When Florida cut $100 million from mental hospitals and fired a third of their workers, patients paid the price — sometimes with their lives. Since 2009, injuries and violent incidents have increased across the state. In some cases, patients died after overworked hospital employees made mistakes or delayed calling 911 for hours. Here are the stories of how 13 patients and a baby wound up dead in the state’s care.
Miguel Menendez-Carrera, 57, was stomped to death earlier this year by a pair of younger mental patients at Florida State Hospital.
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Deontra French, 24, and Christopher Simpson, 21, first attacked Menendez-Carrera with sock-covered fists on Feb. 16 because they thought he had snitched. A hospital employee intervened. But employees did not make sure the three men remained separated, and the next morning Menendez-Carrera, a paranoid schizophrenic, threw urine on French and Simpson.
The younger men beat him until he lay motionless on the floor. Then the 249-pound French pushed his way past guards and jumped with both feet on Menendez-Carrera’s head. A shard of sinus bone ended up in his lung.
He died three days later.
French and Simpson were charged with murder. Simpson was deemed incompetent. French awaits trial.
In June 2014, Tuarus McNair, a 27-year-old schizophrenic, died slumped over on the floor of his room, a few hours after he was punched multiple times at Treasure Coast Forensic Treatment Center.
At 7 that night, technician Anilien Lamarre signed a chart saying he saw Tuarus in good health during a required “face check.” In reality, Lamarre was on a break at that time. Records show no one checked Tuarus for an hour.
The medical examiner’s official cause of death was unusual: sudden cardiac death. Basically, the coroner said, his heart had an electrical short, a rare problem that usually occurs in young athletes or drug abusers.
The autopsy thickened the mystery. Tuarus’s brain was swollen and his toxicology report showed an alarming amount of Thorazine in his system — 10 times the normal therapeutic level.
Two independent toxicologists, who reviewed the case files at the request of the Times/Herald-Tribune, questioned the official findings and said the case should have been investigated further.
A highly medicated Luis Santana, 42, died in a scalding bathtub on July 6, 2011, at South Florida State Hospital in Pembroke Pines. When hospital workers found him, they noticed his skin was “sloughing” off his face, chest, abdomen, back, arms and legs.
Santana, a paranoid schizophrenic who was taking five psychiatric medications, had tried to injure himself before, so he was supposed to be checked every 15 minutes. Mental health technician Patricia Bush missed one of the required checks and returned to find Santana floating beneath the running faucet with his mouth open, according to a police report. The water temperature was 118 degrees, leaving second-degree burns all over his body.
Associate Medical Examiner Lance G. Davis ruled that the burns did not kill Santana. He listed the cause of death as “undetermined.” Police closed the case.
Meanwhile, officials with the private company that ran the state-funded mental hospital at the time did not disclose Santana’s death to the Department of Children and Families abuse hotline, as required. “Facility had not reported death to DCF because they believed, once the ME stated that the resident had not drowned, that the death was due to cardiac problems,” the DCF report states. Bush was fired for inadequate supervision. Officials with Correct Care Recovery Solutions said the hospital has installed hot water monitoring equipment..
On Dec. 2, 2013, a mental health technician locked Morris Celnikier, 62, in a dark seclusion room at South Florida State Hospital. Staff member Debra Judge-Thomas, 59, was supposed to provide him with one-on-one care, but she placed Celnikier in the room and turned off the light in violation of a supervisor’s orders, according to a Pembroke Pines Police Department report.
Security video shows that Celnikier started climbing on the bed, falling multiple times and hitting his head on the concrete floor. He appeared to be trying to find a way out of the room. According to the police report, Celnikier “started pounding on the door attempting to get out, but Judge-Thomas who was sitting outside the door did not take any action to let him out” for 47 minutes.
Four days later, doctors discovered bruises on his body and fractures along his spine and ribs. He needed surgery but doctors said they were unable to perform it given his condition. He was placed in a long-term care facility. Three months later, while bedridden, he choked to death.
Judge-Thomas pleaded no contest to culpable negligence. She was placed on 12 months’ probation. Celnikier’s sister sued the state. Their settlement agreement is private.
James Fleurant, 49, escaped from Northeast Florida State Hospital in August 2011, hopping a 5-foot fence and running into the road, where he was killed by a semitrailer truck. In safety check logs, staff members wrote down that Fleurant was “present and observed” at 10 a.m. — 30 minutes after he was already dead. State inspectors later found no evidence that anyone at the hospital was supervising Fleurant after 8 a.m. The state Agency for Health Care Administration also investigated. It fined the hospital $1,000 because it “failed to keep the resident safe.”
In a “critical incident” report obtained through Florida public records law, the state redacted the names of the three employees involved. The report does not say whether anyone was reprimanded or fired.
Five months after James Bragman, 53, injured himself diving from a stairway head-first at South Florida State Hospital, he jumped to his death from the eighth floor of a Miami parking garage after a doctor’s visit.
On Jan. 11, 2011, three mental hospital workers took the schizophrenic with bipolar disorder to an appointment at Jackson Memorial Hospital. Before starting the trip, a security guard was handed a packet of paperwork on Bragman, including documents showing his recent suicide attempt. The guard never looked at the records, and no one took special precautions to prevent Bragman from escaping.
