A System Gone Mad

Late on the sizzling afternoon of July 25, two police officers saw a disheveled black man pushing a shopping cart along a south Phoenix street.

He staggered a few steps, then dropped face first onto a sidewalk at 16th Street and University.

The man, who carried no identification, had a 108-degree temperature and was suffering from heat stroke. His breathing was shallow and his body seemed to be burning.

Paramedics immediately knew what they were up against.
"His body temperature was incompatible with life," says Phoenix fire Captain John Valenzuela. "It's hard to know what kind of pain he felt. He probably felt disoriented, didn't know where he was or where he was going. He probably didn't know his body was cooking like a piece of meat."

Valenzuela later learned that the victim was on antipsychotic drugs, which suppress a person's ability to perspire--and to cool his or her body temperature.

"Too many people taking the [antipsychotic] drugs aren't told about that," he notes. "The shame is that we see a whole bunch of those guys floating around out here."

The stricken pedestrian didn't have a chance. Within a day, doctors at Phoenix Memorial Hospital pronounced him dead.

The county medical examiner listed the cause of death as "hyperthermia secondary to environmental heat exposure."

Five days passed.
On July 31, an official from the Maricopa County Fiduciary's Office phoned Glendale resident Mary Howard. The morgue had identified the stroke victim through fingerprints. It was her brother, Donald Ray Ellison.

Farewell to a Brother
The midday sun beat down on the mourners at a cemetery near Gila Bend. It was August 3, 1996, eight days after Donald Ellison had died. He was 48.

His eight surviving siblings and about 50 family friends looked on as the Fort Huachuca Ceremonial Detachment performed its grim duties. The Army unit fired a 21-gun salute in honor of the fallen Vietnam veteran. An officer handed Donald's oldest sister a precisely folded American flag that had draped the coffin.

"On behalf of the President of the United States and my country," he told Alice Jackson, "thank you for your brother's service."

Donald was laid to rest in a plot next to his parents, Doshie and Jesse.
After the burial, the Ellison clan gathered to speak about better times, about how Donald loved to tease and laugh--when he was feeling right.

They recalled his jarring transformation from a fun-loving boy in Gila Bend to a combat-ravaged 19-year-old, and how he'd lost his mind in a baffling battlefield incident.

Finally, they lamented Donald's lonely adult life of mental hospitals, boarding homes, park benches and jails.

The family knew that Donald needed almost constant supervision. Why, they wondered, had he been allowed to wander in 109-degree heat, miles from an unsupervised apartment into which authorities had moved him a day earlier, straight from a psychiatric ward?

Everyone turned to Mary Howard, the only sibling who still lives in Arizona and the first relative to learn of Donald's death. But as she huddled with her kin, Howard too had more questions than answers.

After getting word that her brother was dead, she'd immediately contacted the Arizona Veterans Service Commission, which for years had been Donald's guardian/conservator--the legal equivalent of a parent. Donald had paid the state agency thousands of dollars in fees to keep him safe and watch over his finances.

Howard had been stunned to find out that nobody at AVSC knew Donald was dead. Neither, she soon learned, did ComCare, a private agency in charge of providing treatment to Maricopa County's seriously mentally ill.

"My brother was dead and I wanted to know what happened," she says. "What I got was butt-covering and, if you will, lying. Something very bad happened, and I don't think it had to happen."

Mary Howard has a point. The evidence in this tragedy reveals that the very agencies created to protect Donald Ellison--and hundreds of others like him--abandoned him and expedited his death.

Despite clear signs that Donald was unstable, doctors at Maricopa Medical Center and caseworkers at AVSC and ComCare agreed he was well enough to be moved from a psychiatric ward to an unsupervised apartment. In so agreeing, both ignored a litany of warnings in their own files and public records.

"When stabilized and ready for discharge," Arizona State Hospital's Faith LeFeber wrote in a prescient June 1994 evaluation, "Donald will need a supervised placement where his medication will be monitored. DONALD SHOULD NOT BE DISCHARGED TO INDIVIDUAL LIVING."

Remarkably, AVSC never checked on Donald after his July 24 release from the psych unit. Then, after finally learning of Donald's death, the AVSC social worker responsible for his welfare drafted a document that depicted an illogical chronology of events in a crude attempt to shift blame to ComCare.

