Five criminals in far-flung parts of the world, five D.E.A. sting operations, five dubious links between drugs and terror. The characters are different but the story remains the same. Authorities said each case demonstrated alliances between terrorists and drug traffickers, but most of the alleged links fell apart in court. Here’s how narco-terrorism cases are made.
Image may be NSFW.
After slamming his fists into the wall until his knuckles dripped with blood, the raging teenage boy turned to a staff member and shoved him. The teen had recently been admitted to Youth Development Institute, a residential program for children with emotional and behavioral disorders in Phoenix, Arizona. Even the smallest incidents triggered his anger.
Years ago, the response would have been swift and physical: The boy would have been forced to the ground and restrained until he grew calm, which sometimes could take up to 45 minutes.
But this time, Sean Hennessey, a direct care staff coordinator, stepped in front of another staff member, sending him out of the room before the conflict could escalate. Hennessey stood at the door with his head down, avoiding eye contact, and calmly spoke to the boy. When tears rolled down the boy’s face minutes later, Hennessey moved in and offered a reassuring side hug.
“It’s exhilarating when you’ve avoided a restraint,” Hennessey told ProPublica, recalling the incident. “Pinning a kid to the ground until they stop fighting and start crying, it’s barbaric if you think about it.”
Eight years ago, restraints occurred multiple times a day at Youth Development Institute. When children violently acted out, staff would hold them or even strap them down, and sometimes inject them with sedatives. Trish and David Cocoros, the directors of the program, said they hated relying on restraints, but assumed that if they stopped using them, more staff members and kids would get hurt.
Then, in 2012, the program changed course after an industry expert visited and discussedalternatives to restraints such as the approach Hennessey used. Now, the program averages less than one restraint a month.
Youth Development Institute is part of a growing group of residential programs nationwide attempting to improve their work with children in key ways. Eliminating restraints is just one example. Many programs are shortening children’s stays, involving families more, and offering more rigorous classes.
But best practices like these are almost entirely self-imposed.
There are few federal requirements for residential programs involving children, and a patchwork of state regulation has left significant gaps: There is little to no monitoring of how well schools are teaching kids overall, no required national tracking of abuse and neglect allegations, and not even a comprehensive database of all programs.
Efforts to bolster federal standards have drawn fire from some providers and industry groups, which have lobbied lawmakers. Legislation to modestly increase federal oversight has languished for years.
As a result, for years, some programs have continued to thrive despite having long records of mistreating residents that has even, at times, led to injuries and deaths. (Read ProPublica’s recent story about one for-profit company, AdvoServ, that has used its deep pockets and influence to bully weak regulators and evade accountability.)
Because of the wide latitude they’re given, some programs still use extreme methods on children – including forced labor or exercise, electric shock and restraint devices that include shackles and a wrap that resembles a full-body straight jacket. Our recent story also detailed how AdvoServ workers at one campus used mechanical restraints 28,000 times in less than five years. (AdvoServ told us workers only use restraints as a last resort, “when there is imminent danger.”)
At programs across the country, at least 145 children have died from avoidable causes at residential facilities over the past 35 years, a ProPublica analysis of news reports found. At least 62 children died after being restrained, most often because of asphyxiation.
The job of monitoring the wellbeing of children at the programs is spread across so many state and local agencies that kids can fall through the cracks.
State education agencies, for instance, rarely take strong action. A ProPublica survey found that about half of the education departments didn’t have the power to sanction such schools even if they discovered public school students were being mistreated. School officials in just seven of the 44 states that responded to the survey said they had levied penalties on or closed such a program in the last decade.
“State agencies can certainly step up measures to hold all residential treatment programs accountable to high health and safety standards, but the reality is that most have not despite a rash of abuse allegations occurring in programs on their turf,” Rep. Adam Schiff, D-Calif., told ProPublica in an email. Schiff reintroduced a bill earlier this year that would require the tracking of abuse allegations lodged against such programs.
Youth residential centers originated in the 1940s to fill a gap in the therapeutic spectrum: They are less restrictive than psychiatric hospitals and are often a last resort for overwhelmed families. They provide housing, treatment and, often, schooling to kids with a range of issues, from emotional disorders to substance abuse problems to profound disabilities like severe autism. They use a diverse array of approaches and include so-called “wilderness” programs, boot camps and other behavior modification centers.
Public schools funnel roughly 18,000 kids per year into residential programs. Federal law entitles all children with disabilities to free public schooling but school districts sometimes pay private providers to educate students with severe impairments that local classrooms can’t handle. Some of the programs provide 24-hour care and take children from across the country.
Many of the programs are pricey, with total costs for some children soaring past $350,000 per year. A host of other agencies, from child welfare to Medicaid, typically pay the rest of the bill for children’s stays, each with their own standards for the programs.
Despite the public funding, there is little data on residential schools. One federal database collects state data on abuse incidents, but submission is voluntary. There is no required federal tracking of abuse allegations–and there is not even a nationwide list of all residential programs. One often-cited government survey, which is more than a decade old, estimates that there are at least 3,600 facilities across the country, housing more than 50,000 children annually.
Ira Burnim, legal director for the Bazelon Center for Mental Health, believes that the current data gives an incomplete picture. “Our lack of information and data is very troubling,” said Burnim. “To a certain extent, the residential treatment centers are out of sight, out of mind.”
Lawmakers have repeatedly called for changes amid reports of chronic abuse and neglect. A government report in 2008 found gaps in state regulation increased the risk of abuse and neglect at some youth residential programs.
Some state agencies didn’t visit programs often enough to make sure kids were safe and well-cared for, the report found. In other states, some programs, such as private boarding schools and religious treatment centers, are exempt from licensing and do not have direct regulation. The report also found state agencies did not routinely share negative findings on programs, or even inform other agencies when a program had its license revoked.
A few industry groups support greater oversight and transparency.
“Even if it means more regulation and paperwork, we have an obligation to support what would be best for the children,” said Kari Sisson, executive director of the American Association of Children’s Residential Centers.
To help reinforce standards, some states and federal agencies require programs to obtain accreditation from professional standards groups, which generally have more requirements than state agencies.
But the accrediting agencies have few tools to enforce compliance.
“They do a lot of things well and they have a lot of good measures,” said Robert Friedman, a clinical psychologist at the University of South Florida. “But they are not there that often.”
While evidence of abuse of the disabled has piled up for decades, one for-profit company has used its deep pockets and influence to bully weak regulators and evade accountability. Read the story.
It took one mother seven years to learn that the for-profit school she trusted with her son had strapped him down again and again, one time after not picking up his Legos. Read the story.
With few enforcement powers, some federal officials have focused on encouraging best practices. Dr. Gary Blau, the chief of the child, adolescent and family branch of the federal Substance Abuse and Mental Health Services Administration, has led a campaign to promote changes at children’s residential centers, such as eliminating the use of restraints.
In 2006, Blau organized the first “Building Bridges” summit to bring residential program directors and community care providers together to discuss how to improve the standards of therapeutic care for youth.
Although many facilities, like Youth Development Institute, were ready and willing to incorporate best practices, others were resistant to any kind of culture change.
“There were residential facilities that had built fortresses around themselves,” Blau said. “They kept kids in and kept families out.”
Since that first meeting, nearly 130 organizations have committed to the standards set by the Building Bridges initiative.
Blau recognizes that there’s only so much that persuasion can accomplish. “There’s still a lot more work to be done,” Blau said. For facilities that are resistant to change, “that’s where I would look to state licensing and say that we need to include these principles in our licensing requirements.”
Aside from facilities, several states have also begun to formally adopt the standards as their own. Massachusetts, for example, has embedded the Building Bridges’ guidelines into their licensing regulations, including limiting restraints.
“The data made it impossible to walk away from,” said Janice LeBel, the director of system transformation at Massachusetts’ Department of Mental Health. When LeBel compared the psychiatric care of children and adults, the rate at which restraints were used was at least 4 times higher in youth facilities. “There was a moral imperative to do something about it.”
Under LeBel’s watch, the state has reduced the use of restraints in children’s psychiatric facilities by 89 percent. They are now implementing the reduction strategies across children’s residential facilities and schools. But for reductions to happen across the country, LeBel said, national standards should be stronger.
“There is great value to having local oversight, but it’s important for there to be federal standards that drive service advancement,” she told ProPublica.
Industry groups and providers have at times aggressively sought to fend off federal regulation of their programs and worked to undermine stricter rules.
“Lobbying against regulations is traditionally the posture of the providers,” said Burnim of Bazelon Law Center. “They are not fans of regulation, and where they are supportive of regulation, it’s in the service of getting resources.”
The National Association of Therapeutic Schools and Programs, also known as NATSAP, represents over 150 residential treatment programs and was one of the more prominent groups lobbying Congress on earlier versions of Schiff’s bill. Between 2008 and 2009, NATSAP spent $220,000 lobbying Congress, according to disclosure reports.
“We are all for regulation, it just has to be the right kind,” said Clifford Brownstein, the executive director of NATSAP, which requires that its members be licensed and accredited. “We have found that, for a variety of reasons, issues can be dealt with best more locally.”
While NATSAP has not actively lobbied since 2010, another member-based organization, the National Association for Children’s Behavioral Health, or NACBH, has spent at least $100,000 since 2013 lobbying Congress on mental health bills, including legislation on residential program oversight, according to congressional disclosure reports.
Joy Midman, executive director of NACBH, believes that “the field has been swiped with one broad brush.”
Midman, who emphasized that the disclosed dollars spent by NACBH only show what bills her organization has paid firms to monitor and does not necessarily indicate lobbying, described the recent legislation as a “work-in-progress.”
Additional reporting by Heather Vogell and Meral Agish.
Image may be NSFW.The people interviewed for this story include Marie (in our story, we agreed to use only here middle name); Marie’s foster mothers Peggy Cunningham and Shannon McQuery; Marie’s friend Jordan Schweitzer; James Feldman, Marie’s public defender when she was charged with filing a false police report; H. Richmond Fisher, Marie’s attorney in her civil suit against Lynnwood, Washington; Golden, Colorado, police Det. Stacy Galbraith; Westminster, Colorado, Sgt. Edna Hendershot and Sgt. Trevor Materasso; Lakewood, Colorado, police detective Aaron Hassell; Kirkland, Washington, police officer Audra Weber; Lynnwood police Sgt. Jeffrey Mason, Sgt. Rodney Cohnheim and Commander Steve Rider; and Marc O’Leary, who was interviewed at the Sterling Correctional Facility in Colorado. Former Lynnwood police Det. Jerry Rittgarn declined to be interviewed. The description of his background comes from his LinkedIn profile.
We received thousands of pages of documents through public-records requests filed with the following agencies: the police departments in Lynnwood and Kirkland, Washington; the police departments in Golden, Westminster, Aurora and Lakewood, Colorado; and the prosecuting attorney’s offices in Snohomish County, Washington, King County, Washington, and Jefferson County, Colorado.
The records obtained through these requests included investigative reports filed by detectives in Lynnwood and elsewhere; crime-scene photos and surveillance footage collected by the various law-enforcement agencies; the two case reviews of how the Lynnwood police handled the investigation of Marie’s rape report; and video of Marc O’Leary being interviewed by police after his arrest in Colorado.
Words or thoughts attributed to anyone in this story are drawn from these interviews or documents.
We reviewed Marie’s civil suit against Lynnwood, which included such legal exhibits as the medical report from the day she reported being raped and case notes from Project Ladder, the transitional housing program to which she belonged.
Other reporting included pulling transcripts of television news coverage from when Marie was raped and later charged; having court transcripts prepared from when O’Leary was sentenced in Colorado; reviewing grant documents for Project Ladder; and mining the criminal-justice literature for expert views on how rape investigations should be conducted.
We consulted police training guidelines by various organizations, including the International Association of Chiefs of Police and End Violence Against Women International.
Specific statistics:
“Rapes by strangers were uncommon — maybe about 13 percent of cases.” From the National Intimate Partner and Sexual Violence Survey, 2011
“Only about one-fifth to one-third of rapes get reported to police, national surveys show.” From National Crime and Victimization Survey, 2014 and National Violence Against Women Survey, 2006
“Between one-fourth to two-thirds of rapists are serial attackers, studies show.” From JAMA Pediatrics, December 2015 and Violence and Victims, Vol 17, 2002 by David Lisak and Paul M. Miller.
“But most recent research suggests that false reporting is relatively rare. FBI figures show that police annually declare around 5 percent of rape cases unfounded, or baseless. Social scientists examining police records in detail and using methodologically rigorous standards cite similar, single-digit rates.” From research and studies summarized in a Department of Justice-funded study, Policing and Prosecuting Sexual Assault in Los Angeles City and County, 2012 by Cassia Spohn and Katharine Tellis and from an analysis by ProPublica and The Marshall Project of FBI Uniform Crime Reporting program data, 2008–2012.
To determine the rate of rape crimes declared unfounded, or groundless, by law enforcement agencies, we analyzed Uniform Crime Reporting data collected by the Federal Bureau of Investigation. We examined five years of the “Offenses Known and Cleared by Arrest” data to smooth yearly fluctuations common in crime reporting. We excluded agencies that did not report crime statistics in any given month, as well as those that reported no crimes of any kind in a year. We also restricted our examination to only those agencies that reported at least one rape over this timespan.
To calculate the rate, we summed the number of unfounded rapes and divided it by the number of reported rapes. We ran this calculation for all departments that met our criteria on a national level. We also ran the same calculation for Washington state law enforcement agencies that cover cities of the same size as Lynnwood to account for possible variations due to the size of a jurisdiction or local laws.
If you have experience with or information about issues related to this story, email T.Christian.Miller@propublica.org.
Image may be NSFW.No one came to court with her that day, except her public defender.
She was 18 years old, charged with a gross misdemeanor, punishable by up to a year in jail.
Rarely do misdemeanors draw notice. Her case was one of 4,859 filed in 2008 in Lynnwood Municipal Court, a place where the judge says the goal is “to correct behavior — to make Lynnwood a better, safer, healthier place to live, work, shop and visit.”
But her misdemeanor had made the news, and made her an object of curiosity or, worse, scorn. It had cost her the newfound independence she was savoring after a life in foster homes. It had cost her sense of worth. Each ring of the phone seemed to announce another friendship, lost. A friend from 10th grade called to ask: How could you lie about something like that? Marie — that’s her middle name, Marie — didn’t say anything. She just listened, then hung up. Even her foster parents now doubted her. She doubted herself, wondering if there was something in her that needed to be fixed.
She had reported being raped in her apartment by a man who had bound and gagged her. Then, confronted by police with inconsistencies in her story, she had conceded it might have been a dream. Then she admitted making the story up. One TV newscast announced, “A Western Washington woman has confessed that she cried wolf when it came to her rape she reported earlier this week.” She had been charged with filing a false report, which is why she was here today, to accept or turn down a plea deal.
Her lawyer was surprised she had been charged. Her story hadn’t hurt anyone — no suspects arrested, or even questioned. His guess was, the police felt used. They don’t appreciate having their time wasted.
The prosecution’s offer was this: If she met certain conditions for the next year, the charge would be dropped. She would need to get mental health counseling for her lying. She would need to go on supervised probation. She would need to keep straight, breaking no more laws. And she would have to pay $500 to cover the court’s costs.
Marie wanted this behind her.
She took the deal.
A little after 1 p.m. on a wintry day in January 2011, Detective Stacy Galbraith approached a long, anonymous row of apartment buildings that spilled up a low hill in a Denver suburb. Snow covered the ground in patches. It was blustery, and biting cold. She was there to investigate a report of rape.
Galbraith spotted the victim standing in the thin sunlight outside her ground floor apartment. She was young, dressed in a brown, full-length coat. She clutched a bag of her belongings in one hand. She looked calm, unflustered. Galbraith introduced herself. Police technicians were swarming the apartment. Galbraith suggested that she and the victim escape the icy gusts in a nearby unmarked patrol car.
The woman told Galbraith she was 26 years old, an engineering student on winter break from a nearby college. She had been alone in her apartment the previous evening. After cooking green mung beans for dinner, she curled up in bed for a marathon of “Desperate Housewives” and “The Big Bang Theory” until drifting off. At around 8 a.m., she was jolted awake by a man who had jumped on her back, pinning her to the bed. He wore a black mask that seemed more like a scarf fastened tight around his face. He gripped a silver and black gun. “Don’t scream. Don’t call or I’ll shoot you,” he told her.
