Lead Program Investigation Closed Without Criminal Charges

A criminal investigation into former City of Milwaukee Health Commissioner Bevan K. Baker and the Milwaukee Health Department (MHD) concluded without any charges being filed the Milwaukee County District Attorney’s Office and Wisconsin Department of Justice announced Thursday morning.

The investigation was triggered following the January 2018 resignation of Baker and then-Mayor Tom Barrett‘s announcement of problems with the Childhood Lead Poisoning Prevention Program. “We have identified mismanagement and significant shortfalls with how the department follows up with families,” said Barrett in revealing the issue during a January 2018 press conference. Record-keeping problems stretched back to 2015, but Barrett said he learned later as a result of the federal government suspending a grant used to fund the program.

The program’s key function is to intervene when a child, often through a private healthcare provider, tests positive for elevated levels of lead. As MHD previously revealed, the department failed to either intervene appropriately, including emergency chelation therapy, or to keep proper records of what intervention was conducted.

The outside investigation, which was initiated after Baker’s resignation, determined the lead program was mismanaged, but there was insufficient evidence to prove a crime was committed. Documents confirm the three primary subjects were Baker, home environmental health manager Lisa Lien (who chose to resign instead of being fired) and former employee Benjamin James for misconduct in public office.

“The files within the lead program of the MHD were in complete disarray, missing and.. their [sic] appeared to be no oversight of the finances, procedures, and policies of the grant funding,” said a witness according to the District Attorney’s Office two-page statement. District Attorney John Chisholm‘s office and DOJ investigators found policies in conflict with state statutes, but not reliable evidence that they were established with intentional disregard for the statutes.

“In addition, the investigation revealed several conflicting statements from the dozens of witnesses that were interviewed making a prosecution and conviction of any individual(s) unprovable beyond a reasonable doubt,” wrote the District Attorney’s office. A review of emails and other documents found attempts to correct issues with the program, which the DA said would be evidence to the contrary of a knowing violation of state statute to execute the public health program.

Further complicating any possible charges, misdemeanors have a statute of limitations of three years. The investigation is nearly four years old at this point.

“Lastly, it should be noted that the investigation also uncovered substantial improvement in the management of the Childhood Lead Poising Prevention Program since the reports mentioned above were released, which have taken place under the direction of new leadership since that time at MHD,” says the DA’s letter.

An outside agency, the Public Health Foundation, has also been involved in auditing the program and delivered a report in early 2020. Officials on the audit previously expressed that the investigation was delaying their work by inhibiting access to certain records.

The current commissioner is Kirsten Johnson, who was appointed by Barrett in January 2021. She is the fourth commissioner since Baker’s ouster. The council selected Patricia McManus to serve in the interim following Baker’s departure, followed by Barrett’s appointment of Jeanette Kowalik. Marlaina Jackson served as the interim commissioner following Kowalik’s September 2020 resignation.

“The Milwaukee Health Department is thankful to Attorney General Kaul, the Wisconsin Department of Justice, and the Milwaukee County District Attorney’s Office for their diligent investigation into our Childhood Lead Poisoning Prevention program,” said MHD in a statement. “Childhood lead poisoning is a public health crisis in Milwaukee, and eradicating it from our community is a top priority. Any level of lead poisoning is devastating and unacceptable. We are grateful to close this chapter of the Health Department’s history. With guidance from the Public Health Foundation and Wisconsin Department of Health Services and in collaboration with community organizations, we are dedicated to ensuring such oversights in the department never happen again.”

Things, however, have not been perfect under Johnson’s administration. The department admitted to a program breakdown with a Bay View family in June 2021.

The Department of Justice released a 1,167-page PDF that contains redacted records of the investigation, including subpoenas, internal emails and department reports. The report reveals investigators never interviewed Baker, but were still attempting to as late as December 2021. The Common Council also encountered this issue with Baker, who reportedly agreed to appear before the council only to later cancel his appearance. Baker, according to the document, now lives in New Jersey. Investigators did obtain numerous electronic records of Baker’s that were on city cell phones or computers. Baker, through an attorney, declined a voluntary interview as recently as December.

“Other than the rumors and speculation identified by MHD personnel, the DCI investigative team did not discover any documentation that supported the kickback allegations,” wrote DOJ special agent Shannon Jones in a February 2022 report. A contractor scheduled to be interviewed, Felix Questell, died before an interview could be completed. A review of 23 properties where windows had been replaced did not turn up any discrepancies.

The existence of the investigation was first revealed in October 2018 as part of a war of press releases between council members and potential mayoral candidates Tony Zielinski and Ashanti Hamilton. The council also revealed the state’s involvement in late 2019.

Despite the lack of criminal charges, individuals beyond Baker did lose their jobs. Environmental health field supervisor Richard Gaeta was fired and Lien chose to resign rather than be fired. Margot Manassa, public health nursing coordinator, was suspended for five days in April 2018 for allowing children to return to homes with lead hazards after receiving chelation.

A series of text messages revealed Baker knew about the chelation problem as early as September 2017 and was engaged in a discussion on covering it up with city nursing director Tiffany Barta. The director of nursing was suspended for five days in 2018 for working to “sabotage” co-workers.

An outside law firm involved in a separate investigation of department management found “an environment full of bullying and unprofessionalism which affected the effective functioning of the Health Department.”

NOTE: The link to the DOJ report PDF is currently inactive as the department pulled the report. It will be restored at a future date.

UPDATE: On May 5, 2022, DOJ released a new report. We have updated the link within the article. It is 40 pages shorter (for reasons that weren’t immediately clear) and contained substantially more redacted items

On a handful of spot-checked pages by Urban Milwaukee, the new redactions involve hiding the remarks about what others did or didn’t do and redacting who was interviewed. In at least one case, the new redaction shrouds that an employee was believed to have elected to retire to avoid a further investigation into falsifying records. That retirement was not previously publicly reported, but appeared in the report the DOJ released in March.