William James Lamson was born with a devastating form of autism that caused him to obsessively and explosively strike himself. Over time, the damage to Lamson's head was so severe that he became blind in his right eye.
Caregivers at the Carlton Palms Educational Center were told to keep a football-like helmet on Lamson's head to protect him from the blows.
But there was no one to protect Lamson from his caregivers.
When the Mount Dora police were called to investigate Lamson's death on March 1, officers were told the 26-year-old "was a self-harmer, and was constantly banging his head." Authorities were led to believe that Lamson's neurological demons had finally won the battle being waged in his brain.
But a police report offered significant grounds for skepticism: Investigators "did not observe any blood in his bedroom," the report said. Nor did they see "any obvious injuries."
Lamson's death now is a manslaughter investigation. And sources with knowledge of the case say the young man, called "Willie" by his family, died of asphyxiation — not head trauma.
"We thought it was a place that would take care of Willie, and we were grateful. It was the only facility licensed to provide the level of care these individuals needed," David Lamson-Keene, Lamson's uncle, said of the Lake County institution where Lamson died. "But there were so many outcomes that were horrific outcomes, and those are just the ones we know about."
The State Attorney's Office, which is considering whether to prosecute caregivers in Lamson's death, would not release documents that offer details on the case, including autopsy findings, because it is an active investigation, a spokesperson said.
Lamson-Keene's younger brother, James "Jamie" Lamson, is struggling to cope with his son's inexplicable death: "His anguish and grief are so deep that he hasn't been able to open the sympathy cards yet," said Lamson-Keene, 57, who lives in Richmond, Virginia. "We usually talk about once a day. He is now calling four times a day."
"It is devastating to think what he was going through," Lamson-Keene said.
A spokesman for Bellwether Behavioral Health, which operates Carlton Palms, declined to discuss Lamson's death, or the home's long record of resident abuse and neglect.
But in a letter to Barbara Palmer, the director of the Florida Agency for Persons with Disabilities, on Wednesday, CEO Michael J. Martin said that Carlton Palms was "firmly committed to maintain the health and safety of its residents."
"I want to state categorically that CPEC has never and will never abandon its commitment to maintain the safety and well-being of the CPEC residents. We strongly reject any characterization of CPEC's past or contemplated actions as an abandonment of its residents," he added, apparently in reference to Bellwether's decision to leave Florida by the end of the month.
On Thursday the Miami Herald reported that Carlton Palms operators announced plans to leave the state, and that state leaders are moving to take over the home’s management. The state Agency for Persons with Disabilities went to court seeking what is called a “receivership” — the appointment of a new leadership team to oversee the home.
In a letter to Martin last August, Palmer outlined 14 "serious violations that jeopardize the health and safety of the individuals we jointly serve." The incidents "cause or pose an immediate threat of death or serious harm to the health, safety or welfare of a resident and ... require immediate correction," she added.
Lamson was diagnosed as a child with severe autism, a neurological disorder that is believed to afflict one out of every 60 children. He was capable of a small handful of routine tasks, such as changing a roll of toilet paper or washing dishes. He could not tell caregivers or family members that he was being mistreated, though he's been known to say "Daddy, let's go ice cream."
The young man, who had a sweet tooth, was particularly drawn to pumpkin pie, Swiss cake rolls, Pop-Tarts, and Reese’s Peanut Butter Cups. People called him "Buddy."
With its beautifully trimmed lawns and lush landscaping amid the rolling hills of quaint Mount Dora, Carlton Palms looked the part of a home where Lamson would be safe and well cared for, Lamson-Keene said. And if anything sinister was manifest behind the locked doors, Jamie Lamson was unlikely to see it in his weekly visits, his brother said. He was never allowed in his son's room. The visits all were restricted to common areas.
"They kept him hidden," David Lamson-Keene said. "They created an artificial environment of 'isn't it lovely how we take care of him.' "
When the Lamson family was notified of Willie's death, they were stunned to learn of Carlton Palms' history.
In 2013, it was where a non-verbal Broward girl — 14-year-old Paige Elizabeth Lunsford — succumbed to dehydration days after her arrival at her new home. Records show Paige was seriously ill, and had spent days violently vomiting. But instead of seeking medical care, workers bound her wrists, ankles, biceps and waist with restraints to keep her from flailing. She died of a severe — but treatable — infection. In 1997, it was where Jon Henley, 14, was found dead in his bed with inadequate levels of anti-seizure medicine in his system. It was medicine the staff was in charge of administering.
But it's the facility's most recent history that has prompted state disability administrators to scramble to shut it down.
As disability leaders and Carlton Palms management traded angry letters, Bellwether announced it would pull out of the state, choosing not to renew its license, which expires May 31.
In a 17-page administrative complaint filed last month, APD sought to revoke Carlton Palms’ license, chronicling a parade of horrors that occurred in recent years, including rapes, rats and red-hot scaldings.
One man was raped by a known predator who was supposed to be under constant supervision. The alleged rape of another resident was witnessed by a caregiver who chose to do nothing, the complaint said. One resident was burned on his or her head, shoulder, back and elbow when a caregiver apparently doused the resident with scalding water that had been heated in a microwave.
In her letter last August, Palmer described a June 9, 2017, incident in which a resident was "taunted, ridiculed and humiliated," and then locked in a shower naked for four hours. Inside the shower, witnesses heard slapping noises, "hitting sounds and the sound of [the resident] screaming," the letter said. One resident was allegedly dragged by a worker across the floor for 10 or 12 feet by the arms in April 2017. Another was grabbed by a sweatshirt, thrown to the floor and kicked. Yet another was left unsupervised for seven minutes, and yanked staples from his or her head with a plastic hanger, according to APD.
A resident originally from Miami recently was charged with biting off a piece of another resident's nose. The assailant was Antonio Ramos, who has been in state care since 1997, when he threw his twin siblings, 4-month-old Joshua and Jasmin Hernandez, from the sixth-floor balcony of his Kendale Lakes home as his mother slept. "He has the mind of a three-and-a-half-year-old," said his mother, Olga Hernandez.
"I don't want him back at Carlton Palms," Hernandez said. "I don't want him back there.
"One of the staffers hit him with a belt buckle, and took all of the skin off from behind his leg," Hernandez said. "Another staffer slapped him. All they do is cover their butts."
Earlier this year, an investigation by Disability Rights Florida, an advocacy group, cast more shade on the complex, highlighting 28 allegations of abuse or neglect from the first nine months of 2016. The report said surveillance footage showed a resident being slapped by a staffer and residents being strapped into makeshift restraint chairs inappropriately.
The report also detailed how staffers failed to explain why a resident suffered a black eye, and described the staff’s “outright avoidance” to file accurate and timely reports when residents were injured.
In another case, a resident was restrained for almost four hours despite being “calm the entire time.” Florida law prohibits the use of restraints as punishment.
An advocate for people with disabilities told the Miami Herald that the devices looked "medieval."
“They are raised chairs; almost like on a pedestal in the middle of the community room. When a person is restrained, they would put them in the restraint chair while all the residents watch,” said Matthew Dietz, the attorney of a former resident who has since been transferred out.
Lamson-Keene said his brother, who is divorced from Willie's mom, is waiting for half of his son's ashes to arrive so he can scatter them, and move on with his grief. Without his weekly visits to Mount Dora to visit his son, his life has lost meaning.
"That was most of what his father lived for," said Lamson-Keene. "That young man felt loved and cared for by his father. He was the whole focus of his father's life — and that's been wiped away by the horrors behind the scenes that we're, sadly, just learning about.
"It sickens me to think of what we know. What about what we don't know?"