He moved deliberately. He tied her hands loosely behind her. From a large black bag, he took out thigh-high stockings, clear plastic high heels with pink ribbons, lubrication, a box of moist towelettes and bottled water. Over the next four hours, he raped her repeatedly. He documented the assault with a digital camera and threatened to post the pictures online if she contacted the police. Afterward, he ordered her to brush her teeth and wash herself in the shower. By the time she exited the bathroom, he had gone. He had taken her sheets and bedding. She clearly remembered one physical detail about him: a dark mark on his left calf the size of an egg.
Galbraith listened to the woman with a sense of alarm. The attack was so heinous; the attacker so practiced. There was no time to waste. Sitting close to her in the front seat of the car, Galbraith carefully brushed the woman’s face with long cotton swabs to collect any DNA traces that might remain. Then she drove her to St. Anthony North Hospital. The woman underwent a special forensic examination to collect more DNA evidence. Before she left with a nurse, the woman warned Galbraith, “I think he’s done this before.”
Galbraith returned to the crime scene. A half-dozen officers and technicians were now at work. They were knocking on neighbors’ doors, snapping photographs in the apartment, digging through garbage bins, swabbing the walls, the windows, everywhere for DNA. In the snow, they found a trail of footprints leading to and from the back of the apartment through an empty field. They spraypainted the prints fluorescent orange to make them stand out, then took pictures. It was not much. But something. One officer suggested a bathroom break. “Just keep working!” Galbraith insisted.
As she headed home that night, Galbraith’s mind raced. “Who is this guy?” she asked herself. “How am I going to find him?” Galbraith often volunteered to take rape cases. She was a wife, a mother. She was good at empathizing with the victims, who were overwhelmingly women. Most had been assaulted by a boyfriend, an old flame, or someone they had met at a club. Those investigations often boiled down to an issue of consent. Had the woman said “yes”? They were tough for cops and prosecutors. Juries were hesitant to throw someone in prison when it was one person’s word against another’s. Rapes by strangers were uncommon — about 13 percent of cases. But there was still the issue of the woman’s story. Was she telling the truth? Or fabricating a ruse to cover a sexual encounter gone wrong?
In that way, rape cases were unlike most other crimes. The credibility of the victim was often on trial as much as the guilt of the accused. And on the long, fraught trail between crime and conviction, the first triers of fact were the cops. An investigating officer had to figure out if the victim was telling the truth.
Galbraith had a simple rule: listen and verify. “A lot of times people say, ‘Believe your victim, believe your victim,’” Galbraith said. “But I don’t think that that’s the right standpoint. I think it’s listen to your victim. And then corroborate or refute based on how things go.”
At home, her husband David had done the dishes and put the kids to bed. They sank down on separate couches in their living room. Galbraith recounted the day’s events. The attacker had been cunning, attempting to erase any traces of DNA from the scene. Before he left, he showed the student how he broke in through a sliding glass door. He suggested she put a dowel into the bottom track to keep out future intruders. The victim had described him as a “gentleman,” Galbraith said. “He’s going to be hard to find,” she thought.
David Galbraith was used to such bleak stories. They were both cops, after all. He worked in Westminster, some 15 miles to the northeast. Golden and Westminster were middle class bedroom towns wedged between Denver’s downtown skyscrapers and the looming Rockies.
This time, though, there was something different. As David listened, he realized that the details of the case were unsettlingly familiar. He told his wife to call his department first thing in the morning.
“We have one just like that,” he said.
She does not know if she attended kindergarten.
She remembers being hungry and eating dog food.
She reports entering foster care at age 6 or 7.
The report on Marie’s life — written by a mental health expert who interviewed her for five hours — is written with clinical detachment, describing her life before she entered foster care ...
She met her biological father only once.
She reports not knowing much about her biological mother, who she said would often leave her in the care of boyfriends.
She was sexually and physically abused.
… and after, with:
adult caregivers and professionals coming in and then out of her life, some distressing or abusive experiences, and a general lack of permanency.
“I moved a lot when I was younger,” Marie says in an interview. “I was in group homes, too. About two of those and probably 10 or 11 foster homes.”
“I was on like seven different drugs. And Zoloft is an adult drug — I was on that at 8.”
Marie has two brothers and a sister on her mother’s side. Sometimes she was placed in foster homes with her siblings. More often they were separated.
No one really explained why she was being moved, or what was going on. She was just moved.
After Marie became a teenager, her years of upheaval appeared at an end. Her foster family was going to adopt her. “I really loved the family and I made a lot of friends,” Marie says.
The first day of the first year of high school fills many students with anxiety. Marie couldn’t wait for it. She had gotten all the classes she wanted. She had a social circle. She felt like she belonged.
But on the first day, a support counselor came to the school and told Marie the family had lost its foster care license. She couldn’t live with them anymore. The counselor couldn’t offer any more details.
“I pretty much just cried,” Marie says. “I basically had 20 minutes to pack my stuff and go.”
Until something more permanent could be found, Marie moved in with Shannon McQuery and her husband in Bellevue, a booming, high-tech suburb east of Seattle. Shannon, a real estate agent and longtime foster mom, had met Marie through meetings for kids with troubled pasts and had sensed a kindred spirit.
Shannon and Marie were both “kind of goofy,” Shannon says. “We could laugh at each other and make fun. We were a lot alike.” Despite all Marie had been through, “she wasn’t bitter,” Shannon says. She kept in touch with previous foster families. She could carry on a conversation with adults. She didn’t have to be pushed out the door to school.
But no matter her affection for Marie, Shannon knew they couldn’t keep her, because the foster child already in their home required so much care. “We were really sad that we weren’t able to have her with us,” Shannon says.
Marie left Shannon’s home after a couple of weeks to move in with Peggy Cunningham, who worked as a children’s advocate at a homeless shelter and lived in Lynnwood, a smaller suburb about 15 miles north of Seattle. She was Peggy’s first foster child.
“I was preparing for a baby. I had a crib — and they gave me a 16-year-old,” Peggy says, with a laugh. “And it was fine. I have a background in mental health and I’ve been working with kids for a really long time. And I think the agency just thought, ‘She can handle it.’ So.”
At first, Marie didn’t want to live with Peggy. Marie was used to being around other kids. Peggy didn’t have any. Marie liked dogs. Peggy had two cats. “Our personalities didn’t match at first either,” Marie says. “It was hard to get along. For me it seems like people read me differently than I see myself.”
Peggy, who had received a file two to three inches thick documenting Marie’s history, was surprised at how well she was coping. Marie was into boys, drawing and music, be it rock, country, or Christian. “She was very bubbly and full of energy, but she also had her moments where she could be very intense,” Peggy says. Like kids most everywhere, Marie wanted to fit in. She picked out a feminine white coat with a fur collar because she thought that’s what girls were supposed to wear, but then kept the coat in the closet when she realized it wasn’t.
Recognizing that Marie’s high school wasn’t a great fit — “pretty cliquey,” Peggy says — Peggy found an alternative school that was. Marie settled in. She remained close with Shannon, who would joke that she and Peggy were raising Marie together — Shannon the fun one (let’s go boating), Peggy the disciplinarian (be home by …).
Through friends, Marie met Jordan Schweitzer, a high school student working at a McDonald’s. In time, they became boyfriend and girlfriend. “She was just a nice person to have around. She was always nice to talk to,” Jordan says.
Marie figures her happiest years were when she was 16 and 17, and the happiest day may have been one she spent with her best friend, another high school student who was teaching Marie the fine points of camerawork.
“I would spend hours at the beach watching the sunset go down and that was one of my favorite things. There was a particular photo that I really liked that she took. We went to the ocean, it was like 7 o’clock at night, I don’t know what we were thinking, I got in there and I jumped out and swung my hair back.”
Instead of finishing high school, Marie went for her GED. She was 17, starting to stay out late, worrying Peggy, creating tension between the two. In the spring of 2008, Marie turned 18. She could have stayed with Peggy, provided she abided by certain rules. But Marie wanted to set out on her own.
Peggy, searching online, discovered a pilot program called Project Ladder. Launched the year before, the program was designed to help young adults who had grown up in foster care transition to living on their own. Case managers would show participants the dos and don’ts of shopping for groceries, handling a credit card, buying insurance. “The rules about life,” Marie says. Best of all, Project Ladder provided subsidized housing, with each member getting a one-bedroom apartment.
“This was a godsend,” Peggy says.
There were few slots, but Marie secured one. She was a little scared, but any trepidation was tempered by a sense of pride. She moved into the Alderbrooke Apartments, a woodsy complex that advertises proximity to a mall and views of the Cascades. She also landed her first job, offering food samples to customers at Costco. Six hours on her feet didn’t bother her. She enjoyed chatting with people, free from pressure to sell.
So many kids, institutionalized, wound up on drugs or in jail. Marie had made it through.
“It was just nice to be on my own and not have all the rules that I had had being in foster care,” Marie says. “It was just like, freedom.
“It was awesome.”
The morning after the rape in Golden, Galbraith hurried to work to follow up her husband’s lead. At 9:07 a.m. she sent an email to the Westminster Police Department. The subject line was pleading: “Sex Aslt Similars?”
Westminster Detective Edna Hendershot had settled into her morning with her Starbucks usual: a Venti, upside-down, skinny caramel macchiato. She read the email and her mind shot back five months, to a crisp Tuesday in August 2010. She had responded to a report of a rape at a blue-collar apartment complex in the northwest corner of her city. A 59-year-old woman told her that she had been asleep in her home when a man jumped on her back. He wore a black mask. He tied her hands. He stole her pink Sony Cyber-shot camera and used it to take pictures of her. Afterward, he made her take a shower. He picked up a kitchen timer and set it to let her know when she could get out. “I guess you won’t leave your windows open in the future,” the man told the woman, who had recently been widowed.
There was more. Hendershot remembered that while investigating her case, an officer had alerted her to an incident in October 2009 in Aurora, a suburb on the other side of Denver. There, a 65-year-old woman told police that she had been raped in her apartment by a man with a black scarf wrapped around his face. He tied her hands with a ribbon. He took pictures and threatened to post them on the Internet. During the attack, he knocked a yellow teddy bear off a desk in her bedroom. “You should get help,” the woman, a house mother at a local fraternity, told the man. “It’s too late for that,” he replied.
Cops can be protective about their cases, fearing that information could be leaked that would jeopardize their investigations. They often don’t know about, or fail to use, an FBI database created years ago to help catch repeat offenders. Between one-fourth to two-thirds of rapists are serial attackers, studies show.
But Hendershot right away recognized the potential in collaborating and in using every tool possible. “Two heads, three heads, four heads, sometimes are better than one, right?” she said. So did Galbraith. Her department was small — a little more than 40 officers serving a town of about 20,000. It only made sense to join forces. “I have no qualms with asking for help,” Galbraith said. “Let’s do what we can do to catch him.”
A week later, Galbraith, Hendershot and Aurora Detective Scott Burgess gathered around a conference table in the Westminster Police Department. They compared investigations. The descriptions of the attacker were similar. So, too, his methods. But there was a clincher: the woman in Galbraith’s case had remained as focused as possible during her ordeal, memorizing details. She recalled the camera that the attacker had used to take photos. It was a pink Sony digital camera — a description that fit the model stolen from the apartment of the Westminster victim.
Galbraith and Hendershot hadn’t known each other before the meeting. But the hunt for the rapist united them. As female cops, both women were members of a sorority within a fraternity. The average law enforcement agency in America is about 13 percent female. Police ranks remain overwhelmingly male, often hierarchical and militaristic. But both women had found a place for themselves. They had moved up in the ranks.
The two bonded naturally. Both were outgoing. They cracked fast jokes and smiled fast smiles. Galbraith was younger. She crackled energy. She would move “a hundred miles an hour in one direction,” a colleague said. Hendershot was more experienced. She’d worked more than 100 rape cases in her career. Careful, diligent, exacting — she complemented Galbraith. “Sometimes going a hundred miles an hour, you miss some breadcrumbs,” the same colleague noted.
Their initial attempts to identify the attacker faltered. Golden police obtained a surveillance tape showing the entrance to the apartment complex where Galbraith’s victim had been attacked. A fellow detective sat through more than 12 hours of blurry footage. He laboriously counted 261 vehicles and people coming and going on the night of the incident. There was one possible lead. In the predawn hours, a white Mazda pickup truck appeared 10 times. Maybe it was the attacker waiting for the woman to fall asleep? But efforts to identify the vehicle’s owner failed. The license plate was unreadable.
As the weeks passed, the dead ends continued. Hendershot turned to the database meant to capture serial rapists by linking cases in different jurisdictions. It turned up only bad leads. Frustration grew. “Someone else is going to get hurt,” Galbraith worried to herself.
By late January, the detectives decided they needed to broaden their scope. Hendershot asked one of her department’s crime analysts to scour nearby agencies for similar crimes. The analyst turned up an incident in Lakewood, another Denver suburb, that occurred about a month before the rape in Westminster. At the time, police had labeled the case a burglary. But in fresh light, it appeared very much like a failed rape attempt, committed by an attacker who closely resembled the description of the rapist. The analyst shot Hendershot a message, “You need to come to talk to me right now.”
The report detailed how a 46-year-old artist had been accosted in her home by a man with a knife. He wore a black mask. He tried to bind her wrists. But when the man looked away, the woman jumped out of her bedroom window. She broke three ribs and punctured a lung in the 7-foot fall to the ground, but managed to escape.
Investigators at the scene uncovered a few, tenuous pieces of evidence. Thundershowers had soaked the area before the attack. Police found shoe prints in the soft, damp soil outside the woman’s bedroom. On a window, they found honeycomb marks.
Honeycomb marks. Hendershot seized on them. Westminster crime scene investigators had discovered similar marks on the window of the victim’s apartment. Hendershot asked for a comparison. The marks at the two crime scenes were the same. They also appeared similar to prints from a pair of Under Armour gloves that a Lakewood investigator, on a hunch, had discovered at a Dick’s Sporting Goods.
Galbraith checked out the footprints left at the Lakewood scene. They matched the footprints in the snow outside her victim’s apartment in Golden. She sent images of the shoe prints to crimeshoe.com, a website that promised to move an investigation “from an unidentified scene-of-crime shoeprint to detailed footwear information in one simple step.” The site, now defunct, identified the prints as having been made by a pair of Adidas ZX 700 mesh shoes, available in stores after March 2005.
By the end of January 2011, the detectives had connected four rapes over a 15-month period across Denver’s suburbs. The trail started in Aurora, east of Denver, on Oct. 4, 2009, with the 65-year-old woman. It picked up nine months later and 22 miles to the west, when the rapist attacked the artist in Lakewood. A month after that the 59-year-old widow was raped in Westminster, some 10 miles to the north. And then, finally, in January 2011 came the attack on the 26-year-old in Golden, about 15 miles southwest of Westminster. If you drew a map, it was almost like the rapist was circling the compass points of Denver’s suburbs.
Galbraith and Hendershot turned to DNA to identify the serial rapist. The detectives had thoroughly examined their crime scenes. Technicians had swabbed window panes, doorknobs, even toilet handles — anything that the attacker might have touched. But the man was familiar with the ways of law enforcement, perhaps even a cop. He knew to avoid leaving his DNA at the scene. He used wet wipes to clean up his ejaculate. He ordered the women to shower. He took their clothing and bedding with him when he left.
He had been punctilious. But not perfect. The attacker had left behind the tiniest traces of himself. The technicians recovered three samples of so-called touch DNA, as few as seven or eight cells of skin that can be analyzed with modern laboratory techniques.
One sample was collected from the kitchen timer in Westminster. A second came from the victim in Golden. And one came from the teddy bear in Aurora.
A little before 9 on a Monday morning, two Lynnwood police detectives responded to a report of rape at the Alderbrooke Apartments. A couple of other officers were already there, protecting the crime scene. A K-9 officer was outside, his dog trying to pick up a scent.
The detectives, Sgt. Jeffrey Mason and Jerry Rittgarn, found the victim, Marie, on a couch, in a blanket, crying off and on. She was accompanied by her foster mother, Peggy Cunningham, and by Wayne Nash, her case manager with Project Ladder.
Marie, who had turned 18 three months before, told police she had been talking on the phone much of the night with her friend Jordan. After finally falling asleep, she was awakened by a man with a knife — and then tied up, blindfolded, gagged and raped. The man wore a condom, she believed. As for what her attacker looked like, Marie could offer few details. White man, gray sweater. The attack seemed to last a long time, Marie told police, but she couldn’t say for sure. It was all a blur.
Marie said that after the rapist left she had managed, with her feet, to retrieve some scissors from a cabinet’s bottom drawer; she cut herself free, then tried calling Jordan. When Jordan didn’t answer, Marie called her foster mother, then her upstairs neighbor, who came down to Marie’s apartment and called 911.
