Indian Health Service Managers Protected a Pedophile in Their Midst. Now the U.S. Agency Is Protecting Them.
Dr. Stanley Weber at the Andrew W. Bogue Federal Building and U.S. Courthouse in Rapid City, South Dakota, on Nov. 1, 2017. (Kristina Barker for The Wall Street Journal)
After a doctor at the U.S. Indian Health Service accused a colleague of sexually abusing boys in 2009, a senior personnel supervisor at the agency named Paul McSherry quickly took sides, a new internal report obtained by The Wall Street Journal says.
The government should defend the accused, pediatrician Stanley Patrick Weber, and discredit the whistleblower by reassigning him to a remote outpost, Mr. McSherry wrote, according to the report, which the IHS disclosed after a legal effort by the Journal’s publisher.
“The sun is shining in Kotzebue this time of year,” wrote Mr. McSherry, who at the time helped run a human-resources office based at the agency’s Washington-area headquarters, referring to the northwest Alaskan town. Now retired from the IHS, Mr. McSherry said in a text message to the Journal: “This was over 11 years ago and I have no recollection of this communication.”
The accuser, pediatrician Mark Butterbrodt, was ultimately transferred to an agency hospital on the Canadian border, the report says, and quit a year later. Weber was promoted and stayed with the agency for another seven years, it says. After Weber resigned in 2016, he was convicted of sexually abusing Native American boys under his care at IHS facilities over two decades.
Despite pledges to hold its own accountable for their failures to stop Weber sooner, the IHS is still fighting to keep the names of officials like Mr. McSherry secret, citing privacy concerns. The version of the report it released last week redacts the names of agency managers and leaders in hundreds of instances, including current and former officials at the IHS and its overseer, the Department of Health and Human Services, who the report shows did little or nothing when they were warned about Weber’s conduct.
The IHS said in a statement Sunday that it “sincerely regrets that this abuse went undetected for so long, and remains committed to preventing this abuse from happening again, regaining the trust of our patients, and providing safe and quality health care to all we serve.”
The Journal identified many of the officials based on other records and interviews with people familiar with the internal investigation, revealing for the first time just how widely sex-abuse allegations against Weber circulated in the agency.
The IHS commissioned the report in 2019 after an investigation by the Journal and the PBS series FRONTLINE exposed many of the agency’s missteps in handling Weber’s case. Around that time, then-IHS director Michael Weahkee told U.S. senators the report would show exactly “where the breakdowns occurred and who should be held accountable.”
After the report, by contractor Integritas Creative Solutions LLC, was completed in January 2020, the U.S. government fought to conceal the findings from public view for more than 20 months. The IHS said the report was a confidential medical quality-assurance record, but federal judges repeatedly sided with a challenge by Dow Jones & Co., parent of the Journal and The New York Times.
When the agency disclosed the findings last week following a court order, it cited the personal privacy interests of its employees, some of whom helped cover up for Weber, as the reason to redact their names.
Not every name was redacted. The IHS identified some managers who had already been interviewed for the Journal-FRONTLINE report, for instance. Some officials’ names were redacted in some instances and not in others. At times, the agency appeared to have missed names it intended to redact.
The IHS statement didn’t answer a written question posed to it by the Journal about whether the agency had taken any action against employees following the report’s findings. Instead, the agency argued that “due to elapsed time, individual examples and recollections may lack broader details, interpretation, or context.”
The redacted names and titles include a Denver-based HHS attorney who advised the agency on legal affairs and learned about the abuse allegations against Weber in March 2009. The current CEO of one of the Indian Health Service’s North Dakota hospitals was told of the allegations a few months later. The top official now overseeing IHS’s Oklahoma City region knew of Weber’s alleged abuse as early as June 2010, according to the report and interviews.
None of them reported the abuse allegations to law enforcement, as required by law, the report notes.