Not that ComCare also isn't culpable. Its caseworkers were supposed to visit Donald twice daily to see that he took his antipsychotic pills. Instead, when nobody answered at Donald's apartment for days after his release, ComCare caseworkers merely shoved the pills under his door and left.

Those caseworkers never informed AVSC--the guardian/conservator--or police that Donald hadn't answered his door.

That's because he was in the morgue.
It would appear that by their action and inaction, both the agencies' employees broke an Arizona law that says: "A person guilty of . . . any neglect of duty toward a mentally disordered person is guilty of a class two misdemeanor."

Unfortunately, says Phoenix attorney Chick Arnold, "The system is set up to allow something like this to happen."

Arnold knows that system as well as anyone. When he was Maricopa County fiduciary, he filed a landmark class-action lawsuit (Arnold v. Sarn) that won--in theory, anyway--full funding of treatment programs for Arizona's seriously mentally ill.

"That this sad and dramatic result doesn't happen more is a testament to the compassion of the people working in the system," Arnold says. "But far too many sick folks still aren't getting appropriate placements and services."

That's the big picture. Also telling is the outrage over Donald's death inside the mental-health community. Donald was a sometimes-intimidating presence; his mental woes often overwhelmed him. But he also could be playful, courteous and likable.

"Don was a tough guy 'cause he'd had it so tough," says a mental-health worker who knew him well. "He was a big, mean-looking black dude with a jaw that had gotten twisted up somehow. He had a real raspy voice and you could barely understand him. But when he was stable--stable for him--he was a gentleman. What happened to him was a nightmare, a preventable nightmare."

Donald Ellison was a victim of a system that gives lip service to the concept of "least restrictive placement" for the county's seriously mentally ill--but which often can't find appropriate places to put them.

AVSC's failure to protect Donald from that system's shortcomings doesn't surprise those familiar with the obscure agency. Its caseworkers each must manage up to 100 incapacitated vets--more than twice the number recommended by the National Guardianship Association.

And as AVSC indifferently monitored Donald's existence, records show it also was wasting thousands of dollars of his money by paying for his lodging--sometimes two places at once--when Donald was in jail or in a mental hospital.

As for official oversight of AVSC, there has been little. Accountants retained by the court do analyze the financial filings of the county's private guardian/conservators, but not those of AVSC or the Public Fiduciary.

"This is so disturbing," Maricopa County Probate Court/Mental Health Chief Judge Pamela Franks says when shown examples of how Donald's money was misspent. "We have always assumed that we weren't dealing with a known crook with AVSC. Most of the veterans' estates aren't large, and we tried to save them the $175 per accounting that we charge for in-house audits.

And without exception--or objection from Donald's court-appointed attorney--county court commissioners approved AVSC's annual accountings from the time Donald became a ward in 1988.

They did so even though AVSC failed from 1994-96 to submit required annual reports, which are supposed to explain why a ward continues to need a guardian/conservator.

"The way this man was treated by AVSC seems to have been a case of malignant neglect," Franks tells New Times. "A guardian/conservator has legal and ethical duties to serve a ward diligently and properly. This is appalling. If this indicates a pattern, we'll have to reconsider our relationship with the agency."

Growing Up
Donald Ray Ellison was the second of Doshie and Jesse Ellison's ten children. The Ellisons were farm laborers who called Luling, Texas, home, but they moved with the harvest seasons across the Southwest.

The children--four boys and six girls--did their share of cotton-picking. It helped put food on the table.

Jesse Ellison was a stern, almost stoic individual who ruled with a heavy hand, especially with his boys. His wife was the family's heart and soul, a large woman beloved for her patience and sweet nature.

Mary Howard, the second-youngest child, says her mother "made sure we were close and looked out for each other."

In 1959, when Donald was 11, the Ellisons drove to Gila Bend to pick cotton. They didn't expect to stay long, but wound up settling in the tiny desert town located about an hour southwest of Phoenix.

Donald was popular with classmates in the racially diverse community, winning a seat on the student council in seventh grade.

"Don had a great sense of humor and got along with everyone," says Joe Diaz, an old friend who still lives in Gila Bend. "We played a lot of ball together, football and basketball, and he knew how to get after it. Good guy, normal guy. Until 'Nam."

