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Omar Paisley
Final Report of the Miami-Dade
County Grand Jury
http://www.miamisao.com/publications/grand_jury/2000s/gj2003s.pdf
IN THE CIRCUIT COURT OF THE ELEVENTH
JUDICIAL CIRCUIT
OF FLORIDA IN AND FOR THE COUNTY OF
MIAMI-DADE
FINAL REPORT
OF THE
MIAMI-DADE COUNTY GRAND JURY
SPRING TERM A.D. 2003
*******
State Attorney
KATHERINE FERNANDEZ RUNDLE
Chief Assistant State Attorney
DON L. HORN
Assistant State Attorney
BRONWYN C. MILLER
CONCEPCION PORTELA SHIRLEY BOYER
FOREPERSON CLERK
FILED
January 27, 2004
Circuit Judge Presiding
JUDITH L. KREEGER
Officers and Members of the Grand Jury
CONCEPCION PORTELA
Foreperson
DANIEL CALIXTE
Vice Foreperson
DONNIE K. JOHNSON
Treasurer
SHIRLEY BOYER
Clerk
JAIRO ABREU JOSE L. MARCOS
LANA M. ANGEL DOROTHY MILLER
JOSE BELETTE DARQUITA ROBINSON
JULIAN BOWEN JUAN F. RODRIGUEZ
HUMBERTO DURAN GLORIA M. SARDUY
LUIS C. GUIA SANDRA M. SEGURA
MILDRED M. KAVALIR ROYCE E. SMITH
LIBBY KLEIN MARTIN SUAREZ
FELIX M. LORENZO
* * * * * * *
Clerk of the Circuit Court
HARVEY RUVIN
* * * * * * *
Administrative Assistant
ROSE ANNE DARE
* * * * * * *
Bailiff
NELIDO GIL, JR.
I N D E X
INVESTIGATION INTO THE
DEATH OF OMAR PAISLEY
AND THE DEPARTMENTOF
JUVENILE JUSTICE MIAMI-DADE REGIONAL
JUVENILE DETENTION CENTER
Pages 1 - 50
I. INTRODUCTION
..
... 1
II. BACKGROUND REGARDING THE DEPARTMENT OF
JUVENILE
JUSTICE AND THE MDRJDC
.
.
..
.
. 2
III. BACKGROUND REGARDING OMAR PAISLEY
..
... 5
IV. ISSUES REGARDING EMERGENCY PROCEDURES
IN THE
MIAMI-DADE REGIONAL JUVENILE DETENTION
CENTER
.
....... 12
V. OVERCROWDING IN THE FACILITY
.
...
..
...
. 15
A. MODULE STAFFING ISSUES IN THE FACILITY
.
.
.... 17
B. CENTRAL CONTROL STAFFING IN THE
FACILITY
..
. 18
VI. LACK OF A FUNCTIONING SURVEILLANCE
SYSTEM IN
THE FACILITY
..
..
..
....
..
19
VII. PROVISION OF MEDICAL CARE IN THE
FACILITY
..
..
...
....
21
A. MEDICAL REQUEST FORM RESPONSE TIME
..
... 21
B. LACK OF FACILITY OPERATING PROCEDURES
GOVERNING HEALTH CARE REQUESTS
.
..
.. 23
C. ISSUES RELATING TO MEDICAL STAFF IN THE
FACILITY
.
23
1. Lack of a Health Services In-House
Delivery System
.
..
23
2. Failure By Medical Staff to Respond to
Requests for
Assistance and Failure by Medical Staff to
Coordinate
Emergency Efforts
.
.
..
.. 25
3. Failure by Nursing Staff to Contact a
Physician and Failure
by Medical Staff to Follow Standing Orders
.
.
26
4. Failure by Medical Staff to Document
Medical Records in a
Comprehensive & Timely Manner
.
..
.. 27
5. Assigning an Officer Permanently to the
Medical Station /
Requiring That All Patients be Examined in
the Medical
Station of the Facility
...
.. 30
6. Lack of Availability of 24-Hour On-Site
Medical Care
in the Facility
...... 30
VIII. RELATIONSHIP BETWEEN THE DEPARTMENT
OF
JUVENILE JUSTICE AND THE OFFICE OF THE
INSPECTOR GENERAL
..
.
. 31
IX. ISSUES RELATING TO STAFFING AND SUPERVISION
..
..... 32
A. Failure to Conduct Preliminary National
Background Screenings
On Privately Contracted Providers
.
.
.
32
B. Issues Regarding Department of Juvenile
Justice Employees
With Criminal Backgrounds and Pending
Criminal Cases
.. 34
C. Non-Compliance With Quality Assurance
Standards in the
Facility
.
.
..
..
36
D. Issues Regarding Lack of Communication
Between Administration
And Staff in the Facility
...
...
. 39
E. Staff Failure to Comply With OSHA
Requirements and Facility
Operating Procedures Regarding Disposal of
Biohazardous Waste
In the Facility
..
.. 41
F. Staff Failure to Comply with Facility
Operating Procedures
Governing Infectious Disease
.
..... 42
X. CONCLUSION
..
...
43
XI. SUMMARY OF RECOMMENDATIONS
..... 44
INDICTMENTS
.
.
..... 48
- 49
ACKNOWLEDGEMENTS
.
..
.. 50
1
INVESTIGATION INTO THE DEATH OF OMAR
PAISLEY AND THE
DEPARTMENT OF JUVENILE JUSTICE MIAMI-DADE
REGIONAL JUVENILE
DETENTION CENTER
I. INTRODUCTION
Seventeen-year old Omar Paisley spent the
last three days of his life, which ended
June 9, 2003, in agony, lying on a
concrete bed in Room 13 of Module Three in the
Department of Juvenile Justice Miami-Dade
Regional Juvenile Detention Center
(hereinafter MDRJDC). Despite his
repeated requests for help, Omar was denied that
which many of us take for granted,
appropriate and timely medical care.
As grand jurors, we came from different
backgrounds, perspectives, and beliefs.
However, in the course of our service, we
discovered that we were united in our outrage
over the death of Omar Paisley. All of us
shared common values in our belief that
juvenile detainees are entitled to live in
safe, habitable, clean and secure surroundings.
As parents, we knew that we were required
to provide our children with medical attention
or face the consequences. We felt strongly
that when a facility assumes care for the
children of our community, the facility
should be held to this same standard.
We were sensitive to the implementation of
severe budgetary cuts in our State
following September 11, 2001. However,
each of us arrived independently at the same
conclusion: one can never measure the cost
of human life in taxpayer money.
Over the past nine months, we listened
closely and critically to testimony from
various people involved in the
investigation into the death of Omar Paisley, we labored
over a multitude of statewide reports, we
studied statistics and budgets, we toured both
the MDRJDC and the Broward Regional
Juvenile Detention Center and we asked
questions at every step along the way. We
were, above all, determined to make
recommendations, which, if implemented,
would prevent another unnecessary death in
the MDRJDC.
We were appalled at the utter lack of
humanity demonstrated by many of the
detention workers charged with the safety
and care of our youth. Our mission,
constrained by our legally set time limit,
included ascertaining the underlying causes that
2
led to this tragically preventable death
in order to demand reforms, and if appropriate,
concurrently identifying criminal acts
that may have been committed, either by
individuals or the facility administration
or both. At every turn in our investigation, we
were confronted with incompetence,
ambivalence and negligence on the part of the
administration and the staff of the MDRJDC
as well as the nurses employed by Miami
Childrens Hospital. We discovered in the
course of our investigation that numerous
individuals played roles in the death of
Omar Paisley. However, in determining which
individuals should be charged with crimes,
we are compelled to isolate only the most
egregious conduct. In our estimation, the
conduct of two of the nurses was so outrageous
as to rise to the level of criminal
negligence and we have felt compelled to issue
indictments for these acts.
In the process, we became frustrated by
the numerous legal and factual obstacles
we were confronted with, especially with
regard to pursuing criminal charges against the
State, its facility and its direct
employees.
The issues we confronted in this case were
unique. We do not intend that our
decision to issue indictments in this
instance will open the floodgates to consideration of
criminal charges in other cases that are
purely civil in nature, i.e. medical malpractice.
We are hopeful that the present state of
the law regarding public entities, including
administrative rules concerning government
employees, does not diminish in any way the
significance of our findings. Our findings
clearly expose a lack of supervision, a lack of
resources, and above all, a lack of
benevolence in the MDRJDC.
Following are the conclusions we have thus
far reached and the recommendations
we most respectfully request be
implemented. 1
II. BACKGROUND REGARDING THE DEPARTMENT OF
JUVENILE
JUSTICE AND THE MDRJDC
In 1994, the Juvenile Justice Reform Act
created a new state agency designed to
oversee juvenile justice issues, the
Department of Juvenile Justice.2
The Secretary of the
1
We recognize that, as in all cases, the facts and the evidence
essential to the truth of a case surface as the
case unfolds in the
system over time. The law does not permit us to sit as a grand jury
beyond nine months.
We know this case will
remain visible in the system for years to come. Those reforms that
can occur today,
must; however, those
needs that become self-evident over time must also be addressed in
the future.
3
Department of Juvenile Justice was charged
with planning for and managing all programs
and services in the juvenile justice
system, including detention care.3
In addition to
creating the Department of Juvenile
Justice, the Florida Legislature established the
Florida Department of Juvenile Justice
Quality Assurance System.4
The purpose of the
Quality Assurance System was to establish
minimum thresholds for each component of
programs operated by the Department of
Juvenile Justice.5
In the State of Florida, there are a total
of 25 juvenile detention centers with a
total of 2,042 beds.6 These centers serve three
primary purposes: to detain and monitor
juveniles prior to adjudicatory hearings;
to maintain custody of all adjudicated juveniles
awaiting placement in a commitment
program; and to impose sanctions for mandatory
sentences implemented pursuant to state
law.7
The MDRJDC is, by far, the largest in the
State. The funded operating capacity of
the center is 226 beds on any given day.8
Between January 1, 2001 and December 31,
2002, 6,808 juveniles were booked into this
facility, often exceeding the funded
operating capacity.9
The facility is spread out over a large
area of land and is comprised of fourteen
modules intended to house the detainee
population, a public school facility, a cafeteria, a
medical center, a gymnasium and
administrative areas. As with every juvenile detention
facility in the State of Florida, the
MDRJDC has a statutory duty to provide each juvenile
detainee with food, clothing, shelter,
education, and medical care. Historically, the
Miami-Dade County Public Schools have
provided education for the detainees and the
facility has chosen to outsource medical
care.10
In 2001, the MDRJDC entered into a
contract with Jackson Memorial Hospital for
the provision of medical services for all
detainees. This contract was not renewed in
2002. Instead, on July 1, 2002, the
facility opted to enter into a contract with Miami
2
Florida Corrections
Commission, 2001 Annual Report at 5.
3
Id.
4
Florida Department of Juvenile Justice, Introduction to Quality
Assurance revised
March 24, 2003, 2.
5
Id.
6
www.djj.state.fl.us/detention/index.html
at 1.
7
Department of Juvenile Justice, 2003 Outcome Evaluation Report at
29.
8
Department of Juvenile Justice, Response to Subpoena Duces Tecum
dated October 27,
2003.
9
Id.
10
Outsourcing refers to a process by which a State agency enters into
a contract with a private entity to
provide services required
by statute.
4
Childrens Hospital (hereinafter MCH).
The Medical Services contract provided that
the services of five MCH employees (two
licensed practical nurses, one registered nurse,
one physician and one file clerk) would be
used to fulfill the medical needs of the
detainees at the MDRJDC. The contract
specified both hours and shifts: the registered
nurse was to work forty hours per week
(from 8:00 a.m. until 5:00 p.m. Monday through
Friday); each licensed practical nurse was
to work forty hours per week (with one
working from 1:30 p.m. until 10:00 p.m.
Sunday, Wednesday, Thursday, Friday and
Saturday and the other working from 9:30
a.m. until 6:00 p.m. on Sunday, from 1:30 p.m.
until 10:00 p.m., Monday and Tuesday and
from 7:00 a.m. until 3:30 p.m. Friday and
Saturday); the physician was to work nine
hours per week; the file clerk was to work
forty hours per week (from 8:30 a.m. to
5:00 p.m., Monday through Friday).
During the same month that MCH entered
into the contract to provide medical
services with the MDRJDC, the State of
Florida Bureau of Quality Assurance conducted
its 2002 annual inspection.11 Findings issued in the
2002 Bureau of Quality Assurance
Report indicated that the MDRJDC was
non-compliant with statewide facility standards
and rated its overall program performance
as minimal.12
Specifically, the report found
that the facility was non-compliant with
required substance abuse assessment and
evaluation for detainees, screening for
health-related conditions, appropriate inventories
of controlled substances, implementation
of a required system for control of infectious,
communicable diseases, and implementation
of a required system for the provision of
sick call care.13
As reported, surveyed detainees indicated
that they did not see the doctor or
dentist in a timely manner.14 The inspection also
revealed a persistent failure to obtain
consent from parents prior to
administering mind-altering medications to the detainees
and failure to educate staff as to the
side effects of those medications. Detainees
complained of not being provided with
clean towels, clean underwear or clean clothing as
required pursuant to departmental policy.
11
The report itself was issued in September, 2002.
