Journalism That Holds Power to Account

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The neck brace held the unconscious man’s head at a 30-degree angle. The patient’s face — scraped and bruised — was largely covered with a plastic rig holding a breathing tube. Every two hours, hospital staff administered artificial tears.

Shortly before midnight on July 13, 2018, police and hospital records show, the victim of a suspected drug overdose had arrived by ambulance at St. Barnabas Hospital in the Bronx. Officers responding to a 911 call had found the man on the ground at the corner of East 174th Street and Bryant Avenue. CPR administered by the officers had managed to produce a pulse. A breathing tube had been inserted on the way to the hospital.

The man was identified as Frederick Williams, born Feb. 18, 1978, police records show. The hospital looked up the name. Williams had been a patient at the hospital before. His files listed an emergency contact.

Ralph Williams was the first relative to arrive at the hospital. He didn’t live far away.

“I can jump on the 15 bus and be there in five, 10 minutes,” he said in an interview.

Frederick was Ralph’s adopted younger brother, joining the Williams family as a baby. His parents had been drug addicts at the time of his birth.

“Freddy was always into something,” Ralph said. “But he was a good kid.”

It pained Ralph, then, to see Frederick struggle as he grew up — at school, with drugs and alcohol, with the loss of his adoptive mother when he was 18. Ralph had last seen Frederick a couple of years earlier, when his brother was in drug rehab in Harlem.

At the hospital, Ralph made his way to the intensive care unit. Ralph said the hospital staff only told him that his brother had been found on the street. Frederick was not responding to treatment. Drugs had been found in his system. The prognosis was grim.

Over the next several days, more family members came to St. Barnabas. One of Williams’ two daughters, who had been raised by their mother in Virginia, soon arrived. She kissed the patient’s hand before she left. A sister drove up from North Carolina and spent an entire night bedside. She rubbed the patient’s feet and ran her hand through his hair.

Hospital staff began a conversation with the family about ending life support. “Topics covered,” read a July 23 note in the medical file. “Prognosis. End of life wishes. Emotional stress. Spiritual support.”

The next day, the records say, Williams was moved to a hospice within the facility. The 18-bed unit is run by St. Barnabas in partnership with Hospice of New York. Williams had no formal health care proxy, no designated person to make decisions about his care. He was assigned a bed in a private room.

The family soon came to an agreement, and July 29 was set as the date for the removal of the respirator, a procedure known as extubation.

Ralph was there shortly after noon on July 29. Two of Frederick’s sisters were there too. It took only about five minutes without the respirator for the man to die, Ralph said.

“We were crying,” Ralph remembered. “We prayed and everything. After they pulled the breathing apparatus and all that out, he tried to stay for a little while, but he was gone. That was it.”

Except it wasn’t. The patient they’d just had taken off life support was not Frederick Williams.

The body of the man who died on July 29 was sent to the Office of Chief Medical Examiner three days later. Because the death involved a suspected overdose, the office was obligated to take a look.

Eden Naka is the office’s deputy director of forensic investigations, and her team had been given paperwork identifying the body as Williams and listing family contacts. But her job, she said, is to take nothing for granted. Her team began the office’s protocols for conclusively identifying the corpse.

“It’s part of quality control,” Naka said, “making sure that the correct body has been examined.”

The New York office — heralded over the last two decades for its work identifying victims from the 9/11 terrorist attacks — handles a remarkable volume of identifications, some 750 a month. Sometimes, a visual identification by a loved one is enough; sometimes, the team uses fingerprints; DNA is the gold standard.

It is necessary work. Instances of people arriving under one name only to be discovered to be someone else, Naka said, are actually far from uncommon.

“It’s not the norm by any stretch of the imagination,” she said. “But, no, it’s not terribly rare.”

Misidentifications can result from a wide variety of circumstances. An immigrant might have gone by a name other than their legal one. The array of people and institutions involved in some cases — police, doctors, prosecutors — can also lead to mistakes along the chain of custody.

Sometimes it’s a hospital that sends the misidentified body. The notion that hospitals can lose track of who is who will not surprise anyone familiar with the long list of sometimes headline-making cases from years past. Patient has wrong kidney removed. Surgeon operates on wrong side of brain. Transfusion performed with mistaken blood. Major patient identification errors have happened in New York and California, Massachusetts and Texas, sometimes involving prestigious hospitals.

