For more than a decade, Florida juvenile justice administrators have been on notice: Children are not supposed to die in state custody for lack of the same medical care that non-delinquent kids readily receive.
But there was Andre Sheffield — Berlena Sheffield’s grandson, the one she adopted and raised as her own child — in the Brevard County Juvenile Detention Center’s East Module, complaining of a headache and stomach pain, soiling himself, limping, walking strangely sideways and falling over, as if he had no control over his 14-year-old body.
Registered nurse Karen Rainford gave him Tylenol. He died hours later.
Juvenile justice investigators completed a report late last month on Andre’s death, concluding that guards at the 40-bed lockup routinely violated agency rules regarding the treatment of sick detainees, and ignored growing evidence of Andre’s illness before he was found dead in his cell Feb. 19 around lunchtime. The 50-page report also faulted the lockup’s top officer, Superintendent Vicki Alves, for “failing to ensure” that officers under her command were properly trained in agency sick-call procedures.
“We’ve got to hold staff accountable at the very highest level,” DJJ Secretary Christy Daly told the Miami Herald in an interview Friday. “That goes all the way up to the superintendent of the facility. The leadership of the facility sets the tone.”
“We’ve got to have that compassion across the board,” Daly said. “We have gotten rid of a lot of people across the state who have not bought into what we’re trying to do.”
Discipline meted out to six staff members late last week was mild compared to similar incidents in the past: The lockup’s superintendent, Vicki Alves, was suspended for five days for “poor performance” and “negligence.” Her deputy received a written reprimand for poor performance. Three guards who were faulted for ignoring sick-call procedure or failing to seek medical care for a sick detainee were given written reprimands, as well.
Rainford, the Cocoa lockup’s in-house nurse, was “immediately terminated” by DJJ administrators on Feb. 27 after she refused to be interviewed by investigators with the agency’s Inspector General’s Office. The report said she did not follow a medical protocol for the diagnosis of abdominal pain prior to Andre’s death. Rainford could not be reached by the Herald.
“Andre was a fine, loving kid. He smiled all the time,” his grandmother, Berlena Sheffield, said. He was supposed to be released in April, and told his grandmother he was looking forward to returning home, where the family dog, Roxy, a pit bull mix, had given birth to 14 puppies, one of which was going to be his.
“He was anxious to get home, and play with the puppies, said Sheffield, 75, of Jacksonville. “When he came back, he was already dead. It’s so hard. I ain’t quite got over it yet. I try not to think about it much. But when I think about it lately, I have to go into my own space.”
Andre, who was sent to the detention center after running away from a youth corrections program — where he was held after breaking into a neighbor’s home — is at least the third delinquent youth to die in Florida since 2003 of medical conditions that are not fatal with appropriate medical care. The Medical Examiner’s Office determined that Andre died of bacterial meningitis, an inflammation of the protective membranes covering the brain.
A “special needs child” diagnosed with attention-deficit disorder, Andre was adopted by Sheffield when he was 5, she said. His mother, who lost custody of all six of her children, had a severe drug problem, and the drugs she abused left Andre scarred at birth, she said. “He kept getting into trouble. It started young, like in kindergarten. He was thrown out of every program he was in.”
Still, corrections officers quoted in the DJJ report generally described Andre as polite and respectful, seldom requiring attention.
Florida’s youth corrections system has a history of failing to ensure that every child stays alive long enough to be rehabilitated.
Accusations of institutional callousness arose in the summer of 2003, after an Opa-locka teen, Omar Paisley, died a slow, agonizing death from appendicitis while at the Miami-Dade Juvenile Detention Center. Omar, 17, had been arrested on March 24, 2003, after he cut a neighbor with a soda can during an altercation. Beginning around noon on June 7, he began to complain that he was sick and in pain. For three days, guards and nurses ignored the teen’s pleas for help, and he died amid his own waste in a cell just as guards arrived — handcuffs and leg shackles in hand — to take him to the hospital.
A Miami grand jury later charged two nurses with manslaughter and third-degree murder in Omar’s death, calling the caregivers’ actions callous and “outrageous.” One of the nurses pleaded guilty, years later, to misdemeanor culpable negligence. Grand jurors also decried “the utter lack of humanity demonstrated” by officers at the lockup the week Omar died, concluding the 226-bed detention center was poorly administered, woefully underfunded and sometimes left in the hands of officers who showed little empathy or regard for the children in their care.