12
The contract between
MCH and the Department of
Juvenile Justice began on July 1, 2002.
13
See Department of Juvenile Justice, Bureau of Quality Assurance
Report (2002).
14
Id. at 7.15 (page 21). It
should be noted that a timely manner was not defined in the body
of the report.
5
III. BACKGROUND REGARDING OMAR PAISLEY
Over eight months after the release of the
abysmal 2002 Bureau of Quality
Assurance Report, seventeen-year old Omar
Paisley was arrested by the Miami-Dade
Police Department on charges of aggravated
battery. Omar was evaluated pursuant to a
Department of Juvenile Justice Detention
Risk Assessment form to determine whether or
not he should be detained in the MDRJDC
pending the resolution of his case. A
Department of Juvenile Justice Risk
Assessment Tool recommended commitment in
secure detention and the presiding judge
ordered Omar Paisley detained in the
Department of Juvenile Justice MDRJDC.
On March 26, 2003, the State subsequently
filed an announcement of its intent to
review the case for direct file pursuant
to section 985.21(4)(d)5, Florida Statutes (2003).
Following this filing, Omars defense
counsel contacted the State in an effort to convince
the State to retain the case in the
juvenile system. Omar Paisley wrote a letter to the State
Attorneys Office stating: I am sorry for
what I have done. I made a stupid mistake. I
was wrong. I should not have had a fight
with that man. On June 6, 2003, Omar Paisley
entered into a written plea agreement
wherein he admitted to committing the offense of
aggravated battery and agreed to enter
into Bay Point Schools, a moderate risk
residential program, where he would also
receive individual counseling. Omar was to
remain in secure detention at the MDRJDC
pending his placement in the residential
program.15
Day One: Saturday
On Saturday morning, June 7, 2003, less
than twenty-four hours after he entered
into his plea, Omar Paisley began to
complain of illness to both staff members and his
fellow detainees. Omar filled out a Youth
Request for Sick Call form. These forms
were in use in the facility for detainees
to communicate medical complaints to the
Department of Juvenile Justice staff
members.16
Once the form is submitted to a
Department of Juvenile Justice Staff
member, notification of the Request is sent to the
Medical Station. Omar wrote on his form:
My stomach hurts really bad. I dont know
15
The Plea Agreement was filed on
June 6, 2003. The plea
agreement specified that a psychiatric
examination was a
prerequisite for program placement.
6
what to do. I cand (sic) sleep. He signed
the bottom of the form and gave it to a
Juvenile Detention Officer (hereinafter
JDO). Logbook entries reveal that the Medical
Station was notified at 12:10 p.m.17
Omar refused to eat lunch on
Saturday.
At approximately 2:15 p.m., according to
an entry in the Module Three logbook, a
Licensed Practical Nurse (hereinafter
LPN) by the name of Gaile Loperfido saw
Omar.18
This is the first contemporaneously
documented visit of LPN Loperfido.19
LPN
Loperfido filed an addendum to Omar
Paisleys medical records the day after he died.
Her addendum indicates that she first saw
Omar at 9:00 a.m. on Saturday morning.
However, we found no evidence to
corroborate the 9 oclock morning visit.20 LPN
Loperfidos addendum also indicates that
she conducted a physical examination of Omar
on Saturday. Detention staff members
contend that they never saw LPN Loperfido
conduct a physical examination of Omar
that day.21
In fact, these staff members did not
observe LPN Loperfido carrying any
equipment with which to conduct a physical
examination, i.e. a blood pressure cuff or
a thermometer.22
After seeing Omar at approximately 2:15
p.m., LPN Loperfido filled out a
twenty-four hour medical alert form,
specifying that Omars medical alert would end on
Sunday, June 8, 2003. She placed Omar on a
twenty-four hour liquid diet and ordered
him on bed rest.23 LPN Loperfidos addendum
further indicates that she saw Omar at
7:00 p.m. on Saturday. However, this visit
is not corroborated by logbook entries, nor is
it consistent with the testimony of the
Department of Juvenile Justice staff.24
16Miami Childrens Hospital, Sick Call and Injury Response
Procedures.
17
A logbook is maintained in each of the modules at the facility and
is used to record all entries into the
module and any action
taken as to any detainee. According to a June 7, 2003 entry in the
Module Three
logbook: Detainee
Paisley, Omar complaining about being sick. He refused to eat lunch.
Nurses station
notified. (12:10 p.m.)
18
It should be noted that LPN Loperfido has twenty-five years
experience as a medical professional.
19
Her addendum further sets forth that she first saw Omar at
9:00 a.m. on Saturday
morning and documents
a series of visits over
Saturday and Sunday, totaling 5 visits. The logbooks do not reveal
prior documented
visits.
20
See Sworn Statements of JDO Keith North and JDO Nesby Rodriguez.
21
Id.
22
Id.
23
The twenty-four hour liquid diet was in direct contravention with
the Miami Childrens Hospital Sick
Call and Emergency
Response Procedures. These procedures reflect the following for
Abdominal
Discomfort: (i) give
nothing by mouth; (ii) consult with on-call medical provider; (iii)
refer to E.R. if
acute abdomen is
suspected.
24
See Sworn Statements of JDO Johnny Byrd and JDO Kavin Walton.
7
At 3:45 p.m. on the same day, Dr. Lloyd
Miller arrived to perform Omars
psychiatric examination pursuant to the
plea agreement. Dr. Miller noted that Omar was
an average sized young man who was under
the sheets of his bed suffering from
gastroenteritis. He discovered that Omar
was on bed rest which is why Dr. Miller made a
house call to the bedside of this young
man who appeared not to be in one hundred
percent perfect health.25 He further observed that Omar
was sick with a stomach virus
and his physical condition may have
affected his mental outlook during the interview.26
The MCH physician did not work on
Saturday, June 7, 2003, and he was not contacted by
LPN Loperfido regarding Omars condition
on that day.
On Friday, the day before these events
transpired in Module Three, another
detainee was complaining of similar
symptoms in Module Seven. He submitted a Youth
Request for Sick Call Form and the Medical
Station was notified. According to the
medical records of that detainee and the
June 6, 2003 logbook entries, that detainee was
seen by LPN Dianne Demeritte. After
meeting with that detainee, LPN Demeritte
referred the detainee to the physician.
The detainee was indeed physically examined by
the physician and later transferred to the
emergency room.27
Day Two: Sunday
On Sunday, June 8, 2003, witnesses
reported that Omar continued to complain of
abdominal pain, and continued to have
vomiting and diarrhea.28
LPN Loperfido saw
Omar at approximately 9:00 a.m. on Sunday.29
LPN Loperfido continued to order a
liquid diet and bed rest, as she had the
preceding day. As LPNs are traditionally charged
with patient assessment, a major issue in
this case is whether or not LPN Loperfido
conducted a physical examination of Omar
during the Sunday morning visit.30
Detention
25
Dr. Miller received information from the detention staff on duty
and Omar regarding Omars condition.
26
Id.
27
See Medical Records of D.H. (it should be noted that juvenile
detainees are referred to by initials only).
28
See Sworn Statement of JDO Michael Johnson at page 25 (Omar told
LPN Loperfido his stomach was
so sore).
29
The Logbook reflects a
9:05 a.m. visit by LPN
Loperfido. Nurse on mod to see Paisley, Omar. Youth
has a virus and
complaining of serious abdominal pain. Staff advised to give plenty
of liquid and not to
allow youth to leave
room. Again, LPN Loperfidos addendum to Omars medical records
indicates that
she first saw Omar at
9:00 a.m.
on Saturday morning and documents a series of five visits over
Saturday
and Sunday. We do not
have any evidence to corroborate these five visits.
30
It should be noted that a medical diagnosis (as opposed to a
nursing diagnosis) is typically done by a
physician.
8
staff contend that they did not observe
her perform a physical examination.31
Per her
addendum, LPN Loperfido states that she
again saw Omar on Sunday night at
approximately 8:00 p.m. However, detention
staff members contend that she went to
Module Three to see another detainee,
A.W., but did not see Omar.32
The MCH
physician was not working on Sunday, June
8, 2003, and LPN Loperfido did not contact
him regarding Omars condition on that
day.
Day Three: Monday
According to sworn statements of JDOs and
an entry in the Module Three
Logbook, on Monday, June 9, 2003, Omar
woke up at 5:30 a.m. urgently requesting
medical care. The on-duty JDO observed:
Paisley is not looking real well.33
Per JDOs
Burney and Morgan, this message was
conveyed to the Department of Juvenile Justice
LPN at breakfast. However, there was no
apparent follow-up.34
By most accounts, Omar spent Monday in
excruciating pain.35
He was unable to
get out of the bed and continued vomiting
and excreting on himself.36
Payroll records
indicate that at least four of the five
contracted MCH medical personnel were working in
some capacity at the facility on that day.
However, by all accounts, it appears that only
LPN Dianne Demeritte saw Omar on Monday.37
At approximately 1:32 p.m., Indigo38
JDO Alfreda Mitchell picked up
detainee
K.R. on Module Three. Upon arrival on
Module Three, Officer Mitchell was informed of
Omars chronic illness by a JDO. Officer
Mitchell returned to the Medical Station with
K.R. and believes she informed LPN
Demeritte at that time of Omars worsening
condition.39
31
See Sworn Statements of JDO Shana Jerry and JDO Michael Johnson.
32
See Sworn Statements of JDO Johnny Byrd and JDO Kavin Walton.
33
Entry in Module Three Logbook at
9:05 a.m.
34
The Department of Juvenile Justice LPN was in a training during the
day on June 9,
2003.
35
See Sworn Statement of JDO Johnny Byrd at 21; Sworn Statement of
JDO Michael Johnson at 30.
36
See Sworn Statement of A.W. at 22; See Sworn Statement of Terry
Mixon.
37
Detainee S.S. stated that LPN Demeritte saw Omar once before dinner
and once after dinner. LPN
Demeritte indicated to
the Department of Juvenile Justice LPN that she had seen Omar twice
on the date of
his death. See Sworn
Statement of LPN Jeffrey Coachman to Office of the Inspector General
at 20.
38
An Indigo JDO is an officer who is assigned to escort medical
personnel throughout the facility.
39
See Sworn Statement of Alfreda Mitchell to the Office of the
Inspector General at 7.
9
Detention Officer Terry Mixon was alone on
Module Three with over twenty
detainees for much of the afternoon and
early evening hours of June 9, 2003.40
At dinner,
between 5:30 p.m. and 5:50 p.m., Officer
Mixon saw LPN Demeritte in person and asked
her to check on Omar.41 Officer Mixon appeared worried
and told LPN Demeritte that
Omar was real sick, already on a liquid
diet and could not keep anything in his
stomach.42
He told LPN Demeritte that someone
needed to look at Omar.43
Sworn
statements reveal that during the early
evening hours, Officer Mixon contacted Indigo
Officer Talmecia Minnis two times over the
radio in an effort to summon LPN
Demeritte.44
Officer Minnis conveyed these
requests to LPN Demeritte.45
Immediately after dinner, and upon Mixons
return to Module Three, numerous
officers heard Officer Mixon frantically
requesting assistance over the radio from a nurse
or a supervisor.46 These calls continued for an
hour and a half, but there was no
immediate response.47 Although Officer Mixon could
see Omars worsening condition,
he could not leave the module to get
assistance nor could he call 911 to summon help for
Omar. As to the former, he was the only
JDO in the module and he could not leave more
than twenty detainees unattended. As to
the latter, the design of the telephone system
within the facility prevents anyone from
being able to make 911 emergency phone calls
from inside the modules. Further, to do so
without first contacting a supervisor or
making the request through Central Control48
with approval of a supervisor could
constitute a violation of procedure and
could subject Officer Mixon to disciplinary action.
Officer Mixon made radio contact with LPN
Demeritte via Indigo JDO Minnis
sometime prior to 7:00 p.m.49
According to Officer Mixon, LPN
Demeritte asked what
40
Entry in Module Three Logbook at 181.
41
Id. at 8.
42
Id. at 6.
43
Id.
44
Sworn Statement of Talmecia Minnis to Office of the Inspector
General at 8.
45
Id. at 9.
46
See Sworn Statement of JDO Johnny Byrd at 21.
47
Id.
48
Central Control is located directly inside the front entrance of
the facility. All incoming and outgoing
telephone calls,
visitors, employees, mail, and deliveries are directed through
Central Control.
49
See Sworn Statement of JDO Terry Mixon at 9. See Sworn Statement of
Indigo JDO Talmecia Minnis to
Office of the Inspector
General at 8.