Such mistakes have led to concrete efforts at improvement. The Joint Commission, the country’s leading accrediting body for hospitals, has made proper patient identification a top priority. Hospitals now identify patients with bar codes on wristbands issued when they are admitted, and, whenever they administer a procedure, doctors, nurses and even others are encouraged to ask for the patient’s name and date of birth, a two-step process meant to curb mistakes.

Most recently, some hospitals have moved to using biometric means — scans of eyes or palm veins — to more accurately identify patients.

Still, patient identification errors have persisted. A special report published in 2016 by the ECRI Institute surveyed years of scholarship and found a wide variety of mistakes still happening — upon admission, in the operating room, during the distribution of medication. At one hospital, the report said, 97% of its emergency department clinicians (66 of 68) reported charting or entering orders on the wrong patient within the prior three months.

Patients like the man misidentified as Williams, who are so incapacitated they cannot speak for themselves, are among the most likely to be misidentified.

St. Barnabas, while lacking anything as sophisticated as biometric measures, had a pretty straightforward reason for believing the unconscious man brought in on July 13 was Williams. Emergency medical personnel had found a state-issued identification card on him with this name. And family members had raised no alarm.

Family members, though, can and do play a role in misidentifications, both in hospital settings and at the coroner’s office. While it might seem implausible that, say, a child might not recognize a parent, it happens. It might have been years since they’ve seen their mother or father. A terminal disease might have altered their appearance drastically. A life of homelessness or drug abuse might have taken a toll, making seemingly routine visual identifications by family members trickier.

Family members had visited the unconscious patient repeatedly at St. Barnabas. They agonized, they cried, they deliberated, but none of them suggested the man in the bed was not Williams.

“It’s not like he was hit by a bus,” a St. Barnabas official said. “Someone comes in with ID and the family doesn’t say, ‘This is not our brother,’ I think that’s pretty sufficient.”

With the body from St. Barnabas at the medical examiner’s office in August of 2018, Williams’ family prepared for his funeral. Years before, when his adoptive mother was killed in a car crash, the teenager was devastated. He’d already dropped out of high school, but whatever modest life he imagined for himself felt absolutely pointless after her death. Williams climbed to the roof of the family’s house and threatened to jump. When he was at last talked down, the authorities had him hospitalized.

Williams’ family thought he’d want to be buried with his mother at a cemetery on Long Island. Arrangements were made for that to happen. A printed program was created.

But then Naka’s team discovered the mistake. When the man’s fingerprints were fed into one of the office’s databases that stores records of people with criminal histories, another name popped up: Raheme Malik Perry.

Whatever the reasons were for the error, the way forward for Naka’s team was clear. It had to contact two families and deliver very different news. The call to the family of Williams would carry the surprise that the loved one whose death they were grieving was, in fact, alive. The call to this new family, the Perrys, would be no less strange, but its implications would be far more somber — a loved one of theirs was dead, and his death had come after he was taken off life support by strangers.

Raheme Perry’s family had been looking for him for days. He had failed to return calls from his wife, LaTanya, who lived in Texas.

He had grown up in the same Queens neighborhood as Williams, and, like the man he’d be mistaken for, he was handy with cars. But he’d come to have his own troubles, including several arrests. He was fresh out of prison when he first met LaTanya.

LaTanya was introduced to Raheme in 2012. She was an Army vet, with children of her own. A mutual friend had introduced her to Raheme, and she was aware of his troubled past. She said Raheme, fresh out of his latest stint behind bars, seemed to pull himself together during their courtship. They only talked by phone for months, and when they first met in person, Raheme showed up in a white suit, fit and sharp, with his hair, an obsession, styled just right.

He proposed on the street next to Yankee Stadium. He had to borrow money from his father, James Kelley, to pay for the marriage license. LaTanya said she later used her health care plan as a veteran to get Raheme into programs to deal with possible mental health issues and drug addiction.

Ultimately, LaTanya said they determined Raheme’s best chance at getting the treatment he needed was in New York, so he moved back. The two remained committed to each other. LaTanya visited regularly, and she was there for her husband as he bounced in and out of treatment programs.

But in the early summer of 2018, Perry’s often tumultuous life had hit another alarming low. He’d spent time in homeless shelters and become something of a troubled regular in the West Farms neighborhood of the Bronx, where his brother, Raymond, had an apartment.

Perry had been injured in a knife fight, and later he’d been arrested for shoplifting at a dollar store in the neighborhood in early July. He was arraigned and released. Police identified him using his food stamp card.

