Sins of Commission

The story of a psychotic Vietnam veteran who died on the streets rattles the mental-health-care and judicial communities, triggering investigations and calls for reform

A few Sunday mornings ago, Mary and Ernie Howard found a sitter for their three children and drove to American Legion Post 75 in north Phoenix.

The Glendale couple didn't know anyone at the Sunnyslope chapter, but had been invited to attend a flag-raising ceremony in honor of Mary's late brother, Vietnam veteran Donald Ellison.

The idea had come to legion regular Bob Hancock after he read a New Times story ("A System Gone Mad," October 24) about Donald's death on July 26. Donald collapsed on a South Phoenix street in 109-degree heat, one day after his release from the Maricopa Medical Center psychiatric ward.

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The official cause of death was "hyperthermia secondary to environmental heat exposure." He was 48.

The story detailed Donald's life--his upbringing in rural Gila Bend, his traumatic experiences as a 19-year-old Army machine gunner in Vietnam, his struggle with profound mental illness that doctors linked to his war experiences--and his seemingly preventable death.

It described how two agencies responsible for Donald's welfare, the Arizona Veterans Service Commission and the mental-health authority known as ComCare, had failed in their missions.

"When I read it, I felt a great deal of respect for Donald, and sadness, too," Hancock said before the flag-raising ceremony. "It just didn't sound like he got a square deal from the people taking care of him."

Post 75 wears its biases proudly: Men using the urinal relieve themselves on a likeness of "Hanoi" Jane Fonda. Slogans about God and country dot the walls. The American flag is revered.

Shortly before noon, Commander Ed Sherman led members of Post 75's honor guard--five men and three women--into the brilliant sun.

As the Howards looked on, the guard solemnly performed its duties. One man gently unfurled a worn American flag and hooked it to a pole that towers over the building.

"We raise this flag in honor of Donald Ellison, Private First Class and Vietnam vet," Hancock intoned.

A rifleman fired a blank into the air as Hancock raised the flag.
"That's it," he said, after a moment's reflection.
The simple tribute to her brother warmed Mary Howard's heart. She's the last of Donald's eight surviving siblings who still lives in Arizona, and had witnessed his mental deterioration and depressing trek through jails, mental wards and the streets of Phoenix.

A Maricopa County official had notified Howard of her brother's death, but not until six days after he'd collapsed.

She'd then learned that the Arizona Veterans Service Commission (AVSC)--Donald's guardian/conservator and legal equivalent of a parent--hadn't known he was dead. Neither had ComCare, a private agency funded to treat Donald and the county's other 13,000 seriously mentally ill.

ComCare had placed Donald alone in a Phoenix apartment after his release from the psych ward, five days after a supervisory-care home had turned him away because he was too unstable.

Records show ComCare employees who were supposed to monitor Donald's antipsychotic-drug intake instead slipped his pills under his apartment door at least twice after he didn't answer. (He was dead.) ComCare case managers failed to notify police or AVSC of his suspected absence, even after they hadn't seen him for six days.

Records also indicate that Donald's AVSC social worker had no contact with the vet after July 19--the day the supervisory-care home rejected him. The social worker didn't contact Donald after county doctors agreed with ComCare that he'd "stablized" and okayed his July 24 release from the psych ward.

"I'm no expert," Mary Howard said after the flag ceremony, "but I know when something stinks. The way they did Donald stinks. I hope what came out about how they treat people like Donald just doesn't get swept away."

Developments in the wake of "A System Gone Mad" make that unlikely:
* The state's Department of Behavioral Health Services has undertaken an investigation of ComCare's role in Donald's death.

* A Maricopa County court commissioner has ordered AVSC to appear December 10 to explain why it apparently misspent thousands of dollars of Donald Ellison's money. The county's presiding Probate/Mental Health judge also has asked accountants to begin auditing AVSC's handling of its wards' money.

* A top AVSC official who was recently demoted admits the agency is slipshod and routinely breaches its legal duties to its wards.

Not everyone is pleased Donald Ellison's sad saga has come to light. The naysayers include two of the seven AVSC commissioners who oversee the agency.

"I feel the article was truly inappropriate," says Sierra Vista resident Carroll Fyffe, immediate past national president of the Military Order of the Purple Heart. "It subjected the family to an awful lot of pain in my view. It was unfortunate that the man died, but it happened and I have no further comment. Mr. Gallion speaks for the commission as far as I'm concerned."

"Mr. Gallion" is AVSC executive director Norm Gallion, who spoke briefly with New Times before the first Ellison story.

"We do care about the veterans we serve," he said, promising to provide specific answers about the Ellison case. He didn't, and hasn't provided answers to subsequent queries.

"There wasn't a lot of substance against the commission in my opinion," says AVSC commissioner Neal Sundeen, a Phoenix attorney affiliated with the American Legion. "It was a sad story, but I think the focus was ComCare, not the commission. We're not a medical agency, and we didn't shove the drugs under the door. If we erred on the accountings, we'll fix it."

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