10
was wrong with Omar and indicated she was
busy with other things.50
Officer Minnis
recalled that LPN Demeritte indicated
several times via radio she would respond to
Module Three, but did not respond.51
A witness indicates that LPN
Demeritte was not in
a particular hurry that night; rather, she
had time to carry on conversations with staff and
sit down on the various modules for a
period of time.52
LPN Demeritte indicated during
the course of one conversation with
Officer Mixon that she did not wish to examine
Omar due to the fact that she had a sick
child at home.53
Sometime after 8:00 p.m., LPN Demeritte
finally made her way to Module Three
to look at Omar. Per Officer Mixon and the
detainees housed in Module Three, despite
the fact that Omar could barely move, LPN
Demeritte ordered Omar out of his cell.54
Omar dragged himself out of his cell,
clinging to a chair outside the door for support.55
LPN Demeritte stated that she had a child
at home and did not wish to contaminate her
child with Omars virus.56
Cellular telephone records reflect that at
8:08 p.m., LPN Demeritte contacted her
supervisor, Registered Nurse (hereinafter
RN) Stacy Linfors.57
According to detainees,
LPN Demeritte was laughing on the
telephone during the less than two-minute
conversation. At 8:30 p.m., LPN Demeritte
completed the paperwork authorizing Omar
to be transferred to Jackson Memorial
Hospital for emergency treatment. On the transfer
paperwork, LPN Demeritte indicated that
Omar had a 98.5 temperature and a normal
pulse. LPN Demeritte handed the transfer
paperwork to Central Control, told the Central
Control JDO that Omar had a normal
temperature but was delusional, and then left the
facility without coordinating rescue
efforts.58
50
Id.
51
Id.
52
Id. at 33.
53
See Supplemental Sworn Statement of JDO Terry Mixon.
54
Id.
55
Id.
56
Id.
57
The duration of the telephone call was 118 seconds. Based on the
information we received, this was the
first contact anyone made
with the RN regarding Omar. There is no evidence that has been
presented to us
that indicates that the
MCH physician was ever notified of Omars condition before Omars
death.
58
This failure to coordinate emergency efforts is discussed at length
later in this report.
11
As she was leaving the facility, LPN
Demeritte was contacted by JDO Aileru
regarding an ill detainee, I.E., on Module
Eight. LPN Demeritte was told that I.E. was
vomiting, had diarrhea, and needed to be
seen by medical personnel. LPN Demeritte
stated that the detainee should fill out a
Medical Request for Sick Call form and
proceeded to leave the facility.59
Her decision to leave was in direct
contravention of the
Miami Childrens Hospital/Department of
Juvenile Justice Contract for Medical
Services.60
After LPN Demeritte prepared the paperwork
authorizing Omars transfer for
emergency treatment, detention staff
initially made efforts to transport Omar to Jackson
Memorial Hospital with the MDRJDC van and
equipment. However, Facility Operating
Procedures required Omar to be placed in
leg and arm restraints (even though in this
instance the detainee could barely walk).
Because Omar was unmoving and catatonic by
the time rescue efforts were initiated,
lengthy discussion was had regarding the best
means for transport. Omar continued to sit
in the chair outside of his cell on Module
Three. As he remained in the chair, brown
fluid flowed from his nose and mouth.
Eddie Williams, a volunteer for the
Christian Counseling Program, visited the
facility that evening to counsel several
of the juvenile detainees. Mr. Williams proceeded
to Module Three at approximately 9:00 p.m.
He described what he saw when he arrived
as: fear, panic, grief, [and] anger.61
Mr. Williams observed Omar slumped
over in the
chair outside of Room 13. He immediately
checked and noted that Omar had no pulse.
Despite the fact that each detention
worker was trained in First Aid and Cardiopulmonary
Resuscitation, not one of them engaged in
efforts to save Omars life. LPN Demeritte
was nowhere to be found at this time.
59
See Sworn Statement of JDO Ayodele Aileru at 5.
60
The Miami Childrens Hospital/Department of Juvenile Justice
contract specifies that licensed practical
nurses shall provide the
following services: coordinate any emergency medical or dental care
approved by
the facility
superintendent or designee. It further specifies: nursing services
shall provide consultation
and response to medical
crises, by either on-site presence or coordination of care
throughout local
emergency care
facilities. (emphasis added).
61
Sworn Statement of Reverend Eddie Williams at 4.
12
At 9:01 p.m., approximately forty-five
minutes after LPN Demerittes
conversation with RN Linfors, a call was
finally placed to 911.62
At 9:12 p.m., almost an
hour after LPN Demeritte ordered emergency
transport and left the facility, paramedics
arrived on Module Three and found Omar
unresponsive. Omar was transported to
Jackson Memorial Hospital, where he was
declared dead on arrival at 9:43 p.m.
Sometime that evening, JDO Terry Mixon was
instructed by his supervisor to
make delayed entries in the Module Three
logbook detailing LPN Demerittes interaction
with Omar Paisley. He made an entry in the
logbook documenting LPN Demerittes
appearance on Module Three.
The MCH physician was contacted for the
first time regarding Omar Paisley
between 10:30 p.m. and 11:00 p.m. on
Monday, June 9, 2003.
On Tuesday, June 10, 2003, LPN Loperfido
submitted a detailed Addendum to
Medical Records, documenting her
treatment of Omar Paisley on Sunday, June 8, 2003.
That same day, LPN Demeritte told the
Department of Juvenile Justice LPN that she did
not want to go in Omars room the
preceding day because she didnt want to catch his
virus and take it home.63 She further indicated that she
had seen Omar twice the
preceding day.64 She indicated that during her
second visit to Module Three, Omar had
been delusional.65
IV. ISSUES REGARDING EMERGENCY PROCEDURES
IN THE MIAMIDADE
REGIONAL JUVENILE DETENTION CENTER
When we first immersed ourselves into the
facts surrounding the death of Omar
Paisley, each of us listened to the
recording of the call placed by Department of Juvenile
Justice staff to 911 on the evening of
June 9, 2003, with feelings of anger, sorrow, and
confusion. Over forty-five minutes elapsed
between the time LPN Demeritte issued
orders for Omar to be transported to the
hospital and the time a call was placed to 911.
62
We were unable to determine why such a long period of time passed
before a call was made to 911. It
should be noted that
Central Control initially contacted 911 at 9:01 p.m., but the call
was disconnected
prior to any
conversation. Several seconds later, a second call was placed. In
the communications with the
911 operator, the caller
indicated that: the nurse has left the compound.
63
See Sworn Statement of LPN Jeffrey Coachman to Office of the
Inspector General at 17.
64
Id.
65
Id.
13
We listened as a caller told a 911
operator that Omar had a normal pulse and normal
breathing pattern at 9:06 p.m., consistent
with the paperwork filled out by LPN
Demeritte. We knew, based on testimony,
that by this time, Omar had no pulse, was not
breathing, and had brown fluid seeping
from his nose and mouth.
Armed with this information, we carefully
watched the first round of Legislative
Hearings pertaining to the death of Omar
Paisley. In the course of these hearings, we
scrutinized the testimony of Larry Lumpee,
Assistant Secretary of the Department of
Juvenile Justice. Mr. Lumpee stated that
each detention officer was capable of dialing
911 directly from any given facility in
the event of an emergency. The Facility Operating
Procedures in place in the MDRJDC indicate
to the contrary.66
We were further dismayed when we toured
the MDRJDC and visited the
modules. We discovered that when we
attempted to dial 911 ourselves, the telephones
located in each module did not permit
direct access to 911. Instead, workers are required
to contact a shift supervisor and then 911
calls are approved and routed through Central
Control. We further learned that secure
detention workers are not permitted to utilize
personal cellular telephones in the
facility.
Finally, we heard compelling testimony
regarding the fear of detention workers to
defy their chain of command and to reach
out to outside agencies. We learned of specific
instructions communicated by the
Superintendent of the Facility to staff members
prohibiting them from contacting external
agencies without specific prior Superintendent
approval.67
Thus, we concluded that the
legislative testimony of Mr. Lumpee failed to
accurately portray the reality of the
situation at the MDRJDC.
For comparison purposes, we decided to
visit the Broward Regional Juvenile
Detention Center (hereinafter BRJDC).
When we toured the BRJDC, we noted that a
different system for contacting 911 was in
use. Specifically, each room populated by
detainees, staff, or both, had an intercom
on the wall that could be pressed to instantly
connect with Central Control. Engaging the
intercom in this manner instantly allowed
66
We were aware that Miami-Dade Regional Juvenile Detention Center
Facility Operating Procedure 7.13
requires that 911 be .
. .called by the shift supervisor as needed.
14
Central Control to view the room via a
surveillance camera and to assess the situation. It
also permitted verbal contact via the
intercom.
We were disturbed at the looming potential
for both staff and detainee
emergencies in MDRJDC. We firmly believe
that emergency situations require
emergency measures. We observed first-hand
the efficiency of the system implemented
in the BRJDC. We tested it and determined
it was the best means of insuring direct,
immediate contact with Central Control,
and thus with 911. We further believe that each
staff member should have direct
access to 911 from all areas of the facility populated by
detainees or staff.
We recommend that the MDRJDC immediately
install an intercom system
comparable to the system currently in
place in the BRJDC. As an immediate
alternative during the installation
process of the intercom system, we recommend that
the current Facility Operating Procedures
be modified immediately to provide for any
employee noting an emergency situation to
have unimpeded direct access to 911. This
would require Facility Operating
Procedures to reflect that any employee who
perceives an emergency situation, must, as
a matter of responsibility, call 911. This
responsibility should, in our opinion,
exist separate and apart from the mandates
assigned to any medical personnel.
Further, as a practical measure, we believe that a
telephone system must be implemented in
the facility in which each area populated by
detainees is equipped with direct access
to 911. Finally, we recommend that current
Facility Operating Procedures be
re-written to require detention workers to first
contact 911 in an emergency situation, and
only then to contact Central Control.
We recommend that procedures be
implemented requiring that on those
occasions when medical personnel order
emergency transport, either Central Control
or detention workers are required to
contact 911 within one minute. This should not
be problematic, given either the
implementation of direct access to 911 from each
module or the installation of an intercom
allowing for direct contact with Central
Control. Together, we believe that when a
human being is suffering and a life hangs
67
We learned of an altercation that occurred between two detention
workers. An external law enforcement
agency was contacted by
staff following the altercation. The Superintendent of the facility
became angry
and notified the staff
members that all incidents should be handled within the facility.
15
in the balance, the decision to call 911
should be immediate and without
contemplation.
V. OVERCROWDING IN THE FACILITY
We were amazed to learn that many
Department of Juvenile Justice secure
detention facilities in the State of
Florida are populated beyond the recommended
capacity. Statewide, ten of twenty-five
detention centers operated above one hundred
percent capacity during 2001-2002.68
In Miami-Dade County, the Regional
Juvenile
Detention Center had an average
utilization rate of one hundred and thirty-five percent in
2001-2002.69
Thus, despite the fact that the
operating capacity of the facility was 226
detainees, the average daily population
was 304 detainees.70
The obvious result of this overpopulation
is overcrowding and shared quarters.
The less obvious result is the staffing
shortages we observed firsthand. Overcrowding
renders detention difficult to manage and
not as safe for residents and staff as a facility
operating at recommended capacity.71
Residents spend more time in
lockdown. When
staff members must focus primarily on
safety and security, effective intervention and
treatment are compromised.72 Staffing shortages may
result in suicidal detainees being
left unattended for significant time
periods and may increase escape attempts. In the
MDRJDC, specifically, the overcrowding has
resulted in such problems as the failure to
provide one operable shower for every nine
youths, as required pursuant to Quality
Assurance Standards.73
While we heard testimony, provided during
the Legislative Public Hearings that
overcrowding could be attributed to
increased stays in secure detention, we were aware of
68
Detention Services, 2003 Outcome Evaluation Report at 31.
69
Id. We did note that in Department of Juvenile Justice, Response to
Subpoena Duces Tecum dated
October 23, 2003, the average population was stated to be 251 during 2002-2003.
70
Id.
71
JAIBG Bulletin at 3. In the course of our investigation, we learned
of an incident that occurred on
February 11, 2003 in which a Guardian Ad Litem attorney visited a detainee at the
MDRJDC. When the
attorney arrived at the
facility, the JDO on the detainees module did not have a key to
open the detainees
cell. It took approximately ten minutes for the JDO to retrieve
the key that matched that cell from
elsewhere in the
facility. The attorney, rightfully, was deeply concerned regarding
the ability of the staff to
release the inmate in an
expeditious manner in a fire or emergency situation.
72
Id.
73
Department of Juvenile Justice, Bureau of Quality Assurance Report
(2002), 3.03 (page 9).
16
the fact that statewide, the average stay
in secure detention in 2001-2002 was 13.04 days.
This number reflected a decrease
from the average length of stay in 2000-2001 of 13.27
days. In Miami-Dade County, the decrease
was greater. The average length of stay in
secure detention from 2001-2002 was 15.04
days, while from 2002-2003, it was 14.91
days.74
Despite the persistent issue of
overcrowding in the facility, the MDRJDC does not
have a contingency plan for
overcrowding/group arrest. In facilities in which such a plan
exists, operating procedures define
critical population levels and set forth counteractive
measures. Further, allowances may be made
for detainees to be transported to a nearby
facility in situations of severe
overcrowding.75
In the BRJDC, a Contingency Plan
for
Overcrowding/Group Arrest is carefully
delineated within the Facility Operating
Procedures.76
Specifically, the plan sets forth
that whenever the population in the facility
exceeds the available bed space, the
superintendent or designee will perform, at a
minimum, the following actions: (1) notify
the Southern Regional Office, Human
Service program administrator, juvenile
court judges, court unit, Office of the Public
Defender, and Office of the State
Attorney; (2) if the population issue persists, notify the
Regional Director, Assistant Secretary of
Programs, and the Deputy Secretary of
Operations; (3) call in staff to work
overtime at a ratio of one staff per ten detainees
exceeding the recommended number of
detainees; (4) review the capacity of home
detention; and (5) request expedited
placement from commitment managers.77
While we are aware of the waiting periods
associated with entry into many
residential programs, we are confident
that increased efficiency regarding the
performance by medical staff of physicals,
mental health assessments, and the
coordination of transportation efforts
will decrease the length of time that detainees spend
awaiting entry into these programs.