Mason, then 39, had spent his years mostly in patrol and narcotics. His longest law-enforcement stint had been with a small police department in Oregon, where he served for almost nine years and received a medal of valor. He was hired by Lynnwood in 2003, and served on a narcotics task force. He was promoted to sergeant — and transferred to the Criminal Investigations Division — six weeks before the report of Marie's assault. He had previously worked only one or two rape cases. But this investigation was his to lead.
Rittgarn had been with the department for 11 years, the last four as a detective. He had previously worked as a technician in the aerospace industry. Before that, he had served in the Marine Corps, specializing in helicopter avionics.
The Lynnwood Police Department had 79 sworn officers, serving a city of about 34,000 people. In 2008, Marie’s case was one of 10 rape reports the department fielded; with so few, the Criminal Investigations Division didn’t have a separate sex crimes unit.
By the time Marie reported being assaulted, sex crime specialists had developed protocols that recognized the challenges and sensitivity of investigating rape cases. These guidelines, available to all police departments, detailed common missteps.
Investigators, one guide advised, should not assume that a true victim will be hysterical rather than calm; able to show clear signs of physical injury; and certain of every detail. Some victims confuse fine points or even recant. Nor should police get lost in stereotypes — believing, for example, that an adult victim will be more believable than an adolescent.
Police should not interrogate victims or threaten to use a polygraph device. Lie-detector tests are especially unreliable with people who have been traumatized, and can destroy the victim’s trust in law enforcement. Many states bar police from using them with rape victims.
Police, walking around Marie’s apartment, discovered that the rear sliding glass door was unlocked and slightly ajar. It led to a back porch, with a wooden railing that was covered with dirt — except one part, about three feet wide, where it looked like maybe someone had brushed the surface while climbing over. On the bed officers found a shoestring — used, apparently, to bind Marie. On top of a computer monitor they found a second shoestring, tied to a pair of underwear, the apparent blindfold or gag. Both laces had come from Marie’s black tennis shoes, in the living room. Next to the bed was a black-handled knife. Marie said the knife was hers — that it had come from the kitchen, and was what the rapist had used to threaten her. Police found Marie’s purse on the bedroom floor, her wallet on the bed and her learner’s permit, for some reason removed from her wallet, on a bedroom window sill.
Mason told Marie she needed to go to the hospital for a sexual assault examination. After Marie left, accompanied by her foster mom and case manager, the detectives helped process the scene. Looking for a condom or its wrapper, Rittgarn checked the bathroom, trash cans and a nearby hillside, but came up empty. The dog, outside, had tracked to the south, toward an office building, but was unable to lead officers to anything that might identify the rapist.
At the hospital, medical staff collected more than a dozen swabs from Marie. Labs were taken for hepatitis, chlamydia, HIV. Marie received Zithromax and Suprax for possible exposure to sexually transmitted diseases, and an emergency contraceptive pill.
The medical report noted abrasions to Marie’s wrists and to her vagina. The bruising on her right wrist measured 6.5 centimeters, or about 2.5 inches, the one on her left, 7 centimeters.
During the exam, the medical report said, Marie was “alert and oriented, and in no acute distress.”
On the day she reported being raped, Marie phoned Shannon, her former foster mom, after getting back from the hospital. “She called and said, ‘I’ve been raped,’” Shannon says. “There was just no emotion. It was like she was telling me that she’d made a sandwich.” That Marie wasn’t hysterical, or even upset, made Shannon wonder if Marie was telling the truth.
The next day, when Shannon saw Marie at her apartment, her doubts intensified. In the kitchen, when Shannon walked in, Marie didn’t meet her gaze. “That seemed very strange,” Shannon says. “We would always hug and she would look you right in the eye.” In the bedroom, Marie seemed casual, with nothing to suggest that something horrible had happened there. Outside, Marie “was on the grass, rolling around and giggling and laughing,” Shannon says. And when the two went to buy new bedding — Marie’s old bedding having been taken as evidence — Marie became furious when she couldn’t find the same set. “Why would you want to have the same sheets and bedspread to look at every day when you’d been raped on this bed set?” Shannon thought to herself.
Peggy, too, was mystified by Marie’s demeanor. When Marie called her on that first day, before the police arrived, “she was crying and I could barely hear her,” Peggy says. “Her voice was like this little tiny voice, and I couldn’t really tell. It didn’t sound real to me. … It sounded like a lot of drama, too, in some ways.” At the time, Peggy had new foster children — two sisters, both teenagers. Not long before, Marie had accompanied Peggy and the sisters and Peggy’s boyfriend on a picnic. To Peggy’s mind, Marie had spent the afternoon trying to get attention — so much so that Peggy now wondered if this was more of the same, only more desperate.
After rushing to the apartment that morning, Peggy found Marie on the floor, crying. “But it was so strange because I sat down next to her, and she was telling me what happened, and I got this — I’m a big Law & Order fan, and I just got this really weird feeling,” Peggy says. “It was like, I felt like she was telling me the script of a Law & Order story.” Part of it was what Marie was saying. Why would a rapist use shoelaces to tie her up? And part of it was how Marie was saying it: “She seemed so detached and removed emotionally.”
The two women who had helped raise Marie talked on the phone. Peggy told Shannon she had doubts. Shannon said she did, too. Neither had known Marie to be a liar — to exaggerate, sure, to want attention, sure — but now, both knew they weren’t alone in wondering if Marie had made this up.
On Aug. 12, the day after Marie reported being raped, Sgt. Mason’s telephone rang. The caller “related that [Marie] had a past history of trying to get attention and the person was questioning whether the ‘rape’ had occurred,” Mason later wrote.
Mason’s report didn’t identify the caller — but the caller was Peggy.
She called police to share her concerns. Mason then came to her home and interviewed her in person. When she told police of her skepticism, she asked to be treated anonymously. “I didn’t want it to get back to Marie,” Peggy says. “I was trying to be a good citizen, actually. You know? I didn’t want them to waste their resources on something that might be, you know, this personal drama going on.”
In addition, Mason had received a tip that Marie was unhappy with her apartment. Maybe she was making up the rape to get moved to a new one.
On Aug. 13, Marie met with Mason at the Lynnwood police station and turned in a written statement, describing what happened. The statement was only one page. But to Mason, there was one critical passage. Marie wrote that the attacker said she could untie herself once he was gone:
After he left I grabbed my phone (which was right next to my head) with my mouth and I tried to call Jordan back. He didn’t answer so I called my foster mom. … She came right away. I got off the phone with her and tried to untie myself.
This didn’t square with what Marie had previously told Mason. Before, she told the detective she had tried calling Jordan after cutting the laces. In this written statement, she described calling him while still tied up.
Later that day, Mason talked to Rittgarn, his fellow detective, and said that — based on Marie’s inconsistencies, and based on what he had learned from Peggy and Jordan — he now believed Marie had made up the story.
The fear of false rape accusations has a long history in the legal system. In the 1600s, England’s chief justice, Matthew Hale, warned that rape “is an accusation easily to be made and hard to be proved, and harder to be defended by the party accused.” Judges in the U.S. read the so-called Hale warning to juries until the 1980s. But most recent research suggests that false reporting is relatively rare. FBI figures show that police annually declare around 5 percent of rape cases unfounded, or baseless. Social scientists examining police records in detail and using methodologically rigorous standards cite similar, single-digit rates.
The next morning, Mason went to Jordan’s home to interview him. Jordan told the detective that he and Marie had stopped dating a couple months back but remained good friends. He said nothing about doubting Marie’s story, according to Mason’s written summary. But he did say Marie had told him: When she tried calling him that morning, she had used her toes, because she was tied up.
Later that day — Aug. 14, three days after Marie reported being raped — Mason called Marie, to ask if they could meet. He said he could come and pick her up, to take her to the police station.
“Am I in trouble?” Marie asked the detective.
On Feb. 9, 2011, more than a dozen cops and agents from the FBI and the Colorado Bureau of Investigation gathered in a briefing room at the Westminster police station to discuss the state of the investigation.
The news was not great. After a five-week crush, there were few leads and no suspects. The analysis of the touch DNA produced mixed results. The samples narrowed the field of suspects to males belonging to the same paternal family line. But there was not enough genetic material to identify a single individual. Thus the results couldn’t be entered into the FBI’s nationwide DNA database to check for a match to a suspect.
Galbraith was hopeful. At least it was concrete now. The same person was at work. “It’s huge,” she said. “But not enough.”
As the meeting drew to a close, a young crime analyst from the Lakewood police department stood up. She had conducted a search for any reports of suspicious vehicles or prowlers within a quarter mile of the Lakewood victim’s home for the previous six months. She had turned up something. But she didn’t know if it was important.
Three weeks before the attempted rape in Lakewood, a woman had called police late in the evening to report a suspicious pickup truck parked on the street with a man inside. Police checked it out, but the man was gone. The officer filed a brief report on the vehicle. What had attracted the analyst’s attention was the location of the pickup. It was parked half a block from the Lakewood victim’s house, by an empty field adjacent to her backyard.
The pickup was a 1993 white Mazda.
It was registered to a Lakewood man named Marc Patrick O’Leary.
The investigation instantly turned urgent. Could the detectives connect O’Leary’s Mazda with the blurry image of the white Mazda in the surveillance footage from Golden? Aaron Hassell, the detective on the Lakewood case, raced back to his office. Lakewood patrol cars had cameras that automatically took pictures of every license plate they passed. The result was a searchable database of thousands of tag numbers indexed by time and location. Hassell typed in the license plate number from the Lakewood report: 935VHX. He got a hit. A Lakewood patrol car had snapped a picture of O’Leary standing by his white Mazda in the driveway of his house — only two hours after the August attack on the widow in Westminster.
Hassell transmitted the image to Galbraith. Carefully, she compared O’Leary’s white Mazda to the surveillance tape. One freeze frame showed that her white Mazda had a broken passenger side mirror. So, too, did O’Leary’s truck. Both vehicles had ball hitches on the back. Both had smudges on the back in the same place — perhaps a bumper sticker that had been torn off.
“That’s our guy,” Galbraith said.
Hendershot discovered the Lakewood patrol car had snapped its picture as O’Leary was headed to a nearby branch of the Colorado Department of Motor Vehicles. DMV records showed O’Leary sat for a driver’s license mugshot about four hours after the Westminster attack. The photo showed a 6-foot-1 man with hazel eyes. He was 32 years old and 220 pounds. He wore a white T-shirt. The physical description closely matched the descriptions provided by the victims. And the Westminster widow had told Hendershot that her attacker wore a white T-shirt during her assault.
Hendershot did not want to be too hasty. “I’m encouraged, I’m excited,” she said. But “I haven’t made my decision yet, that yay, we’ve got the guy.”
Over the next 24 hours, more than a dozen investigators threw their collective effort and experience into finding out everything possible about O’Leary. O’Leary had no criminal record. He was not a registered sex offender. He had served in the Army.
Galbraith and her husband David once again faced each other on the couches in their living room. They used laptops to search for any references to O’Leary, each using a different search engine. Before long, David stumbled onto something. O’Leary had purchased a pornography website in September 2008. They wondered whether it contained photos of his victims.
The investigators decided to try to get a sample of O’Leary’s DNA. Though the degraded DNA lifted from the crime scenes could not definitively match O’Leary’s DNA, it could show that a male from his family line had most likely committed the crime. If detectives could eliminate O’Leary’s male relatives, they could place O’Leary at the scene of the crimes with a high degree of certainty. “We still have to make that definitive identification,” Hendershot said.
On the morning of Friday, Feb. 11, FBI agents were surveilling O’Leary’s house. It was a small, single-story home with gray siding half a block from a gas station, an auto body shop and a carniceria in a beat-down neighborhood. A low chain-link fence surrounded it. Tall, winter-bare trees towered above the roof. Just after noon, the agents saw a woman and a man who looked like O’Leary leave. They tailed the pair to a nearby restaurant, and watched them eat. When they finished, the agents raced in. They grabbed the drinking cups from the table. The rims would have traces of his DNA.
While the agents were following the man believed to be Marc O’Leary, another FBI agent knocked on the door of the home. He planned to install a surveillance camera nearby and wanted to make sure that nobody was around. Unexpectedly, a man came to the door. He looked like Marc O’Leary. Confused, the agent fell back on a practiced ruse. He told the man he was canvassing the neighborhood to warn of a burglar in the area. The man introduced himself. He was Marc O’Leary. His brother, Michael O’Leary, had just left to get lunch with his girlfriend. O’Leary thanked the officer for the information and closed the door.
Michael’s appearance was confounding. The investigators hadn’t known that Michael lived with his brother. Or that he looked so similar. They decided to run Michael O’Leary’s DNA, collected from the restaurant glass, against the DNA found at the crime scenes. Analysts at the Colorado Bureau of Investigation got the samples. Usually, a DNA analysis took months. But in this case, they worked through the night. By 2 p.m. on Saturday, they had a result. The DNA from the cup matched the DNA collected from the victims. An O’Leary man was responsible. But which one?
Galbraith ruled out the brothers’ father — he was too old and lived in a different state. But investigators could not yet rule out Michael as a suspect. It was possible that Michael had committed the rapes. Or even that Michael and Marc had worked together. They needed more information.
Galbraith hastily typed up a search warrant to enter the brothers’ home. It was dark outside when she finished. She called the judge who was on duty for the weekend. He insisted on a fax. Galbraith rushed to a Safeway near her house to send the warrant. The judge signed it at 10 p.m. on Saturday.
She knew exactly what she was looking for. She trusted her victim’s memory. The dark mark on his leg.
She emailed a crime analyst at another police department, “I so want to see this guy’s leg! BAD.”
In Sgt. Mason’s experience, when someone asked if they were in trouble, almost always, they were.
When Mason, accompanied by Detective Rittgarn, went to pick up Marie at about 3:30 p.m., they found her outside her apartment, sitting on the grass. The three went to the Lynnwood police station, where the detectives escorted Marie to a conference room.
From what Mason wrote up later, he wasted little time confronting Marie, telling her there were inconsistencies between her statements and accounts from other witnesses. Marie said she didn’t know of any discrepancies. But she went through the story again — only this time, saying she believed the rape had happened instead of saying it for certain. Tearfully, she described her past — all the foster parents, being raped when she was 7, getting her own place and feeling alone. Rittgarn told Marie that her story and the evidence didn’t match. He said he believed she had made the story up — a spur-of-the-moment thing, not something planned out. He asked if there was really a rapist running around the neighborhood that the police should be looking for. “No,” Marie told him, her voice soft, her eyes down.
“Based on her answers and body language it was apparent that [Marie] was lying about the rape,” Rittgarn later wrote.
Without reading Marie her rights — you have the right to an attorney, you have the right to remain silent — the detectives asked Marie to write out the true story, admitting she had lied, admitting, in effect, that she had committed a crime. She agreed, so they left her alone for a few minutes. On the form she filled in her name, address and Social Security number, and then she wrote, in part:
I was talking to Jordan on the phone that night about his day and just about anything. After I got off the phone with him, I started thinking about all things I was stressed out and I also was scared living on my own. When I went to sleep I dreamed that someone broke in and raped me.
When the detectives returned, they saw that Marie’s new statement described the rape as a dream, not a lie.
Why didn’t you write that you made the story up? Rittgarn asked.
Marie, crying, said she believed the rape really happened. She pounded the table and said she was “pretty positive.”
Pretty positive or actually positive? Rittgarn asked.
Maybe the rape happened and I blacked it out, Marie said.
What do you think should happen to someone who would lie about something like this? Rittgarn asked Marie.
“I should get counseling,” Marie said.
Mason returned to the evidence. He told Marie that her description of calling Jordan was different from what Jordan had reported.
Marie, her face in her hands, looked down. Then “her eyes darted back and forth as if she was thinking of a response.”
The detectives doubled back to what she had said before — about being stressed, being lonely — and, eventually, Marie appeared to relax. She stopped crying. She even laughed a little. She apologized — and agreed to write another statement, leaving no doubt it was a lie.
I have had a lot of stressful things going on and I wanted to hang out with someone and no one was able to so I made up this story and didn’t expect it to go as far as it did. … I don’t know why I couldn’t have done something different. This was never meant to happen.
This statement appeared to satisfy the detectives. Rittgarn would later write, “Based on our interview with [Marie] and the inconsistencies found by Sgt. Mason in some of the statements we were confident that [Marie] was now telling us the truth that she had not been raped.”
To Marie, it seemed the questioning had lasted for hours. She did what she always did when under stress. She flipped the switch, as she called it, suppressing all the feelings she didn’t know what to do with. Before she confessed to making up the story, she couldn’t look the two detectives, the two men, in the eye. Afterward, she could. Afterward, she smiled. She went into the bathroom and cleaned up. Flipping the switch was a relief — and it would let her leave.
