A wise man once said every society is judged by how it treats it's least fortunate amongst them.

As in such cases, autopsies are performed. And like his life, the veterans death became a battle as well. Weeks would pass before official reports were completed. Family and the public were denied access to the documents which detailed the specifics related to the veterans last moments. A tragic life followed by a horrific death became a political struggle to hide facts, lessen public outrage, protect jobs and hide information that would show the total, absolute, undeniable failure of those we entrust to help the most helpless and needy of our community. This is the story of Corporal Mark Holt US Marine.

As it usually was for this veteran, he frequently roamed his hometown seeking relief from both the cold and his hunger. He was often the victim of beatings; small town criminals who knew when the veteran received his meager payments for his service to our country beat him and stole his few wages. He was hospitalize for head injuries on a few occasions but more often than not his biggest health challenge was the chaotic mix of mental illnesses - schizophrenia, depression and PTSD. He was sometimes a danger to others but he was always a danger to himself. He knew it; we knew it. He often begged the county veterans service officer to help him get his medications; he asked friends for rides to veterans clinics and tried many times to arrange transportation to the veterans hospital in nearby Louisville. He drank too much when paranoid demons consumed his confused mind. Many times he couldn't settle thoughts of violence, death and sorrow that raged through long ago memories in the war torn jungles of Vietnam. He was known to grieve, to cry, to weep and to sometimes break under the depression that often left him with no choice but to end his time on this earth.

Although this veteran walked a tormented difficult path his entire life, it was the last few months that literately brought the The Marine CPL. to his final end. Somehow in a confused disoriented state, the veteran made his way to place he thought he might get a meal and take a shower. How he got there, I do not know and whatever delusions or hallucinations caused him to believe King's Daughter's Hospital ER was a shelter, Salvation Army or YMCA, I do not know. But The ER doctor recognized the veteran and knew he was in distress. The doctor ordered his confused patient to be transported via ambulance directly to VA Hospital ER in Louisville. The veteran was assisted onto a gurney placed in an ambulance with a safety shoulder restraint belt in place as with any other patient being transported in an emergency vehicle to another facility. The VA hospital was notified to expect a new patient in their ER.

But something went wrong- Mark never made it to VA emergency room. He was never given the care his doctor ordered. There are only two people who know exactly what happened. One is the veteran, he is now dead and one is a 23 year old female attendant who decided she wanted the veteran arrested. There's a police report that shows how incompetent the ambulance staff were, especially the young EMT who filed battery charges against one of her patients. The report was taken by an officer who apparently had no problem hauling an emergency transport patient from the back of an ambulance, handcuffing and then rerouting the patient from VA ER to the Jefferson County jail. You can ask where was the doctor, where were the nurses, why didn't someone stop the EMT and police officer? You can ask but those questions will only be answered by attorneys jostling documents in lawsuits and malpractice complaints.

Certain things are easy to see, it was incompetent KDH ER and ambulance staff combined with overeager, irresponsible police officers that began a landslide of tragic events that eventually lead to a veteran being found frozen to death in downtown Madison. It's simple common sense; no legal expertise is required to figure out we don't pull ill patients on their way to an emergency room from the back of an ambulance to toss in a jail cell. Especially when that jail has no medical staff and won't have any medical staff available for at least the next 48 hours. It's this easy; we don't take drunk drivers with broken legs and throw them in a jail cell; they go to ER and the police politely wait their turn and appropriate time to charge and arrest the driver. We don't remove the belligerent old man with Alzheimer's who is smacking and hitting everyone around him from the back of the ambulance and throw him in a police car to haul off to jail. If a patient needs to go to ER then that's where the patient needs to go. Its inhumane to jail the injured or ill. If I know this and you know this- then why didn't our local police force know this. Why didn't KDH ambulance service know this?

Sadly the veterans nightmare only worsens. You would think that upon arrival to the jail the police officer would report to the jailer that he yanked this patient from the back of ambulance headed for an emergency room in Louisville Kentucky. You would think the jailer would tell the police officer it's against jail policy (and the law) to accept someone who is in need of medical attention and clearly someone pulled from the back of an ambulance needs attention and further more that person needs attention right now. You would think the jailer would admit there was no medical staff, not even a nurse, no one could provide for the safe care of the veteran in the midst of a healthcare emergency. But no, the veteran was ushered into the jail, without medications, without medical care, without a single staff person trained in supervising persons in acute medical emergency situations. No one cared except the veteran, who kept asking to see a doctor or a nurse or someone who could help him. Several days past and the company that contracts with the county jail for part time medical services had finally scheduled an LPN who sees the veteran and is concerned so much she calls in the doctor. The part time contract doctor sees the veteran at a later time. Everyone knows something is seriously wrong but no one does the right thing. No one puts the veteran back in an ambulance and sends him for the help he desperately needs at the VA hospital in Louisville. No, instead the veteran sits in jail cell and gets sicker and sicker; the alcohol he drank so often to forget Vietnam is nowhere to be found and withdrawal symptoms begin to ravage his body. They are called DT's; it's like having seizures all the time. But still no ambulance and no medical care but the veteran did get a court appointed attorney.