74
2003 Outcome Evaluation Report at 32; Department of Juvenile
Justice, Response to Subpoena Duces
Tecum dated October 23,
2003.
75
Department of Juvenile Justice, Response to Subpoena Duces Tecum
dated October 27,
2003.
76
Broward Regional Juvenile Detention Center Facility Operating
Procedures, Contingency Plan for
Overcrowding/Group Arrest
No. 49 (Revised
1/15/02).
77
Id.
17
We recommend that the MDRJDC immediately
implement a contingency plan
for overcrowding/group arrest. We further
recommend that such a plan include a
designated overflow facility. The
implementation of such a plan will prevent detainees
from having to share quarters, will ensure
that detainees are provided with adequate
services, and will allay safety and
security concerns.
A. MODULE STAFFING ISSUES IN THE FACILITY
For most of the afternoon on the day of
Omars death, there was only one
detention officer on Module Three. Records
from the facility indicate that there were
twenty-eight detainees on the module that
day.78
This created a situation in which the
officer knew that Omar desperately needed
medical care, but could not leave the module
either to procure medical assistance or to
take Omar to the medical station. This further
presented a safety risk to both the staff
member and the detainees.
We noted that many facilities around the
country require written policies dictating
a minimum staff-detainee ratio. The most
commonly implemented policy requires the
governance and supervision of multiple
detainees on a twenty-four hour basis by a
minimum of two employees, with an
overall staff ratio of eight to one during waking
hours and sixteen to one during sleeping
hours.79
In the State of Florida, recommended
mandatory ratios between detainees and
staff exist in confinement programs, but
were eliminated by the legislature in secure
detention facilities.80
We recommend the implementation of
mandatory detainee-staff ratios. We
recommend that each module be staffed by
no less than two staff members at all times,
with an overall staff ratio of eight to
one during waking hours and sixteen to one
during sleeping hours. We recommend that
the Superintendent of the Facility bear
personal responsibility for signing off on
schedules to ensure that employees comply
with this ratio.
78
See Department of Juvenile Justice MDRJDC Detainee Log.
79
Wyoming Juvenile Justice Study at 5.
80
See Florida Department of Juvenile Justice Policies and Procedures
(specifying a recommended minimal
staff to offender ratio
of 1:5).
18
B. CENTRAL CONTROL STAFFING IN THE
FACILITY
While on our tour of the MDRJDC, we
observed firsthand that the Central
Control booth was overwhelmed with
activity. Central Control handles all incoming
calls; all equipment deliveries; all
visitation requests; all outgoing 911 calls; coordination
of all transportation requests; and the
constant monitoring of surveillance cameras
installed throughout the facility. In
addition, various workers arriving at or leaving the
facility go through Central Control. Thus,
we were stunned to learn that the MDRJDC
does not have a requirement for minimum
staffing in Central Control. On the evening
that Omar Paisley died, there was only one
employee working in the Central Control
area. Since, ideally, working
closed-circuit television cameras reflecting different areas
of the facility would be monitored by
staff in Central Control, a single worker simply
cannot perform the tasks required of this
position.
We recommend that the facility implement a
policy requiring a minimum of two
workers at all times be assigned to
Central Control. One worker should be specifically
assigned to monitor the facility via the
surveillance system and one worker should be
specifically assigned to address all other
duties in Central Control.
19
VI. LACK OF A FUNCTIONING SURVEILLANCE
SYSTEM IN THE FACILITY
During our investigation, we longed for a
dispassionate, objective recording of the
days preceding Omar Paisleys death. We
longed for documentation to verify or dispel
the many complaints lodged by detainees
about physical and verbal abuse at the hands of
detention workers. However, we learned in
the course of our investigation that although
cameras were installed in the MDRJDC
nearly ten years ago, most were not working at
the time of Omars death. Those that did
work allowed only for real-time monitoring, as
opposed to videotaping which would allow
one to playback and review what was
recorded by the camera. Inter-departmental
e-mail correspondence indicates that staff
had begun complaining about the failure of
the system as far back as 1997.81
In 1998, email
correspondence indicated that the
recording equipment is now obsolete-- rendering
it difficult to fix. The warranty was no
good due to incorrect relocation of the
equipment.
In 2000, two incidents emphasized the
continuing failure of the surveillance
system in the facility. On July 25, 2000,
an employee in the facility was reported to the
Office of the Inspector General for
allegations of striking a detainee repeatedly and
excessively with a broomstick.82
The employee was investigated, the
allegations were
substantiated, and a report was issued.
The report contained findings that the Dade
RJDC Management failed to ensure the video
equipment was operating correctly which
prevented review of this incident.83
A second, identical incident was
documented in a
parallel report, issued on August 30,
2000.84
Again, the investigative report findings,
released on April 3, 2001, contained the
provision, it is substantiated the Dade RJDC
Management failed to ensure the video
equipment was operating correctly which
prevented review of this incident.85
81
This is reflected in e-mail correspondence dated
June 20, 2003 between Department of Juvenile Justice
Regional Detention Chief
Karen Cann and Assistant Secretary Larry Lumpee: [staff] began
complaining
about the breakdown in
signals to monitors and recording devices in 1997.
82
This incident is documented in Department of Juvenile Justice
Office of the Inspector General Case
Number 00-05258.
83
Id. at 5.
84
This incident is documented in Department of Juvenile Justice
Office of the Inspector General Case
Number 00-06081.
85
Id. at 5.
20
On June 20, 2003, Department of Juvenile
Justice Regional Detention Chief
Karen Cann sent an e-mail to Assistant
Secretary Larry Lumpee indicating that the
cameras in the facility were faulty at the
time of the death of Omar Paisley: it has been
reported that a playback system was not
included in the design, and the recording system
did not identify which cameras were being
recorded.
While we understand that the existence of
working surveillance cameras and
videotaping equipment at the MDRJDC might
not have saved the life of Omar Paisley,
we are mindful of the fact that it could
have helped us tremendously during our
investigation. For instance, it might have
definitively revealed whether or not Omar
received physical examinations during LPN
Loperfidos Saturday and Sunday visits. It
might have also resolved the conflict
regarding the number of visits she made to Omars
cell on those two days.
We questioned administrators during our
tour of the facility in an effort to
determine whether or not this situation
had been remedied, but were met with conflicting
information. Further, we examined
testimony adduced from detainees during the course
of the first Legislative Public Hearing in
this case regarding physical abuse in
confinement cells. We were disheartened to
learn that repairing surveillance equipment
has not been a priority in past budgetary
requests.
We collectively determined that a
surveillance system is essential in a facility of
this type in order to ensure the safety of
both the juveniles housed in the facility and the
detention workers employed by the
facility. We noted that this would immediately solve
most disputes investigated by the Office
of the Inspector General, as no longer would
these investigators be forced to make a
credibility determination between a detention
worker and a detainee.
We recommend that the existing
surveillance system be replaced immediately
with a system that will allow for
recording in each area of the facility. We further
recommend that an inspection be
implemented at the beginning of each shift to ensure
that the surveillance system is working.
We recommend that the Superintendent and
Assistant Superintendents of the facility
bear personal responsibility for confirming at
the beginning of each shift that the
surveillance system is working.
21
VII. PROVISION OF MEDICAL CARE IN THE
FACILITY
A. MEDICAL REQUEST FORM RESPONSE TIME
When we began to explore the specifics of
Omars death, we were met with the
reality that the provision of medical care
within the MDRJDC was, historically, untimely
and inconsistent. In September of 2002:
there [was] no obvious method for tracking
youth with chronic health issues and needs
[and] laboratory utilization [had] been
reduced.86
The Department of Juvenile Justice
Support Services Division documented
their concern in an electronic
communication to the superintendent of the detention
center: [support services] audited health
services (sixteen records) and [MCH] still have
(sic) eighty-five plus physicals not done.
Physicals are not being done within the twentyone
day time period, immunization records are
not on the charts, consents are not on the
chart, and the required health education
is not being done, etc. . . .87
Further
communications between Department of
Juvenile Justice Support Services and MDRJDC
revealed a flawed tracking system:
[support systems] was especially concerned when the
R.N. [said] that she doesnt make medical
files on all detainees and has no tracking
mechanism for those who are short stays
(three days or less) . . . The excessive backlog of
physicals, lack of health educations, etc.
. . are of great concern. They definitely need to
make better use of their physician/nursing
staff time and start to make some impact on
the backlog.88
A follow-up visit to the facility in
January of 2003 by the Support Services
Division revealed active files without
current physical examinations.89
The
explanation provided was that records had
been misfiled.90
The visit further revealed that
86
Department of Juvenile Justice MDRJDC, Memorandum re: Quarterly
Monitoring Visit dated September
23, 2002 at 1.
87
Electronic mail from Department of Juvenile Justice Support
Services to the Superintendent of the
MDRJDC dated September
18, 2002 at 11:39 a.m.
88
Electronic mail from Department of Juvenile Justice Support
Services to the Department of Juvenile
Justice Southern Regional
Office dated September 18, 2002 at 12:00 p.m.
89
Department of Juvenile Justice MDRJDC, Memorandum re: Follow-up to
Corrective Action Monitoring
Visit dated January 14,
2003 at 1.
90
Id.
22
physicals were being completed in a time
span of sixty to ninety days, as opposed to the
twenty-one days specified by policy and
procedure.91
A surprise visit by Detention Services in
February of 2003 revealed one hundred
and thirteen active files with various
incomplete forms within the active file. Eighty files
were on the shelf awaiting physical
examinations.92
The visit further revealed . . .
inventories have not been maintained on
the Modified Class II Pharmacy Stock as well as
the OTC [over the counter] stock. The
response by the RN to this observation was that
. . . it would be difficult to get all the
nurses to comply with the inventory service.93
The only mandated health care response
time that exists within the Sick Call and
Emergency Response Procedures is the
following: Sick call follow up referrals must be
evaluated within seventy-two hours of
dated request.94
We noted that there did not
appear to be compliance with a
recommendation forwarded as early as September of
2002, urging that the medical department
needs to develop tracking mechanisms, and to
establish controls to meet deadlines for
physicals and recall for chronic health
conditions.95
When we requested statistical
information from the Department of
Juvenile Justice regarding the average
response time of medical staff in addressing youth
complaints, we learned that this data is
not collected.96
The seventy-two hour response time clearly
does not take into account the
potential for emergency or serious medical
situations. Further, as there are medical
personnel on duty every day in the
facility, we thought the existing response period was
much too long. In attempting to construct
a more practical response time, we were
painfully aware of the futile efforts of
one detention worker to obtain assistance on the
evening of Omars death. We were also
affected by Omars own pleas for a nurse or
doctor on the morning and throughout the
day of his death.
91
Id.
92
Department of Juvenile Justice MDRJDC, Memorandum re: Monthly Site
Visit dated March
4, 2003 at
1.
93
Id.
94
Miami Childrens Hospital, Sick Call and Injury Response Procedures
IV(f).
95
Department of Juvenile Justice MDRJDC, Memorandum re: Quarterly
Monitoring Visit dated September
23, 2002 at 2 and 3.
96
Department of Juvenile Justice, Response to Subpoena Duces Tecum
dated October 27,
2003.
23
We noted that nationwide, many facilities
have designated mandatory response
times for health-related situations.
This type of protocol abolishes the need for a
medical judgment call by Department of
Juvenile Justice staff. We were particularly
impressed with Standards in the State of
Washington, which require staff and other
personnel to respond to health-related
situations within a four-minute response time.97
We recommend that health care requests be
addressed on the same day they are
issued. We further recommend that all
detainees complaining of illness undergo
complete physical examinations by medical
personnel. These physicals should always
include vital signs and blood work when
necessary.
B. LACK OF FACILITY OPERATING PROCEDURES
GOVERNING
HEALTH CARE REQUESTS
The Miami Childrens Hospital Sick Call
and Emergency Response Procedures
in place in the facility allows for
detainees to fill out medical request forms when they are
ill. It should be noted that this
procedure has not been incorporated into the Department
of Juvenile Justice Facility Operating
Procedures to ensure the mandatory documentation
of medical complaints by Department of
Juvenile Justice Staff. Thus, the looming
potential for miscommunication between
health care workers and detention staff, as
illustrated by the Omar Paisley case, is
ever present.
We recommend the immediate implementation
of Facility Operating Procedures
to address appropriate procedures
governing medical request forms. These Procedures
should include a requirement that
detention staff members first provide ill detainees
with medical request forms, collect said
forms, and forward said forms immediately to
medical personnel.
C. ISSUES RELATING TO MEDICAL STAFF IN THE
FACILITY
1. LACK OF A HEALTH SERVICES IN-HOUSE
DELIVERY
SYSTEM
Our investigation in this case revealed
that prior to the death of Omar Paisley,
various issues relating to the supervision
and outsourcing of medical staff had been
brought to light by the Commission on
Corrections. In fact, we specifically noted that a
97
Facility Operating Procedures in Washington State at 13.