Donald wasn't much for schoolwork, though a sister recalls him toiling over arithmetic problems, his tongue sticking out in concentration.

He dropped out of school after ninth grade and found work at a Gila Bend fast-food joint as an assistant cook, which he enjoyed.

In Gila Bend, there wasn't much of a ladder for a dropout to climb. Donald worked, flirted with the girls, played ball, drank beer and dreamed of a better place, with brighter lights, bigger buildings, prettier ladies.

In 1966, the 18-year-old heard the Army was interested in people like him. It sounded like a chance to make something of himself. But what he would become is not what he had in mind.

Project 100,000
In August 1966, Secretary of Defense Robert S. McNamara announced a bold new program at a long-forgotten press conference.

McNamara held out hope that "Project 100,000" would salvage tens of thousands of "America's subterranean poor" by luring them into the armed services.

At any other time, most of the 100,000--actually, 354,000 became soldiers before the program ended in 1971--wouldn't have qualified for service. But the war effort was escalating, and the military needed bodies.

Recruiters swept through inner cities and rural outposts, signing up dropouts and even legally retarded young men.

McNamara called his recruits "New Standards Men." Some in the military scorned them as "McNamara's Moron Corps."

Touting the military as an opportunity for remedial education and an escape from poverty made for a convincing pitch. But in fact the recruits provided an abundant supply of cannon fodder, and meant fewer sons of the privileged had to be drafted.

For a majority of the recruits, Project 100,000 was a one-way ticket to Vietnam, where they died at a rate double that of other soldiers. Forty-one percent of the project's soldiers were black, compared with 12 percent of the rest of the armed forces.

Donald Ellison joined the Army on September 21, 1966. At Fort Ord in California, he was taught to use a machine gun.

His next stop was Vietnam. Donald was a few weeks shy of his 19th birthday.

Donald rarely talked about Vietnam, and available records only hint at what he endured there. But those records leave no doubt he faced fierce combat for most of his five months in country.

Few places were more dangerous in 1967 than Quang Tri Province, a hellhole of booby traps, hand-to-hand combat, vermin and oppressive humidity. Located just south of the demilitarized zone, it housed the forward headquarters of the 3rd Marine Division, to which Donald was assigned to provide support.

Donald later told doctors he'd practically lived on a large truck, riding from battle to battle. PFC Ellison would earn the Gallantry Cross With Palm Unit Citation, the Good Conduct Medal, Vietnam Service Medal and Republic of Vietnam Campaign Ribbon.

Donald sent his mother money from Vietnam, telling her to spend it as she saw fit. The Ellisons proudly used the gift as a down payment on property in Gila Bend.

But Donald's family had no idea what he was going through. One historian wrote: "The Marine war along the DMZ was devastating in its intensity, numbing in its length, appalling in its casualties and inspiring in its heroism."

Donald discovered new ways of coping. Like many peers, he started smoking potent Vietnamese marijuana.

"He stated when he used pot, God possessed him and would bring him home safely," a doctor wrote of Donald in August 1967.

By his own account, Donald awoke July 31, 1967, and smoked a joint. That afternoon, he attacked and apparently cut a corporal with a razor.

He was placed in restraints, tranquilized, then evacuated by helicopter to the USS Repose, a medical ship. There, doctors determined that Donald had slipped into an "acute catatonic state."

Official accounts of his attack on his fellow soldier are scarce, and Donald never told his family about it. One tantalizing clue comes in a report filed the day after the assault, in which the Army adjudged his behavior "line of duty [connected], not due to own misconduct."

The Army shipped Donald to a military hospital in San Francisco, where a psychiatrist noted Donald's cryptic account of the violent incident: "God had hit him in the side and forced him to cut the other soldier's throat. He expressed the hope that if God ever spoke to him again, he would not be hit so hard in the side."

The Ellisons learned of Donald's fate shortly after he left Vietnam. "They told my mom Donald was shell-shocked," recalls his sister, Alice Jackson. "They didn't give specifics, other than he had been through too much combat."

Donald seemed to improve at the San Francisco hospital. By late 1967, doctors said he was well enough to return to active duty, stateside.

