Surveillance video captured what happened at 10:30 a.m. on Oct. 12 in the moments before a developmentally disabled man broke his neck at a Panhandle psychiatric hospital: one staff member shoved the resident into his room. Two other employees quickly followed. They remained in the room for several minutes.
It’s what happened inside Reginald Schroat’s bedroom that remains a mystery.
After the three staffers left his room, the 40-year-old man summoned help, saying he could no longer move his legs. Surveillance cameras are not allowed inside living quarters at the state-operated Florida State Hospital. That means only four people know what happened inside Schroat’s room that day.
And one of them is dead, the victim of a broken neck.
“It’s wrong,” said Ethel Siegler, Schroat’s mother. “Something is very fishy there.”
“I told them I wanted answers. I want to know what’s going on,” said Siegler, 57, who lives in Lakeland. But one of the hospital’s administrators told Siegler “we can’t give you that,” she added.
Schroat, who had been declared incompetent to stand trial on a charge of failing to register as a sex offender, became the second man to die this year under suspicious circumstances while under the care of Florida disability administrators. And though his death is eerily similar to the death in March, it is impossible to say precisely what happened to Schroat, as leaders of two state agencies and a local police department have refused to provide crucial information related to the case, or to answer any questions.
The state Agency for Persons with Disabilities, which operates what is called the Developmental Disabilities Defendant Program, released a handful of reports about Schroat’s death to the Miami Herald Thursday night. But the agency obscured the dates related to Schroat’s injury and death — as well as when the agency alerted police and abuse investigators. Lacking dates, the reports suggest events occurred within a compacted time frame, though they did not.
The Department of Children & Families, which is investigating Schroat’s death as a possible abuse of a disabled person, would confirm only that it commenced a probe of possible “institutional abuse” on Oct. 18 at 11:29 a.m. — almost a week after Schroat broke his neck. A DCF spokesman refused to say how many days before the investigation was commenced the agency received its report. State law requires that such probes “begin within 24 hours” of an abuse report.
The Chattahoochee Police Department released a threadbare incident report, with no narrative and no details, only after the Herald asked the Florida Attorney General’s Office to mediate a dispute over public records being denied. The town manager later pledged to provide additional information, but failed to do so by the end of the week.
“The death of this individual is an absolute tragedy, and our hearts go out to the family,” said Barbara Palmer, the disability agency’s director. “Three weeks and several surgeries after the injury, the individual passed away at a hospital. While the investigation is continuing, employees involved have been put on administrative leave and one employee has resigned.”
Amanda Heystek, director of systems reform at Disability Rights Florida, said her advocacy group will be investigating Schroat’s death under its authority as a federally funded watchdog for disabled people. She criticized the state for withholding dates and other details from public records.
“The timeline always matters, and the timeline is part of transparency,” Heystek said.
Deborah Linton, an advocate for disabled people who heads the ARC in Tallahassee, said the state’s lack of transparency makes it difficult to protect people who can’t protect themselves. “They should be moving heaven and earth not to make the same mistakes again,” Linton said. “That’s the sad thing.”
“If you don’t acknowledge and learn from your mistakes, of course you’ll repeat them,” she added.
Siegler, Schroat’s mother, said she was not told her son had been gravely injured until Oct. 20, eight days after the incident inside his room. “All they told me was that he slipped and fell in the shower and broke his vertebrae. They said he broke three of them.”
“You don’t slip and fall in the shower and break three vertebrae,” she added.
Schroat had, in fact, slipped in the shower, but the fall had occurred at least five days before he broke his neck; the exact date is unclear, as APD erased it from an incident report dated Oct. 7. That report said Schroat sustained a three-inch cut on his left forearm, and a “knot on the top of his head.” The report made no mention of paralysis.
The Herald was able to piece together a timeline of events leading up to Schroat’s death, and the investigations it engendered, from sources with knowledge of the case. The chronology raises troubling questions: Why did the state hospital wait 22 hours before summoning an ambulance as Schroat suffered in his room with a broken neck? Why did administrators wait seven days before alerting police? Why did the disability agency wait 16 days to call the state’s abuse hotline?