No one expects an attorney to know much about medicine, especially psychiatric problems as awful as the veterans. But everyone expects most people to know the difference between humane and inhumane treatment. No one knows why the first court appointed attorney didn't do something to protect his client. After all, he was being paid by the taxpayers to do what good attorneys should do. I can't tell you why that attorney was replaced with another court appointed attorney, nor can I tell you why the veteran was assigned a second, different attorney. But I can tell you the first attorney didn't believe the veteran had done anything wrong. You will feel the same when you read the police report. I can tell you the second attorney told his very ill, mentally confused patient to plead guilty to battery charges the young EMT alleged before she abandoned her patient to the police. I can tell you the veteran was released but never showed for a court date and days later was arrested again on a bench warrant for failure to appear.

I can tell you that the veteran received a sentence of time served. (16 days) and was released back to his dirty shack without medications, heat, water, medical assistance or electricity. I can tell you the veteran did not participate in our county CIT program. Supposedly our program is one of the better county programs in the state. Court Initiated Treatment (CIT) is for those persons who are considered a danger to others or themselves. I don't know if those who made the decision not to place the veteran in treatment did so because like the County Veterans Service Officer they didn't think the veteran deserved help, or like the young EMT who just didn't want to bother with an old confused veteran or maybe those who decided thought "institutionalizing " was a bad thing to do someone. Maybe the judge was new and had no experience, maybe the prosecutor was just tired of the veterans problems or too lazy to do what was right. Maybe like the jailer and police officer they believed the veteran wasn't really their problem. I can't tell you why so many got it so wrong.

But I can tell you that a confused veteran went looking for food and shower one cold winter night and ended up dying weeks later still waiting to get back in an ambulance that would transport him safely to the VA emergency room in Louisville Kentucky for the help he so desperately needed and he deserved.

His official cause of death as listed on his politically right death certificate: natural causes complicated by hypothermia. Big words that mean the veterans heart stopped because he froze to death. The veterans permanent home is now the Indiana Veterans Cemetery. He was honored by his fellow servicemen and women. He was carried by soldiers to his final resting place; they saluted, and they honored him. They respected him for his sacrifices for our country. In death, the same veteran who didn't deserve our help, deserved the dignity of shots fired to honor a hero laid to rest. Before his death the veterans family couldn't get the support or help for the veteran. But in death the family was given thanks and recognition of an entire nation signified by one tightly folded red, white and blue flag.

I am told Veterans and family attended the service, along with one solitary elected official, a county judge Hon. Mike Hensley.

We are all to blame- some more than others. But we are all to blame. We need to change the way we treat our veterans. The VSO who refused to help, who thinks some veterans deserve help and others don't- that person needs to find a job where he doesn't make life and death decisions based on his own bias and arrogance. The EMT needs to find another career , one where she can never abandon the injured, ill or confused, the ambulance driver needs trained on how to handle incompetent co-workers. KDH ER doctors and nurses and KDH hospital need to be held accountable publicly, legally and financially for their inhumane, negligent actions. What do you do with police officers so ignorant of decency to yank an emergency transport patient from the back of an ambulance based on the word of a 23 year old girl and no evidence of any wrong doing. There are no classes or books big enough or good enough to teach human decency and common sense. What do you do with a jailer who works late Friday nights and routinely checks in drunk and disorderly inmates but can't recognize acute schizophrenia symptoms? Do you hold the beloved sheriff accountable for his failure to provide adequate and prompt medical care o training? Should he cancel the medical service company's contract and should the family file malpractice against the jail nurse and doctor. The attorneys who represented the veteran and didn't insist on CIT, the prosecutor who didn't offer it and the judge who released Mark all knew better but didn't act in the best interest of Mark or our community. The family will do what they feel best- but we must accept our responsibility to. Every citizen must insist on and support change.      Photo's of Mark's life...    Police report   Incident report     Mark Chapter 2