LaTanya said she last spoke with Raheme on July 9, but he had failed to return calls and texts after that. Days became weeks. Raymond had the idea to go to the hospital that had treated Raheme after he’d been wounded in the knife fight.

The hospital was St. Barnabas. Raymond went, but was told no one by that name was a patient.

As July turned to August, LaTanya began to make plans to drive once more to New York to find her husband.

At the medical examiner’s office, Naka’s team’s examination of the body at the morgue began to shed some light on how the misidentification could have happened.

Perry, his records showed, was 45 years old, just a couple of years older than Williams. His height and weight — barely 5 feet and 130 pounds — matched those of Williams, as well. Both were fond of goatees. Both shared the stocky build common to those who’ve spent time behind bars.

The medical examiner’s office reached Raheme’s father first and asked him to come to the office to view a body believed to be his son. His father then called LaTanya. She’d just set off by car for New York. She’d been on the highway headed north just 10 minutes when she picked up the call.

“I went numb,” she said. “I stopped my car on the highway.”

LaTanya was still frozen behind the wheel of her car when family members found her on the highway outside of San Antonio.

“She just couldn’t move,” Leah, one of her daughters, said.

Leah and other family members, in shock themselves at the news of Raheme’s death, eventually got LaTanya back home and then onto a plane to New York the next day. After landing at LaGuardia Airport, LaTanya made her way to the medical examiner’s office in Queens. She was seated in an office, and a photograph of the body that had come from St. Barnabas was called up on a computer screen.

LaTanya had turned her back to the computer at first but then spun around to look.

“My husband,” she said. “No mistake.”

There was another shock to come.

The medical examiner’s office had made a second discovery in examining the body. While Perry had been brought to St. Barnabas after a likely drug overdose, that is not what killed him. Under cause of death, the medical examiner listed “blunt impact of head.”

“Fell and struck head while being chased by group of people,” the initial death certificate said.

The case was a homicide.

For LaTanya, it was one more jarring development in a deepening nightmare.

Over the next year, LaTanya struggled to piece together what happened to her husband — in the streets of the Bronx, as well as at the hospital where he was taken. And how, exactly, he had come to have another man’s identification.

She pulled together police and hospital records, talked with detectives, compared notes with reporters, even hit the streets trying to find people who might have been witness to what went down at East 174th Street and Bryant Avenue just before midnight on July 13, 2018.

The facts and timeline she assembled look like this:

On the night of July 13, police records show that an officer and a supervising sergeant, upon arriving at East 174th Street and Bryant Avenue, had found what they estimated to be a 40-year-old man unresponsive on the pavement. They administered a nasal spray meant to reverse the effects of a drug overdose to the unconscious man and performed CPR.

“Got a pulse,” the records say.

A New York Fire Department ambulance soon arrived. The EMS personnel’s notes offer greater detail. They show that bystanders had said the unconscious man “was running when he twisted his ankle, tripped/fell and stopped moving.”

The notes list bruising to the side of the face and bleeding from the back of the head. The Fire Department records also confirm that the unconscious male was carrying a legitimate ID: a state-issued non-driver’s license. It had the name Frederick Williams and a number: 00685520.

The man carrying Williams’ ID was then taken to St. Barnabas.

The hospital records obtained by LaTanya, reflecting daily updates on the patient’s status over the next two weeks, contain a mix of information about the unconscious man thought to be Williams, some of it conflicting. One record has an entry called “Problem list.”

“Admitted under the impression cardiac arrest related to drug overdose,” is one problem. There are others: “traumatic injury”; “acute kidney injury”; “sudden collapse while running.”

The records show cocaine and tranquilizers were found in the patient’s system, but another note says that he’d been using cocaine and heroin, and that he’d suffered “respiratory failure due to opioid overdose.” The records include an entry noting “no traumatic injury,” only to later list abrasions to the “right eyebrow, right upper cheek, right shoulder and both wrists,” and “trauma to the head.”

“Per EMS and bystander, patient was running and fell — cracked his neck,” reads one entry.

“Witnessed to run into pole, fall over, pass out,” reads another.

In an interview, Glenmoore Reid, a superintendent at an apartment building near the Bronx intersection, said Perry had indeed fallen, but he had done so while being chased by three men. Something had happened between the men down the block, Reid said, and Perry had taken flight. He briefly hid out in a building, but emerged only to be chased again.

“He came out too soon,” Reid said.

Then, Reid said, Perry’s leg had buckled. He’d fallen and maybe hit his head. The men, thinking he was faking, shook Perry, but then took off. Reid said a security camera on his building had captured the encounter, and he’d given it to the police.

