Richard Daniels died in the state's care, beaten and bruised, a defenseless victim of repeated neglect that slowly killed him.
Today, 2 1/2 years after his unexplained death at North Dade's Landmark Learning Center for the developmentally disabled, no one has yet been held responsible for abusing him despite evidence that the 43-year-old retarded man, his body bent and paralyzed, may have been beaten to an agonizing death.
A Miami Herald investigation into his death, as well as those of dozens of retarded adults in Florida, shows that the Daniels case, like others, has been hampered by reluctant witnesses, sloppy medical records, poor documentation of crucial evidence and waning interest in his death.
"They didn't even tell me he was dead until three days after it happened," said Barbara Daniels, his mother. "It was such a shock, and no one could ever explain to me how he got all those bruises. My son was abused. There's no doubt in my mind."
A Landmark aide who worked in the cottage where Daniels lived has told The Herald that he saw another employee repeatedly beat Daniels in the chest and stomach in the week before he died and that he once tried to warn his supervisor that Daniels was in danger.
Two months later, Daniels was dead, his case a woeful illustration of a social-welfare system that broke down.
"I'm deeply troubled by what I've seen and heard on this case, and it raises more than a reasonable doubt in my mind about just how he died," said Jim Towey, district administrator for the Department of Health and Rehabilitative Services in Dade, which oversees Landmark. "The Daniels case is just an example of the tragedy that, for me, demands a full accounting from the leadership out there."
In the past five years, dozens of physically and mentally disabled adults have suffered similar fates, the victims of alleged abuse or medical neglect. Many lived in state institutions such as Landmark or in homes sanctioned by the state to care for them.
And yet the state has been hard-pressed to protect them.
Incidents of beatings, mistreatment and blatant violations of a patient's dignity often go unreported despite state abuse statutes because front-line health-care workers fear retribution on the job.
Frustrated welfare investigators, despite repeated reports of abuse and neglect, frequently find it difficult to make a case against anyone when dozens have been responsible for the victim's care.
The Herald found that doctors and nurses in some cases repeatedly fail to order critical medical tests and document life-threatening illness or unexplained injuries. They ignore key medical symptoms, sometimes writing them off to "bad behavior," and then don't act swiftly to send their patients to hospitals for treatment.
Against that backdrop, police and prosecutors plod through poorly kept, sometimes falsified records. In the end, their investigations often result in no action.
"I still have to live with the guilt that maybe I should have pushed somebody harder, tried harder, but I tried, I tried," said Helen McMakin after the death of her retarded stepdaughter Sandy McMakin in a state institution. "Everybody told us they would look into it, but I don't really believe anybody cared after she was dead."
For Daniels, a wheelchair user with a troubled mind and a crippled body, there has been no justice. Nor has there been any for many other victims, whose deaths have been under investigation for months, even years, without criminal or punitive action. Other cases include: * Lazaro Diaz, 32, who died last year from internal blood loss, a result of a broken thigh bone. No one at the Landmark Learning Center where he lived for 22 years could say how or when he broke his femur, the largest bone in the human body. The injury went untreated for 11 crucial hours. Diaz died waiting for an X-ray on a hospital gurney.
* 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.
"The boy we knew was gone," she says today. "It was too much."
He lived at Landmark until his death at 12:16 a.m. April 7, 1990. That night, workers said Daniels was restless, endlessly complaining and repeatedly asking for a pitcher that he used as a urinal.
"To relieve him from screaming, I gave it to him," wrote David Medy, a Landmark aide, in a statement to HRS authorities. "Five minutes later, he was complaining about the room temperature and that he was cold. I gave him a blanket and covered him with it."
At 10:45 p.m. the night shift came on.
Betty Williams, another worker, told investigators that Daniels was acting erratically, that he kept asking for the urinal even after he already had it. Saliva was coming out of his mouth. In the shift log later, she wrote:
"I looked at Richard, and he was very quiet. I called his name and got no response."
Minutes later, he was dead.
An autopsy found that Daniels died of blunt abdominal trauma, an injury he likely suffered in the days before his death. His ribs were fractured, his body badly bruised.
Landmark's official explanation at the time was that Daniels must have fallen against the arm of his wheelchair, fatally wounding himself.
"That was the only explanation they could come up with, and that's troubling," said Karen Curran, an attorney for Daniels' family. "The guy was beaten, it's pretty apparent. When is there going to be some justice for that?"
On March 31 -- seven days before his death -- Daniels' medical records show he had several darkened areas over his right lower rib cage area.
"Does not appear to be new," records said. "Client, when asked, stated it hurt. Referring to clinic to be evaluated by physician."
On April 1, Daniels was seen by a Landmark doctor, who also recorded bruising over the ribs. No X-rays or other testing was done to follow up on the injury, however.
"No need for treatment," the records said.
Cottage log entries showed Daniels had been restless in the days before his death even though staff members, when interviewed, said he didn't complain of pain or illness.
On March 27: "Awake and complaining."
On March 28: "Awake and complaining."
On March 31: "Up all night."
On April 1 : "Up all night, screaming for urinal, although already wet and complaining of being cold."
Daniels was slowly dying. But no one noticed.
Dr. Roger Mittleman, who performed the autopsy on Daniels, waited almost five months to close the case. He interviewed workers himself, visited Landmark personally and asked the police to conduct a more thorough investigation. He noted the extent of Daniels injuries, which he said "did not necessarily occur on the night of his death."
