Abuse, Neglect Cited As Factors In Deaths Of Dozens of Developmentally Disabled In State Care

Kimmy Carrignan, top left, choked on cold tablets at a group home; Douglas Davis, top right, severe medication side effects, unaddressed; Jason Schools, bottom left, drowned in Elizabeth Park pond; Tracey Hilliard, bottom right, drowned during group home outing. (HANDOUT)

Paula Berardi thought she'd found a safe haven for her developmentally disabled daughter, Tracey Hilliard.

Four other group homes hadn't worked out, and Tracey, who also had medical problems, was a handful at home. The state Department of Mental Retardation put Tracey with a licensed provider named Sophie Caro, who cared for several developmentally disabled adults at her home in Meriden.

The placement proved tragic. Tracey Hilliard, 30, drowned in a pond at a campground in Clinton on Aug. 4, 2004. Though Hilliard couldn't swim and her treatment plan said she must have a life preserver, Caro let her go in the water with an inner-tube, a state investigation concluded. There was no lifeguard and Caro couldn't swim either, according to the investigation.

Investigators attributed Hilliard's death to neglect on Caro's part, and her license was pulled.

A Courant investigation has discovered that Hilliard is among dozens of developmentally disabled people who died in public and private group homes, institutions and nursing homes from 2004 through 2010 in cases where investigators cited abuse, neglect or medical error as a factor.

Those conditions were cited during investigations into the deaths of 76 intellectually disabled people receiving state services — or 1 out of every 17 clients who died over those seven years, a Courant investigation has revealed.

Another 28 deaths involved allegations of abuse or neglect that couldn't be substantiated by state investigators. Two deaths are still under investigation.

The Courant's review of state records associated with the more than 100 deaths revealed systemic flaws in the care of the developmentally disabled, ranging from breakdowns in nursing care to gaps in the training of staff to lapses in agency oversight.

Developmentally disabled people were scalded to death in bathtubs; were fatally injured in falls while on medication that affected their balance; choked to death on solid food while on ground-food diets; died of illnesses despite showing symptoms for days or even months; and succumbed while being physically restrained.

For the families of the victims, a sense of betrayal compounds their grief.

"I was devastated — and mad," said Berardi, of Clinton. "Tracey died senselessly. If they followed the rules, my daughter would still be alive today. She was a human being. She deserved the same rights as anyone else."

James McGaughey, executive director of the Office of Protection and Advocacy for Persons With Disabilities, said one theme runs through the reports of abuse and neglect: Many of the deaths could have been prevented.

For example, Rebecca Wojcik, 59, stepped out of the bathtub at her group home in March 2004 with burns over nearly half her body. Two group-home workers failed to test the water before she got in. With her skin peeling off her body, Wojcik was taken to a hospital burn unit, where she died, records show.

In another case, Brian Francis Casey, 53, had been suffering from pneumonia for months, an investigation concluded. With his vital signs deteriorating, the staff of the state home sent him to the emergency room. He was dead two days later, his weight down to 55 pounds.

In 2001, a Courant investigation of deaths of intellectually disabled people in state care identified 36 cases from 1990 to 2000 in which abuse or neglect played a role in the death. The Courant found more than twice as many cases from 2004 to 2011, despite added oversight by the agency now known as the Department of Developmental Services. Now, budget pressures are further straining a system that many believe has reached its breaking point.

Danger Always Lurking

The deaths in 2004-2010 ranged from a 21-year-old killed in a car crash to an 86-year-old who died after staff at a nursing home failed to heed a doctor's order to seek emergency medical care, according to case summaries prepared at The Courant's request by OPA.

The state does not disclose the names, but The Courant, through an examination of public records and interviews with families, was able to identify most of the individuals who died.

Deaths came in large, state-run facilities on expansive campuses and in small group homes on residential streets. Some who died led mostly independent lives; others were severely disabled with the mental capacity of a young child.

In addition to the chokings, fatal falls, scaldings and drownings, the deaths included clients who got sick, exhibited signs and symptoms of illness, and died without receiving proper or timely medical treatment. In several cases, staffing and training issues led to breakdowns in care.