The New York Police Department would not discuss what it describes as an open homicide investigation involving the death of Perry. It would not say when it began, who has been spoken to, what evidence might exist. Brian Hernandez, a detective on the case, would not comment when approached at the 42nd Precinct in the Bronx.

LaTanya said she had spoken to the detective in recent months and came away thinking any arrests were a long shot. She said Hernandez told her that the police had reviewed the videotape of Perry and the men chasing him, but that it does not capture anyone actually laying their hands on her husband.

She said the police told her they believed that Perry had stolen papers belonging to Williams, and that they had recovered mail belonging to Williams in Perry’s possession. But they offered no clues about where, how or why the papers had been stolen.

LaTanya said she had walked the streets of the Bronx in the weeks after Raheme’s death, and found witnesses who described Raheme being chased and then thrown to the ground — body-slammed, she said. He staggered to his feet, but collapsed. She does not know if the police have spoken with those people.

Among the many things LaTanya is haunted by is this:

A detective at the 42nd Precinct told her he had gone to St. Barnabas shortly after the man on the street had been taken there. He was supposed to check up on the patient, and maybe get more information about the incident. The detective was told the man was in no shape to talk and was turned away. The officer told LaTanya he knew Raheme. He’d arrested him before. He might have recognized him, he told LaTanya, if he’d been allowed to see him.

Alexander M. Dudelson’s 23rd-floor law office on Court Street in Brooklyn has a spectacular view of New York Harbor. The Statue of Liberty is off to the left; One World Trade Center is off to the right.

The case files stacked inside that Brooklyn office, however, offer a window into less glorious sides of New York — angry divorces, fights over estates, stolen property, a disputed murder conviction. A plaque, given as a gift, sits on Dudelson’s desk: “The Wolf of Court Street.”

“I’m not smarter than anybody,” Dudelson said. “I just put in the time other people may not. I like to learn, that’s the thing. If I have to read 20 books on my own time to figure it out, I’ll do it.”

No book prepared Dudelson for the case that walked into his office last fall. Shirell Powell, one of Frederick Williams’ sisters, told Dudelson the story of what had happened at St. Barnabas. Her family had been told there was no hope for her brother, and they took him off life support only to be told the patient on the respirator had been someone else. She was distraught. She wanted someone to do something.

Dudelson said he found the tale hard to believe.

“Well, I believed her, I mean, I just couldn’t believe, you know, how does this shit happen?” he said.

On Jan. 23, 2019, Dudelson filed suit against St. Barnabas in State Supreme Court in the Bronx.

“The defendants negligently misinformed the plaintiff that her brother Frederick Williams was admitted to the hospital in an unconscious state. The defendants negligently misinformed the plaintiff that her brother had died on July 29, 2018. As a result of the defendant’s misinformation and negligent conduct the plaintiff has suffered severe emotional harm and injuries.”

St. Barnabas, in response, did not deny the mix-up, but argued it was not liable for any damages because no member of the Williams family — not Frederick, not Shirell — had actually been a patient at the hospital. The hospital asked a judge to dismiss the case.

Powell’s lawsuit was reported in a daily story inside the New York Post on Jan. 27, 2019. It did not report the identity of the person taken off life support, but the story was reproduced on a slew of news websites.

LaTanya Perry found the article on her Facebook feed. It had been aggregated on a website called Dearly.com. She eventually realized the story involved Raheme’s death, that he was the unidentified dead man in the article. Months into her efforts to figure out the details of her husband’s death, she saw in Dudelson, who’d been quoted in the article, someone who might help. Maybe Dudelson would represent her, too.

She met Dudelson in his Brooklyn office. He was quite certain she had a case. He was less certain he could represent both families. He arranged for her to call Powell to see if everyone was comfortable with the idea. He got Powell on speaker phone and left the room.

When the conversation was over, Dudelson was representing both families.

“It’s not normal,” Dudelson said. “You don’t see this case in the law journal.”

When Brooklyn Lewis heard her father, Frederick Williams, was desperately ill and in the hospital, she decided she had to see him.

Brooklyn was 16, and had only seen Frederick twice before, fleeting moments in two different jails, the last more than a decade earlier. Now, in July of 2018, Brooklyn packed her bags in Richmond, Virginia, and tried to prepare herself for her third meeting, knowing it might also be the last.

Starr Lewis-Jones, Brooklyn’s mother, was worried but said Brooklyn had always wanted a relationship with her troubled and distant dad.

