A jury found the detox negligent after allegations of inadequate care, falsified wellness checks and staff that didn’t use Narcan.
ROCHESTER, Minn. — Caleb Malek was just 23 years old on the night he walked into Zumbro Valley Health Center’s detox unit.
The former baseball star had tested positive for the powerful opioid fentanyl at his sober home and had chosen to come to detox to get clean.
Seven hours later, another patient would find him unresponsive in his room, and records show no one had checked on him for hours or administered Narcan.
Now, a jury found the detox unit’s negligence contributed to Malek’s death, awarding damages of $1.5 million.
A mother’s fight
On Sept. 21, 2021, Jill Adams, Caleb’s mother, remembers feeling relieved.
Her son, a star athlete whose talent had once led to a Division I baseball scholarship, had suffered with substance use disorder for years.
Earlier that night at his sober home, Caleb admitted taking a drug known as a “Perc 30” — a type of oxycodone — but counterfeit Percocet pills are sometimes laced with powerful fentanyl. When Caleb tested positive for that, he opted to go to detox to get clean.
His counselor brought him to Zumbro Valley.
For Jill, that meant she would sleep soundly knowing her son was being cared for.
“When he was in detox, I felt safe. I felt like he’s being medically supervised,” she said.
Detox was the last place Jill thought her son would die. And what she would learn about the care he received that night outraged her.
“I want justice for my son. He mattered,” she said. “I feel like he was treated like a sack of garbage in a facility that should have been caring for him,” she said.
Death investigation
Zumbro Valley’s policy stated a staff member should have checked on him at regular intervals.
Jill wondered: If that happened, how could her son have died from the effects of fentanyl seven hours after he arrived?
“I was desperate for an investigation because I knew something wasn’t right,” she said.
For months, Jill called and emailed, demanding that the Minnesota Department of Human Services investigate her son’s death. DHS licenses detox units.
Finally, a year-and-a-half after Caleb died, DHS produced an investigative memorandum finding several failures the night Caleb died. Jill said the details were gutting.
Surveillance video showed Caleb did not receive the care promised. Caleb should have been checked on every 15 minutes at first; hourly later.
Neither happened.
Failed wellness checks
The videos showed Caleb entering detox at 3:39 a.m. He’s checked in and then led to his room.
At 3:51 a.m. he went into a bathroom and stayed there for 40 minutes. No one checked on him.
At 6:41 a.m. his roommate left because of Caleb’s loud snoring — a possible sign of respiratory distress.
Again, the video shows no one went to check on him. In fact, according to the DHS report, investigators did not see any staff member go near his room between 6:29 and 8 a.m.
Documents show the detox staff logged that they checked on him at 7, 7:30, 8:30 and 9:30 a.m. — even though the state found no one entered his room at all.
Once at 8:16 a.m. a staff member is seen peeking in the room and shutting the door, but never went inside.
Another two full hours passed without staff checking on Caleb.
At 10:19 a.m. records show Caleb received a phone call on the unit. Another client went to his room to tell him, found he wasn’t breathing and alerted the staff.
“There’s no doubt in my mind, had they made even one check, he’d be alive,” Jill said.
What’s more, DHS investigators found staff waited five minutes before starting CPR.
And despite being a detox, they never used naloxone, known as Narcan, to try to reverse an overdose and revive him. The reason? Staff — and even a registered nurse — said they didn’t know how to use it.
The verdict
Jill sued Zumbro Valley for wrongful death. The facility denied any wrongdoing.
But after the trial, the jury came back with the verdict on March 22, 2024, finding Zumbro Valley Health Center was negligent in its care and treatment of Caleb and that negligence led to his death.
They also found Caleb was negligent by “consuming an illicit substance at Zumbro Valley Health Center.”
In the end, the jury attributed 60 percent of the negligence to Zumbro Valley and awarded Caleb’s family $1.5 million.
In a statement, Zumbro Valley told KARE 11:
This has been a difficult journey for everyone involved. While we are disappointed in the verdict, we have great respect for the legal system and the jury’s work.
Since 2021, the world has been tragically awakened to the growing presence and danger of fentanyl. Our staff training continues to evolve as new protocols are developed by the medical community.
At the end of the day we remain confident in the outstanding care and services we provide to support people as they work toward living healthy and fulfilling lives.
The split decision frustrates Jill, who believes her son was a vulnerable adult in need of protection.
Her lawyer, Oliver Nelson said the verdict does send a message to other facilities as Minnesota continues to confront a fentanyl crisis.
“You need to educate yourself. You need to know what the signs and symptoms of an opioid overdose patient is and you need to make sure that you are training your staff on what they need to do if a patient shows signs of an opioid overdose as Caleb did,” he said.
