The Pennsylvania Department of Military and Veteran’s Affairs has agreed to pay a settlement to the family of a veteran who wandered away from a state veteran’s home in Philadelphia only to tragically freeze to death. The department will pay $250,000 to the estate of Harold Chapman, and in particular to his two surviving daughters. Neither the Chapmans’ attorney, Ezra Wohlgelernter, nor the defense for the Department of Military and Veteran’s affairs responded to requests for comment.

The case, which has been in process since 2007, took several unusual turns. A number of staffers at the facility were reprimanded after Chapman died, with some being suspended. One staffer chose to quit rather than submit to questioning, and further inquiry revealed that he had previously been convicted of stalking. Chapman’s body was ultimately found less than a mile from the home, prompting his widow to comment that the hospital would have tripped over him if they had looked at all. According to officials at the home, which can accommodate 130 residents, the incident has inspired a number of changes in procedures to prevent any residents from wandering off in such a fashion again.

The settlement will be divided up according to terms agreed by the parties. Chapman’s daughters, Cheryl Pieretti and Laura Cerminara, each will receive $30,128, with $90,380 going to the Chapman estate. The remainder will be paid out in attorney’s fees for the plaintiffs’ representatives.

Cases such as this show how utterly unnecessary such wrongful deaths are. Given how close Chapman was to the facility when he was discovered, it boggles the mind that anyone could have missed him if conducting any degree of serious searching. Further, the fact that such an obviously clear-cut case took nearly three years to complete is appalling. It raises serious questions about just what the culture of care is like at the Pennsylvania Department of Military and Veteran’s Affairs.