“She has a strong desire to know him,” Starr said.

Starr had met Frederick as a teenager in Queens. He flirted with her on the street, and while she noticed and was intrigued, it was years before she spoke to him. Her parents worked for the New York Police Department, and she was a member of the choir at Bethany Baptist Church. She was, she said, “a good kid,” and Frederick, she said, had the makings of a bad one.

But the two eventually dated, and had back-to-back girls together in 2000 and 2001. Starr, named for her, was the first, Brooklyn the second. Frederick, though, was not cut out for parenthood. He could not control his cocaine habit or his violence, Starr said, and she wound up taking the girls with her to Richmond, where she had family. She left in the middle of the night.

“I remember it was wintertime, and I didn’t even have a coat,” she said. “I bundled them up. I got in the car, and I was just gone.”

In July 2018, Brooklyn ultimately made two trips to see the man she thought was her father. She called her mother after the first visit.

“Oh, God, she called me on video chat,” Starr said. “She was just hysterically crying. I could barely understand her.”

“She was wrecked,” Starr said of Brooklyn. “You anticipate so long seeing somebody, talking to them, knowing them. And then when you find them, that’s the state they are in.”

It’s not clear how recently any of the family members who visited the hospital had seen Frederick. For any number, it had been a while. Brooklyn hadn’t seen him in more than a decade. For Ralph, his adopted brother, it was at least two years.

Pictures taken of the patient at St. Barnabas show that the lower half of his face was largely covered with the plastic apparatus holding the breathing tube. His neck was in a large brace. Another tube traced along his cheek and was taped to his forehead. Any scrapes or cuts were not disfiguring, but it’s hard to know if the face was swollen to some degree. In one picture, pillows obscured the sides of his head. Starr, the woman who had borne Frederick’s children, refused to go into the hospital room given their acrimonious past. But family members showed her pictures of the patient.

“All you really saw was the nose and the eyes,” Starr said. “And it looked like Freddy from the nose and the eyes. It really wasn’t no face we were actually looking at.”

Keshona Williams, one of Frederick’s two blood sisters, had driven through the night with her husband from Sanford, North Carolina, to see Frederick when she’d been told. She had been adopted into the Williams family along with Frederick as a tiny child and was likely the closest to him throughout his life. She said Frederick’s life went off track with his adoptive mother’s death. He was, she said, the youngest of the brood — “her baby.”

She said she’d first been sent a picture of the man in the hospital bed and it looked like her brother. At the hospital, she sat next to him and massaged his legs. She said she thought she saw him try and blink his eyes.

“I was trying to wake him up,” she said.

Keshona said she had a single flash of uncertainty about whether it really was Frederick. Something, she said, didn’t feel right. But the doctors, she said, were certain. Her other family members were, too. She convinced herself, then, that maybe his face looked odd because it was swollen from the incident and the medication.

St. Barnabas did have medical files from his prior treatment at the hospital. Hospital officials would not say what he’d been treated for or what array of information his records contained.

Medical experts said those files, depending on how much information they held and how extensively the hospital staff referred to them, could have raised red flags about who was really in the hospital bed. Were there scars or tattoos that didn’t match? Was there evidence of prior surgery not reflected in either the medical files or on the body of the patient? Perry had himself undergone surgery for the knife wounds he’d suffered weeks earlier and bore the scars.

St. Barnabas would not say what, if any, comparisons were made between the patient and its files.

Williams’ circumstances were certainly complicated when it came to figuring out who should decide what was in his best interests. His natural and adopted parents were dead; his children were minors. He had two natural siblings and a handful of adopted ones.

The available hospital records capture some of the painful details as the days passed.

Sedatives were sometimes required, the notes say, for the patient tended to bite the respirator tube that was helping to keep him alive. “Suffers from shivering,” his medical records noted. “Slight movement left hand and feet in response to pain,” another note read.

Experts say just 30% of Americans have taken steps to make sure their wishes about end-of-life care are spelled out, respected and followed — whether that be by signing what are known as advance directives, or by formally designating someone to serve as their health care proxy. The people who have put in place such safeguards, experts say, tend to be better educated, with intact families and substantial financial resources.

For close to a decade, however, laws have existed in New York detailing a hospital’s responsibilities in administering end-of-life care, and laying out who gets to make the often painful decisions for people who can’t speak for themselves and who lack any designated health care proxy.