Finally, on Sept. 16 1990, he concluded:
"Extensive police interviews did not reveal evidence of an intentful force applied to the abdomen. . . . At this point in time, in the absence of suspicion of foul play, the MOD (manner of death) will be accident unless subsequent information renders evidence which would change . . . to homicide."
Meanwhile, HRS adult abuse investigators got involved in the case. Jeanette Henao, an investigator, said it was clear Daniels had been mistreated and denied proper medical care when he needed it, but she couldn't say who was responsible. Henao turned to Lawrence Remer, an HRS physician, for advice. In a confidential report, he told her:
"This is a case for the police. This man was murdered. Just from the autopsy report, he suffered a blunt trauma to his abdomen, and this ruptured his small bowel."
Metro-Dade Detective James McDermott interviewed at least 10 workers at Landmark. None claimed to know for sure how Daniels got the bruises.
The one person McDermott didn't interview at the time was David Medy. Medy, a recreational-therapy aide who has worked at Landmark since 1989, said that criminal authorities never approached him about the case and that he was afraid at the time to step forward.
"This kind of thing is nothing unusual at Landmark," Medy says today. "I did not want to say anything else about Richard because I was frightened. It was not only fear. It was like there was a cover-up."
Medy says he saw Alfred Hill, a former behavioral program specialist, repeatedly strike and kick Daniels in the week before his death, but he didn't say anything about it because nothing was done to stop Hill when Medy first reported him in February to Veronica Gaffney, his supervisor.
"I stopped right there," Medy said. "I wasn't going to say anything else. It wasn't just Richard Daniels that was treated this way."
Gaffney adamantly denies that Medy ever came to her to report any abuse of Daniels, saying, "He never ever told me anything like that." Towey said HRS is looking into whether such a report was made to Gaffney.
Davis, the Landmark administrator, called Medy a credible employee, but he wouldn't say whether he believes Medy's account of what happened to Daniels.
"I'm trying to keep an open mind about it," Davis said.
Hill was subsequently fired a year later after he was accused of abusing and withholding food from another retarded man who lived in the same cottage. Hill, now unemployed, denies that he ever mistreated anyone.
"I ain't never hit Richard Daniels, none whatsoever," said Hill, who first started working at Landmark in 1976. "I've always, well, like I said, I always liked what I was doing. I honestly thought when I was working there that I really could make a difference.
"I don't like anybody trying to make me feel guilty for something I didn't have anything to do with. You ask me about Richard Daniels. I didn't have anything to do with that. Period."
State authorities, after numerous requests by The Herald for public records involving the death, say they are now intensifying their investigation and looking at the possible allegations of abuse against Hill.
George Havens, chief investigator for the Dade state attorney's office, would not elaborate, but confirmed that "there is new information which has come to light and we're looking at it." Medy has been interviewed by Metro-Dade homicide investigators and has been asked to take a polygraph test, which he agreed to do.
Hill was never interviewed by police at the time of Daniels' death. But few, including Hill, now believe Daniels' death was caused by a fatal fall on his wheelchair.
"It was alleged that somebody in the cottage hit him," Hill said. "I didn't want to get myself involved with it. Administration have always told us, 'Look, if there's a problem in this building involving questioning by the police and everything, send the police to the front office. We'll handle it from there.' "
In Hill's letter of dismissal obtained by The Herald and dated July 1, 1991, Hill was accused of withholding food from Cornell Williams, a resident, as punishment, twisting his arm behind his body and locking his partially paralyzed arm over the back of the wheelchair to restrict movement.
He was also accused of slapping him in the head and face, using his elbow to deliver a blow to the chest and abdomen, dumping him onto the floor from his wheelchair and tying a sock through the spokes of his wheelchair to keep it from moving.
Hill, who had received two stellar performance evaluations before his firing, appealed the dismissal, saying he never "intentionally or willfully abused" anyone. The appeal has been denied.
"I honestly felt that I was doing something good and something constructive for the benefit of the residents," Hill added. "As far as being aggressive to them . . . no way."
Two men testified against Hill in his state appeal hearing. One was Medy. The other was Moses Monroe, another aide. William Salmon, a Florida hearing officer, found both men to be credible witnesses, although they obviously feared Hill.
"Medy and Monroe candidly admitted that they were afraid of him because of their subordinate positions. . . . However, together they presented a credible version that Hill physically abused a client," Salmon said.
Hill says the two men were going after him, but he says he doesn't know why. And the Landmark administration, he says, wanted to make an example of him because the center was under fire for not acting swiftly and aggressively on complaints of abuse and neglect.
An internal investigation conducted by HRS during Hill's firing noted several problems in the Leon cottage where Hill worked and Daniels lived before his death.
In April 1991, a special investigative committee found that workers were not properly trained in behavioral techniques, that accident reports were not being completed when required and that residents "were having their rights violated on a consistent basis."
But the problems with Hill and the Leon cottage were never linked to Daniels' death -- until now.
Barbara Daniels, a school cafeteria worker in Stuart, has filed a wrongful-death suit against the state. She learned of her son's death three days later in a Western Union telegram:
"We regret to inform you that your son, Richard Daniels, has passed away. We attempted to contact you today without success. Therefore, we are sending you this telegram."
"All these years, and that's what I got, that's what I have left," Barbara Daniels said. "It just breaks your heart, not just for me because I lost my son, but for all the kids who are still out there. I know something went wrong, very wrong."