GAINESVILLE Anthony Barsotti looks on the verge of death. His skin is ashen, his face gaunt. His mouth gapes as he stares at the ceiling, sporadically sucking in breaths.
Three hours earlier, Anthony was a physically healthy 23-year-old living in the state’s care at a Gainesville mental hospital.
Then he took a swing at another mental patient and a hospital orderly launched him head-first into a concrete wall. Workers at North Florida Evaluation and Treatment Center have a good chance to save his life this night in July 2010.
Instead, as hospital security cameras roll, they make one mistake after another.
When Anthony stumbles up with a cracked skull, they put a Band-Aid on his finger. When he clutches his head and howls in pain, they give him Tylenol.
When he stops talking and his body goes limp, no one checks him for a concussion.
It’s clear Anthony is in serious trouble. But for hours, no one calls 911.
Every year, judges send thousands of severely ill people to one of Florida’s mental hospitals because they are a danger to themselves or others. There, as the Tampa Bay Times and Sarasota Herald-Tribune reported last Sunday, supervision is so lax that they assault each other over and over.
When injuries occur, overworked employees — some inept, others poorly trained, all of them underpaid and operating under pressure to keep costs down — often leave patients to fend for themselves.
No one intended for Anthony Barsotti to die. But his case points to a stark reality: Florida’s mental hospitals fail to protect the patients in their care.
Even when the staff on his ward gather around him near the end, they seem incapable of figuring out what to do.
“Look,” registered nurse Debra Engel says as he stares at the ceiling, catatonic, “I think he’s getting his color back.”
Dusty pictures of a little boy line the plywood walls of Luann and Anthony Barsotti Jr.’s rustic bungalow deep in the woods outside Ocala.
A toddler in a red and white jumpsuit at Christmas smiling from an Olan Mills studio shot. A boy with a big grin and a red backpack on the first day of kindergarten. A laughing 9-year-old making coleslaw with grandpa.
It is easiest to think back on moments like these, when their boy, Anthony III, was growing up in Ohio. Before the voices came.
His mother picks up a framed picture of Anthony as a young man with long, curly hair, posing like Popeye.
“He was a good son,” she says, dusting the glass with her shirt. “He didn’t deserve this.”
Anthony loved art and drawing. Once, he dressed up as Pablo Picasso for a school talent show. He taught himself to play the guitar. He read The Lord of the Rings. He loved the rain.
As he got older, there were baseball games and skateboard ramps. There was a girl named Eleanor.
Anthony’s father, abused as a boy by a priest in Ohio, was a schizophrenic who controlled the disease with medication. The son named after him would not be so lucky.
In 2006, his parents moved to Silver Springs, Florida, to start anew. Anthony stayed behind with his grandparents to finish high school.
Schizophrenia lurks in the brain, often emerging in late adolescence like a fierce beast. Soon brain cells stop communicating so that signals pile up, leading into a deceptive world of fake voices, hallucinations, delusions.
By November 2007, Anthony’s grandparents could no longer handle his fitful, sometimes bizarre behavior. They put him on a plane to Florida.
When Anthony’s father picked him up, the easy-going boy he had known was gone.
Anthony, then 20, waved his arms out the car window, yelling at some unknown force. He spoke words his parents could not understand. At home, he pounded the walls and punched himself in the gut.
Several times, Anthony’s parents woke up and he was standing over their bed. “Shut up and leave me alone,” he screamed at himself.
The Barsottis took their son to doctors but he refused his medication. Then he refused to visit the doctors altogether. At one point, they considered calling in a priest for an exorcism.
One day in November 2008, Anthony’s parents asked him to turn down the TV. Anthony snapped, hitting his father and knocking down his mother.
A deputy came. Anthony spit on the officer and slammed his own forehead on the Plexiglas partition in the police car.
“I had never seen anyone that disturbed,” Anthony’s father says. “He’d opened himself up to something he couldn’t control anymore and it was sad. It was so sad.”