For incapacitated patients without health care proxies, New York created a kind of hierarchy of authority. A spouse is the first option, adult children the next. Siblings can make the choices in certain circumstances. If necessary, the law says, the decisions can be left to a category of person listed as “good friend.”

When asked, some Williams family members — Shirell, Crystal, Ralph and Keshona — said little or nothing about any deliberations that took place about who should decide their brother’s fate. Keshona was the most willing to share details.

She said it was “a mess” at the start. Everyone wanted to be heard. No one would listen. Crystal, the oldest sibling, had always made key decisions. But Keshona and Shirell were Frederick’s natural siblings, and they felt that gave them special standing. Emotions ran high. Keshona said the only information the family had about the patient’s treatment was that he was suspected of having overdosed. Keshona said no one ever told them trauma to his head was an issue as well.

Officials with Hospice of New York, responsible for the misidentified patient’s care over the last four days of his life, didn’t respond to repeated phone calls and a list of written questions.

One of those questions involved an assertion made by two of Williams’ sisters. They said hospital or hospice staff had told them that the family, if it decided to keep Williams alive, would be responsible for the costs going forward. No family member had those kinds of resources.

Keshona said no one at the hospital or hospice formally designated a single family member as the final word on what to do. But she said it became clear to all there were no real options. She said the family was told at a certain point the patient had no brain function.

Keshona said doctors made clear removing the patient from life support was the right call.

“It wasn’t like an ask,” she said. “It was like, this is what’s going to have to happen.”

The family didn’t fight it.

“It was no decision; it was like, it is what it is,” Keshona said. “There was nothing they could do, and that’s just how it’s going down.”

Keshona had returned home by July 29. She was on speaker phone when the respirator was removed.

She heard someone say, “He’s still breathing,” and then someone say, “We love you.”

When Keshona first heard that the medical examiner’s office had discovered the mistake, she thought the hospital had sent the wrong body to the morgue. At least two Williams family members went to the medical examiner’s office. Both still thought the corpse was Frederick.

Once the family finally accepted what had happened, they spread the word. Frederick was alive.

“I didn’t know what to say,” said Ralph.

“It wasn’t him, thank the Lord,” said Crystal.

Brooklyn was back in Richmond when word reached the household that her father was not dead. She had been making arrangements to make yet another trip to New York for the funeral. Starr, her mother, thought Brooklyn would be thrilled. Brooklyn, hearing the news, was indeed glad. But she also broke down.

“Mommy, who was in that hospital?” she asked through tears. “Where’s his mom?”

Starr did her best to explain and comfort. But she knew as little as everyone else.

“Mommy, we did that to somebody else,” Brooklyn sobbed.

“Yeah,” Starr said. “Yeah, baby.”

Officials with the New York State Department of Health said that, prior to the summer of 2018, the department had never investigated a case where the wrong person had been taken off life support. Close to a year later, it closed the investigation, finding no fault with St. Barnabas.

The department, by law, is not obligated to make much about its investigation public, but it shared some facts and a redacted version of some of the investigative records.

Jonah Bruno, a department spokesman, said the investigation began “immediately following the patient’s death.”

What exactly that initial inquiry involved is unclear. But it apparently wasn’t enough. The article in the New York Post in January 2019, which noted the lawsuit against St. Barnabas brought by Powell and Dudelson, appears to have provoked another examination by the state.

“A broader investigation was triggered by media reports in January that indicated the circumstances surrounding the patient’s death and identification may have been inconsistent with the information obtained by the Department during its initial review,” Bruno said.

The state would not say what the inconsistencies in information were or how the second inquiry was broader. But it said the information given to it by St. Barnabas had been accurate.

Bruno issued a statement in August summarizing the state’s findings.

“The New York State Department of Health conducted an investigation of St. Barnabas Hospital to review the actions taken by the hospital upon the admission in July 2018, of an individual who was unconscious and ultimately misidentified as another person,” he said. “The investigation determined that the hospital had a policy in place regarding the process for determining the identity of a patient in situations like these. Evidence indicated that the hospital followed their policy. As a result, there is no regulatory standard under which the hospital will be cited.”

St. Barnabas, having learned of the state’s findings, seemed grateful, if a bit surprised. The state had credited the hospital with having followed its policies for identifying an unconscious patient, and yet, when asked what those policies were, St. Barnabas said there actually weren’t any. If someone is admitted bearing identification and visiting family members don’t alert the hospital to the mistake, there’s not much more the hospital is required to do, St. Barnabas said.

“If the state Department of Health says we do have specific policies, that’s news to me,” a St. Barnabas spokesman said.