Instead, Weber was promoted. He was named medical director of the IHS hospital in Pine Ridge, S.D., where he supervised potential witnesses to his crimes and maintained access to teenage patients, even after agency officials were notified he was under federal investigation for sex crimes in 2015. He resigned the next year.
Weber was sentenced to five life prison terms in 2020 for a series of crimes that included raping a drugged teenager at his IHS housing unit and penetrating an 8-year-old boy in an IHS exam room. The agency faces several civil lawsuits by victims of the abuse. Weber’s lawyer didn’t respond to a request for comment.
The new report says that Weber’s conduct at the IHS was an “open secret.” Newly hired nurses were warned to keep track of how long Weber was in exam rooms with boys as part of their training, it said. One staff member recalled hearing Weber had been discovered playing videogames in the hospital bed of one of his patients.
On Monday, the Journal published a version of the report disclosed by the IHS. While the IHS concealed the names of its employees in many instances, it didn’t protect the identities of three alleged victims of sexual misconduct by agency workers. The Journal has removed those names from the version it published.
The report shows how rare efforts by Weber’s colleagues to flag his abuse — at stints in New Mexico; Browning, Mont.; and finally Pine Ridge, S.D., spanning more than 20 years — often hit dead ends. Sometimes they were met with retaliation.
In 2009, Jan Colton, an IHS dentist who then oversaw medical care at Pine Ridge, received a complaint from Dr. Butterbrodt, the IHS pediatrician, alleging Weber was engaged in misconduct with teens and cherry-picked adolescent males to be his patients, the report says. She sought advice from HHS’s Denver-based attorney, Jim Cribari, the report shows.
Health department lawyers and medical providers are required to report sexual abuse allegations to law enforcement. Mr. Cribari instead advised Dr. Colton to set up an “ad hoc Investigative Committee” to look into the complaint and suspend Weber pending the resolution, Integritas reported.
“You need to read it and understand that it is just one view point,” Mr. Cribari said of the report. He declined to comment to the Journal on his conversations with agency officials, citing attorney-client privilege.
The investigative committee appointed to look into Weber never interviewed any witnesses and didn’t pursue other evidence, the report says. Hector Burgos, a general surgeon who still practices at Pine Ridge, told Integritas he recalled only one meeting of the committee. It concluded the allegations couldn’t be substantiated, Dr. Colton said in an earlier interview with the Journal.
Drs. Burgos and Colton didn’t respond to requests for comment on the report.
At the time, Weber’s standard biennial application to be reappointed to the Pine Ridge medical staff was pending. On the application, Integritas found, Weber disclosed that he faced a South Dakota Board of Medicine investigation: “One of the complaints if (sic) that I am [a] child molester.”
Nevertheless, Dr. Burgos and other members of the medical staff and Pine Ridge management team, who faced a chronic shortage of doctors, signed off on his reappointment in May. Among them was Frankie Delgado-Canas, by then the facility’s medical director.
Dr. Delgado-Canas was charged in 2011 with federal felonies related to alleged sexual harassment of two nurses. He pleaded guilty to two counts of disorderly conduct. Dr. Delgado-Canas, who now works for the Department of Veterans Affairs, couldn’t be reached for comment.
Few aside from Dr. Butterbrodt raised their complaints up the chain of command, in part due to a fear that managers would retaliate, the report says.
In June 2009, Ron Keats, one of Weber’s regional managers, emailed colleagues at headquarters that Dr. Butterbrodt “is still up to no good” and that “Weber has had a rough 3-4 months” fending off the allegations, the report shows.
At that point, Mr. McSherry, then the deputy director of the IHS’s Rockville, Md.-based Office of Commissioned Personnel Support, proposed a solution. Referring to Weber by his U.S. Public Health Service Commissioned Corps rank, he advised: “Move CAPT Weber to restore him. Move the other guy too so there is no implication that his actions or accusations have merit.”