In jail, and later in treatment centers, Anthony only got worse.
He refused to take medication. Gangly and not very strong, he repeatedly started fights, but rarely won.
There were two more arrests for fighting. Once, his jailers locked him in solitary confinement for five months because of his volatile behavior.
He grew even more psychotic, laughing and grimacing for no reason one minute, despondent and immovable the next. A psychiatrist declared him incompetent to stand trial.
A month later, on Feb. 18, 2010, Anthony was transferred to the state-run mental hospital in Gainesville.
His parents had high hopes that he would get treatment they could never afford.
They learned that the mental hospital offered music therapy and a swimming pool. They envisioned top-flight doctors and hours of counseling and a place where their son would be safe. Here, doctors, paid for by the state, could force him to take his medication.
What Anthony found inside the Gainesville hospital was nothing like that. He was brought down a winding road with sprawling live oaks, to a block of gray buildings surrounded by razor wire. There he lived in a chaotic environment where psychopathic killers mingled — often unsupervised — with those who had committed minor crimes.
One man a few doors down was accused of killing his mother. Anthony’s neighbor across the hall had been charged with breaking down a family’s front door with an ax. Down the hall lived a man who broke into a Tallahassee home and sexually assaulted a 2-year-old girl on the couch. He said voices in his head told him to do it.
So at times, the environment inside the hospital was rough. Four men beat and kicked a 25-year-old patient in the head in an argument over using the phone. Another suffered a broken jaw after he was attacked for passing gas. A 21-year-old accused of murder punched staff members on two separate occasions.
Hospital medical records show that about six weeks after arriving, Anthony stopped eating. Then he stopped taking his medications. He told a counselor he was trying to rid himself of “toxins.”
Every weekend, Anthony’s parents drove to visit their son. Sometimes Anthony showed up in a stupor, his legs wobbly, his pupils big and glassy.
He had always been thin. But the Barsottis watched their son, 6 feet tall, dwindle to 127 pounds.
On July 30, five months after arriving at the mental hospital, Anthony walks past a fellow mental patient, a black man almost twice his size. Nothing seems amiss; just two mental patients passing each other in the hall. But then, out of nowhere, Anthony swings at the man.
The man holds him off with one arm and pushes him up against a wall, but Anthony continues to swing.
For the past month, Anthony regularly has been getting into fights. He regularly loses.
This scuffle is Anthony’s eighth in eight days.
“He kept going after these guys and he was so little and these guys were so much bigger than him,” employee Katie Estrada says.
Later that night, a security camera in the community room shows a staff member talking to Anthony, who has refused to shower for two weeks.
He watches Anthony, with scraggly long hair and a beard, slowly circle the edge of the room.
“Is it black people?” he asks. “You don’t like black people?”
“No, it’s not that,” Anthony replies, his voice monotone.
He scratches his head, looks right at the counselor.
“Is it fat people? Tall people, short people?”
“You hear voices in your head?”
“Tell me about these blackouts you have been having. Do you feel it coming on? What’s it like?”
“They’re demon-like figures.”
“Any sign of these demons, you let us know, OK?”
“What are these demons like?”
“They are like shadows.”
“Are these shadows dark or light? Do they have color?”
“They’re just black and white.”
Anthony sits down.
“Are they scary?”
The next day dawns as a typical Saturday in Building 8 at North Florida Evaluation and Treatment Center.
The nurse responsible for Anthony’s ward calls in sick. Registered nurse Debra Engel, responsible for patients in two other buildings, is told to handle rounds at Anthony’s ward, too.
Later that day, another staffing problem crops up. The hospital needs someone to man the control room, a critical post that monitors the ward through closed circuit cameras. So Janice Roper, a former custodial worker who now works as a behavior program specialist, is brought over from another building to keep tabs on patients and staff she doesn’t really know.
For Roper, that also means working a double shift — 16 hours standing watch over combative patients and staring at video monitors. She is supposed to call security if a patient or one of her coworkers runs into trouble.