The next day, Marie told Wayne Nash, her case manager at Project Ladder, that the police didn’t believe her. Recognizing the jeopardy she was in, she said she wanted a lawyer.
The Project Ladder managers instead reached out to Sgt. Mason. He told them the evidence didn’t support Marie’s story, and that she had taken her story back.
But now, Marie wouldn’t give. On Aug. 18, one week after she reported being raped, she met with the two Project Ladder managers and insisted she had signed the recantation under duress. The three then went to the police station so Marie could recant her recantation — that is, tell detectives that she had been telling the truth the first time.
While the program managers waited outside, Marie met with Rittgarn and another officer.
Rittgarn asked Marie what was going on. Marie said she really had been raped — and began to cry, saying she was having visions of the man on top of her. She wanted to take a lie detector test. Rittgarn told Marie that if she took the test and failed, she would be booked into jail. What’s more, he would recommend that Project Ladder pull her housing assistance.
Marie backed down. The police officers walked her downstairs, where the Project Ladder representatives asked if she had been raped. Marie said no.
After leaving the police station, Marie learned that she still wasn’t through. There was something else she had to do. The Project Ladder managers told Marie that if she wanted to stay in the program — if she wanted to keep her subsidized apartment — she would have to confess to someone else.
Later that day a meeting was called at the housing complex, with all of Marie’s peers gathered in a circle. Marie, as directed, told her fellow participants in Project Ladder that she had lied about being raped. They didn’t need to worry, she told the group. There was no one out there who had hurt her and no one who might hurt them next.
If there was sympathy in the room, Marie sensed it from only one person, the young woman to her right. The rest was awkward, excruciating silence.
After the meeting, Marie started walking to a friend’s place. On her way, she crossed a bridge. She considered jumping. “Probably the only time I just wanted to die in my life,” she says. She called a friend and said, “Please come get me before I do something stupid.” Afterward, Marie hurled her phone over the side.
Later that month, there was a final surprise. Marie got a letter, notifying her that she was wanted in court. She had been charged with false reporting, punishable by up to a year in jail. The criminal citation was signed by Sgt. Mason. Afterward, the paperwork went to a small law firm that Lynnwood had hired to prosecute misdemeanors.
For Mason, his decision to file the citation required no complicated calculus. He was certain Marie had lied. The police had spent a lot of resources chasing that lie. The law said her lie was a crime. Really, it was as simple as that.
There are no firm statistics on how often police arrest women for making false rape reports, nor on how often prosecutors take such cases to court. Nobody collects such data. But leading law enforcement organizations urge caution in filing such charges. The International Association of Chiefs of Police and the FBI stress the need for a thorough investigation before discounting a report of rape. Cops must work as hard to prove a falsehood as they do to prove a truth.
In practice, many police departments will pursue charges against women only in extreme circumstances — say, in a highly public case where a suspect’s reputation has suffered, or where the police have expended considerable investigative resources. This reluctance stems from the belief that in rape cases, the biggest problem is not false reporting, but no reporting. Only about one-fifth to one-third of rapes get reported to police, national surveys show. One reason is that women fear police won’t believe them.
Within days of reporting being raped, Marie had quit her job at Costco, unable to stand there, looking at people, lost in her head. Now, her losses mounted.
Project Ladder gave her a 9 p.m. curfew and doubled the number of times she had to meet with staff.
The media wrote about Marie being charged, without identifying her. (The Seattle Post-Intelligencer headline read, “Police: Lynnwood rape report was a hoax.”) Marie’s best friend from high school — the one who had taught her photography and had taken that picture of her emerging from the surf — created a webpage that called Marie a liar, with a photo from Marie’s Myspace page, with police reports, with Marie’s full name. Alerted to the site, Marie went into a frenzy, trashing her apartment.
Marie stopped going to church. “I was mad at God,” she says. She lost interest in photography. She feared going outdoors. “One night I did try to walk to the store by myself and felt like I hallucinated someone following me,” she says. “It freaked me out. I didn't even get a half mile from my house. I ran home.” At home she avoided the bedroom, choosing to sleep on the couch with the lights on.
“I went into this dark hole,” she says.
Self-esteem gave way to self-loathing. She started smoking, drinking, gaining weight.
For Marie, this was a familiar drill, one she could trace to her years of being abused as a kid, and to her years in foster care, bouncing from home to home and school to school. Shut down. Hold it in. Act like nothing bad had happened, like nothing ever affected her. Because she craved normalcy, she would bury the hurt.
Neither Peggy nor Shannon abandoned her, but things weren’t the same. Marie knew that both had doubted her story, even before the police had.
For Marie, Shannon’s home had long provided an escape or respite. Marie and Shannon would walk in the woods, or take out the boat, then, at day’s end, crash in Shannon’s home. Now, fearful he could become the target of a wrongful accusation, Shannon’s husband decided it would be best if Marie no longer spent the night. “When you become a foster parent, you’re open to that,” Shannon says.
It fell to Shannon to break the news. Delivering it crushed her. Receiving it crushed Marie.
In early October, less than two months after Marie was charged with false reporting, a 63-year-old woman reported being raped inside her condominium in Kirkland, east of Seattle. The stranger wore gloves. He held a knife. He tied the woman up — with her own shoelaces. He took pictures and threatened to post them on the Internet. For the last two or three months, the woman told police, she felt as if someone had been following her.
Shannon saw an account of the attack on the television news and was taken aback. Her father had been the chief of police in Kent, south of Seattle. She grew up with police, trusted police, knew how the police worked. She went to her computer, looked up the number, and called — immediately — to alert police in Kirkland to Marie’s story, to advise them of all the parallels.
Shannon called Marie and suggested she also contact the Kirkland police. Marie never did.
“I was just too scared,” Marie says. She’d gone through so much already. She couldn’t bring herself to meet with the police again and say anything more. But she did go online and look up what happened to the woman in Kirkland. When she read the story, she cried.
A Kirkland detective eventually called Shannon back. Based on Shannon’s tip, Kirkland investigators had reached out to their Lynnwood counterparts and had been told the Lynnwood victim was no victim, the story had been made up.
One of the detectives working the Kirkland case was Audra Weber. She remembers calling the Lynnwood detectives twice and being told they didn’t believe Marie’s account. “I just kind of trusted their judgment, in terms of it’s their case, they know the details and I don’t,” Weber says. But she remembers being “kind of shocked” to learn that they had charged Marie. She let it go and hung up, thinking, “Okay, I hope that works out for you guys.”
At 8:15 a.m., Galbraith knocked on O’Leary’s door.
“Police. Search warrant. Open the door,” she shouted repeatedly. Seven cops stood behind her, pressed against the house, their guns drawn.
After a pause, O’Leary opened the door. He looked confused and shocked as he stepped out into the bright winter sun. Two dogs, a small pit bull and a Shar-Pei, tumbled out ahead of him. He wore a gray hoodie, baggy gray sweatpants and gray slip-on houseshoes. He was alone.
Galbraith pulled him to the side and patted him down. When she got to his legs, she raised his pant leg to look.
There it was, on O’Leary’s left calf: a dark birthmark the size of a large chicken egg.
It was him. He was the rapist. Galbraith flashed a quick thumbs up.
As an FBI agent confronted him, O’Leary immediately invoked his right to an attorney. Galbraith had maneuvered herself to stand behind O’Leary. At 8:35 a.m., she handcuffed him. “You’re under arrest for burglary and sexual assault which occurred in the City of Golden on January 5, 2011,” she told him. O’Leary was put in a patrol car and transported to the Jefferson County Jail.
She was wearing new boots that day. Whenever she looked at them in the future, she would remember catching O’Leary. For Galbraith, it was important to be the one who made the arrest. “I wanted to see the look on his face, I guess,” she said. “And for him to know that we figured you out.”
The search of the home validated the detectives’ investigation. Investigators found a pair of Adidas ZX 700 shoes in O’Leary’s closet. The treads matched the footprints in the snow in Golden and outside the window in Lakewood. They discovered a pair of Under Armour gloves with a honeycomb pattern. In the bathroom was a black headwrap, tied to serve as a mask.
“He was military — so he was very organized,” Galbraith said. “This was the cleanest house I’ve ever searched. It was so organized, we were like, ‘Oh, thank God.’”
The victims’ accounts were also borne out. Most had described a white man with green or hazel eyes, about 6 feet tall, weighing about 200 pounds. They talked about being tied up. They mentioned that he had stolen their underwear. In O’Leary’s house, investigators turned up a black Ruger .380-caliber pistol, a pink Sony Cyber-shot camera and a large backpack, along with wet wipes and lubrication. Hidden inside a piece of stereo equipment in his closet, detectives found a collection of women’s underwear. Trophies.
That night, Hendershot drove to break the news to her victim, the 59-year-old widow in Westminster. The woman had lost her husband to cancer the previous year. She had no family nearby. She was still emerging from the mental and physical suffering she endured during the attack. Hendershot met her at a Denny’s restaurant. She found her in a back corner, eating dinner alone.
“I walked in, and she was super happy to see me, and I told her. I mean, I get shiver bumps thinking about it, just even now,” Hendershot said. “I told her, I said, ‘It’s over. It’s over. We have him.’”
By early March, a forensic computer specialist cracked into files that O’Leary had stored on his hard drive. He found a folder called “girls” — and pictures that O’Leary had taken of his victims in Golden and Westminster. Galbraith recognized them by sight.
But then Galbraith stumbled across an image of a woman she didn’t recognize. It was a young woman — far younger than the Colorado victims, perhaps a teenager. The pictures showed her looking terrified, bound and gagged on a bed. Galbraith felt sick. How would she identify her? How would she find justice for her?
After looking through the images, she found an answer. It was a picture of the woman’s learner’s permit, placed on her chest. It had her name. And it had her address.
Lynnwood, Washington.
He arrived in the predawn hours, then waited outside her apartment, outside her bedroom, listening to her on the phone, waiting for her to fall asleep.
The night was dry, letting him settle in. The wall was thin, letting him hear her voice. A couple of times he left his position, for just a while, for fear of being spotted lingering.
He liked trees, for the cover they provided, and the Alderbrooke Apartments had plenty of them. Apartments didn’t offer the privacy of a house, but still, there were advantages. All those windows, for one thing. And all those sliding glass doors — ridiculously easy to pick, when they weren’t left unlocked, which so often they were.
She wasn’t his type, not really. He’d realized that before while peeping into her bedroom. But he spent so much time hunting (that’s what he called it, hunting), hundreds of hours, maybe even a thousand, that he conditioned himself to incorporate as many women as possible, young or old, into his fantasies.
That way his work wouldn’t be wasted.
He had prowled before and broken into women’s homes before, but following through was another matter. He had learned from past failures — one time, a guy walked in as he stood there, mask on, outside the bedroom door of the woman he planned to rape — so now, he did painstaking surveillance: peeking in windows, breaking in beforehand, gathering information. Years later, detectives would find notes on his cellphone from his surveillance of another target (his word) that detailed which room she was in and when, what lights were off or on, which windows and blinds were opened or closed, whether her boyfriend was there or gone. “BF in PJs, game over,” he wrote in one night’s entry.
He would rifle a target’s personal documents. He would learn her date of birth and license plate number. He would watch her watching TV. And at the hunt’s end, before he committed, he would take a final pass through the home, or what he called “precombat inspection,” to make sure there weren’t any weapons within the target’s reach.
At a little before sunrise, he heard the phone conversation end. He waited a little longer, letting the silence stretch out, then climbed over the railing and slipped through the unlocked sliding glass door. For the next half hour or so, while she slept, he got ready while talking himself into following through.
He had first spotted her a couple of weeks before, through a window, while lurking outside her apartment. He had since broken into her place twice, both times through that same glass door.
He had a term for what he was about to do: “rape theater.” Deviant fantasies had gripped him since he was a kid, way back to when he had seen Jabba the Hutt enslave and chain Princess Leia. Where do you go when you’re 5 and already thinking about handcuffs? he would ask himself. He was only 8 the first time he broke into a home. It was such a rush. He had broken into more than a dozen homes since.
Now he was 30, an Army veteran — infantry, two tours in South Korea — who had enlisted in the Reserves, only he hadn’t appeared for duty in months.
In the kitchen, he went to the knife block and removed a black-handled blade from the top row, far left.
In the living room, he removed the laces from her black tennis shoes and put the shoes back. One detective later wrote in a report, “The shoes were lying next to each other near the end of the couch and the bedroom door, on the soles as if placed there (not disturbed).”
He was just being neat and orderly, the way he was with everything.
He threaded one of the shoelaces through a pair of underwear.
Then he walked to the bedroom.
Around 7 a.m., he stood in her bedroom doorway, holding, at shoulder height, a knife in his left hand.
He watched as she awoke.
Turn away, he told Marie — and she did. Roll over onto your stomach, he told her. She did — and then he straddled her, putting the knife near her face.
Put your hands behind your back, he told her. She did. He bound her wrists and he covered her eyes. He stuffed cloth into her mouth to muffle any sound.
That was an interesting conversation you were having, he said, letting her know that he had been there, listening, waiting.
You should know better than to leave the door unlocked, he told her.
Roll back over, he told her — and she did, and then he raped her, and while he raped her he ran his gloved hands over her.
He put her learner’s permit on her chest and took pictures of her.
When he was finished, he said that if she told the police, he would post the photos online so that her kids, when she had kids, could see them.
He took out the gag and removed the blindfold, telling her to avert her eyes and to keep her head in the pillow.
One of the last things he said was that he was sorry. He said he felt stupid, that it had looked better in his head.
He left the room, and walked to the front door, and he was gone.
Marie’s account, in her own words. It is graphic, but she told us people should hear it. Warning: This material may be disturbing to some listeners.
Listen to Marie
O’Leary pleaded guilty to 28 counts of rape and associated felonies in Colorado. On Dec. 9, 2011, almost a year after his arrest, O’Leary was sentenced to 327½ years in prison for the Colorado attacks — the maximum allowed by law. He is currently housed in the Sterling Correctional Facility in the barren, remote northeastern corner of Colorado. He will never be released.
In an interview with police after his conviction, O’Leary recounted his attacks in detail. He described the feeling after raping one elderly victim. “It was like I’d just eaten Thanksgiving dinner,” he said.
He let spill some lessons for law enforcement. He boasted of the countermeasures he’d taken to avoid getting caught. He knew that the Army had a sample of his DNA. So he took steps to avoid leaving any traces of genetic material. He also realized police departments often did not communicate. So he deliberately committed each rape in a different jurisdiction.
The five other attacks — one in Washington, four in Colorado — all came after the attack on Marie.
“If Washington had just paid attention a little bit more, I probably would have been a person of interest earlier on,” O’Leary said.
Working from Colorado, Galbraith not only linked O’Leary to the rape in Lynnwood, Washington, but to the rape in nearby Kirkland. She made the connection by working with a Washington state criminal analyst to search a database for unsolved cases similar to O’Leary’s crimes. She then found the Kirkland victim’s name on O’Leary’s computer, attached to an encrypted file.
O’Leary pleaded guilty in both of the Washington cases. In June 2012, he was sentenced to 40 years for the rape in Kirkland and to 28½ years for the rape of Marie in Lynnwood.
After O’Leary was linked to Marie’s rape, Lynnwood Police Chief Steven Jensen requested an outside review of how his department had handled the investigation. In a report not previously made public, Sgt. Gregg Rinta, a sex crimes supervisor with the Snohomish County Sheriff’s Office, wrote that what happened was “nothing short of the victim being coerced into admitting that she lied about the rape.”
That Marie recanted wasn’t surprising, Rinta wrote, given the “bullying” and “hounding” she was subjected to. The detectives elevated “minor inconsistencies” — common among victims — into discrepancies, while ignoring strong evidence the crime had occurred. As for threatening jail and a possible withdrawal of housing assistance if Marie failed a polygraph: “These statements are coercive, cruel, and unbelievably unprofessional,” Rinta wrote. “I can’t imagine ANY justification for making these statements.”
Jensen also ordered an internal review, which was similarly damning. Mason’s judgment was unduly swayed by Peggy’s phone call. The detectives’ second interview with Marie was “designed to elicit a confession of false reporting.” The false reporting charge arose from a “self-imposed rush.”
Despite the reviews’ tough language, no one in the Lynnwood Police Department was disciplined.
In a recent interview, Steve Rider, the current commander of Lynnwood’s Criminal Investigations Division, called Marie’s case a “major failing” that has left members of the department with a profound sense of regret: “Knowing that she went through that brutal attack — and then we told her she lied? That’s awful. We all got into this job to help people, not to hurt them.” Lynnwood Sgt. Rodney Cohnheim said of Marie, “She was victimized twice.”
