Teen cried for help, got little
Up to death in lockup, girl’s complaints discounted
BY AMY UPSHAW
ARKANSAS DEMOCRAT-GAZETTE
June 15, 2005
LaKeisha Brown had slept through
the night, but she awoke on April 9 exhausted.
Instead of dressing for breakfast,
"Keisha" remained in her small metal-frame bed.
Her lips were pale and dry. She was
thirsty.
For most of her 17 years, she had
felt abandoned and unwanted. In just over two hours, she was going
to die.
Employees in her dorm at Alexander
Youth Services Center, a state juvenile lockup where she had lived
for nearly two years, asked the nurse to check on Keisha.
Nurse Lynetta Buckley arrived about
6:20 a.m. Keisha’s eyes were closed, and she responded only after
Buckley called her name and shook her.
Her pulse and respiration levels
were slightly high, but Buckley said they were normal.
"Client very weak," Buckley later
wrote in a report about that visit. By the time the nurse left, she
thought her patient appeared more alert.
A worried employee had asked
treatment supervisor Joy Cole if Keisha, who had been placed on bed
rest, could eat in her room.
"Make Keisha put on her clothes and
go to breakfast, because security is not to bring her any food," one
employee wrote that morning in recording Cole’s orders. Two months
later, an internal investigation by the state Youth Services
Division would cite "credible evidence" that Cole’s supervisor,
program director Joann McCoy, violated policy by telling Cole to
send Keisha to the cafeteria. The report also found that nurses
should have called a doctor about Keisha and that Cole dismissed an
employee’s request to call an ambulance for Keisha, and found
credible evidence that several employees failed to properly document
her failing condition.
An investigation by the Arkansas
State Police into Keisha’s death produced no evidence of criminal
wrongdoing.
But state legislators want to know
exactly how Keisha was treated in the hours before her death. So
far, Youth Services Division officials have declined to discuss her
case, citing federal patient-privacy and state youthful offender
laws. A joint meeting of legislative committees that deal with youth
services is to discuss the case today at 1:30 p.m.
Most of the adults who knew Keisha
best — employees who saw her every day — declined the Arkansas
Democrat-Gazette’s request for an interview, did not return messages
or could not be located.
Officials with the state Department
of Human Services, the agency responsible for Alexander, declined to
discuss Keisha’s case, citing federal patient-privacy laws.
But employees at Alexander are
required to keep meticulous notes, and those notes, along with
medical and psychological records obtained by the Democrat-Gazette,
tell the story of the end of Keisha’s life.
When Keisha was born, her mother
was a 17-year-old high school dropout with a toddler. The "club
life" — with its late nights and fights — excited Michelle Brown
more than full-time motherhood.
"I just didn’t want to have another
baby," Brown acknowledged.
So she sent Keisha to live with
Keisha’s father and grandmother in Osceola.
Only after Keisha’s death did Brown
learn through psychological reports how her decision devastated
Keisha, who complained for years that her mother abandoned her.
After giving birth to her third
child, Brown brought 4-year-old Keisha home to Blytheville, but
Keisha’s hurt remained. In later years, she would complain that
Brown beat her. Brown felt she simply disciplined a daughter who was
out of control.
Brown was still staying out late,
she recalls now. She dated the wrong men. Didn’t have a lot of
money.
When Keisha’s older brother Tracy,
then 10, waited up one night and eagerly asked his mother if she’d
fought anyone at the club, Brown decided to change. She eventually
became a church youth adviser and earned her General Educational
Development certificate. But she couldn’t change Keisha.
There is a Polaroid picture of
Keisha from elementary school days. Her hair is neatly braided as
she snuggles in her young mother’s arms on a sunny Easter. She’s
wearing a black dress with puffy sleeves and bright-colored flowers
and holding a basket her beloved "Granny Pooh" made before Granny
Pooh went to prison for selling drugs.
Nothing in the photo gives away
Keisha’s secret — that she was being sexually abused. The abuse
continued into her adolescence.
At age 12, she told her mother
about one incident, and they reported it to police. Police arrested
a relative’s boyfriend but he was not prosecuted.
