Nolan, appointed to the commission this year, says most discussion at the board's meetings revolves around the Arizona Veteran Home, also headed by director Gallion.
The 200-bed nursing home opened in September 1995 at Third Street and Indian School Road in Phoenix. The $14 million facility has been plagued by cost overruns, lower-than-expected census and personnel problems, and has dominated much of Gallion's time.
But there's no place for seriously mentally ill vets of Donald Ellison's ilk at the shiny new facility, though his disability income of about $2,000 per month would have allowed him to pay his own way.
People familiar with Donald's plight say it's cruelly ironic that authorities deemed him stable enough to live alone in an apartment, but too unpredictable to reside at a nursing home for military veterans.
Norm Gallion claimed before the first Ellison story was published that he didn't know the details surrounding Donald's death. But Barbara Valdez says she pieced together what had happened--and it chilled her.
It was Valdez who took the call from Mary Howard, Donald's sister, informing AVSC of his death. And it was Valdez from whom Howard later demanded Donald's case file.
"I was shocked we hadn't known he died," Valdez says. "Then, after [Donald's social worker] Gary Warner gave me his case notes, I knew something was really, really screwed up."
She's talking about two things:
Warner's notes indicate he didn't check on Donald's welfare for days before, and never after the vet's release from custody.
Then, in an apparent effort to deflect blame from himself and AVSC, Warner's notes dated July 29 summarize phone messages that a ComCare case manager allegedly left for him--". . . ComCare had spoke to Donald through the door on Saturday, 7-27, and that he was not doing well . . . Donald passed away on 7-26-96."
Valdez believes the document is phony, because neither she, Warner nor anyone else at AVSC learned of Donald's death until July 31--two days after Warner's accusatory case note.
Warner did not return a message requesting comment.
"I'm sure Mrs. Howard suspected we were covering our butts, and it was true," Valdez says. "I wanted to tell her, 'We've got a problem here, ma'am,' but I just kept my mouth shut. That's something I'll have to live with."
Randy Brumm is blunt, practical and compassionate, traits valuable to a psychiatric nurse and union leader.
He's also outraged about what happened to Donald Ellison.
"When Donald was crazy, he was real crazy," says Brumm, who has worked at the Phoenix VA Hospital for two decades. "There were times I had to get down on the ground with him, subdue him, 'cause he was out of it. But when the meds were clicking, you could see another part of him. He was always crazy, but he'd give another vet his last cigarette if the other guy really needed it. He was part of the family."
No stranger to the labyrinthine mental-health "system," Brumm sees the Ellison case as horrific, but not exceptional:
"ComCare makes one awful decision after another about where to put all these SMI [seriously mentally ill] folks. They base their bullshit on supposed marching orders from the Arnold v. Sarn [class-action] case, which says we've got to put SMI back in the, quote, community. Their idea of stable is different than the rest of the world's, partner.
"AVSC had the legal duty to tell ComCare where to stick it--'It's our ward, and he's just not safe on the streets!'--but they really don't seem to care where their wards are. . . . Anyone who had anything to do with Donald Ellison going down should be fired, at the least."
On October 31, the state Department of Behavioral Health Services initiated an investigation into ComCare's role in Donald's death.
BHS is expected to probe ComCare's role in Donald's release from the psych ward, the propriety of placing him in an apartment, leaving drugs at his apartment when he didn't answer the door, and not notifying proper authorities of his absence.
State rules provide for several possible sanctions, though it remains to be seen if the BHS investigation will have teeth.
Also, at a December 10 hearing before Commissioner Robert Colosi, AVSC and its attorney, Harold Merkow, will be compelled to answer questions about the apparent mishandling of Donald Ellison's money.
However, it is beyond that hearing's scope to consider other glaring issues raised in the Ellison case.
Ultimately, AVSC and ComCare--which failed as sentries for a most vulnerable veteran--are likely to carry on as if Donald Ellison never existed.
