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."
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.