Meanwhile, the medical staff issues an order that requires someone to attend to Anthony at all times. They must stand watch to prevent him from starting fights and injuring himself or one of the other patients.
As a lightning storm crackles outside late that afternoon, Michael Shea Henderson, then 49, volunteers to watch over the combative Anthony so another employee can take a break.
Henderson is on his own second eight-hour shift that day, having started at 7 a.m.
He joined the hospital as a janitor when he was 20, then worked his way up to behavior specialist, someone who watches over patients for about $14 an hour.
Despite nearly 30 years at the hospital, he has not been taught how to react when one patient attacks another.
“No training is provided on physical intervention when an altercation is in progress,” a state Department of Children and Families report would later conclude.
Shortly before 3 p.m., Henderson stands with a group of coworkers to discuss what to do with Anthony, who had just gotten into another fight, this time with a white man who paced the halls. Neither man was injured, but a frustrated Henderson thinks it is time to isolate Anthony. Perhaps he should be taken to jail, Henderson suggests, or at least placed in a building without other patients.
The medical staff decides no.
In 2009, hospital administrators eliminated bed restraints and drastically reduced the practice of secluding unruly patients, all part of a national movement away from restraining mental patients. State regulators track each time a patient is placed in restraints, and hospitals that do it too often can be deemed out of compliance.
For Anthony, that means free movement around the hospital, despite the fights he starts.
At 5:07 p.m., Anthony leaves his room to watch TV.
“Are you going to be good?” Henderson asks, before allowing him into the TV room.
It’s a decision Henderson will come to regret.
He follows Anthony into the common area, then stands near the back. He is close enough to see Anthony sit down in front of the TV, but not within arm’s reach.
Anthony watches the man he’d fought with three hours earlier walk into view and pause in front of the television.
At 5:08, Anthony lunges.
His feeble swing glances off the right ear of the man, a 49-year-old paranoid schizophrenic.
Henderson, 6-foot-1 and 200 pounds, is still standing in the back of the room. In an extreme reaction that state investigators would later label an “excessive use of force,” he rushes at the 127-pound Anthony and shoves him.
The crack of Anthony’s head on the concrete wall is so loud that another patient sitting nearby grabs his own head.
Someone yells, “Oh my God!”
Anthony collapses in a heap on the floor.
The mental hospital’s emergency guidelines state that when a patient’s head is injured, staff must trigger a medical alert or call 911. They must also “know to evaluate for obvious head injuries and keep the victim lying down.”
But Henderson does not check Anthony’s head or call a medical emergency.
Instead he pulls Anthony up by his wrist and leads him, hunched over and woozy, to an empty holding room with a cot, a metal toilet and cracked concrete walls.
What Henderson doesn’t know is that Anthony has fractured his skull and torn an artery near his left temple. Blood is pooling inside his skull.
In the minutes after his injury, Anthony’s chances of surviving are excellent, medical experts say.
“It’s fixable,” says Pinellas-Pasco Chief Medical Examiner Jon R. Thogmartin, who reviewed Anthony’s autopsy for the Times/Herald-Tribune. “This is a treatable condition.”
With every passing minute though, Anthony’s chances dwindle.
This day, there are five nurses, including the supervisor, to cover nine buildings, a total of 173 mental patients. Because it is the weekend, there is no doctor to help.
Nurse Engel is assigned to patients in Anthony’s building, along with the patients in two other similarly sized wards. She arrives at Anthony’s holding room at 5:28 p.m. — 20 minutes after Anthony slammed his head.
What happens next is in dispute. Henderson says Anthony told Engel he hit his head. Engel denies she ever knew.
Engel spends 75 seconds treating Anthony, who is still conscious. She puts a Band-Aid on his cut finger and gives him his regular medications.
Then she leaves.
She never examined him for a head injury.
LATE CALL FOR HELP
For the next two hours, Anthony remains in the unlocked holding cell.