David Hoffman, a lawyer, clinical ethicist and lecturer at Columbia University, said St. Barnabas was obligated to do its own “root-cause analysis” — an internal review meant to examine every aspect of the episode to determine if there was anything that could have been done differently then or going forward.

“It’s the ethical obligation born of humility,” Hoffman said. “Any mistake that happened once is going to happen again. You must have an adequate response even to a freak occurrence.”

St. Barnabas would not say if it had done such an analysis, and, when asked, it would not say if it had altered any of its practices or procedures as a result of the mistake. Bruno said the state Health Department’s investigation had not produced any recommendations for possible improvements.

The state’s own records and interviews make clear the inquiry was ultimately quite limited. State investigators did not speak to the Williams or Perry families. The state, while saying Perry had been appropriately treated for his condition, did not explore whether the hospital had properly counseled the Williams family about the patient’s condition or met its obligations for handling the termination of life support.

There is a federal agency that could have launched its own inquiry — CMS, or the Centers for Medicare and Medicaid Services. Asked if it had, CMS said it had accepted the state’s investigation as adequate.

Arthur Caplan, founding head of the Division of Medical Ethics at NYU School of Medicine, said the New York State Health Department should have looked harder at whether St. Barnabas followed the state’s laws governing a hospital’s obligations to families facing end-of-life decisions.

Health care providers treating the terminally ill are required to inform patients and their families of the full range of options for navigating their final days. There are strict protocols for doctors to follow if they have decided ending life support is the appropriate option.

LaTanya Perry, whose husband’s life was ended, wants to know if those laws were followed. Was the Williams family properly advised? If Perry was admitted as an overdose and died of blunt force trauma, had he been properly treated? Had there been any disagreement about the assessment of her husband’s chances? Had staff at the hospice really told the Williams family it would be liable for the costs of continued life support.

Right now, she has only the hospital’s word — the same hospital that saw the wrong person have his life ended.

David Leven, executive director emeritus for End of Life Choices New York, an advocacy organization, said too many health care providers remain uninformed about their obligations under the law.

“The vast majority of doctors have never been trained in end-of-life care, or palliative care, or hospice care,” Leven said. “The vast majority of doctors have not been trained on how to have difficult discussions with their patients, and family members of patients.”

Bruno said the state Health Department makes considerable effort to educate providers with information about their obligations for end-of-life care. He said its surveyors conduct regular checks on whether health care providers — including hospitals and nursing homes — are abiding by the laws on end-of-life care. He said the department provides surveyors with guides for conducting those checks — sample interview questions, lists of documents to review and observations they should make to determine whether the hospital is complying with regulations. The department, he said, had posted ample information about the relevant legislation online.

Bruno said the department over the years had cited providers for violations of federal and state regulations governing end-of-life care. But he conceded the department had never cited a health care provider for violating the laws relating to end-of-life decisions for an incapacitated patient without a health care proxy.

“Why have a law if no one is going to enforce it?” Leven asked.

St. Barnabas said responsibility for Perry’s final days rested with the Hospice of New York.

Hoffman, the bioethics professor, said when a hospital works hard to explore ways of determining whether an incapacitated patient had ever expressed his or her wishes for end-of-life decisions, they often seek out doctors who had treated them before. Talking to those prior doctors, Hoffman said, might have led to a discovery.

“It’s possible,” he said, “they might have figured out they were talking about two different people.”

Frederick Williams sat on a plastic chair inside the chapel at the Anna M. Kross Center, one of the jails on Rikers Island. “Every Moment, Thank God,” reads an inscription on a nearby wall.

Williams was not happy to be back at Rikers, and he later pleaded guilty and accepted a five-year prison term for assault. Still, given everything that happened a year ago, he is grateful to be alive.

“Could have been me,” Williams said of what happened in the Bronx in July 2018.

After his family learned he was not the man who had died at St. Barnabas, they set out to track him down. They eventually learned he’d been arrested that August and had a court date pending.

Williams thus first learned of his role in an improbable saga when he was in what’s known as a “bullpen” — essentially a cage in a courthouse anteroom where inmates are placed to await a hearing before a judge. The public defender representing Williams in State Supreme Court in Manhattan passed him a taped-together single-page letter through the bullpen’s bars. It had been given to the lawyer by two relatives of Williams outside in the public courtroom.

“They want you to read this,” the lawyer told Williams, not having looked at the letter himself.