Administrators won’t answer those questions, because they insist the dates are sensitive health information protected by federal medical privacy laws.
“That’s crap,” said Barbara Petersen, who head’s the Tallahassee-based First Amendment Foundation and is one of the most respected authorities on open government. “How a date of an incident could somehow reveal personal medical information is just crap. What it does is protect the agency.”
“All they’re doing is protecting themselves,” Petersen added.
Siegler said her son, whom family members called “B.J.” and “Bud,” was diagnosed at age 10 with an intellectual disability. As a six-foot-tall adult, he still had the mind of a 7-year-old child, she said.
Schroat liked to watch football games and wrestling. He was an avid reader, and especially liked novels by Stephen King or adventure books about the heroes of Texas history. “When he was little, a baby-baby, he’d go in the dirt and play with cars,” Siegler said. “Mostly, he stayed to himself, amused himself.”
Destiny Schroat says her cousin suffered from intellectual and developmental disabilities for as long as she can remember. “I was raised with him,” she said. “He was a child in his brain.”
“He had a lot of problems,” said Karl Schroat, his uncle, in Texas. “He was constantly using the restroom on himself. He had a hard time comprehending things.”
Family members said Schroat’s size, temperament and intellectual impairments could have made him a target, especially in an institutional setting.
APD reports on the events leading up to his death say Schroat had attempted “to engage in physical altercations with other residents” before he was “forcefully taken” into his bedroom by an employee.
Whatever happened inside that bedroom left Schroat paralyzed — and the medical care he received at Tallahassee Memorial Hospital was not enough to save him.
The Chattahoochee police report confirms only a “custody incident” on Oct. 12 involving employees of the state-run program. APD’s summary said Schroat remained in his room for several minutes with three staff members — beyond camera range — before the employees were seen leaving. At some point, a nurse was told that Schroat “was complaining he was unable to move.”
An examination showed Schroat’s “lower extremities [were] flaccid with no obvious voluntary or involuntary movement,” and “only limited movement of right arm and hand.” APD’s last notation was that Schroat “passed away at 4:52” on a date that was erased. He died on Nov. 3, sources told the Herald.
“If he got his neck broken, they should have gotten him help immediately,” said Siegler. “They should be the ones put in prison, because it’s their duty to protect my son.”
Schroat’s death is a significant blemish for the state’s disability agency, which is still dealing with the consequences of another in-custody death last March.
William “Willy” Lamson was a resident of the long-troubled Carlton Palms Educational Center in Mount Dora when he, too, suffered fatal and unexplained injuries while in a room with staff members. His encounter also was just beyond the range of surveillance cameras.
An autopsy concluded Lamson, 26, died of “traumatic asphyxia” — an explanation that was greatly at odds with the story Carlton Palms caregivers offered shortly after his death. Employees told Lake County Sheriff’s detectives Lamson died from banging his head after a staffer inexplicably seized a protective helmet he was supposed to wear at all times.
Lake County prosecutors declined to press charges against the caregiver with Lamson when he stopped breathing.
In a memo explaining their decision to forgo prosecution, they wrote that considering that Lamson “had a history of attacking his caregivers, the state would be unable to establish beyond and to the exclusion of every reasonable doubt” that his caregiver’s actions “constitute a reckless disregard of human life that would rise to the level of culpable negligence.”
In the wake of Lamson’s death, the state disabilities agency shuttered the facility.
David Lamson-Keene, Willy Lamson’s uncle, said this past week that the tragedy wrecked his family, especially his younger brother, James “Jamie” Lamson, the young man’s father. And the fact that prosecutors declined to press charges made it impossible for the family to understand and accept what happened.
“It was extremely frustrating, and I don’t know if we will ever get to the bottom of it,” Lamson-Keene said.
Lamson-Keene said he would encourage Schroat’s family to “turn over every rock” in their efforts to hold authorities accountable for what happened to Schroat. “The system seems to work in favor of” the employees, he said, not the residents.
Everyone, Lamson-Keene said, “seems to look the other way, and have it disappear. That’s what we faced.”
“The system failed us.”