24
prior recommendation to in-source medical
care had been made as long ago as in early
2001: The Department of Juvenile Justice
should develop a Health Services delivery
system whereby all health-related
personnel and services report directly to the Chief
Medical Officer. In developing this
system, the Department of Juvenile Justice should
consult with the Department of Corrections
and the Correctional Medical Authority.98
With the exception of one LPN, whose
duties are generally limited to assisting
with routine physical examinations and
dispensing medication, the Department of
Juvenile Justice does not directly employ
medical personnel.99
Rather, each facility
enters into a contract with a private
entity to ensure the provision of medical care. This
outsourcing allows for the great potential
for a communication failure between medical
personnel and facility administration.
Although the medical provider is required to sign
off on all Facility Operating Procedures
and educate staff as to the relevant provisions,
the lack of compliance with these
procedures is evident and is discussed in detail in
subsequent sections.
We further noted that this combination of
in-house medical personnel and
outsourcing allows for a lack of
communication between the LPN employed directly by
the Department of Juvenile Justice and the
medical personnel contracted with MCH.
Specifically, on the date of Omars death,
the Department of Juvenile Justice LPN was
notified of Omars chronic illness in the
cafeteria in the early morning hours. There is no
indication that the Department of Juvenile
Justice LPN notified any of the medical staff
from Miami Childrens Hospital of this
issue.100
Disturbingly, we noted that there is no
chain of command in the MDRJDC by
which medical personnel must report to
anyone from the Department of Juvenile Justice
subsequent to arriving at the facility or
prior to departing the facility. There is, quite
simply, no in-house system in place to
monitor the working hours of medical
98
Review of the Florida Department of Juvenile Justice (draft
11/9/01 at 46).
99
It should be noted that the salary of the Department of Juvenile
Justice LPN was significantly lower than
the salaries of the LPNs
employed by Miami Childrens Hospital and assigned to the MDRJDC.
See
Contract between Miami
Childrens Hospital and Department of Juvenile Justice MDRJDC;
Department of
Juvenile Justice,
Response to Subpoena Duces Tecum dated November 7, 2003.
100
See note 34, supra and accompanying text.
25
personnel.101
There is no system of supervision
to assure that medical personnel are
using their time to render treatment to
detainees. There is no effective communication
regarding required treatment of detainees.
We agree with the Commission on
Corrections and recommend that the
Department of Juvenile Justice consult
with the Department of Corrections and make
every effort to build an in-house health
services staff designed to provide
comprehensive medical, dental, and mental
health services for male and female
detainees throughout the facility. This
should include health education, preventative
care, and chronic illness treatment plans
at the minimum community standard of
care.102 We further recommend that the
Department of Juvenile Justice designate a
single Chief Medical Officer to oversee
the medical care in each detention facility.
2. FAILURE BY MEDICAL STAFF TO RESPOND TO
REQUESTS FOR
ASSISTANCE AND FAILURE BY MEDICAL STAFF TO
COORDINATE
EMERGENCY EFFORTS
The lack of supervision of medical staff
by MDRJDC administration manifested
itself in the failure of medical staff to
respond to requests by staff for assistance and,
ultimately, the failure by medical staff
to coordinate emergency efforts on the evening of
the death of Omar Paisley.
On the date of Omars death, Monday, June
9, 2003, LPN Demeritte was assigned
to work from 1:30 p.m. to 10:00 p.m.103
Beginning in the early afternoon,
detention
officers began requesting assistance for
Omar. LPN Demeritte failed to respond to these
repeated requests for assistance until
approximately 8:00 p.m. After she finally arrived to
assess Omar, LPN Demeritte ordered
emergency transport, but then left the facility prior
to coordinating this care
and well before the end of her shift.
During the course of our
investigation, we discovered that LPN
Demeritte indicated on her time card for June 9,
2003 that she had worked from 9:30 a.m. to
10:00 p.m.
101
Although medical personnel must certify their working hours to
Miami Childrens Hospital, we
discovered, at least in
the case of LPN Demeritte, that the certification does not
necessarily reflect actual
hours worked. See, also
Section C-2 infra.
102
See
http://www.dc.state.fl.us/employ/health/index.html.
103
Contract between Miami Childrens Hospital and Department of
Juvenile Justice MDRJDC at 12.
26
We believe that LPN Demerittes abrupt
departure from the facility prior to
coordinating rescue efforts curtailed the
prompt delivery of lifesaving efforts. Further,
her departure from the facility prior to
the arrival of emergency medical services
eliminated the possibility that medics
would have an accurate medical assessment of
Omars condition.
It is imperative that health care workers
from the hospital inform a designated
Department of Juvenile Justice Assistant
Superintendent prior to leaving the facility
during an unscheduled time period. It is
also essential that a system exist whereby the
Department of Juvenile Justice is able to
monitor any deviation from contractual
provisions, either in the form of failing
to comply with standing orders or failing to
comply with hourly requirements.
Until the in-house provision of medical
care is finalized, we recommend the
immediate implementation of a system
whereby medical staff are required to report to
Department of Juvenile Justice MDRJDC
administration upon their arrival at the
facility and prior to departing from the
facility. We further recommend that
Department of Juvenile Justice MDRJDC
administration be responsible for certifying
the hours worked by medical staff.
Finally, we recommend the implementation of
immediate, personal sanctions by a
contracting medical entity for the failure by
medical staff to coordinate emergency
efforts.
3. FAILURE BY NURSING STAFF TO CONTACT A
PHYSICIAN AND
FAILURE BY MEDICAL STAFF TO FOLLOW
STANDING ORDERS
The contract between MCH and the
Department of Juvenile Justice required that
final medical judgments regarding the
health care of a detainee must rest with a single
designated physician.104 However, we noted that in
reality, detainees are fully dependent
upon the medical judgment of nurses. In
the case of Omar Paisley, there is no indication
that the physician was ever even informed
of Omars condition by any of the nurses until
104
The contract specifically states: the physician is responsible for
care of the treatment of common, nonemergency
illnesses and injuries.
It further adds: [nurses are to] review medical intake forms with
the
physician and consult
with the physician on specified youths needs.
27
after his death.105 We observed further that these
nurses failed to comply with the
standing orders issued by the MCH
physician in conjunction with the MRJDC.106
We recommend that a physician be required
to review in a timely manner the
chart of each and every detainee rendered
treatment by nursing staff. We recommend
that this review include an analysis of
follow-up treatment rendered and compliance
with standing orders.
4. FAILURE BY MEDICAL STAFF TO DOCUMENT
MEDICAL RECORDS
IN A COMPREHENSIVE AND TIMELY MANNER
The Bureau of Quality Assurance Standards
issued by the State of Florida dictates
all sick call encounters provided by the
licensed healthcare professional will be
documented in the chronological progress
notes of the healthcare record and on the sick
call index.107
The standard further mandates all
findings should be recorded at the time
of the health encounter.108
The Facility Operating Procedures
implemented in the MDRJDC reiterate this
principal: on-site sick call care,
including the administration of over-the-counter
medication by unlicensed staff members and
care administered by licensed health care
professionals and health care
paraprofessionals must be legibly documented in ink. Such
documentation must be made in the
Chronological Progress Notes in the Individual
Health Care Records and [include] (1) date
and time of the sick call encounter; (2) the
detainees sick call complaint; (3) the
findings of the person rendering sick call care; (4)
treatment rendered; (5) education and
instructions given to the detainee; (6) plans for
future treatment or follow-up, if any; (7)
need to notify parents/guardians; and (8)
signature of staff member rendering care.109
The purpose of these guidelines is
clearly
105
It should be noted that LPN Loperfido specified in her own
handwriting on the only medical paperwork
she placed in Omars file
prior to his death that his twenty-four hour medical alert was to
end on June 9,
2003. Only detainees with
active Youth Request for Sick Call forms and twenty-four hour
medical alerts
are referred
automatically to the physician.
106
As previously stated, the Miami Childrens Hospital Sick Call and
Emergency Response Procedures
delineated a specific
requirement for treating Abdominal Discomfort: (i) give nothing by
mouth; (ii)
consult with on-call
medical provider; (iii) refer to E.R. if acute abdomen is
suspected.
107
Bureau of Quality Assurance Standards, No. 7.15.
108
Id. at No. 7.20.
109
Department of Juvenile Justice MDRJDC Facility Operating Procedure
7.15 revised January, 2003 at 3.
28
communicated: [d]ocumentation . . .
provided by a licensed health care professional . . .
[must] communicate pertinent information
to other health care professionals.110
Health care staff in the facility has had
a history of not documenting the
administration of medication. During one
Inspector General investigation concerning the
failure by staff to document the
distribution of medication, one member of the medical
team stated in November of 2001, . . .
the practice is to simply give over the counter
medications to [detainees] and not record
it on a form.111
This failure to document was
not limited to those detainees suffering
from physical ailments; it was rampant in the files
of detainees residing in the mental health
specialty units. On January 14, 2003,
Department of Juvenile Justice Detention
Services observed [t]here was concern about
the lack of timely documentation on the
detainees residing in the mental health specialty
units. The crisis unit psychiatrist came
in today and documented three months worth of
progress notes and orders with backdates
(emphasis added).112
When we reviewed the medical files of
other detainees housed in the Miami-Dade
Regional Detention Facility, we realized
that this failure to document medical treatment
was commonplace. On Friday, June 6, 2003,
the Module Three Logbook reflected an
altercation between two detainees.113
An entry in the logbook indicated
that one of the
detainees had been physically injured and
had been referred for appropriate medical
treatment.114
A review of the medical file of the
detainee failed to reveal what treatment
medical staff had administered to the
detainee.115
Three days later, on Monday, June 9,
2003, the Module Three Logbook reflected
that a detainee was complaining of stomach
pains.116
The medical file for this detainee
does not reflect treatment.117
Further, this
particular detainee was taking
psychotropic medication and there is no indication as to his
110
Id.
111
This quote is contained within Department of Juvenile Justice
Office of the Inspector Report for Case
Number: 01-06647.
112
Department of Juvenile Justice Memorandum dated
January 14, 2003, Follow-up to Corrective Action
Monitoring Visit.
113
Module Three Logbook entry dated
June 6, 2003 at 4:30 p.m.
regarding C.S.: Detainee [C.S.] seeks
medical attention.
114
Id.
115
See Department of Juvenile Justice Medical Records for detainee
C.S.
116
Module Three Logbook entry dated
June 9, 2003 at 8:15 a.m.
regarding D.D.: [Detainee, D.D.,
complaining of stomach
pains.
117
See Department of Juvenile Justice Medical Records for detainee
D.D.
29
dosage or his progress on the medication.118
Later on that same day, medical
records
reveal that yet another detainee had been
taken to the medical station.119
However, the
Tracking Tool for Nurses120 failed to reflect
contact with the detainee. We noted that
this inconsistency in documentation
ensures miscommunication between medical staff.
We concluded that LPN Loperfido failed to
comply with required documentation
procedures when she treated Omar Paisley
on Saturday, June 7, 2003 and Sunday, June 8,
2003. Her recorded impressions of Omar for
Saturday, June 7, 2003 were incomplete.
She did not record any impressions of Omar
at all from Sunday, June 8, 2003 until the
day after his death. She did not make a
notation of medication administered, which could
have potentially impacted Omars symptoms
or placed him at risk of over-medication by
a subsequent staff member.121 The combination of these
failures further prevented the
commencement of a chart review on Monday,
June 9, 2003, by other nursing personnel
or the physician.
Similarly, we concluded that LPN Demeritte
also failed to comply with the above
detailed provisions when she treated Omar
Paisley on Monday, June 9, 2003. She did not
record any visits to Omar during the day
on June 9, 2003. She did not record
observations, medication administered, or
any other critical information. She did not
contemporaneously record accurate vital
signs, as her documentation regarding Omars
condition at 8:30 p.m. is medically
impossible and contradicted by eyewitnesses.
We recommend that health care workers who
fail to document medical records,
progress notes, the administration of
medication, and follow-up treatment in an
accurate and timely manner be subject to
immediate, harsh sanctions.
118
Id.
119
See Department of Juvenile Justice Medical Records of K.R.
120
The Tracking Tool for Nurses is an internal tracking device
utilized by
MCH/MDRJDC to maintain a
record of which detainees
were treated by nurses on any given day.
121
It should be noted that Omars name did not appear anywhere on the
Medication Administration
Records for the relevant
time period.
30
5.
ASSIGNING AN OFFICER PERMANENTLY TO THE MEDICAL
STATION / REQUIRING THAT ALL PATIENTS BE
EXAMINED IN
THE MEDICAL STATION OF THE FACILITY
During our visit to the MDRJDC, we noted
that although a written policy
delineated where a patient would be
examined or treated, most officers were unfamiliar
with the policy.122 Further, there is no
indication that medical personnel comply with the
policy.123
The natural result of this is a
system in which detainees were consistently
waiting for medical staff to visit a
module, but no means existed to track the medical
staff. Thus, patients were not treated in
a timely fashion.
When we visited the BRJDC, we immediately
noted that the Medical Station was
staffed at all times by a detention
officer. We further noted that a policy existed
mandating that all detainees be examined
and/or treated by the medical staff in the
Medical Station. As a result, sick calls
were handled in a timely, efficient, and orderly
manner.
