(L.A.) Cole Hartman, 8, Died in a Hospital

Case Number: 2013-05434

Los Angeles County is reporting the death of an eight-year-old male that occurred in a hospital.

The coroner’s office identified the child as Samuel Hartman of Castaic.

Manner of Death : Undetermined

Manner of Death: Homicide

Cause of Death: Sequelae of Near Drowning

RIP SAMUEL HARTMAN (May 28, 2005 – August 4, 2013)

Formal pronouncement of death was made on Sunday at 11:09 a.m.

The decedent’s passing was the subject of much controversy whilst his name was provided widely as Cole Hartman.

In fact, the Department of Medical Examiner has attempted to hide this record by changing the boy’s name and also removing the line: “Other Significant Conditions: History of Fragile X Syndrome, Effects of Fentanyl Toxicity”

CBS: cbsnews.com/news/child-organ-donor-death-ucla-fentanyl-investigated-by-low-angeles-police/

According to the coroner’s report and a 911 recording, his father came in from mowing the lawn on July 31, 2013, and found Cole headfirst in a running washing machine. His parents estimated he could have been underwater for up to 25 minutes.

archive.today/2026.08.08-045214/https://laist.com/news/cole-hartman-investigation

The 8-year-old on the circulatory death track.

https://www.celinegounder.com/p/organ-procurement-donors-still-alive

Cole Hartman was 8 years old. He had Fragile X syndrome. On July 31, 2013, his stepmother found him head down in a top-loading washing machine full of water and clothes. He was resuscitated at Henry Mayo Hospital. The sheriff’s homicide unit was assigned because the injury looked suspicious. The next day he was moved to Ronald Reagan UCLA Medical Center. His pupils became reactive. He was minimally responsive. He did not meet the criteria for brain death. He was placed on the DCD track.

I asked the Los Angeles County medical examiner for its file on the case under the California Public Records Act. The county released it, with redactions, in April 2026.

Denise Bertone was the pediatric death investigator assigned to it. She had conducted more than 2,500 death investigations. On August 4, 2013, Hartman was taken to the operating room. Bertone says his intensive care physician also sat on UCLA’s liver transplant team, and served as the anesthesiologist for the recovery. Those roles are supposed to be held by different people. He was on a continuous morphine drip. When the ventilator came off, he kept breathing. The physician then gave 500 micrograms of fentanyl. Hartman weighed 21 kilograms and had never had opioids. He was pronounced dead at 11:03 a.m.

The dose never went into the medication record. It was handwritten on a slip of paper and scanned into the chart. Bertone subpoenaed the pharmacy logs. One vial of 250 micrograms had been checked out for him. The source of the second was never established.

Then the toxicology, which is the part that makes the case. Blood drawn in the operating room was couriered to the coroner by OneLegacy. It showed morphine and no fentanyl. Bertone asked the pathologist to also draw blood from the body at autopsy. That sample sat untested for 7 months. When it was finally run, in March 2014, it showed morphine and a lethal level of fentanyl.

The case was first closed in October 2013 as the sequelae of a near drowning, with the manner of death undetermined. It was reopened in November 2016. A pediatric toxicologist found the fentanyl inconsistent with a therapeutic dose, and the death certificate was amended to add fentanyl toxicity. In June 2017, the chief of anesthesiology at USC reviewed the records. He found the dose 250 to 300 micrograms above what was safe. The manner of death was changed to homicide.

That is a finding about how a death came about. It says nothing about intent, and it brings no charge on its own. No charge followed. The deputy district attorney assigned to the case never issued the written rejection notice explaining why the prosecution was declined. Bertone says the family was told it was comfort care. UCLA Health declined to comment, citing privacy law. It said that “potential organ and tissue donations are not a consideration in decisions about life-sustaining care.”

Then the money. Bertone sued the county, saying she was pushed out for pursuing the case. Dr. Lakshmanan Sathyavagiswaran, the chief medical examiner, testified at that trial. He said the coroner’s office took in $140,000 to $150,000 a year from OneLegacy, depending on the year. He called it cost recovery, approved in the contract, for organ and tissue procurement and for the time his staff spent on it. He said the office ran on about $40 million a year. He also acknowledged serving on OneLegacy’s board for a period, before he came back as interim chief. He denied that anyone retaliated against Bertone. She says OneLegacy also helped his son-in-law get a job. On December 17, 2021, after 90 minutes of deliberation, the jury found for her.

OneLegacy told me California law requires its agreement with the medical examiner. State law authorizes coroners to enter those agreements. It doesn’t require them. The requirement in Los Angeles is a county ordinance. OneLegacy has the same arrangement in all 7 counties it serves. “The Medical Examiner independently reviews, releases, and/or restricts the recovery of organ, eye, and tissue,” said Shaan M. Johri, director of communications for OneLegacy.

I asked Bertone what changed after the trial. “I was really surprised that after the trial, nothing happened,” she said. “Absolutely nothing.”