At 7:30 p.m., he is still coherent but in serious pain.
He holds his head in his hands and asks for a Tylenol.
Ward attendant Dwayne King sees Anthony crying and tells a supervisor. Someone calls Engel at 7:31 p.m.
But she is passing out medications in Building 7 and can’t come right away. She’s been busy all day, covering dozens of patients and responding to four emergencies.
At 7:52 p.m., Anthony’s loud wail echoes over the Pirates of the Caribbean movie other patients are watching on TV in Building 8.
At 7:53 p.m., 22 minutes after the call to check on Anthony, Engel returns to him, the video shows.
“Barsotti, where does your head hurt?” she asks.
At 7:56 p.m., she gives him a Tylenol. But by now, Anthony is sweating and his speech is garbled. Engel realizes something is seriously wrong.
She checks his blood sugar and his blood pressure. She wonders aloud if he has a perforated ulcer. She calls another nurse for help.
Around 8 p.m., three hours after Henderson shoved Anthony into the wall, Engel tracks down the hospital’s on-call doctor at home. He tells her to call 911.
Engel calls Janice Roper, the fill-in from another ward who is manning the control room, and asks her to call for outside help.
But Roper does not call. She tells Engel she has to talk to her supervisor first.
At 8:10 p.m., Engel reaches security officer Jeremy Miller and asks him to call 911. He misunderstands her instructions, thinking she plans to make the call and was only informing him.
Engel, unaware that no one has called an ambulance, returns to Anthony to find other employees gathering around him.
A security guard trains a handheld camera on Anthony; the facility requires staff to record events when someone is badly hurt.
He lies there, eyes unfocused, mouth open. His hands are curled like a man with palsy. His breaths have gotten shallower, almost raspy.
Engel presses down on his sternum, trying to push oxygen into his lungs.
“Come on,” she tells him urgently. “Breathe.”
Roper, the control room operator, still hasn’t called 911.
At one point, her supervisor yells through the window: “Make the call.”
Because Roper normally works in another building and does not know the names of the patients in this building, she wants her supervisor to call paramedics.
More than three hours after he hit his head, there is still no ambulance on the way.
Back in Anthony’s holding room, minutes pass as his caretakers look on helplessly.
His breaths come out as loud snores. Tears pool in the corners of his eyes.
“He’s not responding at all,” Engel says. “He just had a shot two days ago and the doctor thinks it may be from that.”
A few minutes later: “I’m wondering if he hit his head.”
More than 15 minutes after the first order to call 911, no one has placed the call. At 8:26, Engel’s nursing supervisor shows up and dials the number himself.
It takes 14 minutes for Alachua County Fire Rescue paramedics to arrive. At 8:43 — almost four hours after Anthony’s skull was broken — they call his name and feel for his pulse. Anthony lies there mutely.
“Did he hit his head? Did he fall?” a paramedic asks.
No one answers.
Anthony’s parents are asleep when the phone rings at 2 a.m. on Aug. 1.
It’s a doctor from the mental hospital. He tells them their son has been hurt and to get to North Florida Regional Medical Center. There, the doctor meets them in the hallway and leads them to a room.
“There’s been an accident,” he begins.
Someone had shaved Anthony’s head to prepare him for surgery and relieve the pressure in his brain. But it was too late. Doctors determined he was brain dead.
They wait a day, so his organs can be harvested for donation, then take him off life support.
“What the hell happened?” Anthony’s father asks.
Five years later, the administrator who ran the mental hospital at the time of Anthony’s death sits on his living room couch in rural Gainesville and answers the question.
Bill Baxter, who retired in 2012 after 35 years with Florida’s mental hospitals, thinks the state has neglected its hospitals for far too long.
Did staffing shortages cause Anthony’s death?
“Absolutely,” he says without hesitation. “That was a function of inadequate staffing.”
Henderson, the guard in charge of watching Anthony, often worked double shifts and that day was no exception.