“It does confirm my suspicion that people at the very highest levels of the Commissioned Corps were complicit in the cover up,” Dr. Butterbrodt told the Journal in an interview this past week. The Commissioned Corps is a group of uniformed health workers that includes many IHS medical providers. Dr. Butterbrodt, seen as an outsider in the Corps for rarely wearing his uniform and frequently bucking orders, resigned in 2011.
Mr. Keats sought support for the plan from the agency’s top regional official in South Dakota, Charlene Red Thunder, and her deputy Shelly Harris, emailing that Dr. Butterbrodt, “based on arbitrary information without any evidence or proof, accused CAPT Weber of non-professional behavior.”
Ms. Red Thunder approved Weber’s reappointment application three days later, Integritas noted.
Ms. Harris, who remains a senior official at the IHS, overseeing its Belcourt, N.D., hospital, declined to comment. Ms. Red Thunder, now retired, didn’t respond to requests for comment.
A year later, Mr. Keats, who helped manage Weber, was forced out of the agency over a child pornography investigation that later resulted in his conviction on related charges. Mr. Keats’s lawyer didn’t respond to a request for comment.
Mr. Keats’s replacement, Travis Watts, also dismissed Dr. Butterbrodt’s reports of Weber’s misconduct, the report shows. Mr. Watts told a colleague he knew of allegations that Weber had “acted inappropriately with teenage boys,” but that law enforcement had looked into it and “came up with nothing,” according to an email cited in the report.
Mr. Watts, a pharmacist who is now a rear admiral in the Commissioned Corps and the head of IHS’s Oklahoma regional office, told Integritas he based this information on Mr. McSherry’s version of events and didn’t attempt to verify it. Integritas found no meaningful investigation into Weber had been conducted. Instead, HHS’s Office of Inspector General had just declined to follow up on a tip, the report shows.
Mr. Watts declined to comment.
The report says IHS failed to produce emails spanning 2010 until mid-2015. In an interview, Carl Caulk, Integritas’ leader, said the agency had fully cooperated with his requests, but struggled to locate records and appeared not to have documented important events. Other health department units, including the Office of General Counsel, didn’t respond to requests for Integritas interviews or declined to make employees available, the report says.
In July 2015, a Bureau of Indian Affairs law-enforcement official informed IHS and HHS managers that it had opened a federal investigation into Weber.
Mr. Cribari, the health department lawyer, recommended that Ms. Harris and other officials suspend Weber’s clinical privileges and put him on administrative duty.
Instead, IHS officials did nothing for nearly four months, and Weber continued seeing pediatric patients, including making nighttime visits to hospitalized teens, Integritas found.
Officials finally barred Weber from patient care in October of that year, after the Office of Inspector General joined the investigation. But the IHS didn’t remove Weber from his other role as the hospital’s acting clinical director—one of the most powerful positions at Pine Ridge.
Integritas investigators say in the report that the move “allowed him continued access to the same adolescent Indian male population into which he had spent years ingratiating himself.”
Despite a restriction from treating patients, Weber continued seeing teenage boys in the administration office in plain view for months, the report says.
IHS officials finally suspended Weber in May 2016. Just beforehand, an administrative assistant told Integritas, she saw him shredding documents in his office. “He is shredding the evidence,” she recalled thinking, the report says.
Integritas said its investigators never found copies of key documents from Weber’s time at Pine Ridge, such as the ad hoc investigative committee’s report.
Weber quit days later, the report says.
A few days after Weber resigned, an HHS Inspector General’s agent visited Weber’s house to question him as part of the investigation that would ultimately lead to his convictions, according to the report and court records.
Weber wasn’t home, the court records show. In a sign of how open Weber’s conduct was, the report notes, “a young boy was at Weber’s house” at the time.
“For every known victim there are likely dozens of victims who endured their abuse in silence and will do so until the end of their life,” the report concluded.
This story has been updated to correct the frequency of Weber’s Pine Ridge reappointment.