A Beating At Bellevue, Then Months Of Silence
By the time the blows stopped and his caretaker climbed off of him, Elimeen Carter’s face was a tangle of fractures. The bottom of his left eye had been crushed, and his nose had shifted visibly to the right, fragments of it loose under his skin. Blood spattered his pale blue pajamas.
Rewind the surveillance footage a few minutes to 7:53 a.m., Feb. 12, 2014. Carter stepped out of his room on the prison psychiatric ward of Manhattan’s Bellevue Hospital. Outside his door sat Dwain Rodrigues, an orderly assigned to be his monitor.
Rodrigues stood and advanced on Carter. The footage has no audio, so it’s impossible to tell what they said to each other. Carter stretched his arms out, palms flat, as he backed away.
Suddenly, Rodrigues kicked Carter’s groin and grappled him to the ground, flipping him onto his back. He slammed his fist into Carter’s face and smashed his head against the white linoleum floor. Then he stood and dropped onto Carter, driving his knee into the side of Carter’s head as Carter held his face in pain.
Rodrigues grabbed Carter by the hair and dragged him into his room. Other staff gathered and watched. No one stopped Rodrigues, who continued to beat Carter in the room, still visible from the hallway camera. About 30 seconds later, Rodrigues left the room. Carter lay on the floor, motionless, in his bloody pajamas.
Even though the beating was captured on video, Rodrigues was not charged with a crime for more than two years. What happened in the interim is a story of investigative and prosecutorial bungling — failures endemic to the New York State Justice Center for the Protection of People With Special Needs, a little-known but critical government agency whose mission is to safeguard disabled people in the state’s care and to make sure those who harm them are held accountable.
The Justice Center — granted full powers of law enforcement to protect the state’s most vulnerable citizens — is all but toothless, according to a BuzzFeed News review of court records and data on thousands of cases.
Last year, the Justice Center substantiated more than 4,000 cases of abuse or neglect — including 731 cases in its two most severe categories, which include assault, rape, and other acts that harm disabled people in the state’s care. But as of May 2016 only 52 of those cases had been prosecuted. That means that more than 92% of serious cases were never criminally prosecuted.
For the ultimate harm — death — the Center found 37 incidents in 2014 and 2015 when a caregiver’s abuse or neglect was involved in a patient dying. It prosecuted only one.
Justice Center officials, speaking on background, defended their record, saying that substantiated allegations can still be hard to prove in court beyond a reasonable doubt. They also said the Center was never meant to replace prosecutors statewide, but rather to backstop district attorneys and ensure that abuse didn’t slip through the cracks of the justice system. Indeed, of the 52 cases prosecuted in the last two years, local district attorneys handled 41 and the Center picked up 11.
“The agencies investigate themselves, and of course nobody’s going to take responsibility.”
Officials said the Justice Center punishes perpetrators in other ways, such as removing them from their jobs and blacklisting them for life, making it impossible for them to ever work with disabled or mentally ill people again in New York state. In 2015, the Center placed 138 people on its blacklist.
The Justice Center was founded in 2013 to fix the abject failure of its predecessor, the Commission on Quality of Care and Advocacy for Persons With Disabilities. That institution was so broken that in 2012 it pronounced itself incapable of effectively advocating for people with disabilities and asked the governor to shut it down. In response, New York’s legislature created the Justice Center, which Governor Cuomo announced with great fanfare as a new defender of the vulnerable, “dedicated to implementing the strongest protections in the nation for over one million New Yorkers with special needs.”
The state gave the Justice Center hundreds of investigators, a small army of lawyers, and an annual budget that is currently $54 million. It was granted exhaustive access to facility records and personnel, and its jurisdiction is extremely broad: The Center can prosecute anywhere in the state, with or without the consent of the local district attorney. With this expansive mandate, it was also supposed to put an end to the old system that allowed facilities in which abuse occurred to investigate themselves.
In practice, however, little has changed.
The Justice Center continues to farm out about half of its investigations to the very departments of the state government that licensed the facilities in the first place. And in many cases, those departments turn the investigations right back over to the facilities where the alleged abuse took place for internal investigators to handle. The Center has also systematically stonewalled an important watchdog, according to a suit filed by Disability Rights New York, which by federal and state law is mandated to monitor the Center’s investigations. Last year, the Associated Press reported that less than 2.5% of the Center’s substantiated cases had resulted in criminal charges.