Sgt. Mason is now back in narcotics, in charge of a task force. Interviewed in the same room where he had confronted Marie seven years before, he said: “It wasn’t her job to try to convince me. In hindsight, it was my job to get to the bottom of it — and I didn’t.”
Marie’s case led to changes in practices and culture, Rider said. Detectives receive additional training about rape victims. Rape victims get immediate assistance from advocates at a local healthcare center. Investigators must have “definitive proof” of lying before doubting a rape report, and a charge of false reporting must now be reviewed with higher-ups. “We learned a great deal from this. And we don’t want to see this happen to anybody ever again,” Rider said.
Rittgarn, who left the Lynnwood Police Department before O’Leary’s arrest, declined to be interviewed for this story. So did Zachor & Thomas, the law office that handled the prosecution of Marie on Lynnwood’s behalf.
In 2008, Marie’s case was one of four labeled unfounded by the Lynnwood police, according to statistics reported to the FBI. In the five years from 2008 to 2012, the department determined that 10 of 47 rapes reported to Lynnwood police were unfounded — 21.3 percent. That’s five times the national average of 4.3 percent for agencies covering similar-sized populations during that same period. Rider said his agency has become more cautious about labeling a case unfounded since Marie. “I would venture to say we investigate our cases a lot more vigorously than many departments do,” he said. “Now, we're extra careful that we get the right closure on it.”
Two and a half years after Marie was branded a liar, Lynnwood police found her, south of Seattle, and told her the news: Her rapist had been arrested in Colorado. They gave her an envelope with information on counseling for rape victims. They said her record would be expunged. And they handed her $500, a refund of her court costs. Marie broke down, experiencing, all at once, shock, relief and anger.
Afterward, Shannon took Marie for a walk in the woods, and told her, “I’m so sorry I doubted you.” Marie forgave, immediately. Peggy, too, apologized. She now wishes she had never shared her doubts with police. “Because I feel that if I would have shut my mouth, they would have done their job,” she says.
Marie sued the city and settled for $150,000. “A risk management decision was made,” a lawyer for Lynnwood told The Herald in Everett, Washington.
Marie left the state, got a commercial driver’s license and took a job as a long-haul trucker. She married, and in October she and her husband had their second child. She asked that her current location not be disclosed.
Before leaving Washington to restart her life, Marie made an appointment to visit the Lynnwood police station. She went to a conference room and waited. Rittgarn had already left the department, but Mason came in, looking “like a lost little puppy,” Marie says. “He was rubbing his head and literally looked like he was ashamed about what they had done.” He told Marie he was sorry — “deeply sorry,” Marie says. To Marie, he seemed sincere.
Recently, Marie was asked if she had considered not reporting the rape.
“No,” she said. She wanted to be honest. She wanted to remember everything she could. She wanted to help the police.
“So nobody else would get hurt,” she said. “They’d be out there searching for this person who had done this to me.”
Join ProPublica, The Marshall Project, and Joanne Archambault of the nonprofit End Violence Against Women to discuss pitfalls and best practices of sex crimes investigations. You can also read more about how ProPublica and The Marshall Project reported this story.
T. Christian Miller joined ProPublica in 2008 as a senior reporter. He spent the previous 11 years reporting for the Los Angeles Times. His work included coverage of the 2000 presidential campaign and three years as a bureau chief for the Times, responsible for 10 countries in South and Central America.
Ken Armstrong is a Pulitzer Prize-winning investigative reporter who previously worked at The Seattle Times and Chicago Tribune, where his work helped prompt the Illinois governor to suspend executions and later empty death row. He has been the McGraw Professor of Writing at Princeton and a Nieman Fellow at Harvard.
Detectives investigating a Lynnwood, Washington, teenager’s rape in our latest investigation, An Unbelievable Story of Rape, concluded she hadn’t been assaulted based in part on “her answers and body language” during an interview with police. But as our investigation with The Marshall Project revealed, the police who confronted Marie made a number of mistakes in her case that would have grave consequences — for the 18-year-old in Washington and for several other women who lived hundreds of miles away.
This Thursday, December 17, at 12:30 pm ET, ProPublica and The Marshall Project are hosting a Digg Dialog with retired San Diego Police Sgt. Joanne Archambault, who leads the nonprofit End Violence Against Women International, to discuss best practices for law enforcement investigating sex crimes.
Reporters T. Christian Miller (@txtianmiller) and Ken Armstrong (@bykenarmstrong) will join Archambault to discuss their story on Marie’s “unbelievable” rape, and the search for a serial rapist that spanned the Denver metro area three years later.
Read the story, then head over to Digg to join the discussion (you’ll need to sign up for an account to weigh in), or you can tweet us your questions in advance with #ProPubChat.
Image may be NSFW.In between Colombian drug lord Pablo Escobar and Mexico’s El Chapo, the world’s most powerful drug trafficker, there were the Arellano brothers. In the early 1990s, the Arellano Felix Organization and El Chapo’s Sinaloa cartel fought each other to be the biggest, baddest drug traffickers in Mexico. At one point, the AFO was responsible for 40 percent of the cocaine consumed in the United States. One former lieutenant said that Benjamin Arellano, an AFO leader, was responsible for more killings than the 9/11 terrorists.
When DEA agent Jack Robertson started investigating the AFO in the early ‘90s, the agency thought the inquiry would last six months. It lasted 20 years. For the first time, Robertson went on the record to talk to ProPublica reporter David Epstein about the case that ate up 200,000 man-hours and millions in taxpayer money. One of the biggest questions remains: Was it all worth it? All three of the brothers ended up in U.S. jails, though one will be out in just a few years. But DEA intelligence that might have helped the government pursue El Chapo never was used.
On Thursday at 2 p.m. EST, you’ll get a chance to ask Robertson — who went on to help take down Lance Armstrong — anything about fighting narco-traffickers and the challenges of federal drug enforcement. ProPublica reporter Epstein will also be on hand to talk about this never-before-told chapter on the rise of El Chapo, and the role the U.S. government played in it.
Have a question for Robertson or Epstein? Tweet us with #ProPubChat and we’ll do our best to log them in the Reddit. Or visit Redddit’s IAmA thread on Thursday to join the discussion.
New to Reddit? Click here to create an account, check out this beginner’s guide from Mashable or Reddit’s official FAQ.
Image may be NSFW.For 14 months, the first thing Dave Herrod, a special agent with the Drug Enforcement Administration, did every morning was boot up his laptop and begin tracking a 43-foot yacht with Dock Holiday painted on the stern.
In the summer of 2005, the DEA had intercepted a conversation in which members of a Mexican drug cartel known as the Arellano Félix Organization discussed buying a yacht in California. Herrod and his colleagues studied the classified ads in yacht magazines and determined that the Dock Holiday was the boat the AFO members wanted. DEA agents then managed to get on board and install tracking devices before the sale went through. That’s when Herrod started watching the boat on his laptop.
Since the early 1990s, the Arellano brothers — the inspiration for the Obregón brothers in the movie Traffic — had controlled the flow of drugs through what was perhaps the single most important point for illicit commerce in the world: the border crossing from Tijuana to San Diego. Much of the AFO’s success derived from its predilection for innovative violence. The cartel employed a crew of “baseballistas” who would hang victims from rafters, like piñatas, and beat them to death with bats. Pozole, the Spanish word for a traditional Mexican stew, was the AFO’s euphemism for a method of hiding high-profile victims: Stuff them headfirst into a barrel of hot lye or acid and stir for 24 hours until only their teeth were left, then pour them down the drain.
Dismantling the AFO had been an official project of the U.S. government since 1992, and an obsession of Herrod’s since the year before that, when he’d started chasing the cartel as a rookie agent stationed near San Diego. A former athlete, he spent years guzzling Pepsi and Mountain Dew to power through long workdays. His health, like everything else, took a backseat to the AFO case.
After the sale of the Dock Holiday, the trackers showed the vessel hugging the coast of Mexico’s Baja California peninsula, rounding the tip of Cabo San Lucas, and heading north into the Gulf of California to La Paz. Once in a while, it sailed to Rancho Leonero, where Javier Arellano Félix, the head of the AFO at the time, had a beach house. Herrod knew that Javier loved deep-sea fishing, and he was convinced that the cartel’s chief executive was using the boat. So the DEA launched Operation Shadow Game. The plan: Watch the Dock Holiday to find out if Javier would be on it, then intercept the boat should it stray beyond Mexico’s territorial waters.
For six weeks, the U.S. Coast Guard cutter Monsoon stood sentinel off Baja California, waiting for the yacht to venture more than 12 nautical miles off the coast and into international waters. But it never did. On August 12, 2006, Operation Shadow Game came to an end. The Monsoon set off for other duties, and Herrod left his laptop dark for the first time since the previous summer.
Two days later, he got a call at 8 a.m. from the Florida-based Joint Interagency Task Force South, which was still monitoring the tracking devices. The Dock Holiday had left Mexican sovereignty south of Cabo San Lucas. The men on the boat were chasing marlin, zigzagging in and out of international waters: out to 19 miles, back to 10 miles, then out to 15, then back to 12. The task force wanted to know whether the Coast Guard should board the Dock Holiday if the opportunity arose.
Herrod had only a hunch as to who was on the boat. The DEA had deemed the operation an expensive failure and pulled its on-the-ground surveillance weeks earlier. Agents who had worked on the AFO case for years were being reassigned entirely. Herrod figured he’d never have another chance to catch Javier outside of Mexico. Without asking his supervisors, he gave the order: Send the Monsoon back.
At 1 p.m., 13.1 nautical miles off Mexico, the Coast Guard intercepted the Dock Holiday. Herrod waited at the office in San Diego, pacing back and forth, as the Coast Guard collected identification from those on board. Agents shuffled past his cubicle asking for updates, like restless children on a road trip. After two hours, he got a message from the Monsoon: eight men and three boys on board. At 4 p.m., photographs started coming through by e-mail. The first two faces, those of the captain and a crewman, were unfamiliar. So were the next two. Could he have been wrong? Then came the fifth picture, and it took Herrod’s breath away: a mustachioed man in a pale-yellow Lacoste shirt, reclining on white-leather seats. This was “El Nalgón,” or “Big Ass”: Manuel Arturo Villarreal Heredia, the 30-year-old chief enforcer for the AFO. According to agents, he was known for his facility with knife-based torture.
Herrod had never seen the young man in the sixth photo, though he had the Arellano family’s heavy eyebrows. Next came pictures of the three children and another unfamiliar man. In the final photo, staring wide-eyed into the camera, was a compact, square-jawed man wearing a thin gold chain that disappeared under the collar of his salmon-colored T-shirt. His pursed lips were framed by stubble and his eyebrows arched in subtle confusion. Herrod and an agent sitting beside him shot out of their chairs. The man was Javier.
The youngest of the Arellano brothers, he was the AFO’s Michael Corleone. He hadn’t asked to be in the family business — had left Tijuana and gone to business school, only to be called back — but, like Corleone in The Godfather, the young overlord had displayed a talent for organized crime and calculated violence. As the head of the AFO, he had directed hundreds of killings and kidnappings in Mexico and the U.S.
Javier’s arrest would be hailed by officials in the States as a decisive victory in what may have been the longest active case in the DEA’s history — a rare triumph in the War on Drugs. “We feel like we’ve taken the head off the snake,” the agency’s chief of operations announced. I can’t believe it actually fucking worked, Herrod recalls thinking.
But did it? Herrod is 50 years old now and nearing the end of his career with the DEA. In the time he spent hunting the Arellanos, his hair and goatee went from black to salt-and-pepper to finally just plain salt. He’s proud of the audacity and perseverance it took to bring down the cartel, and he knows he helped prevent murders and kidnappings. But when he looks back, he doesn’t see the clear-cut triumph portrayed in press releases. Instead, he and other agents who worked the case say the experience left them disillusioned. And far from stopping the flow of drugs, taking out the AFO only cleared territory for Joaquín Guzmán Loera — aka “El Chapo” — and his now nearly unstoppable Sinaloa cartel. Guzmán even lent the DEA a hand.
This is the story of the investigation as the agents saw it, including accounts of alleged crimes that were never adjudicated in court. “Drug enforcement as we know it,” Herrod told me, “is not working.”
Dave Herrod came to the DEA in 1991 from the U.S. Customs Service, looking for work with more gravity. He was 26, just two months out of the academy, when he got his first tip: Two vans, one tan and one blue, parked near a liquor store at Third and Main in Chula Vista, had recently crossed into the U.S. with one ton of cocaine. The tip came from a man named Joe Palacios, a Mexican who would have been a DEA agent had he been born a few miles north. Instead he earned his living as a DEA adjunct, gathering intelligence in exchange for payment. Agents called him “Eye in the Sky,” because they operated him like a satellite: Direct him to a target, and he would send back information. The tip sounded preposterous. A ton of cocaine, parked in the open in Chula Vista? But sure enough, there, at Third and Main, was a tan van with the windows blacked out. Agents followed it to a house, where they found the blue van.
Inside the two vans, they discovered 1.8 tons of cocaine bricks where the seats should have been. The DEA is going to be easy!, Herrod thought. He had no idea that the drugs belonged to the AFO, and that he’d just stumbled into the investigation that would haunt him for the next 20 years. But he got a hint that this was not an isolated bust when agents discovered that the vans had been let through the Tijuana crossing by a corrupt U.S. border inspector named John Salazar. After flunking a polygraph, Salazar came clean: He had been taking bribes from smugglers.
A few months later, Jack Robertson — another special agent, only slightly less green than Herrod — officially opened the DEA’s case targeting the Arellano brothers. Robertson was as idealistic as investigators come: empathetic and devoutly Christian, with a knack for getting young gang members to open up. He was also ambitious, and he’d been hearing about the AFO, which had just begun to dominate the Tijuana corridor. One informant was afraid to even utter the Arellano name.
Robertson says his boss, Michele Leonhart — who would go on to become the head of the DEA — thought they could wrap the case in six months. But six months in, the case was just getting under way. The Arellano brothers kept themselves insulated from their street dealers and low-level thugs — hit men had to pass requests for permission to murder through a dispatcher, who would relay a coded answer back. So agents had to start by pressuring arrested smugglers to give up information about their superiors, and then work toward identifying the key lieutenants in Tijuana and Mexicali. These were the men who took orders directly from the brothers.
Following on the success of the vans’ seizure, the DEA began working with the Customs Service on Operation Bus Stop. The idea was to follow Sultana Express tour buses, which were thought to be smuggling drugs across the border. Palacios would tail the buses once they entered Mexico to see where they were getting loaded up with drugs. On his first attempt, he slid in behind a bus as it passed into Tijuana but was immediately pulled over at gunpoint by Mexican police demanding to know why he was following the bus. Palacios talked his way out of trouble — What bus? — but suddenly the case felt bigger.
U.S. agents were disappointed that Palacios had lost the bus so quickly. But that night, he did a complete grid search of Tijuana, scouring the city one street at a time. At 6 a.m., he called Herrod from the beach community of Playas de Tijuana, where he read the plate off a Sultana Express bus. “I just could not believe he pulled that off,” Herrod told me. He marveled at Palacios’s tirelessness, and his courage.
For months, Palacios followed buses to an AFO warehouse, where they were fitted with secret compartments and loaded with cocaine. Based on his surveillance, U.S. authorities made more than 50 arrests north of the border over the course of nine months and intercepted drugs, guns, and grenades.
The agents and their bosses were ecstatic, but Palacios was nervous. He’d noticed the AFO stepping up its countersurveillance. He spoke with Herrod about ensuring that his family would be taken care of should something happen to him. His wife had just had a baby, their fifth. Herrod tried to reassure him. “We’re doing some great things,” he said, “but if you’re getting a funny feeling, just bail. It’s not worth anybody’s life.”
Palacios was paid a few thousand dollars a month, Herrod told me, some of which he spent on gas and on hiring people to help him keep watch. Herrod urged the higher-ups on the investigation from both Customs and the DEA to rent Palacios a new car each week, so that his brown van wouldn’t be recognized. After repeated requests, Herrod said, the government finally bought Palacios a used Volkswagen Rabbit that barely ran. He didn’t end up driving it.
One Monday afternoon in March 1992, Palacios didn’t respond when Herrod paged him “911,” their code to drop everything and call immediately. Herrod called Palacios’s wife. She couldn’t reach him either. That night, Palacios’s number popped up on Herrod’s phone, but the caller quickly hung up. Desperate, Herrod and a colleague asked a Mexican police commander to search for him. “He said, ‘Oh, yeah, we’re right on it,’ ” Herrod told me.