His so-called recovery would be short-lived.

While stationed at El Paso's Fort Bliss in 1968, Donald Ellison forever lost his tenuous grip on reality.

Military police that January took Donald to a mental hospital after he began making threats. One MP recalled him repeating, "I am confused, but I must regroup. I must."

"Patient became very anxious and upset tonight," a nurse wrote on January 27, 1968. "Paced ward. Talking loudly and at times almost constantly--was hearing and ducking from machine guns and seeing people throwing grenades at him. Appeared frightened and angry. . . . Saw a cobra in his bed."

"War is different from peace," he told a shrink. "You just don't understand. You have to make the best of it. . . . I may not have been the best soldier in 'Nam, but at least I was a good one."

In May 1968, the Army granted Donald an honorable discharge. The Veterans' Administration awarded him a 70 percent disability for service-connected disabilities--"a severe schizophrenic reaction, paranoid type." His disability compensation would jump to 100 percent a few years later.

Donald returned to Gila Bend. The Army gave him prescriptions for antipsychotic pills and the address of the Phoenix VA hospital.

"My mom got her son back from Vietnam," says Mary Howard, "but she didn't get the same son. We got him back in his darkest hour--and we got what we got."

Mary Howard, 12 years Donald's junior, was a young girl at the time. But she recalls his return vividly and chillingly:

"He'd just set in the La-Z-Boy and stare, watch the windows with a shotgun on his lap. He wouldn't talk about the war, and I'd be wondering what was going on in his mind. I saw so much confusion in his eyes. I don't think I ever saw him cry. It was hell."

Donald did discuss some of his war experiences with another sister.
"He was all locked up into what he went through in Vietnam," recalls Alice Jackson, two years younger than Donald. "He'd talk about not trusting anyone there because people wanted to get him. Even children were dangerous because they could be all boobied up. He said he had to watch his back and his front at the same time."

Donald often refused to take his pills, preferring alcohol and illegal drugs. He couldn't hold a job. And he started to have run-ins with the law.

Months after Donald returned to Gila Bend, police arrested him on a disorderly conduct charge, his first of dozens of similar arrests over the next quarter-century.

"He'd walk around town in a daze most of the time," recalls Joe Diaz. "He'd just stare or be in people's faces just like that. 'Nam must have been hell on that dude."

Into the Darkness
A discouraging pattern had developed by the early 1970s: Donald would get arrested for something and end up in a mental hospital.

There, he'd be heavily medicated, "stabilized," then discharged with orders that he take his pills and try to behave.

Donald often tried to turn his life around.
In 1976, he lived alone in a Phoenix apartment and found work as a gardener at Brophy College Prep. He was well-liked, and his employers encouraged him to seek his GED.

He earned it, then lost his job because of chronic tardiness.
He took to pacing the streets for hours, often stopping to drink at seedy bars. Donald had few friends, mostly because he was wildly unpredictable. One minute, he'd confront someone over a perceived slight; the next, he'd laugh and walk away.

In the late '70s, Donald moved to Southern California, where most of his siblings had migrated. The change of scenery did no good.

"He claims that nothing goes right for him," a doctor there noted in July 1977, "that he was fired from his job. He has been drinking quite a bit and so he sought help in the hospital. It is doubtful if this patient will ever be able to hold onto a job."

Donald moved to L.A.'s Skid Row. In 1979, his VA disability checks--his sole source of income--stopped coming to his post office box. Donald phoned the Veterans' Administration and was told to put his complaint in writing.

In a handwritten letter dated June 4, 1979, Donald stated:
"I recall my first two months in Los Angeles, which I received the VA check. For the next five months I lived in the streets withstanding the cold and rain of the winter. There were times I sought work through the employment office. Jobs were slow to come by . . ."

Donald won his appeal. The government sent him a letter of apology, and a check for the erroneously terminated payments.

But he could not halt the encroaching darkness.
In 1980, Los Angeles police arrested Donald after he brandished a small knife at a bus stop. A judge committed him to a state mental hospital.

Two years later, with Donald's release imminent, a psychiatrist issued a warning: "The veteran continued to be impaired by his experiences in Vietnam. . . . He requires continued comprehensive care and treatment. His behavior at this time would be unacceptable in home and community."