“He was tired. That contributes,” Baxter says. “Having a person perform a double shift in a high stress job — 16 hours straight — should only be done in an emergency and we were doing it as a matter of routine. You can’t keep doing that.”
Conditions got worse in 2009, just before Anthony arrived, after the hospital changed its policy about restraining patients. Baxter says his staff had been using seclusion and restraints as a crutch because they did not have enough staff to handle patients.
When that ended, the hospital needed more workers to monitor patients, Baxter says.
Instead of adding staff, the Florida Legislature and DCF, which oversees the state’s mental hospitals, continued to cut.
Baxter recalls nights when just two nurses covered the entire facility, nearly 200 patients. The hospital could never keep enough nurses on staff because of low pay and dangerous working conditions, Baxter says.
“We began to see the results of putting staff under such stress,” Baxter says. “There were injuries, more staff injuries, even more employees falling down the stairs.
“You can’t subject individuals to that level of stress and that level of responsibility,” Baxter says, “and not have incidents of this type.”
The budget cutting only got worse after Anthony’s death.
Statewide the hospitals eliminated hundreds of workers. North Florida Evaluation and Treatment Center alone fired 97 people, a quarter of its staff.
The Gainesville mental hospital’s bills for sending patients to nearby emergency rooms increased from $79,733 in the 2009-10 fiscal year to $731,910 in 2012-13. Mental hospitals have to pay those bills from their own budgets.
Several former staff members said that as emergency room costs increased, supervisors discouraged them from calling 911.
“It became an issue,” says Vince Druding, a night nursing supervisor who retired from the North Florida mental hospital in 2013. “They started asking questions: ‘Why was this guy sent out? We’re sending out too many people.’
“There was a lot of intimidation,” he adds. “A lot of suggestions we were spending too much money.”
The medical examiner for Alachua County ruled Anthony’s death a “homicide,” a term that means someone killed him, but not necessarily that a crime was committed. No one was ever charged.
Dr. Lisa Flaherty, a neurologist at Northside Hospital in St. Petersburg, reviewed Anthony’s autopsy report. She said that based on the symptoms described in mental hospital records, Anthony likely could have been saved in the three hours after he hit his head, before his brain was irreparably damaged.
The official investigation by the Department of Children and Families blamed Henderson. “Given the respective sizes of Mr. Barsotti and Mr. Henderson, the intense level of force appears unnecessary and inappropriate,” the report concluded. He used improper technique to subdue a patient, the report said, and he failed to tell the nurse Anthony hit his head.
The state fired Henderson, but only after he reached 30 years on the job and earned full retirement benefits.
Nurse Engel received a written reprimand for medical neglect. She still cares for patients at North Florida Evaluation and Treatment Center.
Anthony’s parents remain angry over his death.
“God, I miss him so much,” says his father, Anthony Jr. “He had us behind him. But what about all the people who have no one?”
Anthony’s parents sued. The state settled almost immediately, paying out the maximum allowable under state law. After attorney’s fees: $140,000.
About this story
The Times/Herald-Tribune obtained security footage of Anthony Barsotti’s time at North Florida Evaluation and Treatment Center from his family. The video shows Anthony Barsotti III getting into several fights, a conversation with an employee at the facility, the moment he held his head in his hand and asked for a Tylenol and his final moments at the mental hospital before paramedics arrived. Information about other patients and other incidents that took place inside the North Florida Evaluation and Treatment Center at the time Anthony was there came from police reports and Anthony’s medical file while at the mental hospital, which Anthony’s family provided. Michael Henderson’s recollection of that day came from an interview with him as well as audio recordings of an interview he had with the Alachua County Sheriff’s Office. Nurse Debra Engel’s role in Anthony’s care, including the fact that she was taking care of three buildings at the time, came from an audio recording she gave the Alachua County Sheriff’s Office, video footage of the ward and an investigative summary of the incident by the Department of Children and Families. The accounts of other employees came from interviews, statements made to investigators or security video.