We believe that the Broward system has
obvious merit. We therefore
recommend that this system be implemented
in Miami-Dade County. After filling out a
Youth Request for Sick Call, each youth
should be accompanied to the Medical Center
by a Detention Officer. The youth should
then wait in the center until a health care
worker is available. In the event that a
detainee is too ill to walk, serious consideration
should be given for immediate emergency
transport at that time.
6. LACK OF AVAILABILITY OF 24-HOUR ON SITE
MEDICAL CARE IN
THE FACILITY
When we initially delved into the facts
surrounding Omars death, we learned that
Omar had complained of severe pain
throughout the very early morning hours on the date
of his death. At that time, there were no
medical personnel on duty. However, later the
same morning no fewer than three nurses
and one doctor were on duty at the same time.
We were at a loss as to why there would be
consistent overlap in staff and no
provisions in place to allow for
twenty-four hour medical care. We noted that
122
The Sick Call and Injury Response Procedures differentiate between
Clinic Sick Call (during office
hours) and Unit Sick
Call (after hours or during medication rounds).
31
nationwide, there is a trend in larger
detention facilities to provide a full medical clinic
with both general and psychiatric services
available twenty-four hours per day.124
It was
very simple for us to envision scenarios
in which twenty-four hour medical care could
mean the difference between life and
death.
Based upon the size of the MDRJDC, we
recommend the immediate
implementation of twenty-four hour on-site
medical care for all detainees.
VIII. RELATIONSHIP BETWEEN THE DEPARTMENT
OF JUVENILE
JUSTICE AND THE OFFICE OF THE INSPECTOR
GENERAL
The Office of the Inspector General of the
Department of Juvenile Justice
provides auditing, investigative,
management advisory and background screening
services for the Florida Department of
Juvenile Justice.125
The duties of the Department
of Juvenile Justice Office of the
Inspector General are prescribed pursuant to section
20.055, Florida Statutes.126 There are approximately
eight Inspector Specialists from the
Department of Juvenile Justice Office of
the Inspector General responsible for
conducting investigations at over two
hundred and twenty facilities in the State of
Florida.127
The investigations conducted by
these specialists involve everything from
allegations of sexual harassment and
employment discrimination to allegations of
physical abuse.128
We noted that many criticisms have arisen
regarding the chain of command of the
Department of Juvenile Justice Office of
the Inspector General and the final outcome of
past investigations into incidents in
juvenile detention facilities. As a result, we carefully
and critically examined the structure of
the existing complaint system and made several
determinations.
123
On Monday morning, Omar requested a nurse. There is no indication
that a nurse saw him during the
morning medication
rounds. See Sworn Statement of JDO Troy Morgan.
124
Juvenile Detention Standards in Washington State, at 21.
125
http://www.djj.state.fl.us/agency/inspectorgeneral.
126
Id.
127
At the time of the writing of this report, there were two vacant
positions of Inspector Specialists within
the Office of the
Inspector General of the Department of Juvenile Justice.
128
We noted that the Inspector Specialists staff an employee hotline.
However, we noted that this hotline
appeared to be both
underpublicized and underutilized, as policy violations were rampant
in the Miami-
Dade Regional Secure
Detention Center.
32
Typically, Department of Juvenile Justice
Inspector Specialists are notified of an
incident and have a prescribed time period
in which to conduct a thorough investigation
into the incident. Ultimately, the
findings of the Department of Juvenile Justice
Inspector Specialist are forwarded to the
Inspector General of the Department of Juvenile
Justice for a final determination as to
whether or not a complaint is substantiated or
unsubstantiated. The Department of
Juvenile Justice Inspector General, in turn, reports
the results of the investigation to the
Secretary of the Department of Juvenile Justice.
The Department of Juvenile Justice will
determine what action, if any, should be taken in
any given case. However, this decision is
made without input from the Department of
Juvenile Justice Inspector Specialist
assigned to the case.
The Inspector General of the Department of
Juvenile Justice and his or her
Inspector Specialists are at-will
employees, meaning they serve in selected exempt
service at the pleasure, ultimately, of
the Secretary of the Department of Juvenile
Justice. They do not report to the Chief
Inspector General of the State of Florida.
Despite their desire to maintain the
integrity of the investigations they undertake,
Inspector Specialists are not immune to
the pressure to maintain their employment by
projecting a positive image of the
Department of Juvenile Justice. Conceivably, the same
may be said of the Inspector General of
the Department of Juvenile Justice.
We recommend that the Department of
Juvenile Justice Office of the Inspector
General report directly to the Chief
Inspector General of the State of Florida in order
to ensure the neutrality and the integrity
of all investigations. We further recommend
that the Department of Juvenile Justice
receive input from the assigned Inspector
Specialist in making disciplinary
determinations as the result of any given
investigation.
IX. ISSUES RELATING TO STAFFING AND
SUPERVISION
A. FAILURE TO CONDUCT PRELIMINARY NATIONAL
BACKGROUND
SCREENINGS ON PRIVATELY CONTRACTED
PROVIDERS
We all agreed that the skills and
qualifications required of juvenile detention
officers are oftentimes greater than those
necessary in a jail or prison setting. We
33
recognized that detainees are uniquely
reliant upon Department of Juvenile Justice
workers and privately contracted agencies
for their health and safety. We thought it was
particularly important for juvenile
detention workers to serve as positive role models for
the troubled youth housed in secure
detention. As a result, we were disturbed by many
departmental practices that appeared to
result in the hiring and retention of unqualified
and incompetent staff.129
As mentioned previously in the course of
this report, each individual detention
facility has the capability of privately
contracting with individual entities for the
provision of services in the facility. As
a result, oftentimes, non-State employees work
on-site in a detention facility. These
non-State employees frequently interact with
detainees.
During the course of our investigation, we
discovered that the Inspector
Specialists employed by the Department of
Juvenile Justice utilize Florida Department of
Law Enforcement (hereinafter FDLE)
equipment to conduct preliminary criminal
background screenings on potential
employees. Both national and statewide background
screenings are conducted for those
employees working directly for a Department of
Juvenile Justice facility. However, the
Federal Bureau of Investigation prohibits
Inspector Specialists from utilizing FDLE
equipment to conduct preliminary national
background screenings for those employees
working for a private entity contracting with
the Department of Juvenile Justice for the
provision of services. 28 U.S.C. Sec. 20.33(a)
is cited in support of this prohibition.130
Final fingerprint screenings,
including national
background screenings, are completed on
all private contractors and direct employees
within approximately one to two months of
the employee commencing employment.
Thus, a worker employed at the facility
through a private contract to provide drug
counseling or medical care to detainees
could potentially have significant, violent
national criminal records and have direct
contact with the detainees housed in the facility
without the knowledge of the Department
for a two to three month period.
129
We were not unmindful of the potential benefit of detainee exposure
to ex-addicts and ex-felons. See,
generally, A
Comprehensive Therapeutic Community Approach for Chronic
Substance-Abusing Juvenile
Offenders: The Amity
Model, Rod Mullen, Naya Arbiter, and Peggy Glider.
130
This statute sets forth the perimeters governing the utilization of
federal equipment for background
screenings.
34
We are mindful of the limited resources
endemic in our community. However,
we learned in the course of our
investigation that the Department of Children and Family
Services recently purchased several live
scan machines to conduct full, immediate
background screenings on all potential
employees. With a live scan machine,
prospective employees insert their finger
into the machine so that a fingerprint scan is
obtained. This scan is then automatically
and immediately checked against the criminal
database files of local, state and federal
law enforcement agencies.
We recommend that the Department of
Juvenile Justice immediately begin the
practice of conducting full national
criminal background screenings on all workers,
even non-direct care workers, employed in
any facility housing our youth. As we are
cognizant of limited resources, we
recommend that the Department of Juvenile Justice
require all potential privately contracted
employees to report to the live scan
machines recently purchased by the
Department of Children and Family Services to
quickly, efficiently, and economically
conform with this recommendation.
B. ISSUES REGARDING DEPARTMENT OF JUVENILE
JUSTICE
EMPLOYEES WITH CRIMINAL BACKGROUNDS AND
PENDING
CRIMINAL CASES
In the course of our investigation, we
were disturbed to learn of the many
Department of Juvenile Justice employees
with sordid criminal histories. We felt
strongly that the individuals charged with
caring for and rehabilitating our children
should not have a history of engaging in
destructive criminal activity or serious, pending
criminal cases.
We learned that a new criterion by which
employees were hired was developed
following the creation of the Department
of Juvenile Justice in 1994.131
This criterion
precluded employment for any employee who
had been convicted of an enumerated,
disqualifying offense.132 However, employees hired by
the Division of Health and
Rehabilitative Services prior to the
formation of the Department of Juvenile Justice who
131
We noted, however, that individuals seeking employment with the
Department of Juvenile Justice
subsequent to October 1,
1999 with felony convictions or misdemeanor convictions involving
perjury or
false statement are
ineligible for employment. See 985.406(3)(a) Florida Statutes
(1999).
132
A complete list of these offenses is set forth in the Department of
Juvenile Justice Statewide Procedure
on Background Screening.
These offenses shall hereinafter be referred to as enumerated,
disqualifying
offenses for purposes of
this report.
35
had been convicted of an enumerated,
disqualifying offense were permitted to apply for
an exemption or were simply permitted to
continue working. Those who received
exemption approvals were permitted to
continue working for the Department of Juvenile
Justice.
We learned that currently, nine employees
who do not meet current Department
of Juvenile Justice hiring standards work
at the MDRJDC.133
Their adult, criminal
convictions vary from possession,
manufacture, or distribution of marijuana to
aggravated stalking, cocaine possession,
robbery, and aggravated assault.134
Further, we
learned that between January of 1999 and
November of 2003, fourteen MDRJDC
workers were arrested.135 Of those, four were convicted
of crimes. Nearly all of these
convictions involved substance abuse.
The Department of Juvenile Justice Office
of the Inspector General requires each
employee who is arrested during the course
of his or her employment to report said arrest
to the Office of the Inspector General
Hotline. A misdemeanor arrest must be reported
within twenty-four hours and a felony
arrest must be reported within two hours. The
Department of Juvenile Justice then tracks
the outcome of the arrest. If conviction results
and the offense is a disqualifying,
enumerated offense, termination is the end result.
However, the Office of the Inspector
General does not have the power to conduct
an independent investigation on the merits
of the arrest during the time the case is
pending or if the arrest does not result
in conviction. Thus, a technical defect in the arrest
or charge that might result in a dismissal
of the charge(s) would not warrant suspension
or termination. Further, an arrest without
an accompanying conviction for an
enumerated, disqualifying offense would
not warrant suspension or termination. A
worker charged in a homicide case, which
can oftentimes take years to proceed to trial,
could conceivably maintain employment
during the pendency of the case.
Although we were cognizant that an arrest
alone should not result immediately in
termination or suspension, we did agree
that the Office of the Inspector General should
be empowered to conduct an independent
investigation regarding the merit of the charges
133
Department of Juvenile Justice, Response to Subpoena Duces Tecum
dated October 29,
2003.
134
Department of Juvenile Justice, Response to Subpoena Duces Tecum
dated November 10,
2003.
36
upon arrest
to prevent the continued employment of
potentially dangerous or corrupt
employees.
We were also deeply concerned when we
learned that Department of Juvenile
Justice employees are subject to a
criminal background investigation re-screening only
once every five years. Thus, if an
employee fails to report his or her arrest or conviction,
it is conceivable that the employee may
continue working with youth until the arrest or
conviction is discovered a number of years
later.
We recommend that the Department of
Juvenile Justice re-assess the current
exemption policy and re-assess all
employees who do not conform to current hiring
standards. We recommend that all employees
in direct-care positions be held to the
same hiring standard, regardless of the
date of their hire. We further recommend that
the Department of Juvenile Justice empower
its Office of the Inspector General to
conduct independent investigations in
tandem with law enforcement agencies into the
circumstances surrounding the arrests of
all direct-care workers charged with
enumerated, disqualifying offenses to
determine whether or not continued employment
is prudent based upon the factual
circumstances of that arrest. We recommend that
employees convicted of an enumerated,
disqualifying offense during their tenure at the
Department of Juvenile Justice be
terminated from employment and not be permitted to
apply for an exemption. Finally, we
recommend that each Department of Juvenile
Justice employee be subject to criminal
background investigation re-screening every
year. In the event that it is revealed
that an employee failed to report an arrest, we
recommend that the Department of Juvenile
Justice immediately terminate that
employee.
C. NON-COMPLIANCE WITH QUALITY ASSURANCE
STANDARDS IN
THE FACILITY
The Florida Department of Juvenile Justice
Quality Assurance system was
established by the Florida Legislature in
1994 as part of the Juvenile Justice Reform
135
Department of Juvenile Justice, Response to Subpoena Duces Tecum
dated November 17,
2003.
37
Act.136
Chapter 985, Florida Statutes,
requires the Department of Juvenile Justice to
submit an annual report to the legislature
assessing the quality of its programs and
services.137
As such, the Bureau of Quality
Assurance designates minimum program
standards and makes a periodic inspection
to determine whether or not each program
throughout the state has complied with
these standards. If a program fails to meet the
established minimum standards, the
Department of Juvenile Justice must take necessary
and sufficient steps to ensure compliance
with the minimum standards.138
If the program
fails to achieve compliance within six
months, and the program has not documented
extenuating circumstances, the Department
of Juvenile Justice must notify the Executive
Office of the Governor and the Legislature
of proposed corrective action.