But authorities then told Donald he was free to go where he wished.
Bright moments were rare. One came in 1984, when his sister Mary asked him to escort her at her wedding.

"Our dad died [in 1981] and Donald was my next in line," Mary recalls. "Someone before the service asked him if he was nervous. He says, 'Hell no, I been fighting with the Vietnamese. I can handle this.' No smile, no nothing."

When his mother died in January 1987, Donald was enveloped by a new wave of depression. More run-ins with police ensued, and an attorney representing Donald suggested that the Arizona Veterans Service Commission be appointed as his conservator.

The Arizona Legislature created AVSC in part to "act as guardian of an incapacitated veteran . . . or as conservator of the estate of a protected veteran." AVSC may charge a "conservator's fee" of up to 5 percent of a ward's income--about $1,000 a year in Donald's case. That doesn't include "legal accounting" fees, which came to about another $500 per year.

For fiscal 1994, the agency reported cash disbursements on behalf of its wards of $11.2 million.

In 1992, AVSC also became Donald's legal guardian. Arizona laws spell out the agency's duties: to do what's best for its wards, personally and financially.

Donald's relationship with AVSC was never good, and he complained time and again to his family that he was getting ripped off.

"My brother was sick," Mary Howard says, "but he kept telling me [AVSC] was paying for services he wasn't using. I know now he was telling the truth. He lived on the streets far more often than not, and they would go for weeks not knowing where he was."

Records submitted to the Probate Court, which must approve all AVSC expenditures, confirm Donald Ellison's suspicions.

From March 1993 through March 1994, for example, the VA mailed Donald's disability checks totaling $20,892 to AVSC. With that money, AVSC paid itself $1,146 in "conservator's fees," and its attorney, Harold Merkow, another $561.

Also from Donald's account, AVSC paid the Burkeshire Retirement Hotel $620 a month from April to December 1993. It paid Burkeshire an additional $25 a month during that time to do Donald's laundry, and $50 monthly to "monitor" his intake of antipsychotic pills.

At the same time, AVSC also paid Fountain in the Green Apartments $341 monthly to cover Donald's rent. In a July 1993 "annual report" to the Probate Court--the last such report it would file--AVSC listed Donald's address as Fountain in the Green.

Exacerbating this misfeasance was the fact that, according to jail and hospital records, Donald spent much of 1993 in custody of some sort, or on the streets.

AVSC only rarely sought and received refunds from Donald's landlords, and none in 1993. One reason is that the agency automatically pays "vendors" each month before receiving itemized bills.

Months may pass before AVSC gets wind that a client's living situation has changed.

For example, AVSC in November 1995 issued rent checks on Donald's behalf totaling $2,150 to one boarding home and $950 to another home. Donald was in jail or in a mental hospital for all but six days that month.

In another instance, on February 1, 1996, AVSC paid La Fontenelle Guest Lodge $528 to cover a month's lodging for Donald. But Phoenix police jailed Donald on assault and disorderly conduct charges February 5. That day, a court commissioner ordered Donald to the county psych ward as "persistently, acutely disabled." He wouldn't be released for six months.

That didn't stop AVSC from remitting another $650 in rent to La Fontenelle on February 28. (AVSC hasn't yet submitted its final accountings to the Probate Court, and it is not clear when they stopped paying the boarding home.)

Because of large court calendars, jurists must rely on a ward's attorney to raise objections to fiscal or other matters. Records in Donald's case show no instances of his attorney objecting to the agency's accountings.

"In the past, we'd never get notice from the court that AVSC had even filed its accountings," explains Connie Leon, Donald's attorney since 1992. "There was nothing to object to. That's the way it was until Judge Franks changed things a few months ago."

Court commissioner Robert Colosi says he and the other jurists who routinely approved AVSC billings over the years should bear some responsibility.

"It would be easy for me to say we don't have enough time to pore over every bill," he says, "but that's not a good enough excuse. . . . I hope it's not the tip of the iceberg."

A Protected Class
The outlook brightened in the early 1990s for Maricopa County's 10,000-plus seriously mentally ill people--SMIs in health-care vernacular.

Until then, Arizona had ranked at or near the bottom in spending on services for its SMI population.

