It took a full day for the top medical official on duty at Miami’s juvenile lockup to read the “sick call” report on Elord Revolte, a 17-year-old who said he had been “stomped in his chest” during an Aug. 30 beatdown by more than a dozen detainees.
By then, it was too late.
“No intervention was needed,” the nurse manager explained to investigators, “as the youth had already passed away.”
Elord, who wasn’t taken to the hospital until just under 24 hours after the beating, became the second child to die in the custody of state juvenile justice administrators last year. He was the fourth to die since the Department of Juvenile Justice, in the wake of a horrific 2003 death at the Miami detention center, pledged that its officers would “treat every child as if he were [their] own.”
Late Monday, DJJ administrators released to the Miami Herald a 66-page inspector general report on Elord’s death. The report concluded that a dozen detention center employees — from front-line officers to the 126-bed lockup’s assistant superintendent — violated agency rules and procedures in the hours leading up to Elord’s death. Five employees have resigned or been fired and another seven were later reprimanded.
“The Florida Department of Juvenile Justice’s primary focus is to ensure the safety and security of all youths in our care, and our entire staff was saddened by the very sudden and tragic death of Elord Revolte,” Secretary Christina Daly said in a prepared statement.
Daly said she will hold everyone — DJJ staffers and those with private providers — accountable when lapses in judgment or performance harm juvenile detainees. “It is my expectation of everyone who works with every child in our system that they treat that child as they would want their child treated.”
Agency records do not suggest that Elord might have lived had he received more prompt medical attention, and Daly said she does not yet know the official cause of Elord’s death.
But concerns over the quality and timeliness of medical care within the state’s juvenile detention centers have lingered since at least the summer of 2003, when 17-year-old Omar Paisley of Opa-locka died a slow, agonizing death from a burst appendix while at the Miami-Dade Juvenile Detention Center — three days after he first began to beg for help. It was in the wake of that death that agency heads pledged to “treat every child as if he were your own.”
But in January 2006, July 2011 and again in February 2015, other children died: Eric Perez, 18, died of a cerebral hemorrhage at the West Palm Beach lockup in 2006 after a guard dropped him on his head during “horseplay,” and officers failed to act as his condition worsened. Martin Lee Anderson, 14, died following a violent restraint at the Bay County Boot Camp in 2011, an episode that a facility nurse watched without intervening. And last year, 14-year-old Andre Sheffield died of bacterial meningitis at the Brevard County lockup while officers delayed seeking help.
In the immediate aftermath of Elord’s death, a DJJ spokeswoman said, five employees who were accused of failing to properly do their jobs quit or were fired. Administrators now say that seven additional workers were reprimanded. The agency said it also has implemented several changes to detention policy.
Miami-Dade police are conducting a criminal investigation. Daly said it does not target DJJ staff.
Among the inspector general’s findings:
▪ Several records from officers documenting the beating Elord sustained from a dozen or more other detainees “made it appear there was an altercation between [Elord] and a few youth, not that almost the entire module participated in the assault in some manner,” the report said. Even after two officers were instructed to rewrite their reports to better document the reality, the reports “did not accurately reflect what is seen on the video surveillance.”
And the discrepancies matter, the report said: Nurses who treat detained youth usually don’t have the luxury of watching video “showing the magnitude of fights [so] it is critical that the written report specifically details what occurred,” the IG wrote.
▪ Lockup nurses were not alone in their lack of knowledge about the severity of the attack on Elord.
The lockup’s top officer, Superintendent Steve Owens, and a deputy, Samuel Thelon, watched a video of Elord’s assault at around 4 p.m. on Aug. 31 — about an hour before the youth was taken to Jackson Memorial. Thelon “observed [Elord] being jumped,” the report said. “After reviewing the video,” the administrators asked their staff why they hadn’t been called “and advised of the magnitude of the fight.”
▪ Lockup staff did not call police to report the beating until after Elord had died. Administrators said it had long been their policy not to alert police when a youth is battered, unless the youth wished to press charges.
In Elord’s case, the teen initially said he wanted authorities to press charges. But when asked again, Elord said he “knew where the other youths lived, and he wanted to kill them” instead.