From 2001 to 2002, the MDRJDC suffered a
decrease in its overall program
performance and compliance ratings as
determined by the Bureau of Quality
Assurance.139
In 2001, the Bureau of Quality
Assurance determined that the facility had
an acceptable performance range and was
substantially compliant with statewide
requirements.140 By 2002, the facility was no
longer achieving an acceptable
performance, but was designated to be at a
level of minimal performance.141
Further,
the facility was non-compliant with
statewide standards.142
We noted that while the MDRJDC appeared to
be struggling to conform to
statewide standards, this was not the
trend among other detention facilities in the State.
The Bureau of Quality Assurance has
instituted a deemed status program in which
Department of Juvenile Justice programs
achieving a performance rating of at least eighty
percent and a compliance rating of at
least ninety percent are granted special
136
Department of Juvenile Justice Office of the Chief of Staff, An
Introduction to Floridas Juvenile Justice
Quality Assurance System:
Promoting Continuous Improvement and Accountability in Juvenile
Justice
Programs and Services
revised March
24, 2003, at 2 and 7.
137
Id.
138
Id.
139
At the time of writing this report, the Bureau of Quality Assurance
Program Review for the MDRJDC,
October 20-24, 2003 had
just been published.
140
Department of Juvenile Justice, Bureau of Quality Assurance Program
Review for the MDRJDC, July
23-27, 2001.
141
Department of Juvenile Justice, Bureau of Quality Assurance Program
Review for the MDRJDC, July
8-12, 2002.
142
However, in the most recent Bureau of Quality Assurance report, the
MDRJDC was determined to be
acceptable.
38
consideration and not subjected to a full
review at regular intervals.143
The number of
deemed or special deemed programs
statewide has increased from forty-seven in 1997 to
one hundred twenty-three in 2002.144
By 2002, the MDRJDC ranked last in
the State based on performance standards
for detention programs assessed by the
Bureau of Quality Assurance that year.145
It
received a Quality Assurance performance
score of just sixty-eight percent.146
The
facility failed to meet state standards
for mental health and substance abuse.147
The
facility also failed to meet required
minimum standards for behavior management.148
Program performance regarding health
services, program security, and living
environment was determined to be
minimal.149
The Quality Assurance reviewers
did, in
assessing health services, take into
consideration external control factors in assessing
performance. Specifically, despite
allowances made for the fact that MCH had recently
assumed responsibility as the healthcare
provider for the facility and was attempting to
catch-up on old sick call requests and
comprehensive physical examinations, health care
services were still rated as minimal.150
Overall, program performance was
determined to
be minimal and compliance was determined
to be non-compliance.151
It should be
noted that both the facility targeted for
inspection and any subcontractors are placed on
notice many months prior to a scheduled
inspection.152
In the recently released 2003 report, the
facility obtained an acceptable rating;
however, it failed to meet statewide
standards governing health services, mental health
and substance abuse assessments, and
school district management.153
Program security,
143
Id. at III-1.
144
Id.
145
See Florida Department of Juvenile Justice 2002 Quality Assurance
Report at VIII-7.
146
Id.
147
Bureau of Quality Assurance Performance Rating Profile MDRJDC
(2002).
148
Id.
149
Id.
150
Id.
151
Id.
152
Electronic mail correspondence between
MCH and Department of
Juvenile Justice employees dated
March 24, 2003 reveals an effort to change the date of the Quality Assurance
Inspection. The inspection
was slated for July,
2003.
153
Bureau of Quality Assurance Program Review for the MDRJDC, October
20-24, 2003.
39
transition, and service delivery were all
characterized as meeting minimal
performance.154
The existing Quality Assurance system
allows for a facility to be designated noncompliant,
but as long as the facility obtains
minimal performance (a rating of sixty to
sixty-nine percent), it avoids a six-month
review. In our minds, this allowed a facility to
fall abysmally below standards in certain
areas with no immediate recourse. This clearly
presents safety concerns when designated
areas of non-compliance and low performance
include such urgent issues as health care.
We recommend that any facility determined
to be non-compliant as defined by
the Bureau of Quality Assurance be
required to submit a written plan of action to
remedy shortcomings within one month of
the issuance of the relevant Bureau of
Quality Assurance Report. We further
recommend that any facility determined to be
non-compliant be subjected to the same
six-month follow-up review as a facility that
fails to meet program performance
standards. Finally, we recommend that the
Department of Juvenile Justice implement
immediate consequences for the
superintendent of the facility rated as
non-compliant.
D. ISSUES REGARDING LACK OF COMMUNICATION
BETWEEN
ADMINISTRATION AND STAFF IN THE FACILITY
We were confronted with numerous issues
regarding supervision in the facility in
the course of our investigation. We
attributed many of these issues to the lack of
effective communication mechanisms in the
facility and the structure of the facility itself.
However, some of these issues were
symptoms of an overall lack of hands-on
supervision.
We discovered that staff-supervisor
communication issues have historically been
a problem and often inure to the detriment
of the youth housed in the MDRJDC. We
learned in the course of our investigation
about the failure of workers to provide
detainees with requisite clean underwear
and linens due to the failure of administration to
dispense these items to the workers for
appropriate distribution. We learned of staff
members purchasing toothpaste for
detainees with their own money, again due to the
154
Id.
40
failure of administration to distribute
necessities. What we found most outrageous about
this was the apparent surplus of such
items that accumulated due to the fear of
administration that the workers would
steal them.
Most striking, perhaps, in the contrast
between the MDRJDC and the BRJDC,
was the overall attitude of the staff.155
We noted immediately in Broward
that the
Superintendent of the facility chose to
make rounds several times a day. This, naturally,
resulted in employees behaving in a much
more efficient and professional manner. We
further noted that the structure of the
Broward facility was conducive to these rounds, as
the shape of the facility did not permit
any warning as to when these rounds would occur.
In the MDJRDC, staff was casual and
measurably less professional. We learned
that the Superintendent and Assistant
Superintendents at the MDJRDC do not conduct
surprise rounds. Further, the ratio of
employees to administrators does not allow for
frequent rounds.
The means of communication between staff
and administration was also severely
curtailed in the Miami-Dade facility. This
could be partially attributed to the failure of
the administrators to carry radios, as
without radios, administrators are not privy to
communication regarding serious issues in
the facility.
This communication failure was
particularly apparent on the evening of Omars
death. As previously noted in this report,
one juvenile detention officer made numerous
efforts to raise either medical personnel
or a supervisor on the radio, but to no avail.
We recommend that the supervisors and
superintendents in the facility be
assigned the same radios as the staff
members, in order to prevent communication
failures. We further recommend that the
Superintendent and Assistant
Superintendents be required to complete
several rounds per shift. We further
recommend that the Superintendent and
Assistant Superintendent be personally
responsible for ensuring that detainees
are provided with all necessities required by
existing Bureau of Quality Assurance
Standards.
155
It should be noted that Broward has been designated a deemed
facility for the past two years.
41
E. STAFF FAILURE TO COMPLY WITH OSHA
REQUIREMENTS AND
FACILITY OPERATING PROCEDURES REGARDING
DISPOSAL OF
BIOHAZARDOUS WASTE IN THE FACILITY
Occupational Safety and Health
Administration (OSHA) provisions are
incorporated into mandatory Bureau of
Quality Assurance Standards to require
mandatory bloodborne pathogen training
for each detention worker in secure detention
facilities throughout the State of
Florida.156
The purpose of this training is to ensure
that
workers take adequate precautions in
handling biohazardous materials. Further, the
superintendent of each secure detention
facility is required to ensure that workers observe
universal precautions in handling any
materials containing blood or other bodily
fluids.157
We discovered in the course of our
investigation that detention workers were
unaware of whether or not biohazardous
waste kits even existed in the MDRJDC.158
We
further learned that it was permissible
practice in the facility for staff members to assign
detainees to a detail or trustee
status. On the days preceding the death of Omar
Paisley, these detail detainees were
ordered to clean Omars cell. This cleaning duty
entailed the collection of sheets,
pillowcases, and blanket and the mopping of the cell.159
The detainees then placed the sheets,
pillowcases, and blankets in a barrel to be
forwarded to the laundry service.160
These detail detainees were not
provided with
gloves, face masks, or any type of
protective equipment to ensure against exposure to
bodily fluids.
Facility Operating Procedures require that
linens soiled with emesis be marked to
ensure that laundry staff would follow
all biohazard procedures in sanitizing linen.161
Interviews conducted with both detainees
and laundry personnel reveal that Omars
linens were indeed soiled, but were not
properly separated as required.
156
Bureau of Quality Assurance Standard No. 7.22.
157
Bureau of Quality Assurance Standard No. 7.14(b); 7.14(c).
158
See Sworn Statement of JDO Michael Johnson at 14.
159
See Sworn Statement of A.H. at 17, 19; Sworn Statement of S.S. at
39.
160
Id.
161
As required pursuant to Department of Juvenile Justice MDRJDC
Facility Operating Procedure 7.14
revised January, 2003 at
3.
42
We recommend the facility take immediate
action to train all employees
regarding dangers associated with
bloodborne pathogens and all other biohazardous
waste. We further recommend that there be
specific Facility Operating Procedures
instituted to require that appropriate
disciplinary action be given to any employee who
either fails to comply with existing
Facility Operating Procedures governing the
disposal of hazardous waste or orders
detainees to participate in the clean-up of
biohazardous materials.
F. STAFF FAILURE TO COMPLY WITH FACILITY
OPERATING
PROCEDURES GOVERNING INFECTIOUS DISEASE
The MDRJDC is governed by a series of
Facility Operating Procedures. These
procedures define acceptable standards
within the facility and address everything from
appropriate employee dress to emergency
evacuation plans. We noted a lack of
compliance with the Facility Operating
Procedures in the course of our investigation.
While some lack of compliance had minimal
impact, other failures contributed, in our
opinion, to the death of Omar Paisley and
heavily impacted the safety, security, and
efficiency of the institution.
Facility Operating Procedure 7.14 sets
forth a facility-wide criterion for infectious
disease. Specifically, the facility
definition of a communicable disease includes the
common cold [and] flu.162 The relevant procedure
mandates that [a]ll detainees
suspected of communicable diseases will be
referred to the responsible physician for
examination and treatment. The medical
department will be notified to do an immediate
assessment to determine if detainee (sic)
needs to be isolated and if isolation precautions
are indicated.163 The procedures further specify
Cardiopulmonary Resuscitation and
First Aid must be given to people who are
in need of this life-saving procedure.164
Our investigation revealed, despite
contentions by various detention workers and
nurses that they believed Omar to be the
victim of a virus, no effort was made to refer
Omar to the physician. It is undisputed
that the physician was at the facility on Monday,
June 9, 2003, thus such a referral would
have required minimal effort.
162
Department of Juvenile Justice MDRJDC Facility Operating Procedure
7.14 revised January, 2003 at 2.
163
Id. at 3.
43
Further, despite the numerous individuals
employed at the facility, not one
attempted to perform lifesaving efforts on
Omar Paisley. It is uncontraverted that
detention workers were alerted to the fact
that Omar did not have a pulse and was not
breathing.165
Yet, nobody attempted to perform
cardiopulmonary resuscitation on Omar.
We recommend that the Facility Operating
Procedures be amended to include
immediate sanctions for the failure of a
staff member to perform potentially lifesaving
cardiopulmonary resuscitation or to
administer first aid.
X. CONCLUSION
The tragic death of Omar Paisley has left
us with clear insight as to the glaring
deficiencies endemic in the Department of
Juvenile Justice and its MDRJDC. During the
course of our investigation, we have been
keenly aware of public legislative hearings,
other grand jury investigations, and
probing media coverage all focusing on systemic
flaws in the Department of Juvenile
Justice. We are cognizant that it will take a great
deal of time for our community to heal
following the senseless death of Omar Paisley.
We are acutely aware of just how important
our role is in determining what change
should be implemented to improve the dire,
substandard conditions in the MDRJDC.
Our investigation has revealed a juvenile
justice system plagued by a lack of
commitment, a lack of supervision, a lack
of guidelines, a lack of proper structure, and a
lack of resources. As a result, we were
forced to narrow our findings to the most
egregious of issues. We have observed
firsthand the most tragic result that inevitably
ensues with the unchecked nonfeasance in a
state-run facility.
We, as grand jurors, as parents, and as
citizens of this community, cannot bear the
thought of another child suffering
unbearably and, ultimately, slipping through the cracks
of our system. We are charged with
ensuring the safety and protection of our youth. We
are confident that the commitment of
resources to our children will prevent future similar
tragedy. Thus, we implore the Department
of Juvenile Justice to begin to take greater
responsibility for the children entrusted
in its care, custody, and control. We recommend
164
Id.
165
See Sworn Statement of Reverend Eddie Williams.
44
that our Legislature commit adequate
resources to improving the quality of life for
children housed in the MDRJDC. We strongly
urge that our findings be widely
recognized and our critical
recommendations be implemented in an expeditious manner.