She also learned to play a game
that most children couldn’t fathom. In "hide-and-go-get-it," one
child would cover his eyes while others scrambled under beds and
behind doors. When he found one of the hiding children, the two of
them would have sex.
In those days, Brown worked 12-hour
shifts at a local factory until nearly 3 a.m. Often unsupervised,
Keisha was smoking marijuana daily and defying her mother. She ran
away from home several times.
She called bomb threats in to
school, and school officials complained that Keisha broke every rule
she knew about.
Once when police hauled her to jail
for disorderly conduct, she snorted cocaine she had in a plastic bag
in her cell in hopes officers wouldn’t find it.
As her life spiraled out of control
over the next three years, she became suicidal, and went in and out
of psychiatric and juvenile detention facilities.
One day when she was 15, Keisha
failed to show up for cosmetology class, and Brown tracked her to a
crack house. She waited outside all day, yelling at approaching
customers and screaming at the dealers that they wouldn’t make any
money as long as Keisha remained inside.
When Keisha finally came out, Brown
called police.
"I can’t stand you. I can’t stand
you," Keisha screamed at her mother. "Why did you call the police?"
The answer, though clouded by anger
at that moment, was clear to Brown.
"It just got to the point that
every time I turned around, I had to go look for her," Brown
recalled. She could no longer handle Keisha, who by then was 200
pounds and taller than her mother. "I always said I didn’t ever want
to find her in no ditch."
After bouncing from a juvenile
detention facility to home and then back again, Keisha was sent to
Alexander in April 2003.
Maybe, just maybe, Brown thought,
they could protect Keisha from herself.
Like Keisha, the Alexander facility
has a troubled past.
It is the state’s largest juvenile
lockup, and workers there handle nearly 140 of the worst young
offenders at a time.
Over the years, the inmates have
complained that employees kicked, slapped and even threatened them
with death. Others killed themselves while there.
One boy, known for days to be
suicidal, was able to hang himself with a bed sheet because his
guard didn’t check on him. Another boy hanged himself in the same
cell just a few months later — just as the state hired Cornell
Companies Inc. to take over the facility and fix problems there.
In 2002, the U.S. Department of
Justice found that dozens of problems remained. Though most have
been resolved, state officials have said it will be at least six
more months before all are fixed.
In September 2003, Keisha was
transferred from Alexander to another facility after a fellow inmate
accused her of a sexual attack. Keisha later pleaded guilty to rape.
She returned to Alexander for the
final time Nov. 3, 2003.
Eventually, Keisha’s behavior began
to change. By late 2004, written complaints about her aggressive
behavior stopped. Her suicide attempts stopped, too.
She earned her GED and mailed
black-and-white copies of her certificate to relatives.
She finally began to think about
her future, beyond her planned May 1 release, and hoped to someday
help other girls like her, an idea she put into a poem in November:
The revelation of God’s plan is oh
so near.
It’s come to me, but not in a
dream, I’m suppose to help others as part of a team.
We will start up a home for other
lost souls.
To teach them God’s Word, and help
them reach goals.
So when someone else finds their
self in my place, They can turn to the Lord, and seek His face.
No matter how bad your situation
may be, Remember Jesus saved a hopeless case like me.
Brown, who lived about three hours
away, visited her daughter for the first time in almost two years
just a few weeks before Keisha died. She hadn’t visited sooner
because she didn’t want Keisha to think she approved of her past
behavior.
But now she felt Keisha had found
some answers and might someday lead a normal life. Just when they
had begun mending their relationship, Brown would later say, Keisha
died because the medical staff brushed aside her complaints.
The medical staff at Alexander had
a forced familiarity with Keisha.
In late 2004 and into 2005, Keisha
regularly asked for medical attention.
But the nurses who staffed the
facility until 10 every night and on-call doctors didn’t believe she
was sick, according to their notes. Psychiatrist Richard Livingston
described Keisha as "hysterical."
On Dec. 30, 2004, Keisha spent most
of the day at Alexander’s school crying and screaming that her back
hurt. The same day she wrote a three-page letter begging for help.
My medical conditions are being
neglected and ignored. I have taken the proper commands for some
attention. I’ve been complaining for exactly one week about my back
being hurt.
Nurse Kimberly Colclough received
the handwritten grievance and typed a response.