That changed after 1989's Arizona Supreme Court ruling in the historic lawsuit known as Arnold v. Sarn. In a bold move, the court ordered Arizona lawmakers to start funding programs for SMIs.

Since 1992, the county's SMIs have been treated through ComCare--Community Partnership for Behavioral Health Care--under a contract the agency holds with the state.

As a member of the "protected class" in Arnold v. Sarn, Donald Ellison automatically became a ComCare client, meaning he had two systems designed to look after him--the Arizona Veterans Service Commission and ComCare.

"Of all the vets I have represented, Donald was among the most special," says Connie Leon. "He could be a very enchanting person when he was well, though even on his good days he would talk delusionally. His was a true psychosis induced by his experience in Vietnam. He couldn't help himself."

In March 1989, a car struck Donald as he wandered onto East Van Buren Street one evening. He declined medical treatment for an injured leg.

Days later, he again was involuntarily committed to the Arizona State Hospital. It happened after he turned on the stove in his latest residence--a rickety motel on Van Buren--and piled a stack of wood on his bed.

Doctors at the mental hospital ordered x-rays of Donald's injured leg: It was broken.

His ever-revolving-door--jail, mental hospital, discharge--continued. In 1995, Donald again was incarcerated after he allegedly threatened a Phoenix cop with a knife. That December 6, a judge ordered him to undergo one year of mental treatment--with a maximum of 180 days in a mental ward and the rest prospectively as an outpatient.

Such court-ordered treatment is allowed in Arizona when "a patient is unwilling to accept or incapable of accepting treatment voluntarily."

They could call it the Donald Ellison Law.
A variety of records makes it possible to retrace the last months of Donald's life almost by the hour.

Last February 6, after a week of freedom, Donald again was back behind bars on the assault and disorderly conduct charges.

County doctors blamed the relapse on a "substance-induced mood disorder"--booze and illicit drugs. But a blood test showed he hadn't been drinking or taking drugs.

His mind was malfunctioning on its own.
In previous years, several judges had committed Donald to the Arizona State Hospital as gravely disabled and incompetent to stand trial. Although Donald hated ASH, hated all forced treatment, his family always considered him to be at his safest there.

But ASH is far less often an option these days for people like Donald.
One reason is the Arnold v. Sarn "exit criteria" agreed to last November 13 by attorneys for the plaintiff SMIs and the defendants, the state of Arizona and Maricopa County.

Diverting patients from ASH and preventing "unnecessary and inappropriate hospitalization" of the mentally ill are linchpins of the agreement. The pact also discourages placement in supervisory-care homes "except in a unique situation." Again, the reasoning seems sound: Many boarding homes aren't even fit for animals.

Most experts agree deinstitutionalization is a noble concept, a compassionate way of freeing the mentally ill from the ghetto of government psychiatric incarceration.

But authorities couldn't find a "least restrictive placement"--short of the homeless shelter or the street--that would accept a degenerating Donald Ellison. He was far too sick.

The prime alternative to ASH and supervisory-care homes is called "community placement," which ideally includes intensive monitoring of clients in their own homes.

"The prevailing theory is that supervisory-care homes are in place only because there aren't good community-based services available," attorney Chick Arnold explains. "Discouraging placement in supervisory-care homes, the theory goes, is going to provide an incentive to the system to develop the kind of individual living services that are needed. Theoretically."

In truth, Donald was in limbo, caught between the lofty aims of Arnold v. Sarn and real life.

By last May, records show, ComCare inexplicably had dropped him as a client, despite his permanent status as a gravely disabled patient.

But a May 10 fax from ComCare to the Maricopa County Jail confirms its action: "Case closed, but can be reopened if he wants it."

ComCare reopened its file on Donald, though it's unlikely he knew what he wanted.

Jail records paint a disturbing portrait of a pathetic figure.
May 10: "Reeks of BM [feces] . . . Noted to be hoarding BM in Styrofoam cups."

May 28: "Screaming--threatening and out of control."
June 2: "Became loud, hostile, threatening, banging on doors. 'I want my Bible, my food and my bag of shit.'"

On July 3, authorities transferred Donald to the county psych annex at Maricopa Medical Center. It marked his 12th admission to the facility in less than a decade.