Late that Friday, just as Herrod was arriving home for the weekend, his phone rang. It was the resident agent in charge, his boss’s boss, telling him that Palacios had been found. “Great!,” Herrod exclaimed. “Where the fuck has that guy been?”
“You don’t understand,” the agent in charge told him.
An AFO enforcer had caught Palacios in his van with binoculars, a laptop, and a bedpan. He was executed, his body tossed on a hillside in Rosarito Beach, a coastal town 10 miles south of the border. Herrod went to Mexico to identify the body; it was the first corpse he’d ever seen. Palacios’s lips were swollen. His chest and arms were purple from blunt trauma. His throat had been slit from beneath one earlobe to beneath the other.
Herrod vowed to bring Palacios’s killers to justice. But they weren’t the only ones he blamed. An American agent never would have been expected to operate with so little support, he told me.
“We abused him,” Herrod said, “telling him to stay on stuff for weeks on end. Imagine doing surveillance 24/7 for 10, 12, 14 straight days. He was going to die eventually. You can’t do what he was doing, against the people he was doing it against, for that long a time and survive.”
The U.S. government gave Palacios’s family $350,000. But Herrod couldn’t stop thinking about Eye in the Sky, and the contrast between his fate and that of John Salazar, the corrupt border agent Palacios had helped catch. Salazar was sentenced to 30 years, but had to serve only five because he provided information that helped law enforcement intercept marijuana shipments. According to Office of Personnel Management records, he was allowed to keep his government pension.
That Jack Robertson’s boss thought the Arellano brothers could be caught in six months shows just how little American law enforcement knew about the drug leviathan to the south.
For the first 20 years of the War on Drugs, started by President Nixon in 1971, Mexican traffickers were a footnote, little more than border smugglers for Pablo Escobar, the Colombian billionaire drug trafficker. But in 1989, in an attempt to kill a Colombian presidential candidate, Escobar orchestrated the suitcase bombing of a commercial airliner that happened to have two Americans on board. That put Escobar in the crosshairs of the U.S. military. Four years later, he was gunned down after a massive manhunt.
As Ioan Grillo observed in his 2011 book, El Narco, “Typical of drug enforcement, solving one problem had created another bigger one.” The U.S. Navy blocked smuggling routes to Florida, and trafficking spidered along the Mexican border. Into the post-Escobar vacuum strode a cadre of ambitious Mexican criminals, including Benjamín Arellano Félix. The second-oldest of seven brothers — he was 37 when Escobar blew up the plane — Benjamín became the first head of the AFO. By the early 1990s, the cartel was smuggling in 40 percent of the cocaine consumed in the United States.
Months before Joe Palacios was killed, Benjamín threw a first-birthday party for his daughter at his ranch outside Tijuana. A home video shows the cartel family in its prime: the brothers dressed in garishly patterned short-sleeved button-downs, their wives in pendulous earrings and large sunglasses. Beneath a sprawling white tent, guests sipped from brown bottles of beer and red cans of Coke. Alongside an inflatable bouncy castle was a veritable menagerie — not just miniature horses and llamas, but also zebras, reindeer, and ostriches.
Less obvious, but no less exotic, were the cars: the bulletproof blue Toyota 4Runner given to a top AFO enforcer, and next to it the bulletproof white Dodge Shadow that belonged to Eduardo Arellano Félix, the saturnine brother known as El Doctor because he had once been a practicing doctor. Ramón Arellano Félix’s armored Grand Marquis was something out of a video game, wired to deliver an electric shock to any stranger who touched it; in the event of a chase, a button inside would release a trail of oil.
Ramón, the fifth of the seven brothers, was building a reputation as the most ruthless killer in Mexico. Carne asada — “grilled beef” — was the term he used to describe the practice of throwing a body on a bonfire of car tires to incinerate it. Rumor had it that Ramón would sit calmly and barbecue his own dinner in the flames. He wore ruby-, sapphire-, and emerald-encrusted watches and a skeleton belt buckle with diamonds for eyes. He once shot a bouncer at a bar because the man had asked him to pour his beer from a bottle into a cup.
As brutal as the brothers were, their first line of defense was not their own men but Mexico’s law enforcement. Mexican officials’ corruption “wasn’t a matter of if, but when,” Herrod told me. The head of Mexico’s equivalent of an attorney general’s office received $500,000 a month from the cartel, a former AFO lieutenant told investigators. Certain military generals made $250,000 a month. Prosecutors were paid à la carte. The system was so effective that AFO prisoners would occasionally escape torture houses only to be returned to the cartel by the very police into whose arms they had fled.
So when Jack Robertson met Jose “Pepe” Patino Moreno, an incorruptible Mexican investigator, he quickly grew to admire the man. Robertson appreciated Patino’s humility, and respected his willingness to stand up to colleagues he knew were working for the other side. “He was one of the most decent men I ever met,” Robertson told me. “I always had a sense of trust in him that I didn’t have in anybody.” In that way, he was to Robertson what Palacios was to Herrod. In another way as well: Patino was captured by AFO members, who reportedly crushed his head in a pneumatic press and smashed his bones with baseball bats. His body, a Los Angeles Times article reported, was as broken as a bag of ice cubes.
Through the 1980s, Mexican drug traffickers had worked in relative harmony to move Escobar’s product. To impoverished Mexicans, narcos represented brave resistance to a corrupt government and imperious American law enforcement. Popular folk ballads known as narcocorridos lionized drug lords. There was enough turf and money and inventory to accommodate every criminal appetite, and the Arellano brothers and Chapo Guzmán not only tolerated each other; they worked together when it suited them.
That began to change in 1989, when Ramón murdered a man who had assaulted one of his sisters years earlier; the man happened to be one of Guzmán’s closest friends. Ramón also killed several of the man’s family members for good measure. Soon thereafter, the Arellanos declared all of Baja California their territory. “No one needed to be greedy,” Robertson told me. “But the Arellanos were like, ‘No, this is ours. Come here, and we’ll kill you.’ That did not sit well with Chapo.” Guzmán started digging the Sinaloa cartel’s first known drug-smuggling tunnel under AFO turf (a primitive one compared with the engineering marvel through which he escaped from prison last summer) and made plans to kill the brothers.
In November 1992, Ramón and Javier Arellano were at the Christine discotheque in Puerto Vallarta when 40 assassins posing as policemen burst in shooting. They’d been sent by El Chapo. One of Ramón’s bodyguards, a preternaturally poised man named David Barron Corona, shot and killed a gunman, then picked up the man’s AK-47 and held off the attackers while shoving Ramón and a top lieutenant into a bathroom. From there, he pushed them through a window and onto the roof — an arduous task, because Ramón was obese. The men clambered down a tree. On the ground, an assassin was waiting with a machine gun, but Barron killed him with his last bullet and all three escaped. Javier got away too, via a different route.
Barron hailed from a rugged neighborhood of San Diego called Logan Heights. He wore a downturned mustache and was built like a mailbox, his short arms hanging away from his body as if he’d just finished lifting weights. Skull tattoos decorated his torso, each said to represent a victim. He’d gone to prison at age 16, for killing a cross-dressing man who’d reprimanded him for urinating on a parked car.
After Barron’s performance at the discotheque, Benjamín Arellano recognized him as a fearless warrior. He bestowed upon Barron the code name “Charlie,” as in Charles Bronson, the actor famed for playing relentless vigilantes, and gave him a mission: Assemble a team of assassins who could vanquish Guzmán. Barron returned to Logan Heights to conscript about 30 enforcers from Mexican immigrant families. He offered $500 a week, plus kill bonuses. Taking out El Chapo would be rewarded with $1 million and a ranch.
Barron hired trainers — Mexican police officers and a Middle Eastern man whom recruits knew as “The Terrorist.” He equipped his men as though they were soldiers, with bulletproof vests, hand grenades, AK‑47s, and night-vision goggles. “He never asked his employees to do anything he wouldn’t do himself,” a former AFO lieutenant who worked closely with Barron told me. He ordered his men to keep their mustaches neatly trimmed and to dress in Dockers and polo shirts. This would be a refined gang of assassins. They would kill for drugs, but never use them. The AFO built detox holding cells where any enforcer caught using would be stashed for a month. The sentence for a second offense was 60 days. A third meant death.
In May 1993, Ramón summoned Barron and a dozen of his men to accompany him to Guadalajara to kill Chapo Guzmán. They searched the city but found no sign of Guzmán, and after a week they prepared to return to Tijuana. While Ramón passed through security for his flight home, five carloads of his soldiers, including Barron, sat in an airport parking lot. Suddenly, at about 3:30 p.m., an AFO lookout spotted Guzmán, right there at the airport. He and his bodyguards were getting out of a green Buick near the main entrance.
Barron grabbed a rifle. Guzmán’s bodyguards saw him. A firefight began. The AFO hit squad fired its AK‑47s indiscriminately. Bullets flew toward the terminal and struck a woman and her nephew while they were crossing the street. Barron and two other AFO shooters poured bullets into a white Grand Marquis — they knew Guzmán owned one — killing the driver and a passenger. Guzmán himself commandeered a taxi and sped away.
When the shooting ended, several AFO members tossed their guns in garbage cans and ran for Aeromexico Flight 110 to Tijuana. It was being held because of the commotion outside. Nonetheless, a group of anxious, sweaty men were allowed to board. Ramón was already in first class, spitting on the floor — a nervous tic. When the flight took off, seven people — five bystanders and two of Guzmán’s bodyguards — lay dead or dying in the parking lot.
In the passenger seat of the white Grand Marquis, a plump man dressed in black slumped to his side, a cross dangling from his chest. He had been hit 14 times. He was Cardinal Juan Jesús Posadas Ocampo, the second-highest-ranking official in Mexico’s Roman Catholic Church. The brothers knew right away that the cartel had made an Escobar-size mistake. “The AFO instantly went from folk heroes to villains,” a former lieutenant in the cartel told me.
Guzmán fled to Guatemala, where he was arrested two weeks later. He was sent to the Puente Grande maximum-security prison in Mexico, where everyone from guards to cooks ended up on his payroll. He occupied himself with chess, basketball, sappy movies, and the bands he brought in to perform — not to mention enough women that he needed regular Viagra shipments. And, of course, he continued to run his business.
The Arellano brothers managed to avoid arrest by sending $10 million and two gang members willing to give false confessions to the director of the Mexican Federal Judicial Police, according to a former cartel member. In return, the police bought the brothers time by raiding houses that the cartel had already abandoned. Meanwhile, the AFO scattered. David Barron headed south, to Rosarito, Mexico, while his men went home to California. Benjamín Arellano also retreated deeper into Mexico. Eduardo stayed in Tijuana, but disappeared from sight. Ramón and Javier escaped to Los Angeles. They landed in tony, seaside Santa Monica, far from their hard-won turf.
The cardinal’s murder made the AFO case a U.S. priority. Jack Robertson helped create an AFO task force consisting of agents from the DEA and the FBI as well as Customs, Immigration, the IRS, the U.S. Marshals, and the Justice Department. The task force arrested some of Barron’s men as they fled Mexico and interrogated them. Slowly, it gained a keyhole view into the cartel. Then one day in 1995, a clean-cut young man with no criminal history walked through the door of the DEA office in San Diego and widened the keyhole into a porthole.
Beaten down by stress, the young man, an American whom agents dubbed “Joe Camel” for his prolific smoking, was ready to spill AFO secrets. Pickup trucks with false beds were being delivered to his father-in-law’s home in La Jolla, each loaded with a ton of cocaine. Trucks were parked in the garage, in front of the house, and around the block. He had, he confessed, been driving cocaine across America. The cartel used his father-in-law, a man in his 70s whom agents nicknamed “Grandpa,” to ferry drugs through border checkpoints, because he seemed harmless and was never searched. Grandpa explained how cartel smuggling worked and put names with faces and job descriptions. He also gave agents a piece of information that had eluded them: the identity of the Arellano brothers’ top lieutenant in Tijuana, Arturo “Kitty” Páez Martínez.
Agents were confused when they tried to check Grandpa’s criminal background, until he revealed that he had been living under an assumed identity provided by the U.S. government. Thirty-four years earlier, he had been caught participating in a heroin-smuggling ring — part of the events later fictionalized in the movie The French Connection. He then became an informant and entered witness protection, only to leave the program and return to drug trafficking. Now, for the second time, Grandpa would become a government source, allowing the DEA to mount surveillance equipment at his home. And again his crimes would pay off. He and his son-in-law were paid $100,000 for their cooperation.
The new prominence of the AFO case meant not merely increased manpower but millions of extra dollars for operations and paid informants. One AFO operative in California signed on as an informant just a day before cartel members riddled him with bullets. The man survived, and acquired the nickname “Swiss Cheese.” After the shooting, he started collecting workers’ compensation — criminal informants who are injured in the line of duty can qualify — in addition to his informant’s pay. He also received $1.5 million from the State Department for information that helped the DEA apprehend an AFO lieutenant.
Steve Duncan, a San Diego–based special agent in the California Department of Justice, says that after he and other agents made arrests, federal prosecutors would cut deals and let enforcers and traffickers go free in single-minded pursuit of the cartel’s top leaders. “The prosecutors never wanted to go sideways or down [the cartel hierarchy], just up,” Duncan told me. “So a lot of gang members who murdered people, they never got prosecuted. Some guys would give us what they wanted to give us and get off.”
None of the agents liked watching criminals walk away free — and in some cases flush with cash. But they could live with that bargain if it meant the task force would eventually work its way to the top. Bringing the Arellano brothers to justice would make it all worthwhile.
After the killing of Cardinal Posadas, Ramón Arellano had to lie low. In his absence, the rank and file got sloppy. From California, Ramón sent David Barron to kill a man in Playas de Tijuana named Ronnie Svoboda, who had had the temerity to hang out with a woman Ramón was involved with. When Svoboda’s sisters, Ivonne and Luz, told the police, Ramón sent a crew to San Diego to kill them, too.
One of the hit men, who went by the name Martín Corona, watched the sisters get into their car. Ivonne was tall and lithe and exceptionally beautiful. She had spent the previous year in Paris as a model. Corona approached the driver-side window and saw her lock the door. His first bullet shattered the window. Three hit Ivonne in the head. One hit Luz, who was pregnant. As Ivonne tipped to her side, Luz’s 9-year-old daughter — who would see Corona again a month later when he and Barron arrived at her house to bludgeon her father to death — started screaming in the backseat. Corona ran, and both women survived. Sloppy.
One bungle followed another. The AFO somehow managed to procure a six-foot-long military-grade bomb for $150,000 in San Diego. In 1994, two low-level enforcers drove it to the El Camino Real Hotel, in Guadalajara, where they were supposed to use it to vaporize the building, and several of El Chapo’s associates along with it. But the bomb detonated prematurely, killing the AFO enforcers instead.
The next year, the cartel landed a commercial jet loaded with about 10 tons of cocaine on a makeshift airstrip in the desert near La Paz, Mexico. When the plane hit the sand, it sank in and got stuck. AFO workmen unloaded the coke into trucks, then tried to blow up the plane. That didn’t work, and a couple of men died. So they brought in construction equipment and tried to bury the plane in the sand instead. They managed to cover only part of it before drawing the attention of the Mexican military.
All this time, Ramón was hiding out in L.A., growing his belly and his hair — now shoulder-length and dyed blond. One day in Hollywood, while hanging out in front of Mann’s Chinese Theater, wearing a Nike cap, sunglasses, and a Michael Jordan jersey, he was approached by Rupert Jee, a New York City deli owner and a regular on the Late Show With David Letterman, who was taping a man-on-the-street segment. “No entiendo,” Ramón said, as he tried to shoo Jee away. In the segment, Jee draws attention to Ramón by yelling, “Hey, everybody, it’s Michael Jordan! Look!” to the great delight of the studio audience. Slung over Ramón’s shoulder was a black satchel in which he typically concealed a gun.
In September 1997, Ramón was added to the FBI’s “Ten Most Wanted” list. He fled back to Mexico, and the Arellano brothers reassembled. They were still dominant in Tijuana, but the Sinaloa cartel was gaining strength. And they could no longer operate as openly as they once had. Their unhinged violence, in fact, began to backfire.
Two months after Ramón made the most-wanted list, he sent Barron to kill a Tijuana journalist named Jesús Blancornelas, who had dedicated his life to exposing the AFO and other cartels. Among the articles that had drawn the Arellanos’ ire, his magazine, Zeta, had published an open letter to Ramón written by a woman whose two sons “served you in a time of need” and had then, she maintained, been murdered. The letter fingered AFO figures by name.