XI. SUMMARY OF RECOMMENDATIONS
1. We recommend that the MDRJDC
immediately install an intercom system
comparable to the system currently in
place in the BRJDC. As an immediate
alternative during the installation
process of the intercom system, we recommend
that the current Facility Operating
Procedures be modified immediately to provide
for any employee noting an emergency
situation to have unimpeded direct access
to 911. This would require Facility
Operating Procedures to reflect that any
employee who perceives an emergency
situation, must, as a matter of
responsibility, call 911. This
responsibility should, in our opinion, exist separate
and apart from the mandates assigned to
any medical personnel. Further, as a
practical measure, we believe that a
telephone system must be implemented in the
facility in which each area populated by
detainees is equipped with direct access
to 911. Finally, we recommend that current
Facility Operating Procedures be rewritten
to require detention workers to first
contact 911 in an emergency situation,
and only then to contact Central Control.
2. We recommend that the MDRJDC
immediately implement a contingency plan for
overcrowding/group arrest. We further
recommend that such a plan include a
designated overflow facility. The
implementation of such a plan will prevent
detainees from having to share quarters,
will ensure that detainees are provided
with adequate services, and will allay
safety and security concerns.
3. We recommend the implementation of
mandatory detainee-staff ratios. We
recommend that each module be staffed by
no less than two staff members at all
times, with an overall staff ratio of
eight to one during waking hours and sixteen to
one during sleeping hours. We recommend
that the Superintendent of the Facility
bear personal responsibility for signing
off on schedules to ensure that employees
comply with this ratio.
4. We recommend that the facility
implement a policy requiring a minimum of two
workers at all times be assigned to
Central Control. One worker should be
specifically assigned to monitor the
facility via the surveillance system and one
worker should be specifically assigned to
address all other duties in Central
Control.
5. We recommend that the existing
surveillance system be replaced immediately with a
system that will allow for recording in
each area of the facility. We further
recommend that an inspection be
implemented at the beginning of each shift to
ensure that the surveillance system is
working. We recommend that the
Superintendent and Assistant
Superintendents of the facility bear personal
responsibility for confirming at the
beginning of each shift that the surveillance
system is working.
45
6. We recommend that health care requests
be addressed on the same day they are
issued. We further recommend that all
detainees complaining of illness undergo
complete physical examinations by medical
personnel. These physicals should
always include vital signs and blood work
when necessary.
7. We recommend the immediate
implementation of Facility Operating Procedures to
address appropriate procedures governing
medical request forms. These
Procedures should include a requirement
that detention staff members first provide
ill detainees with medical request forms,
collect said forms, and forward said forms
immediately to medical personnel.
8. We agree with the Commission on
Corrections and recommend that the Department
of Juvenile Justice consult with the
Department of Corrections and make every effort
to build an in-house health services staff
designed to provide comprehensive
medical, dental, and mental health
services for male and female detainees
throughout the facility. This should
include health education, preventative care, and
chronic illness treatment plans at the
minimum community standard of care.166
We
further recommend that the Department of
Juvenile Justice designate a single Chief
Medical Officer to oversee the medical
care in each detention facility.
9. Until the in-house provision of medical
care is finalized, we recommend the
immediate implementation of a system
whereby medical staff are required to report
to Department of Juvenile Justice MDRJDC
administration upon their arrival at the
facility and prior to departing from the
facility. We further recommend that
Department of Juvenile Justice MDRJDC
administration be responsible for
certifying the hours worked by medical
staff. Finally, we recommend the
implementation of immediate, personal
sanctions by a contracting medical entity for
the failure by medical staff to coordinate
emergency efforts.
10. We recommend that a physician be
required to review in a timely manner the chart
of each and every detainee rendered
treatment by nursing staff. We recommend that
this review include an analysis of
follow-up treatment rendered and compliance with
standing orders..
11. We recommend that health care workers
who fail to document medical records,
progress notes, the administration of
medication, and follow-up treatment in an
accurate and timely manner be subject to
immediate, harsh sanctions.
12. We believe that the Broward system has
obvious merit. We therefore recommend
that this system be implemented in
Miami-Dade County. After filling out a Youth
Request for Sick Call, each youth should
be accompanied to the Medical Center by a
Detention Officer. The youth should then
wait in the center until a health care
worker is available. In the event that a
detainee is too ill to walk, serious
consideration should be given for
immediate emergency transport at that time.
13. Based upon the size of the MDRJDC, we
recommend the immediate implementation
of twenty-four hour on-site medical care
for all detainees.
166
See
http://www.dc.state.fl.us/employ/health/index.html.
46
14. We recommend that the Department of
Juvenile Justice Office of the Inspector
General report directly to the Chief
Inspector General of the State of Florida in
order to ensure the neutrality and the
integrity of all investigations. We further
recommend that the Department of Juvenile
Justice receive input from the assigned
Inspector Specialist in making
disciplinary determinations as the result of any given
investigation.
15. We recommend that the Department of
Juvenile Justice immediately begin the
practice of conducting full national
criminal background screenings on all workers,
even non-direct care workers, employed in
any facility housing our youth. As we
are cognizant of limited resources, we
recommend that the Department of Juvenile
Justice require all potential privately
contracted employees to report to the live
scan machines recently purchased by the
Department of Children and Family
Services to quickly, efficiently, and
economically conform with this recommendation.
16. We recommend that the Department of
Juvenile Justice re-assess the current
exemption policy and re-assess all
employees who do not conform to current hiring
standards. We recommend that all employees
in direct-care positions be held to the
same hiring standard, regardless of the
date of their hire. We further recommend
that the Department of Juvenile Justice
empower its Office of the Inspector General
to conduct independent investigations in
tandem with law enforcement agencies into
the circumstances surrounding the arrests
of all direct-care workers charged with
enumerated, disqualifying offenses to
determine whether or not continued
employment is prudent based upon the
factual circumstances of that arrest. We
recommend that employees convicted of an
enumerated, disqualifying offense during
their tenure at the Department of Juvenile
Justice be terminated from employment
and not be permitted to apply for an
exemption. Finally, we recommend that each
Department of Juvenile Justice employee be
subject to criminal background
investigation re-screening every year. In
the event that it is revealed that an
employee failed to report an arrest, we
recommend that the Department of Juvenile
Justice immediately terminate that
employee.
17. We recommend that any facility
determined to be non-compliant as defined by the
Bureau of Quality Assurance be required to
submit a written plan of action to
remedy shortcomings within one month of
the issuance of the relevant Bureau of
Quality Assurance Report. We further
recommend that any facility determined to be
non-compliant be subjected to the same
six-month follow-up review as a facility that
fails to meet program performance
standards. Finally, we recommend that the
Department of Juvenile Justice implement
immediate consequences for the
superintendent of the facility rated as
non-compliant.
18. We recommend that the supervisors and
superintendents in the facility be assigned
the same radios as the staff members, in
order to prevent communication failures.
We further recommend that the
Superintendent and Assistant Superintendents be
required to complete several rounds per
shift. We further recommend that the
Superintendent and Assistant
Superintendent be personally responsible for ensuring
that detainees are provided with all
necessities required by existing Bureau of
Quality Assurance Standards.
47
19. We recommend the facility take
immediate action to train all employees regarding
dangers associated with bloodborne
pathogens and all other biohazardous waste.
We further recommend that there be
specific Facility Operating Procedures
instituted to require that appropriate
disciplinary action be given to any employee
who either fails to comply with existing
Facility Operating Procedures governing
the disposal of hazardous waste or orders
detainees to participate in the clean-up of
biohazardous materials.
20. We recommend that the Facility
Operating Procedures be amended to include
immediate sanctions for the failure of a
staff member to perform potentially
lifesaving cardiopulmonary resuscitation
or to administer first aid.
48
INDICTMENT
NAME OF DEFENDANT CHARGE
RETURNED
RICHARD THOMAS GIORDANI
Murder First Degree
Kidnapping True Bill
KEVIN EVERS Murder First
Degree
Murder First Degree
Murder First Degree
Murder First Degree /
With a Deadly Weapon / Attempt
Murder First Degree /
With a Deadly Weapon / Attempt
Deadly Missile / Shoot,
Throw
Firearm/Weapon/Possession
by Convicted Felon True Bill
JESUS CHIRINO Murder
First Degree
Firearm/Use, Display
While Committing
a Felony True Bill
ARTHUR R. COLPITT III
Murder First Degree True Bill
RODGER LOVETTE Murder
First Degree
Robbery/Strong Arm
With/Aggravated Battery
Abuse/Aggravated/Elderly/Disabled Adult/ Phy/Psy True Bill
JEFFREY S. WORLEY Murder
First Degree True Bill
LAWRENCE S. BRYANT Murder
First Degree
Robbery/Armed/Attempt
Kidnapping/With a Weapon
Burglary/With Assault or
Battery/Armed
Battery/Aggravated/Great
Bodily Harm/ Firearm True Bill
ANTOINE LINDSEY and
PATRICK LINDSEY Murder
First Degree True Bill
NATHANIEL STEVENS Murder
First Degree True Bill
ENSI PRUDENT Murder First
Degree
Firearm/Possession by
Convicted Felon True Bill
DUANE ISAAC WALKER Murder
First Degree
Child Abuse/Aggravated
True Bill
JOSE GREGORIO MARCANO
First Degree Murder True Bill
BARON EARL MOORE Murder
First Degree True Bill
CHARLES D. BYRD Murder
First Degree
Child
Abuse/Aggravated/Great Bodily Harm/Torture
Sexual Battery/On a Minor
by an Adult True Bill
TERRIC JEFFERY Murder
First Degree
Child
Abuse/Aggravated/Great Bodily Harm/Torture
Child
Abuse/Aggravated/Great Bodily Harm/Torture
Child
Abuse/Aggravated/Great Bodily Harm/Torture True Bill
49
INDICTMENT
NAME OF DEFENDANT CHARGE
RETURNED
DAVID DWAYNE BROWN, also
known as
DABO Murder First
Degree
Murder First Degree
Murder First
Degree/Attempt
Firearm/Concealed
Weapon/Possession by Violent Career Criminal
Firearm/Use, Display
While Committing a Felony True Bill
DANNY PIERRE-LOUIS (A)
and
RICHARD RAMBARAN (B)
Accessory After the Fact (A) (Murder)
Accessory After the Fact
(A) (Burglary)
Murder First Degree (B)
Burglary/With Assault or
Battery/Armed (B)
Aggravated
Stalking/Deadly Weapon/Prior Restraint (B)
Murder First
Degree/Attempt (B)
Stalking/Aggravated (B)
True Bill
ANDREW OMAR FOSTER Murder
First Degree
Murder First
Degree/Attempt
Robbery/Armed/Attempt
Burglary/Armed
Firearm/Use, Display
While Committing a Felony
Firearm/Possession by
Convicted Felon True Bill
VICTOR EVELIO PESTANO and
(A)
DULIE ALONZO GREEN, JR.
(B)
Murder First Degree
Sexual
Battery/Firearm/Deadly Weapon or Serious Injury
Kidnapping/With a Weapon
Robbery/Carjacking/Armed
True Bill
HECTOR DARIO TRELLEZ
Murder First Degree True Bill
GAILE TUCKER LOPERFIDO
(A) and
DIANNE MARIE DEMERITTE
(B) Manslaughter/Aggravated/Child Under 18 (A)
Manslaughter/Aggravated/Child Under 18 (B)
Murder Third Degree (A)
Murder Third Degree (B)
True Bill
50
ACKNOWLEDGMENTS
Nine months ago our only commonality was
that individually we were part of a
large grand jury pool. By the luck of the
draw, our names were selected out of a fishbowl
and at that moment we became the
Miami-Dade County Grand Jury, Spring Term 2003.
Randomly selected, we were initially
separated by age, ethnicity and cultural
diversity. In spite of our differences, we
quickly came together and formed a motivated
team that possessed a strong desire to
speak in a single voice.
This process and our accomplishments as
jurors could not have been possible
without the efforts of Chief Assistant
State Attorney Don L. Horn who guided and
educated us. Thank you for your direction
and patience during these past months. For
the portion of our term dealing with the
Department of Juvenile Justice, we are indebted
to Assistant State Attorney Bronwyn Miller
for her unrelenting fervor in uncovering and
exposing the problems with the Department
of Juvenile Justice. She consistently led,
enlightened and encouraged us.
To those witnesses who appeared before us
and gave us a first rate education
regarding the Department of Juvenile
Justice, we offer our heartfelt thanks. We are truly
grateful for the dedicated men and women
of the various law enforcement agencies who
provided us with critical testimony.
Through their often-thankless efforts,
professionalism and dedication we were
able to make informed decisions.
The Grand Jury expresses its sincere
gratitude to Rose Anne Dare, Administrative
Assistant, and Nelido Gil, Bailiff, for
their dedication and commitment to making the
Grand Jury run efficiently and smoothly.
Their professionalism and skills made our days
enjoyable and our task easier to perform.
We also wish to convey our thanks to the
Honorable Judge Judith L. Kreeger and
State Attorney Katherine Fernandez Rundle
for their continued commitment and many
years of service to the Miami-Dade County
community and the judicial system, which is
an integral part of this great country in
which we live.
Our task was difficult and our journey
through the judicial system was at times
disturbing, frustrating, surprising and
enlightening. Ultimately, despite the great personal
and professional sacrifices made by each
of us, it was an experience we will never forget.
Respectfully submitted,
Connie Portela, Foreperson
Miami-Dade County Grand Jury
Spring Term 2003
ATTEST:
Shirley Boyer
Clerk
Date: January 27, 2004
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