These days, the county hospital serves as a treatment "provider" to ComCare, the same as the private Samaritan hospitals and other area facilities. In effect, ComCare purchases a service from such providers, and ultimately decides who's admitted and who isn't.

But doctors retain the right to disagree with the ComCare clinical team's evaluation. This right--and responsibility, and how doctors in Donald's case failed to utilize it--loomed large in what was about to happen.

A few days after he arrived at the county hospital, Donald tried to fill out a questionnaire. "Why were you admitted to this hospital?" it asked.

"Paranoid schizophrenia, Donald Ellison, my illness," he scrawled.
Two of Donald's sisters from California visited him at the hospital over the July 4 weekend.

"It was really sad," says Alice Jackson. "He was very sick and he was slipping away from us. He said, 'You think you're so smart, but you don't know nothing on my life.'"

On July 9, Donald met at the psych annex with a ComCare case manager, who made notations after the meeting: "Discussed with [Donald] where he needed to go after discharge, and that it would be a place where staff can monitor his meds, and [Donald] agreed with this."

Toward the end of his three weeks at county, Donald did show slight signs of "stabilizing": He wasn't hoarding feces anymore, and he wasn't drooling as profusely.

But his sister Mary Howard wasn't convinced. She expressed her feelings during a July 17 meeting with his AVSC guardian/conservator Gary Warner, a ComCare case manager and county hospital personnel.

"I said Donald didn't seem to be snapping back like he had before," Howard says. "He seemed just sicker than ever to me."

No one, she adds, broached the possibility of moving Donald into his own apartment.

"We discussed the option of him going into New Life, a residential abuse program," a ComCare case manager wrote after the meeting, confirming Howard's recollections. "If he is not accepted in the program, he can come back to the hospital."

Mary Howard spoke with her brother for the last time shortly before she left for a family reunion in Texas.

"He told me, 'Buy me a ticket, sister,'" she says. "I told him it was too late. He said he was getting out real soon. I said I'd see him soon."

Howard wouldn't know how badly Donald's interview at New Life had gone until after he died and she got access to AVSC records.

"Took Donald to New Life for an interview for possible placement," AVSC social worker Gary Warner wrote in a case note dated July 19. "Shelly from ComCare helped transport, was at the interview. Donald did poorly at the interview. Facility stated they would take him only if he was stabilized further through longer hospitalization.

"Returned Donald to MMC Psych Annex. Shelly asked if ComCare could put Donald in an apartment, near one of their programs, so the program could monitor and administer Donald's medication. I agreed to this."

Actually, the reference to Donald's doing "poorly" is an understatement. Sources tell New Times he defecated on himself at New Life and acted, predictably, like a profoundly disturbed man.

"They had told me, 'We'll put him in residential treatment for a month and see what happens,'" Mary Howard recalls. "So he got rejected by the home. Being out there all alone was Plan B?"

Donald's lawyer, Connie Leon, visited him that week, and says she also assumed he'd be moved into a supervised-care home.

"He always would need extra supervision," says Leon. "There's no possible way he could have made it on his own. Donald wouldn't know how to make a hot dog, do laundry--life skills like that didn't stick with him. But ComCare wanted him out of the hospital because of Arnold v. Sarn, and I guess everyone else fell into line."

The conformists included Donald's doctors at Maricopa Medical Center.
"There was improvement in his thought process and the patient exhibited no violent behavior," doctors Balwinder Pawar and David Kidwell concluded in a July 23 discharge summary. "The patient was compliant with the treatment, and free from alcohol and drug abuse. . . . ComCare to do the follow-up."

The next morning, Wednesday, July 24, ComCare signed Donald out of the county hospital and into an apartment.

He would survive for less than 48 hours.

The End
ComCare case manager Steve DeGroot bought Donald food and kitchen utensils and moved him into an apartment complex at 6110 North Seventh Street.

Mary Howard was at the family reunion. But her husband, Ernest, and her brother Bubba spoke briefly with Donald by phone on the evening of July 24 and on the following morning. During the first conversation, Donald told them he was partying with an unidentified woman.

Those were the only clues Mary Howard had when she called AVSC on July 31 to learn more about her brother's death--only to discover the guardian/conservator didn't even know he was dead.