Barron’s hit squad intercepted the journalist’s car en route to his office in Tijuana and unleashed a fusillade. Blancornelas’s bodyguard was killed, and Blancornelas himself was hit four times. As Barron approached for the coup de grâce, he suddenly dropped. A fellow assassin’s bullet had flown clear of the car, struck a metal post, and ricocheted through Barron’s eye, killing him instantly. Police found him on the sidewalk, a bright-red stream oozing from his eye socket, his body collapsed on his shotgun stock, which propped him up as if he had decided to take a nap mid-killing. Blancornelas survived.
Months later, an informant told the FBI and the DEA the location of Eduardo Arellano’s new house in Tijuana. A corrupt Mexican police chief tipped Eduardo off and he fled with his wife, Sonia, and their two children to a safe house that wasn’t quite ready to be lived in. Sonia had to use a propane tank for cooking.
One morning, Sonia came downstairs to make breakfast. The tank had been left open all night by accident, dribbling gas into the house. As soon as she struck a match, the house exploded. The baby in her arms went flying and was critically injured. Sonia’s patrician face melted into a welter of raw flesh and blisters.
Eduardo sent Sonia and the baby north for treatment, to the burn center at the University of California at San Diego. Eduardo himself didn’t risk crossing the border. He was right to stay behind: At the burn center, Sonia met Dr. Dave Harrison, who happened to be Dave Herrod in disguise, hoping to glean information about Eduardo through small talk with his wife. By now Herrod felt like he knew the Arellanos. It was surreal, after all this time, to actually talk with one of them.
Officially, only John Hansbrough, the head of the burn center, and two other senior hospital staff members knew that Herrod was posing as Dr. Harrison. But Herrod suspects the nurses noticed that his arrival coincided with that of the special guests from Tijuana — and that he knew shockingly little about burn physiology. He occasionally followed Hansbrough into surgery but mostly stayed out of the way, and he had to offer excuses every time he was called to cover a night shift. On Christmas Eve 1998, Herrod had the bizarre experience of wheeling Eduardo’s wife out of the hospital and watching her drive away with her parents and a lawyer.
The baby, Eduardo Jr., later died, and Sonia blamed her husband for the accident. According to witnesses, she wished death upon the children of his assistant, because he hadn’t gotten a stove ready. Eduardo’s brothers were incensed by her behavior and feared she might go to the police. In October 2000, Benjamín ordered Sonia killed. Javier gave instructions for the murder. Sonia was strangled with a tourniquet and her body was dissolved into pozole. Benjamín told Javier that, should Eduardo ever ask what happened to Sonia, he was to be told that she had fled to the U.S. But Eduardo never asked.
For a group that counted family as perhaps its lone object of loyalty, the murder of one brother’s wife was an act of supreme desperation. The Arellanos couldn’t bribe their way out of everything anymore — they could only kill their way out. When Sonia’s mother and sister began asking questions, Benjamín ordered them killed too. The women were pulled from their car at a busy intersection and never seen again.
On January 18, 2001, Mexico’s highest court handed down a decision that gave the DEA new leverage: Mexican citizens could now be extradited to the United States to face drug charges. Chapo Guzmán escaped from maximum-security prison the next day, reportedly wheeled out of the facility in a laundry cart.
Kitty Páez, the AFO’s top lieutenant in Tijuana, had been arrested several years earlier and now had the honor of becoming the first Mexican drug trafficker extradited to the U.S. He was charged with engaging in a continuing criminal enterprise, which carried a mandatory life sentence for cartel leaders. Páez was the highest-ranking AFO member authorities had ever captured, one rung down from the brothers.
Herrod had by now taken over for Jack Robertson as the lead AFO case agent. He met with U.S. prosecutors when Páez was first arrested in Mexico and says they swore that if they ever got their hands on Páez, they would offer a plea deal only if he agreed to provide information about the brothers. Once extradition occurred, however, Herrod says all that tough talk melted away. He claims that, faced with a potentially long and difficult prosecution, senior officials in the U.S. Attorney’s Office began discussing a 30-year plea deal with no requirement to cooperate.
As far as Herrod was concerned, any deal that didn’t compel Páez to talk about the Arellano brothers would be a betrayal of the strategy that had driven the case. After all the small fry — the drivers and smugglers and enforcers — the task force had at last gotten someone who could confirm the brothers’ orders to kill and kidnap. Why wouldn’t prosecutors do everything they could to get information out of him?
Herrod told me that high-level officials from the DEA and the Justice Department met several times to discuss requiring Páez to cooperate or else face trial. He asked Laura Duffy, a federal prosecutor who spent a decade on the AFO case, to hold off on making a final decision until investigators and prosecutors could discuss the matter as a group one more time — but to no avail. Word came down that very same day: The U.S. Attorney’s Office had reached a plea agreement with Páez. He would serve 30 years and would not have to provide any information or even acknowledge his affiliation with the Arellanos. (Duffy told me that she was under no pressure to resolve the case quickly, and that she’d believed Páez would cooperate eventually.) Disgusted, Herrod and his fellow agents realized they would have to go after the brothers some other way.
In the summer of 2001, Herrod discovered that Ramón’s wife, Evangelina, was renting a house somewhere in the expensive Westwood neighborhood of Los Angeles. There was a brazenness about it that taunted him. Herrod felt a surge in his chest when he pulled up to a house that had a red Dodge Durango with Tijuana tags sitting outside. His team got a Durango skeleton key from Dodge, stole the car for a few hours while Evangelina was out, installed tracking devices, and then returned it to the same spot.
That fall, the agents learned that Ramón and Evangelina’s 12-year-old daughter, Paulina, was attending an elite private school known for educating the children of Hollywood celebrities. In a stroke of luck, a DEA employee happened to have a friend who worked at the school. Agents encouraged the friend to make small talk with Paulina, and learned that she would be ringing in 2002 at Lake Tahoe. The Arellanos always got together for holidays, and Herrod had heard that Ramón liked Tahoe. Of course he would travel from Tijuana to celebrate with his family.
The DEA rented cabins at Lake Tahoe, one just 50 feet from where the family would be staying, and sent tech specialists to set up cameras inside and outside the Arellanos’ rental. They finished and rushed out of the house moments before Evangelina arrived, sans Ramón. It was a few days before New Year’s, and a cadre of agents was on 24-hour surveillance. When Evangelina and Paulina went skiing, agents traced sinuous arcs down the mountain behind them.
By New Year’s Eve, there was still no sign of Ramón. But when the family emerged from the house that evening, Paulina was carrying a pillow and suitcase. She’s going to spend the night with her father, the agents thought. The family piled into the Durango — the one agents had equipped with trackers — and drove through the snow, a caravan of federal agents in their wake. On the hunch that the Arellanos would join the thousands of revelers at Caesars Tahoe, as they had in years past, agents were sent ahead to coordinate with security at the casino so that cameras could be used to track the family. Herrod recalls the adrenaline of the hunt. “It’s beyond belief how pumped we were. To follow a family in a crowd of 100,000 people is frickin’ nuts,” he told me. “It was the very best surveillance we’ve ever done.”
The family walked to an empty restaurant in the back of the casino, away from the celebration, and sat. Not eating, barely talking, just waiting. The agents waited too, for one of the world’s most wanted men to come and scoop up his daughter with her pillow and suitcase. A raid team stood by with keys that could open any room in the hotel.
The family sat. And sat. The ball dropped in Times Square. Then midnight in Tahoe came and went. Agents who had been sitting bolt upright slumped in their seats. Around 1 a.m., Paulina, her grandparents, and her nanny got up and headed back to the cabin. Evangelina walked into the casino and picked up a phone. Agents watched on security cameras as she gesticulated in argument with someone on the other end. Ramón never showed.
The task force, however, was about to catch a massive break. On the morning of February 10, 2002, police in the vacation town of Mazatlán, Mexico, pulled over a white Volkswagen Beetle. Ramón was patrolling with two of his men, hoping to catch one of the Sinaloa cartel’s kingpins out in the open during Carnival. Ramón was carrying a high-ranking Mexican federal-law-enforcement credential that should have allowed him to talk his way out of any trouble with the police. But something went wrong.
A DEA informant later claimed that Ramón had been given false intelligence by a Sinaloa operative and lured to Mazatlán, where police friendly to Guzmán were waiting. But according to another informant, Ramón’s bodyguard simply misunderstood Ramón’s command to stay cool when they were pulled over. He got out of the car and started firing, and the traffic stop turned into a shoot-out. Ramón and a police officer ended up an arm’s length apart, guns drawn, shouting their law-enforcement credentials at each other.
Witnesses reported that the officer yelled for Ramón to get on his knees, and that Ramón began to comply. The precise details of what followed are unclear. But it seems that in an attempt to take the officer by surprise, Ramón fired while bending down. The officer returned fire. One point-blank bullet to the heart from Ramón’s gun killed the officer, and one point-blank bullet to the head from the officer’s gun killed Ramón. The picture in the local paper the next day showed two bodies on the ground, close enough to touch each other. Ramón had shaved his head, and because he’d had his stomach stapled he looked at least 50 pounds lighter than when he’d appeared on Letterman. It took a week for the DEA and the FBI to confirm that the dead man was indeed Ramón.
Ramón had often promised to kill the entire families of anyone who cooperated with the authorities. But now he was gone. Kitty Páez’s lawyer contacted the U.S. Attorney’s Office. With Ramón out of the picture, Páez wanted to discuss cooperating in return for a reduction of his 30-year sentence. Soon, Herrod was spending eight to 10 hours a day talking with him. Páez was a veritable AFO search engine, ready with an answer to any question, from names of lieutenants to smuggling tricks to the structure of the cartel hierarchy.
Mexican authorities were emboldened as well. A month after Ramón’s death, the Mexican military arrested Benjamín Arellano, the 49-year-old cartel mastermind, in a house in Puebla, southeast of Mexico City. Javier — at 32, the youngest of the brothers — was left to lead the cartel.
As the AFO teetered, a new informant emerged: Chapo Guzmán’s attorney and confidante Humberto Loya Castro. He met with agents in restaurants and hotels in Mexico City and Tijuana. He wore elegant suits, carried Montblanc pens worth thousands, and wielded a politesse incongruous with the world of drug smuggling. Even more unusual, he came with the blessing of his boss. “I met with my compadre,” he might say, meaning Guzmán. “He sends his regards.” Herrod told me there were obvious downsides to working with Loya. But El Chapo’s attorney offered precious information. His tips, for example, led to the capture of the AFO’s “chef,” the man who had developed the recipe for pozole. He also saved the lives of several Mexican officials by alerting the DEA that they were going to be murdered.
Loya was a fugitive, so agents needed special permission to speak with him. He claimed he was cooperating in the hope of having U.S. charges dismissed — he had been indicted in San Diego, along with Guzmán, back in 1995, for drug trafficking. But he continued to cooperate after the charges were dropped. By passing tips to DEA agents, he was able to undermine the AFO and therefore help his boss. As an agent who declined to be identified put it: “We dismantled a rival cartel because of information that [Guzmán, through Loya] was able to provide. It definitely helped Sinaloa stay in power.” At one point, agents heard through intermediaries that Guzmán himself was interested in becoming an informant, but top DEA officials wouldn’t grant the same special permission that had been extended for his attorney.
Meanwhile, the DEA had set up a hotline and put up posters at border crossings promising up to $5 million per brother for information that led to their arrests. Most of the tips were nonsense. But late on Christmas Eve in 2003, a call came from a man claiming to be part of the security detail for the AFO. Agents dubbed him “Boom Boom.” He wanted out of the cartel, and was willing to give up AFO radio frequencies. The DEA started listening, nearly around the clock. For the first time, they could overhear a drug cartel operating in real time. It took a while to get used to the coded language. A reference to an “X-35 with shorts, pantalones, and frijoles” meant an armored car with handguns, rifles, and bullets. The office of Zeta, the investigative magazine, was “X-24.” Cocaine was “varnish.” Mexican federal police officers were “Yolandas.” Over two years, the DEA recorded the AFO planning 1,500 kidnappings and killings, including those of at least a dozen Mexican police and government officials. Agents had to listen — in real time — to people being tortured; they were often helpless to do anything about it. “Cover his mouth,” one man said in Spanish, chortling, after a long scream. “Cover his mouth! Cover his mouth!”
Among the half million AFO radio transmissions that the DEA recorded was one that led them to intercept a phone conversation about the purchase of a 43-foot yacht. This was the information that gave rise to Operation Shadow Game and the 2006 capture of Javier Arellano on the high seas, as the Dock Holiday chased marlin into international waters. Once in port in San Diego, Javier was loaded into a bulletproof Suburban and driven five minutes through closed streets, under the gaze of government snipers, to a federal detention center. His arrest was the cartel’s death knell. Soon after, AFO lieutenants began defecting to rival cartels or splitting into their own factions.
In 2008, one of Eduardo’s confidantes gave him up — he was the last brother who was alive and free and had any experience leading the cartel. He was captured in his home in Tijuana. The eldest brother, Francisco, who’d helped get the cartel started but had been in prison during most of his brothers’ reign, was the last to meet his fate. He was at his 64th-birthday party in Cabo San Lucas in 2013 when a man dressed as a clown walked in, shot him dead, and walked out.
Two decades after Jack Robertson opened the case against them, every one of the Arellano brothers who had helped run the cartel was either dead or behind bars. Benjamín and Eduardo were extradited to the United States. It was a crowning achievement for the DEA, complete with promotions, political appointments, and chest-puffing press releases.
“It was an audacious goal to take this cartel down, and I’m extremely satisfied with the outcome,” Laura Duffy, the prosecutor, said in a press release after Eduardo was put behind bars. She urged “others who aspire to take their place to take note.” In 2010, Duffy was appointed by President Obama as the U.S. attorney for the Southern District of California.
Michele Leonhart, Robertson’s boss in San Diego when he opened the AFO case, became the head of the DEA in 2007. The next year she said that Eduardo’s arrest “closes the book on this once powerful and brutally violent criminal band of brothers … He will now face justice for the misery and destruction he caused.”
For Eduardo, facing justice meant accepting a plea deal: 15 years, with no cooperation.
“Fifteen years?,” Herrod says. “I worked on the case longer than that.” Assuming good behavior, Eduardo will be out less than six years from now. Kitty Páez, whom the government spent four years working to extradite, served nine years and is now free. Benjamín, who led the cartel in its heyday, agreed to a plea deal of 25 years and a $100 million fine, with no cooperation. “That’s nothing,” a former AFO lieutenant told me, pointing out that he was probably responsible for more deaths than the terrorists who carried out the 9/11 attacks. “And $100 million isn’t a lot when you have a billion dollars buried somewhere.” To put Benjamín’s sentence into context, in 1991 the Supreme Court upheld a life sentence without parole for a Michigan man convicted of possession of one and a half pounds of cocaine. The Arellano brothers were shipping up to 40,000 pounds of cocaine each month to just one distributor in Los Angeles. In court, the federal judge who sentenced Benjamín lamented the constraints of the plea deal. “If I had it in my power,” he said, “I would impose a longer sentence.”
Duffy told me that the case strategy — piecing together a full portrait of the cartel, rather than just aiming to get the brothers for a specific recent act — created problems for the prosecution. “We wouldn’t repeat that going forward,” she said. By the time some witnesses were needed to testify, they had returned to crime, destroying their courtroom credibility. “Would it have been ideal to have captured Eduardo closer in time to when we developed the case against him? Yes,” she said. “I think he would’ve received a more severe sentence.” Duffy also pointed out that, considering Benjamín was 60 at the time of his sentencing, 25 years effectively amounted to life in prison. “I felt, of course, conflicted,” she said.
Only Javier faced the death penalty. Because he was picked up in international waters, the U.S. government didn’t have to bargain over capital punishment with Mexico, which has no death penalty. Javier admitted to committing one murder and ordering many others, including killings of government informants and law-enforcement officers. He took a plea deal and was sentenced to life in prison and had to forfeit $50 million. After his sentencing, Javier began to cooperate, and court records show that his sentence was recently reduced to 23.5 years. He will be a free man by age 60 at the latest.
Some of the others involved made out like, well, bandits. Ramón’s wife and other members of the family continued to live off the AFO’s drug money. According to Steve Duncan, David Barron’s brother-in-law — a man agents called “The Mailman” because he worked for the U.S. Postal Service — confessed to helping smuggle at least $200,000 back to the U.S. after Barron was killed. The Mailman went on to work for, of all places, U.S. Border Patrol. Boom Boom, the enforcer who had passed along the AFO radio frequencies, was paid $4 million. More than 100 people — AFO operatives and their family members — were relocated to the U.S. Some were paid for their cooperation and given housing, driver’s licenses, and work permits.
