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.