Orlando Sentinel Lauren Ritchie column

Sept. 28--Dead bodies don't lie.

State investigators should listen more closely to what the body of 14-year-old Paige Lunsford had to say about her death at Carlton Palms Educational Center for severely disabled people.

Paige, who couldn't talk because she was severely autistic, physically fought employees there at every turn. She wore a soft helmet because she would bite her arms and shoulders without it.

But Paige's body left a sickening message when she died July 6, 2013, at the facility in the rural Lake Jem area. And the agencies that oversee Carlton Palms had better pay attention.

Investigators from the state Department of Children & Families concluded that Paige, who had been vomiting for days "like a waterfall," according to one staffer, died because staffers failed accurately to report her illness to superiors, and the nurse and doctor in charge didn't pay enough attention to her.

The report on the teen's death says she died of dehydration caused by a stomach bug. Dehydration? In this day and age? How is that even possible? Dehydration is a condition easily solved in minutes by an intravenous drip of fluids at a hospital if the patient can't keep water down.

DCF's 22-page report on the child's death revealed disgusting facts about how this facility that is supposedly equipped to handle the most difficult of disabled people botched a simple case of the stomach flu, resulting in the death of a child.

Virtually everyone interviewed gave a different account of when and how much Paige was throwing up, whether she was strapped into restraints while vomiting, when she died and how she died.

And, of course, the surveillance cameras the state required Carlton Palms to install after an earlier episode of abuse at the facility didn't capture what happened. They were accidentally erased, according to Tom Shea, Carlton Palms director.

Here's how the very slight teenager died that Saturday morning, according to what account you choose to believe:

After having thrown up for five days, Paige was tenderly cradled in the arms of the weekend and nighttime supervisor, who said she held the girl on and off throughout the night, giving her Tylenol and chocolate milk. She was still holding the child at 7:20 a.m. when another staffer came into the room and noticed Paige's lips were blue. The supervisor put her on the floor and began to perform CPR. A defibrillator was available, but staffers neither used it nor explained why they failed to do so.

That was the "good" explanation. Here's another, pieced together from the statements of a variety of staffers and patients:

Paige spent that final Friday night sometimes tied into a restraint chair because she kept banging her head on a wall and biting herself, typical behaviors for her level of autism. One supervisor described her projectile vomiting 25 to 30 times. Staffers called the director of nursing, who didn't come to see the child.

Carlton Palms residents told investigators they listened to Paige scream and cough all night. In the morning, she had her medicines and a Popsicle at 7 a.m., and 20 minutes later her heart stopped.

Either of these scenarios is gruesome. Why would a supervisor give milk to a child who has been vomiting for days? Milk can irritate the stomach lining and cause increased vomiting and anyway does not contain electrolytes needed by someone who has been throwing up. A supervisor in such a facility doesn't know something so basic about first aid?

Indeed, who lets a child vomit for five days without taking her to a hospital? What kind of person watches a kid throw up 25 to 30 times in a single night without dialing 911? How easy it would have been to save Paige's life. What is wrong with these people?

As if all this isn't bad enough, buried on the final page of the DCF report is something even more troubling than what Carlton Palms staffers admitted.

It is a single paragraph that seems almost an afterthought, brushed off. It states, in part:

" ... when EMS arrived, the child was already in rigor mortis, which indicates she had been dead for some time. This does not match up with the statements of the facility staff."

Dead bodies don't lie.

Corpses typically don't begin to stiffen until two to four hours after death.

So when and how did the teen really lose her life?

The state Agency for Persons with Disabilities threatened to keep Carlton Palms, Florida's largest licensed residential and education facility for severely handicapped people, from accepting new patients.

The agency has scheduled a meeting next month at the center with its managers and watchdog groups, said Barbara Palmer, director of the state Agency for Persons with Disabilities. Palmer told a reporter she is getting impatient with Carlton Palms.

Clearly, Palmer is not nearly impatient enough. Carlton Palms has continued to operate on its own in the 14 months since Paige died, and the DCF report on her death took nearly a year to complete. That's inexcusable. If Palmer jerked its license, things would change quickly at this for-profit facility, which received $25 million in tax dollars last year to take care of the patients who are wards of the state.

Carlton Palms has been the subject of 139 complaints of abuse and neglect from 2001 to 2013, and the disability agency required the facility to install surveillance cameras last April.

That's useless. Cameras, when not "accidentally" erased, can provide information about what happened to any of Carlton Palms' nearly 200 patients. But they don't prevent someone from doing harm to society's most vulnerable people. Nailing the culprit shouldn't be the goal -- ensuring disabled people aren't maltreated should drive the actions of the Agency for Persons with Disabilities.

Carlton Palms shouldn't be allowed to accept more patients, and investigators from both state agencies who have control over the facility temporarily should be stationed there 24 hours a day -- at the expense of Carlton Palms -- until it becomes clear how Paige Lunsford lost her life and what can be done to make sure such a thing can never happen again.

Lritchie@tribune.com. Lauren invites you to send her a friend request on Facebook at facebook.com/laurenonlake.

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