▪ Again and again, supervisors and administrators said that, as no formal policies or procedures mandate that bosses ensure checks take place and youth be hospitalized promptly, they were not at fault for failing to do so.
Most of the discipline imposed as a result of the investigation involved failure to perform 10-minute checks on Elord while he was being confined for medical observation. Room checks during the night of Aug. 30 and in the early morning of Aug. 31 “were sporadic and inconsistent,” the report said.
One officer acknowledged he falsified bed check records to make it appear he had observed the youth.
Elord “demanded to be taken to the hospital,” during a 3:40 p.m. visit with the nurse. But it was not until almost 5 p.m. that officers finally drove Elord to the hospital, the lockup’s master control log showed.
Likewise, the lockup’s “head injury protocol provides for continuous assessments and notifications of the medical doctor,” the report said. “Both nurses testified these actions were not taken.”
The lockup’s on-call physician “was only notified when [Elord] was sent to the hospital,” the report said.
Elord was booked into the detention center around Aug. 28 on armed robbery charges. In the days before his arrest, Elord had been living on the beach after he ran away from a Miami Beach foster home, where he was sent after his father was accused of abandoning him.
The inspector general report sheds little light on why many of the 20 detainees in Module 9 attacked the teen on Aug. 30. None of the detainees who might have helped answer that question were available to investigators, as police kept the youths at arm’s length while conducting a criminal probe.
The Miami-Dade Juvenile Detention Center’s nurse manager told DJJ that, although Elord was complaining only about widespread body soreness, she had been told that Elord was under close observation to ensure he did not have a head injury. Records suggest the nurses were unaware of how badly Elord had been beaten and kicked when a horde of other teenagers “jumped” him at around 5:30 p.m.
At 3:40 the next day, Elord told a nurse he was suffering from “stabbing pain in the middle to right side of his chest” and that it “felt like something was stuck in his chest.” Though Elord denied having trouble breathing, notes show “he was clutching the right side of his chest and vomiting.”
Elord “demanded to be taken to the hospital,” during the 3:40 p.m. visit with the nurse.
But it was not until almost 5 p.m. that officers drove Elord to the hospital, the lockup’s master control log showed. Video surveillance of the lockup’s nursing station shows that, in the intervening nearly 80 minutes, Elord was seen grasping his chest, appearing to be “agitated and in pain,” and most likely vomiting into a “biohazard bag.”
Officer AuthorGlanville told investigators he sat with Elord on a white slab in a waiting area while the youth waited for a transport van to arrive. Another officer “kept looking out the door, asking the supervisors where the transport was,” the report said. Elord told Glanville “that a group of youths had jumped him,” and he had “asked the nurse since Sunday [Aug. 30] to send him to the hospital.”
Another officer, Yves Ferrier, also told investigators that Elord said he told a nurse “multiple times he needed to go to the hospital,” reporting to the nurse that he “was having sensations on his right side, upper chest area” that felt like “crackling.” The report added: “Ferrier said he told the youth to calm down and to breathe.”
Ferrier said he saw the nurse manager bring Elord a plastic bag in which to vomit. But, he added, she did not ask [Elord] any questions.”
“Some 20 years ago, [Ferrier] was an emergency medical technician,” the report said, and in Ferrier’s “opinion, it was not okay to wait an hour before transporting [Elord] to the hospital. He felt [the nurse] should have responded to [Elord] immediately, and said, had the youth indicated he was having pain more to the center of his chest, he would have called 911.”
An assistant superintendent, Ell Fance, also questioned why it took officers so long to get Elord to Jackson. “Fance advised that, given only the fact that a youth had complained of a stabbing chest pain at 3:40 p.m. on a Monday afternoon, he would have called 911,” the report said.
According to the report, Owens, also “felt it took an exorbitant amount of time to transport” Elord to the hospital.
The inspector general’s report, nonetheless, declined to find fault on the part of any DJJ staff for the delay in driving Elord to Jackson, saying agency policy is “deficient” in not mandating a time frame for securing emergency care.