Starting with then-Secretary W.G. “Bill” Bankhead, 25 administrators and officers were allowed to resign or retire, or were fired. Shortly after his arrival, incoming Secretary George Denman adopted a new motto in April 2004: “Treat every child as if he were your own.”
Four months later, Denman’s replacement, Anthony Schembri, said “you can’t teach compassion by modeling callousness, and you can’t teach respect for the law if you are showing disrespect.”
But more children died. On Jan. 6, 2006, 14-year-old Martin Lee Anderson stopped breathing as guards at a Panama City military-style boot camp used physical force to coerce him to run a track — even as the teen complained he was having trouble breathing. One of two autopsies concluded Martin suffocated when guards shoved ammonia capsules up his nose. The half-hour restraint was captured on video, sparking a nationwide outcry. Seven guards and a nurse were charged on Nov. 28 of that year with aggravated manslaughter; they all were later acquitted.
Then, in July of 2011, 18-year-old Eric Perez died of a cerebral hemorrhage, records said, after a guard dropped him on his head during horseplay — and other staff failed to act as the teen’s condition worsened. One guard, a report said, was convinced Perez was “faking it.” He told a colleague it was not worth the required paperwork to send Perez to a hospital. Perez’s death, like that of Omar Paisley, prompted an agency housecleaning: Nine employees were fired, including the lockup superintendent.
The report detailing Andre’s demise reads like a kind of Rashomon tale: The guards entrusted with Andre’s care generally insisted the youth displayed no signs of distress, and did not seek their help. “He never displayed any type of behavior to indicate that he was ill,” the report quoted an officer as saying. Detainees who were interviewed told a dramatically different story, and surveillance video often was consistent with their account.
As many as six different detainees told the inspector general that Andre had complained that his leg, head and stomach hurt him, and that he had asked to be placed on sick-call. A youth on the sick call log must have his request reviewed by a lockup supervisor -- if no healthcare staff are on site -- within four hours ”to determine if there is an immediate need for healthcare,” according to procedure.
One youth said he explicitly asked a guard to “keep an eye on” Andre because the teen did not look well. He said the officer “responded that the youth would be fine.”
Another youth detained at the lockup told investigators Andre had asked to be placed on sick-call as early as Feb. 15 — four days before he died. The guard denied receiving the request, which was never recorded. That detainee also said an unnamed nurse told him Andre “was lying about his complaints.”
The report quoted another detainee as saying Andre had asked to have his name placed on sick-call to see the nurse on Wednesday, Feb. 18, “but was told he had to wait until the following morning.”
That Wednesday, Andre began to have trouble walking. Detainees reported seeing Andre limping, and surveillance video confirmed he was walking unsteadily, and “suddenly fell sideways onto a chair.” He also complained that he was very cold, though other youths insisted the temperature inside the module wasn’t uncomfortable.
At 7:55 the following morning, records say, Andre told a female officer he “was not feeling good.” He had defecated on himself, and had “begun to hyperventilate.” Rainford “offered youth Sheffield two Tylenol and encouraged him to drink a lot of fluids.”
When Andre was placed in “medical isolation” for better observation, “the staff who checked on him would sometimes open the door and ask him if he was okay or if he needed anything. Otherwise, most of the staff merely just looked inside the room to make sure he was there,” the report said, quoting detainees.
At lunchtime, officers entered Andre’s cell to deliver his lunch. He didn’t reply when they called him name. “Youth Sheffield,” the report said, “was ice cold.”
The staff’s reluctance to seek help for the teen was not an isolated event, the report said. DJJ’s report quoted eight officers — including three supervisors — as saying staff routinely refused to enter sick-call requests at night because there was no nurse on duty to see them. “The reason the sick-call requests were delayed was to prevent the appearance that nothing was done for the youth,” the report quoted one officer as saying. The lockup’s assistant superintendent seemed “unaware” of sick-call rules, the report said.
Kelvin Lewis, who worked with Andre and his family as director of the Federation of Families of Northeast Florida, said sometimes youth corrections officers display a kind of “compassion fatigue,” and forget that the detainees in their custody are, first and foremost, children.
“The onus is on the state to make sure it never plays out this way, never results in a death. That can never happen,” Lewis said. “You have to do everything humanly possible, and everything medically possible, to make sure it never plays out this way.”