* Juanita Durden, 48, who died this year of a bowel obstruction while a resident at Landmark. A state abuse investigation found that health-care workers didn't act swiftly in caring for her, and in fact, hadn't noted in her records that she was having medical problems. An autopsy showed that Durden had a complete hysterectomy sometime during her stay in state institutions, but nothing in her medical records reflects why or when. Her family knew nothing about the surgery. * Trina Waldon, 25, blind and disabled, died of pneumonia. A year earlier, she broke her upper right arm in three places, an injury no one at Landmark could explain, even though her doctor said such a break is usually caused by severe trauma. State abuse investigators determined Waldon had been neglected, maybe even abused, but they couldn't document how or by whom. At the least, the staff was "neglectful in not knowing how or when such a severe bone break occurred," abuse investigators concluded.

* Sandy McMakin, 27, dead from cancer so widespread that the Dade County medical examiner couldn't determine where it started. The disease was never diagnosed or treated by doctors at Landmark even though McMakin in her last days stumbled around and complained of pain incessantly. Aides reported they thought the complaints were "attention getting devices or acting-out incidences."

* Roland Duxbury, 51, died at Landmark five years ago after suffering an epileptic seizure. He fell to the floor, where aides left him for three hours, thinking he was sleeping. Later, when they checked on him, he was dead.

"These are people who are living fragile, vulnerable lives to begin with," said Kathy Burton, acting regional director of the Advocacy Center for Persons with Disabilities, a group based in Tallahassee. "They should, at the least, have some dignity in death."

Earlier this year, the group criticized the state over its treatment of residents at Landmark, saying that health care is inadequate, that the center is plagued by a high rate of unexplained injury among patients and that "residents are living in an environment where their health and safety are at risk."

Towey said that after Durden's death earlier this year "red flags went up" and that he immediately demanded a review of health-care procedures at Landmark, which houses about 350 developmentally disabled adults. Towey's chief deputy, Anita Bock, has been assigned to review aggressively the quality of care patients are getting, he said.

Ulysses Davis, Landmark's administrator, said: "I don't feel we made any mistakes. As I say, there's always room for improvement."

No case exemplifies the state's shortcomings like that of Richard Daniels.

A paraplegic wheelchair user, Daniels had been a resident at Landmark all of his adult life. At 17, he was an avid athlete and an outstanding student who spoke German and French. But in his ninth day as a senior at South Broward High School, Daniels, a quarterback, was sacked in a football game and suffered a severe internal head injury.

Doctors performed brain surgery to try to save him. He remained comatose for five weeks, then went home in a full body cast, paralyzed and permanently brain-damaged.

Barbara Daniels kept her son home for three years. Helpless and hostile, he babbled incessantly. Finally, Barbara Daniels says, the frustration of caring for him became too difficult, and in 1966 she placed her son in Landmark.