AVSC's Gary Warner wasn't available, so Howard spoke with an administrator and then with social worker Liz Robertson.

Robertson made detailed notes of what she discussed with Howard, and with ComCare's Steve DeGroot.

"ComCare staff were supposed to administer meds to Donald every day," Robertson wrote on July 31. "The last time that Steve saw Donald was 7-25-96, Thursday. On 7-26-96, Friday, ComCare staff went to administer meds, but there was no response at Donald's apartment, and then the same thing on Saturday.

"On Sunday, there was no response. They knocked on the door and then pushed the envelope [containing medicine] underneath the door. The ComCare staff member says someone pulled that envelope from the inside."

What Robertson was learning troubled her.
"ComCare were supposed to administer meds to Donald," she wrote. "How come they did not do the same thing [push meds underneath the door] on the previous days? Other questions: If they did not see their client for three days, how come they did not call the police? Too many unanswered questions."

She spoke again with DeGroot, and again documented the conversation:
"Steve called [Donald's apartment complex]. They checked in. No one in the apartment and the meds are still on the floor, and there was an empty bottle of gin.

"Earlier, [DeGroot] had stated that he saw Donald on 7-25-96. Questioned him about that. He said that he checked his notes and that the last time anyone from ComCare saw Donald was 7-24-96--the day he was released from the county psych annex and moved into an unsupervised apartment although he could not administer his own meds."

Connie Leon also was outraged when she heard this. "It's sick that ComCare thought it was sufficient to stick his meds under a door," she says. "A guy with Donald's history?"

Robertson limited her report to ComCare's role, not her own agency's, but her observations have the ring of truth. Not so with Gary Warner's typewritten file notes.

By his official account, Warner apparently did nothing on Donald's behalf after July 19--the day of the disastrous New Life interview.

His next entry is dated July 29:
"Had two calls on voice mail from ComCare casemanager Steve. First one stated that ComCare had talked to Donald through the door the evening of 7-25. He would not open door, so they slid the medications under the door.

"The second message stated ComCare had spoke with Donald through the door on Saturday, 7-27, and that he was not doing well. Was wondering if AVSC could go see client on 7-29. Donald passed away on 7-26-96."

Not doing well, indeed. Donald was dead.
But Warner didn't know this, despite what his note says. Neither Warner nor AVSC knew Donald had died until at least two days after Warner's purported July 29 entry.

Moreover, someone--AVSC's Warner or ComCare's DeGroot--lied about ComCare's supposed July 25 and July 27 "through the door" contacts with Donald. Donald had collapsed before either contact could have occurred.

Warner was responsible for more than 75 veterans at the time, in the Valley and northern Arizona. It's understandable, if not excusable, that he dropped the ball in Donald's case.

What's intolerable, says Mary Howard, is that Warner tried to cover up his mishandling of the case.

"Gary was trying to put stuff on ComCare and he bit himself hard in the butt," Howard says of the dubious case notes. "ComCare has its own problems. They lied about when they saw Donald, when he was already dead. None of these people should be let off the hook."

Warner referred questions from New Times to AVSC director Norm Gallion, but not before he tried to explain his official notes:

"I'm sure you've seen where people type things on computers and you can print them up on one page. Those are a couple of lines summarizing things that have happened. Obviously, you need to have a lot of gaps filled in here--but not from me."

Not from Norm Gallion, either. Gallion spoke briefly to New Times this Monday, and promised to supply answers to a written list of questions. But he didn't respond to calls after the first interview.

Other questions persist:
How did Donald get from his new apartment in north central Phoenix to a street near the Salt River, a distance of some eight miles? And who drank the "bottle of gin" Liz Robertson referred to in her notes? Blood tests at Phoenix Memorial and Donald's autopsy revealed he hadn't been drinking.

Ultimately, says Mary Howard, none of that matters much. What does matter to her is what she told the emergency-room doctor who treated her brother.

"He told me he'd thought Donald was a transient, a bum," she says. "I said Donald was a Vietnam vet who fought for his country and had gotten sick doing so. The doctor apologized. 'I'm sorry. I didn't know that.


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Paul Rubin
Contact: Paul Rubin