The nurses, Colclough wrote, found
nothing wrong with Keisha.
About a week later, Dr. Robert
Choate, a North Little Rock pediatrician on contract with Alexander,
examined Keisha. Choate ordered her to see a psychologist in hopes
of curbing her continuous complaints.
"She was counseled that her chart
had more complaints than I’ve seen from any other client," Choate
would later write in her medical records. "She has lost all
credibility with the staff."
The medical staff tested Keisha for
a possible urinary tract infection, her records show, but ordered no
other tests.
For four weeks, Keisha quit asking
for help.
But by February, she renewed her
almost daily requests for medical attention.
BACK PAINS.
Having asthma attack.
Chest & back pains Been coughing &
wheezing a lot today.
In early February, Choate refused
to see Keisha. He later wrote that her requests for attention
"appear to be manipulative and not valid."
On Feb. 6 she again filed a
grievance.
I’ve been writing sick calls
about my chest and breathing. [A]ll the nurses has been telling me
they can not do anything. I’ve been hurting like this since
Wednesday and the doctor refused to see me.
I feel my medical concerns are
being ignored.
"That was Keisha’s standard
response with every complaint that she brought to us, whether it was
a stubbed toe or shortness of breath," Choate said in a phone
interview Monday.
Three days after Keisha filed the
grievance, Colclough wrote Choate:
"This is becoming a problem because
she is crying in tears every morning that she can’t get out of bed
or walk to the kitchen. She is also missing groups and gym. ... I
have multiple staff approaching me daily on her situation. I have
been instructing staff that she is to continue to participate in
everything and to be held accountable for her behavior if she
doesn’t... it is becoming very time consuming for me."
But Keisha kept on.
I am short of breath at all
times even worse when I lay down.
Chest is tight. Having
difficulty breathing.
Chest & back aches hurts when I
breathe.
Eventually, Keisha’s therapist
confronted her, warning that her behavior could "negatively affect"
her expected May 1 discharge.
Within a few days, Keisha stopped
asking to see the nurses.
From Feb. 17 until her death,
Keisha requested medical attention only twice, once for dry skin and
once for a broken tooth.
But she told her family she was
still ill.
On Feb. 19, three days after her
last written complaint about her back and breathing, Keisha wrote
her Granny Pooh.
Things are getting a little
shaky for me. I plan on hanging in there though. ... I been sick a
lot lately. These nurses suck here. My back hurts a lot. When I
breathe a certain way it hurts in my left rib.
They tell me I’m not hurting but I
stay strong anyhow.
In the end, when Keisha lay dying,
no one with authority to get medical help believed her.
But other employees became
concerned about Keisha’s condition in the days before her death.
The night of April 7, as Keisha
stood in line to walk back to the dorm after softball, she stumbled
and fell. Though she never lost consciousness, she seemed very
sleepy.
Nurse Colclough found Keisha lying
on the ground, face up and unable to move.
"I found nothing out of the
ordinary," Colclough wrote in an e-mail to her bosses.
When Keisha nearly fell again,
employees drove her to the infirmary.
Colclough told employees everything
seemed fine.
"I was unable to find any physical
findings of a serious medical problem that would render Lakeisha
motionless, unconscious or unresponsive," she wrote in an e-mail.
Employees took Keisha to the dorm.
She did not come out of her room that evening, not even to shower or
write letters as she usually did.
Cole, the treatment supervisor, and
Colclough told employees they thought Keisha was just trying to
attract attention.
Keisha spent most of the next day
on a bench in the school office. Employees described her as "very
sick." To librarian Tressa Matthews, Keisha seemed pale and unable
to move. Cole again instructed employees to give Keisha no special
treatment.
The administrative assistant to the
medical staff would later tell investigators that Matthews called
and asked that Keisha receive medical attention. But, the assistant
said, the medical staff thought it was "just another complaint from
client Brown."
That evening, Keisha collapsed in
the cafeteria. Case manager Mary Taylor started to write a report
about Keisha’s worsening condition but Cole told her not to,
according to the internal investigation.
When two nurses arrived, they found
Keisha sitting on the sidewalk, breathing fast. As she had more than
a month before, Keisha said her chest felt tight, that she was short
of breath, and this time, dizzy.
