all the time: So-and-so killed themselves; why wasn’t that preventable? People just have a sense of belief that everything can be prevented. And even though we’re in the business of an oversight agency, often…there are times something happens and we can’t make a determination that it was because something wasn’t done.

“Even if there was a prior case where there was a seat-belt issue — again, I can’t speak to that, but let’s assume that there was — the fact that I don’t see that addressed in that letter tells me something…It tells me it wasn’t necessarily relevant to the investigator and their supervisor reviewing the investigation in this particular case.”

He concluded, “I think since Watergate — and you know, I’m guilty of the same thing — we jump to assumptions where we don’t really have an evidentiary trail.”