A System Gone Mad

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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.

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Paul Rubin
Contact: Paul Rubin