As a result, as the group was leaving, Bragman dashed out of an elevator and leaped to his death. Mental health technician Lavonia Smiley was cited by the state for inadequate supervision.
Joerhonda Griffin, 33, killed herself with a blanket on Feb. 16 at South Florida Evaluation and Treatment Center in Florida City. Staff at the mental hospital were supposed to check on Griffin every 15 minutes and search her room and closet for any objects or linens she might use to hurt herself. Griffin, who suffered from bipolar disorder and other mental problems, somehow got a blanket and used it to hang herself.
In its death investigation, DCF found that “unknown” caretakers had inadequately supervised her. A DCF report said there was no video available. No one was found responsible or disciplined in connection with Griffin’s death, according to the report.
Taalib Glover, 22, killed himself in the late afternoon on April 11, 2014. He had time to throw a sheet over the top of the door to his room and wedge it in the hinge while another patient looked on. A staff member found Glover on his knees in his room at Florida State Hospital with the bedsheet wrapped around his neck.
John Kenyon Whitaker
John Kenyon Whitaker, 50, choked to death on a piece of pizza in his room because there weren’t enough workers on duty to help him, according to an employee who was caring for the patient. When Whitaker started choking on Jan. 30, 2010, orderly Kiren Saucier said he first tried the Heimlich maneuver. Saucier said he tried to call for help but the person who could trigger a medical alarm wasn’t in the control room because she was out delivering lunch trays. By the time someone came to help, Whitaker was dead.
Steven A. Frank
Steven A. Frank, 47, was so constipated that his stomach was distended, he was seeing double and his urine turned the color of coffee. He suffered for hours one day in 2009 while Florida State Hospital workers first diagnosed him with the flu and later neglected to get a urine specimen because of a shift change. They sent him to a hospital for treatment eight hours after he first complained of pain. Frank died on Oct. 24, 2009, of an infection after his colon bled.
Loida Espina, 46, died on Aug. 28, 2011, nearly four hours after falling and hitting her head so hard that she dented a wall at South Florida State Hospital.
Espina, a paranoid schizophrenic who was committed to the Pembroke Pines facility, was waiting for a staff member to retrieve her shower sandals when she fell over into the wall, according to the police report. A DCF investigation revealed the staff was “used to” her falling. A DCF investigator also heard allegations that someone “put her head through the wall.” During the autopsy, the coroner found a small brain bleed as a result of the head injury but said the death was natural. Espina, he ruled, died from heart disease.
Workers at Florida State Hospital knew Michael Salacup, 56, liked to stick things in his mouth. Still, it took half an hour to find a latex glove in the back of his throat when he started choking one night in November 2009. After taking his medicine, Salacup went to his dorm. Five minutes later, a worker found him unconscious and a nurse called a “Code Blue” medical emergency. A doctor in the mental hospital’s emergency room later discovered a latex glove in his throat. Salacup choked to death.
Blondine Williams, 61, was slapping the window in her room at Florida State Hospital on April 21, 2013, when a nurse gave her a shot of Ativan and Benadryl to calm her down. Twenty minutes later, the schizophrenic woman was struggling to breath. She died within an hour of receiving the shot. Security cameras showed she fell earlier in the day, hitting her stomach on a chair. The medical examiner cited Williams’ schizophrenia and obesity — she was 5-foot-4 and 260 pounds — and blamed her death on “undetermined natural causes.”
Rashida Wills, 34, was schizophrenic, eight months pregnant and locked inside Florida State Hospital two days before Christmas in 2011 when she realized something was wrong with her baby. She had struggled with hypertension throughout her pregnancy, but the hospital did not have an obstetrician on staff.
On Dec. 23, 2011, workers did not believe that Wills was in labor because she was not due until Jan. 11. They told her she would not be able to get an ultrasound until after Christmas. In Florida State Hospital’s medical wing, Wills began to writhe in pain and bleed profusely and was eventually sent in a helicopter to Tallahassee Memorial. The baby was stillborn.
Wills hired attorneys and, in 2014, the state settled with her for $1 million, according to a settlement agreement.
Prosecutors charged Kathryn Cottle, 55, a licensed practical nurse at the mental facility, with neglect of a disabled adult. During Cottle’s trial, medical experts testified that she did nothing to cause the baby’s death. An Inspector General report on the incident said staff levels fell below required numbers. Of the 14 direct care staff on duty, five were required to perform double shifts, according to the report. This past summer, a jury found Cottle not guilty.
About the story
A TEAM OF REPORTERS AND data specialists from the Tampa Bay Times and the Sarasota Herald-Tribune spent more than a year investigating Florida’s largest state mental hospitals. Reporters interviewed dozens of current and former employees, then crisscrossed the state to talk to mental patients and their families.
They also collected thousands of pages of incident reports, health and safety inspections and investigative files from state agencies and police departments across Florida. Using those records, the reporters created the first comprehensive database of injuries and violent episodes at Florida’s mental hospitals.