It was a doozy. Life support. Funeral plans. Mistaken identity. And joy that he hadn’t died.

“I’m like, what the fuck is going on?” Williams said. “Is this a joke or something?”

Williams said he finished only half of the letter before being called before the judge. He saw two of his siblings in the courtroom, smiling.

When he got back to the bullpen, Williams finished the letter.

“I kept reading it and reading it and reading it,” he said. “Thinking the words would change.”

Williams, in an interview, did his best to reconstruct the events of the summer of 2018.

At the time, he said, he had been renting an apartment in Lower Manhattan, but because of issues with his landlord, he and his girlfriend often found themselves sleeping on the street. He said he remembers losing his state ID while roaming the streets of Manhattan. He said he often stuck flyers and other papers in his pocket, and believes the ID tumbled out with some flyers.

“It’s got your picture on it, it says your name, date of birth,” Williams said of the ID. “You could use it just about anywhere.”

He said he didn’t apply for a replacement because he still had what he called his “welfare” ID card. It substituted just fine, he said.

On July 1, Williams was arrested for assaulting his landlord, and was held for several days. Police records show he used an electronic benefits card as his ID.

On Aug. 21, Williams was again arrested, this time for assaulting his girlfriend, and it was at a court hearing for that arrest that he learned of his strange connection to Perry’s death.

Williams, in multiple interviews, said he’d never met Perry.

“Until this day, right now, I didn’t know his name,” Williams said in the interview this summer.

Later shown a picture of Perry, Williams insisted he didn’t recognize him.

“I just send my condolences,” Williams said.

Williams acknowledges the remarkable series of events and coincidences that had to happen to produce the error at St. Barnabas. He had to lose an ID he’d had for years. It had to wind up in the pocket of a man close to him in age and appearance. That man had to have fallen in the street close to a hospital that had once treated Williams and had his information on file. The discovery of the misidentification happened only because both men had criminal records and fingerprints in a database.

“This,” he said by way of summary, “is crazy.”

What feels almost as crazy is that Williams has the rare opportunity to pass judgment on his family’s decision to end his life.

Thaddeus Pope, a law professor and the director of the Health Law Institute, said no one really knows if the decision to end an incapacitated patient’s life is, in truth, what they would have wanted. The scholarship that does exist, he said, has consistently shown that the decisions surrogates make for loved ones are often mistaken.

Williams, for his part, said he was touched that his family seemed to rally to his situation. His siblings showed up; his child came to see him; the decision to let him die was not made hastily; he liked their idea to bury him next to his adoptive mother.

But he admits he was at first angry and hurt that his family was willing to give up hope.

“If it was me,” he said, “why would you pull the plug?”

More than a year after her husband’s death, LaTanya Perry feels deeply frustrated, and increasingly doubtful that her husband’s death will ever be fully explained or that anyone will ever be held accountable. The police have all but stopped speaking to her. St. Barnabas seems to have been cleared by the Health Department.

“It was like they just did have no regards for his life at all,” she said.

Her remaining chance at what she wants — a full explanation and punishment if warranted — appears to rest with Alexander Dudelson, the lawyer also representing Shirell Powell.

This summer, a judge in the Bronx rejected St. Barnabas’ motion to dismiss Powell’s lawsuit. Dudelson is eager to start collecting more material in discovery.

No other Williams family member has joined Powell in the lawsuit. Most just want to put the episode behind them, and maybe recommit to helping Frederick straighten his life out.

Keshona, for one, can’t shake the upset, embarrassment and guilt.

She often feels ashamed for not having been able to identify the mistake — it was her closest sibling, after all.

“Stupid, literally stupid,” she said of how she can sometimes feel.

But she also feels somehow complicit in a killing.

“I feel like I murdered someone’s family member,” she said.

Dudelson, of course, still represents LaTanya, as well.

In July, he filed a notice of claim on her behalf against the city of New York seeking $10 million. The claim, a simple filing without much legal detail, suggests that the Police Department’s initial assessment that Perry had likely overdosed on drugs had compromised the hospital’s ability to treat him for the injuries he’d suffered to his head in a possible attack.

It’s a long shot, Dudelson said, but he wanted to preserve LaTanya’s right to sue.

She is not particularly hopeful. But she does hold on to one satisfaction. She got her husband a proper burial. Because he was her spouse, and she’d served in the Army, Raheme Perry was entitled to a burial at a national cemetery. He was laid to rest at Calverton National on Long Island.

His headstone correctly identifies him as Raheme M. Perry.