The Justice Center said it reviews all investigations conducted by the departments and facilities it oversees, but conceded that those are “desk reviews,” in which the Center’s investigators usually do not re-interview witnesses or inspect facilities. According to job listings for the Center’s staff who review facility investigations, they are not required to have any investigative experience.
“The agencies investigate themselves, and of course nobody’s going to take responsibility,” said Harvey Weisenberg, a former New York State assemblyman who helped pass the legislation that created the Justice Center.
The result is that caretakers get away with abuse or neglect with few consequences.
Take the 2013 death of an 18-year-old man, who is identified as M.H., at a group home in Goshen, New York. The man, who was autistic and had intellectual disabilities, relied on a feeding tube, which progressively failed over eight months until he finally died. During that time, his doctor “repeatedly instructed staff not to take M.H. to the emergency room” and “did not assess M.H. for nearly three months prior to his death,” according to a report by the watchdog organization Disability Rights.
Rather than investigating whether the man’s doctor had been guilty of neglect, the Justice Center focused on the narrower question of whether the neglect had led directly to the man’s death, Disability Rights found. The investigation took 11 months, a delay that the Center has never publicly explained despite a statutory requirement to document the reasons for any investigation that takes longer than 60 days.
Ultimately, the Justice Center concluded that the conduct of M.H.’s doctors was “inadequate and inappropriate” but continued to allow his doctor at the group home to treat other patients there. (He was eventually removed by the administration of the home itself.)
In a written statement to BuzzFeed News, Justice Center officials said they had been unable to take action because the man was transferred to a hospital the day before the Center was legally created. (He died there of sepsis a few days later.) Since he had left the group home by the time the Justice Center started operating, the Center determined it could not prosecute the case.
Even when the Justice Center does take cases, it sometimes flubs them. In January 2015, Ryan Quinion, a guard and counselor at a juvenile center in Claverack, New York, was charged with multiple counts of assault by the Justice Center for allegedly unlocking the door of a 17-year-old resident’s room the previous March, allowing three other teenagers living there to enter and attack him.
Judge Charles Hoag dismissed the charges, finding, among other things, that the Center’s investigator had failed for two months to request crucial security footage, allowing it to be erased.
In August 2015, a jury took 10 minutes to dismiss charges brought by the Justice Center against two women who worked at a group home in Niskayuna, New York, who had allegedly overturned a couch while a disabled man in their care was sitting on it. It turned out the Justice Center’s case was built on the testimony of a single witness who changed her story each of the four times she testified during the trial.
What happened after Elimeen Carter was brutally beaten on the 19th floor of Bellevue Hospital epitomizes many of the Justice Center’s failures.
Carter, now 35, is a tall, heavy man with a thick beard and no front teeth. He was 16 years old when his relatives began to notice something wasn’t right. He would brag about his fame and success as a rapper, said his cousin Tamika Coleman, or point to cars on the street and say he owned them.
Sometimes he refused food, telling his family he thought someone was trying to poison him. “At first, we thought he was joking,” Coleman said. “We thought it was funny because we didn’t realize there was something wrong.”
A year later, his father, Willie Carter, got a call from Carter’s mother asking for help. For three weeks, she told him, their son had been isolating himself in his bedroom, refusing to eat or bathe.
Willie rushed over, he recalled, and found his son sitting in bed, distant and staring. “I thought maybe it was drugs of some kind,” Willie said. “Maybe he had smoked something or someone had put something in his drink.”
Carter was diagnosed with schizoaffective disorder, which joins psychotic symptoms such as delusions and hallucinations with bipolar traits, subjecting him to sudden, massive mood swings. When his delusions take him, Carter often believes that he is a prominent rap producer, a billionaire, and the son of Jay Z. Other times, he becomes suddenly enraged.
Since his diagnosis in 1998, Carter has spent much of his life in jails and hospitals, including stints on Rikers Island, at the Essex County Correctional Facility in Newark, and, repeatedly, at Essex County Hospital Center in Cedar Grove, New Jersey.
The result is that caretakers get away with abuse or neglect with few consequences.