The nurse recorded her vital signs,
including her pulse at 100 and her respiration at 30. A normal pulse
in a resting adolescent is between 60 and 90; the normal respiratory
rate is between 12 and 16.
Nurses did not notify Choate on
April 7 or 8, he said.
"I would have liked it if they had,
but, once again, I have to rely on their judgment," Choate said.
He believes that he and the nurses
provided Keisha with good medical care. They had no idea, he said,
that she might be suffering from blood clots in her legs.
A preliminary autopsy report shows
that those bloods clots likely traveled to her lungs and killed her.
"Even with good care people get
sick," Choate said. "Her nurses and me cared for her more than her
family did."
Dr. Barry Brenner, who heads the
emergency department at the University of Arkansas for Medical
Sciences, said in an interview that Keisha’s respiration and pulse
oxygen level, which was 95 percent, were alarming.
Vital signs exceeding normal levels
combined with complaints of shortness of breath and chest pains
often signal heart problems or pneumonia, said Brenner, who never
evaluated Keisha but discussed aspects of her condition at the
Democrat-Gazette’s request.
"Because of the pulse/ox and the
respiratory rate, you get an evaluation in the emergency room, which
includes a chest X-ray, an EKG and a blood gas," Brenner said. "I
bet something would have been wrong on those things.
"But you don’t know unless you
look."
The night before Keisha died, no
one looked.
Instead, the nurse gave Keisha two
puffs from her asthma inhaler, put her on bed rest and left.
7:20 a.m.: Shift supervisor Eva
Davis walked with Keisha as she shuffled the 350 feet to the
cafeteria. Twice they stopped so Keisha could rest.
Davis urged Keisha to eat at least
a little food and drink her orange juice. Eventually, Keisha ate a
few bites, her head resting on the table the whole time. Arkansas
State Police Special Agent Mike Dawson would later note that McCoy,
the program director and second in command at Alexander, told him
Keisha "ate good" that morning.
Just before 8, Davis and Keisha
left the cafeteria.
Keisha was too weak to make it back
to her dorm room. So employee Fannie Holt directed her to the gym,
50 feet closer.
As they walked, Keisha could barely
breathe. Once at the gym, she crawled onto a green-and-yellow
gymnastics mat while other girls played basketball.
"Keisha baby, are you OK?" a
16-year-old friend asked.
"I’m cold. I’m cold," Keisha
responded in a faint whisper.
Keisha was covered in chill bumps,
and her teeth chattered. Buckley gave Keisha 400 milligrams of
Ibuprofen — the equivalent of two pills. In Keisha’s chart the nurse
noted that the medication was for "minor pain/fever/ toothache."
About 20 minutes later, Davis asked
Holt to take Keisha back to the dorm.
Once outside, Keisha collapsed.
9:15 a.m.: Three employees and an
inmate carried Keisha to the infirmary.
At first, some staff were
unconcerned. A video surveillance tape shows three employees near
her feet, laughing and talking for several minutes.
But her condition quickly
deteriorated.
As she lay on the couch, she tugged
at her clothes, gasping for air and moaning.
Her pulse and blood pressure
dropped.
Her breathing became labored.
Her lips and fingernail beds were
white.
She lost consciousness.
"Keisha," the employees called.
Nothing.
One of the nurses called Choate at
9:22 a.m.
As they discussed Keisha’s vital
signs, the nurse suddenly said, "Doctor, I think she’s gone."
"Have you called 911?" Choate
asked.
9:28 a.m.: Nurse Buckley called
911. Though standing orders from a doctor and the facility’s written
nursing protocols require staff to give a patient oxygen and an
adrenaline shot during a respiratory emergency, the medical records
show they did neither.
Keisha had no pulse.
She wasn’t breathing.
Her eyes rolled back. Her face was
cold.
One employee suggested nurses try
CPR.
But nothing brought Keisha back.
In written reports about that
morning, some employees would remember the last moments of Keisha’s
life in the infirmary.
As she lay dying, Keisha thrust
herself into a near sitting position, grabbed employee Kenneth
Cooperwood’s pants leg, gasped loudly and collapsed — the last time
she ever reached out for help.
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