Herrod, Robertson, Duncan, and agents who spoke on the condition of anonymity say that payments and plea deals for informants are necessary evils in investigating organized crime, smaller sacrifices toward a greater good. But as one agent who spent years on the case told me, “There are more drugs coming across the border than ever.” While the cocaine trade has plunged in the United States in recent years, the heroin and methamphetamine markets have exploded. The amount of meth seized at the southwest border has more than quintupled since 2008, and the amount of heroin has more than tripled. Asked what could have been done better, the agent said, “I don’t know. I wish I’d gone to law school instead.” (The DEA’s press office did not answer specific questions for this article. A longtime senior DEA official told me: “We’re not policy makers, we’re cops. We leave the policies up to other people.”)
As the Sinaloa and other cartels have spread, they’ve brought killing in all directions. Moving south, according to a United Nations World Drug Report, they’ve partnered with organized-crime groups in Honduras, where homicides nearly tripled from 2005 to 2011. To the north, “just look at Chicago,” Herrod told me. That city’s homicide rate was up 20 percent in 2015 from the previous year, a trend that DEA officials attribute to the heroin trade, a burgeoning segment of the Sinaloa cartel’s entrepreneurial portfolio. In January, two Chicago brothers acting as wholesale distributors for billions of dollars’ worth of Sinaloa drugs were sent to federal prison. According to the U.S. Attorney’s Office, the brothers were part of a network that shuttles drugs to a raft of cities that saw homicide spikes in 2015, including Washington, D.C., and Milwaukee, where the murder rates were up 58 percent and 70 percent, respectively, as of November.
David Shirk, the director of the University of San Diego’s Justice in Mexico program, tracks violence in Tijuana — which has seen a recent increase in homicides, including beheadings — and has concluded that the killings ebb and flow without relation to law-enforcement efforts. “We’re all up here in a little boat,” he told me, “and we see the bodies floating up, and we see blood, but we have little idea of what’s happening below. We just know there are sharks.”
In 2011, a children’s-rights group in Mexico estimated that at least 1,000 minors had been killed in cartel violence over a four-year period; the actual number is likely higher. That same year, Michele Leonhart said: “It may seem contradictory, but the unfortunate level of violence is a sign of success in the fight against drugs.” The cartels, she added, “are like caged animals, attacking one another.” By that measure, the war may be going even better now. (Leonhart retired from the DEA last spring after agents were caught in a prostitution scandal. She could not be reached for comment.)
Herrod still follows reports of beheadings and shootings on the Internet. In September, a Web site called Borderland Beat posted pictures of banners going up bearing the initials C.A.F. — Cártel Arellano Félix — marking territory that, the banners declared, would be reclaimed with blood.
Steve Duncan takes solace in having put violent criminals behind bars. But he’s angry that prosecutors didn’t go after lower-level AFO enforcers he’s convinced they could have gotten on murder charges. Some of them went on to kill again. In a file labeled “Unfinished Business,” he keeps reams of testimony that the government assembled against AFO hit men who were never punished. “Frustration and outrage are two emotions that will haunt us (law enforcement) to our deaths,” he wrote in a memo.
Duncan even runs into some of the unpunished men in his own neighborhood. He lives near San Diego’s new central library, a landmark with a soaring steel dome. A few years ago, during the final stages of construction, he would pass by the building and see a man nicknamed “Roach” — a former AFO enforcer — wearing an orange vest and lounging in the shade, on his lunch break from helping to build the library. Duncan had gathered information implicating Roach in three murders and four attempted murders, none of which he was ever prosecuted for.
Martín Corona, who participated in the bludgeoning death of Ronnie Svoboda’s brother-in-law and shot Ronnie’s two sisters, confessed to Duncan his involvement in nine other murders or attempted murders. He was never charged for those crimes. Corona grew up in California, the stepson of a marine, and says there’s no excuse for what he did. “That one haunted me,” Corona told me, recalling how Ronnie Svoboda’s 9-year-old niece had watched while he shot her mother and aunt. He was convicted of one count of conspiracy to distribute cocaine and served 13 years. Herrod and Duncan say he’s the only former AFO member they’ve met who is truly remorseful. Today, Corona makes a living as an electrician.
Duncan has also kept in touch with a man named Jesús Zamora Salas, a member of David Barron’s Logan Heights crew. He was jailed in Mexico in the ’90s and then released; he later moved back to the U.S. and cut his ties with the cartel. In 1998, he wrote to Duncan asking him to act as a reference for a law-enforcement job in Georgia. Duncan explained that his criminal past would prohibit such work. He was surprised later that year to get a Christmas card in which Zamora described his new job as a guard in a Georgia prison. In 2001, Zamora called Duncan to let him know that he had moved up in the corrections world: He was now a guard at a federal prison. In 2012, Duncan got another update. “Some local law enforcement from around Vandenberg Air Force Base called me about him and told me he was working security there and had security clearance,” Duncan told me.
Jack Robertson, who launched the AFO investigation, went on to be a highly decorated agent — retired agents once voted him “agent of the year,” out of 5,000 at the DEA. But he was frustrated that his bosses and the U.S. Attorney’s Office stopped pursuing the last vestiges of the AFO. Among the suspects never pursued was a man who later became one of the top five figures in the Sinaloa cartel. Robertson was also angry that, in many cases, the punishment didn’t match the crime. He considered the sentence one nonviolent AFO messenger got — 20 years, more than Eduardo — so disproportionate that he referred the man’s case to the Medill Justice Project at Northwestern University, which investigates miscarriages of justice. “To me it’s like prosecuting the guy at Enron who delivers the mail while the top executives go free,” he told me. Robertson left the agency in 2011 to become the chief investigative officer at the World Anti-Doping Agency, where he helped expose Lance Armstrong’s elaborate use of performance-enhancing drugs.
As for Herrod, though he still works for the DEA, his clashes with prosecutors over plea deals eventually got him removed from the AFO case. He lives in a quiet neighborhood of San Diego speckled with eucalyptus trees. In a small upstairs bedroom, near a schedule for his daughter’s softball team, he keeps mementos: a cocktail napkin from the Dock Holiday, monogrammed with a blue sketch of the yacht. A picture of himself, smiling in jeans and a Michigan State sweatshirt, bending down in what looks like a cave. It could be any tourist’s vacation shot, until you see the cables running along the walls, and the pinpricks of light in the distance. It’s Herrod in 1993, crouching in the first of El Chapo’s smuggling tunnels ever discovered. In a closet, Herrod keeps a commendation from the Department of Homeland Security for the DEA’s work on Operation Shadow Game. The AFO case was the biggest the San Diego division had ever seen, and the commendation once hung proudly on the office wall, but eventually Herrod had to save it from the trash.
Herrod’s bookshelves are packed with pristine hardbacks, because mixing in a paperback would spoil the clean look. He removes the dust jacket before reading a book, so as not to leave wrinkles, then replaces it when he is done. Herrod does not like loose ends. Every unfinished detail, every too-short sentence or wasted lead, keeps him awake. One recent afternoon, he gazed into the middle distance as he repeated aloud several times, clearly to himself, that he had told Eye in the Sky Joe Palacios that everything would be okay.
“At the end of the day,” Herrod said, “before you go to sleep, the big moral question I ask myself: ‘Everything you’ve done, was it really all worth it?’ And you never get an answer.”
Or maybe you do, and it’s just not the one you want to hear.
Production by Emily Martinez and Rob Weychert.
David Epstein covers sports science, including the use of performance-enhancing drugs. He is the author of the 2013 book “The Sports Gene: Inside the Science of Extraordinary Athletic Performance” and a former senior writer at Sports Illustrated.
The U.S. government has wasted billions of dollars in Afghanistan, and until now, no one has added it all up. Project after project blundered ahead ignoring history, culture and warnings of failure. And Congress has barely blinked as the financial toll has mounted. Here’s just what the Special Inspector General for Afghanistan Reconstruction found. See for yourself how that money could have been used at home.
Image may be NSFW.Three years ago, it looked like the Florida agency that oversees care for children and adults with disabilities had finally had enough.
It filed a legal complaint that outlined horrific abuse at Carlton Palms, a rambling campus of group homes and classrooms near the small town of Mount Dora.
A man called “R.G.” was punched in the stomach, kicked and told “shut your fucking mouth,” the complaint said. “R.T.” was left with a face full of bruises after a worker hit him with a belt wrapped around his fist. A child, “D.K.,” who refused to lie face down so he could be restrained, was kicked in the face and choked until, eyes bulging, he nearly passed out.
State officials wanted to bar Carlton Palms from accepting new residents for a year.
“[A] moratorium on admissions,” wrote a lawyer with the Agency for Persons with Disabilities, “is necessary to protect the public interest and to prevent the continuance of conditions that threaten the health, safety and welfare of Carlton Palm’s (sic) residents.”
Two months later, the state backed down.
Carlton Palms’ owner, the for-profit company AdvoServ, had deployed a Tallahassee lawyer and lobbyist who counted a former governor among his clients. The company admitted no wrongdoing and paid no fines when it settled with the state. It did agree to install more cameras to monitor workers.
The state of Florida — and its public schools — then went right back to sending Carlton Palms new clients.
AdvoServ’s homes and tens of thousands of facilities like them were supposed to be an antidote to the ills of institutional care for society’s most vulnerable: children and adults with profound disabilities like severe autism. Tucked away in neighborhoods across the country, the homes are often a last resort for overwhelmed families and schools, as well as state officials who shuttered their public asylums over concerns about mistreatment.
But the sprawling system of privately run residential programs is quietly — and with few repercussions — amassing a record as grim as the institutions it replaced, a ProPublica investigation found.
Particularly haunting are the deaths of children in residential facilities, often far from their homes. At least 145 kids have died from avoidable causes in such facilities over the last three decades, a ProPublica review of news accounts found.
In one group home, a worker strangled a teenaged resident during a struggle; at another, a boy died of an infection after employees taunted him and accused him of faking illness. Other children suffocated while workers held them down.
AdvoServ’s Carlton Palms is one of a dozen residential programs nationwide where two or more children have died in separate incidents from potentially preventable causes. Most recently, a 14-year-old girl died there after a night during which she was tied to a bed and chair. She’d entered the program just six months after the state dropped its call for a year-long moratorium.
A deep examination of AdvoServ — a veteran industry player now owned by a private equity firm — shows how a powerful, well-financed provider can exploit a fractured system, using its deep pockets to beat back sanctions, bully regulators and shape the very rules it plays by.
The company’s ascension reveals, too, the fraught marriage of convenience that binds the growing ranks of private providers to the public agencies that rely on them, sometimes paying upwards of $350,000 a year in taxpayer money for each resident’s care.
Officials with Florida’s disabilities agency said the state sees itself as partnering with, as well as policing, Carlton Palms.
“Our approach has been very, very aggressive in working with Carlton Palms,” said Tom Rankin, a top official with the agency. “It’s also been very, very collaborative.”
State and federal officials often give operators like AdvoServ wide latitude on key decisions such as figuring out how to control unruly patients, meet medical needs and staff homes. When problems occur, the limits of regulators’ power can become starkly clear.
One infamous program for instance, the Judge Rotenberg Educational Center outside Boston, has been condemned for its use of electric shocks to halt residents’ undesirable behaviors. At least two states tried and couldn’t get Rotenberg to stop. The facility continues to receive more than $60 million a year in mostly public money to care for 240 people with developmental, intellectual or emotional disabilities.
Calls for federal action have failed. A bill first introduced in 2008 would have required the federal government track abuse complaints and create a website listing residential providers for kids nationwide. It has gone nowhere.
Even some in the industry say more oversight is needed. “We definitely support regulation because bad things have happened to kids in residential programs, and not just 10 years ago,” said Kari Sisson, executive director of the American Association of Children’s Residential Centers, which promotes best practices. “They happen to kids today.”
Florida’s aborted effort to sanction AdvoServ surprised few who knew of its nearly five decades of dealings with regulators. The company cares for roughly 700 people with intellectual and developmental disabilities and behavioral problems in Delaware, where it is headquartered, as well as New Jersey and Florida.
“I always got the feeling they were pretty untouchable,” said Kevin Huckshorn, a national behavioral health consultant.
AdvoServ executives say there is no pattern of abuse in its facilities and that employees who mistreat residents are disciplined. “In a program like ours in which we serve individuals with significantly challenging behaviors, incidents are going to be inevitable,” said Robert Bacon, the company’s chief operating officer and a 29-year AdvoServ veteran.
“We acknowledge we are not perfect,” CEO Kelly McCrann told ProPublica. “But what we do does not allow perfection.”
In a written statement, top officials at AdvoServ also said they are proud of the company’s record and that they “responsibly” address problems when they arise. AdvoServ supports strong oversight and clear standards, the statement said, “because they help us deliver the highest quality care.” (Read the full statement.)
The parents of five teenagers and adults living at AdvoServ homes praised the company, which provided ProPublica their contact information.
“We have had nothing but unbelievably good experiences with Carlton Palms,” said Ginny Robinson of Kennesaw, Georgia, whose son Jonathan has an intellectual disability and can have violent tantrums. He first entered the program 19 years ago. “I truly believe had we not found them he would be either in jail or dead.”
But a more troubling picture emerges from thousands of pages of public records reviewed by ProPublica, as well as from the accounts of current or former residents laid out in lawsuits and in interviews with relatives. Many complaints have centered around the company’s aggressive use of mechanical restraints, such as leather cuffs, chairs with straps, and a “wrap mat” akin to a full-body straight-jacket. Such tactics, records show, have resulted in broken arms, collarbones and jaws, knocked-out teeth and cuts needing stitches.
In late June 2013, Carlton Palms’ staff members assured Paige Lunsford’s parents in emails that their daughter, a waifish girl with brown eyes, “was having a nice day in class today” — even though she had begun vomiting and clashing with staff just days after arriving. Lunsford had autism, was bipolar and schizophrenic, and couldn’t speak. She struggled with compulsions to bite her skin or bang her head. Workers tied her down when she ran from them, threw things or tried to hurt herself.
A Carlton Palms doctor saw her but, despite her worsening condition, chose not to send her to the hospital. The next morning a 911 call brought medics to Lunsford’s bedroom, where they found her dead of dehydration brought on by her stomach illness.
The sole concession Florida regulators wrung out of AdvoServ after dropping the admissions moratorium — that the company improve video monitoring — did little to bring about accountability.
When detectives went to examine video from cameras where Lunsford lived, they discovered all but an hour or so was gone. Company officials said the footage was mistakenly erased.
In recent decades, states have largely outsourced the day-to-day care of people with developmental and intellectual disabilities. Group homes are now overwhelmingly run by private organizations, and while nonprofits rule the sector, for-profit investors have increasingly taken interest. AdvoServ founder Kenneth Mazik was at their vanguard.
Mazik opened the Au Clair School for autistic children in 1969 in a stern-looking 28-room mansion in Bear, Delaware. A broad-shouldered University of Delaware graduate who had worked at a state institution, he said a particularly gruesome encounter had inspired him: A boy he was counseling had pulled out his own eye. “So, following my usual pattern, I overcompensated,” he told a reporter at the time. “I threw myself into autism - which was what was wrong with the boy.”
He took in castaways — his first patients were teenage boys who had been kicked out of another program — and Au Clair soon had 30 children. It received national attention in the early 1970s when “Silk Stockings,” a racehorse owned by Mazik and his then-wife, started winning harness-style races, infusing the school with prize money. The media loved the tale of how the horse saved the little school for autistics.
Another source of cash for Au Clair appeared when Congress mandated in 1975 that public schools take responsibility for educating all children with disabilities. Local classrooms still sometimes couldn’t handle children with the most serious impairments, so families implored local officials to pay tuition for special private schools. Mazik’s Au Clair, and schools like it, took the cases no one else would.
But signs of trouble began soon after the glow from Silk Stockings’ wins faded, when former workers said they had witnessed children being beaten at Au Clair as part of their treatment.
Articles in the Wilmington News-Journal in 1979 described children hit with plastic bats and dunked in a dirty swimming pool. Mazik himself, the newspaper said, had repeatedly whipped a 16-year-old boy with an intellectual disability across his backside with a riding crop.
Mazik acknowledged in the story that he had struck the boy, but said it didn’t constitute abuse. The employees who complained were disgruntled, he said.
Delaware officials considered shutting down the school, but instead chose to work with it to improve conditions.
The company continued to grow, opening a second Au Clair in 1987 in Florida, northwest of Orlando. That school — later rechristened Carlton Palms — took root on the isolated lakeside campus of a former retirement community, tucked between orange groves.
The company had told local officials the school would house 20 to 30 children, ages seven to 18. But within three years, it had grown to 48 students coming from 28 states.
Keeping large numbers of disabled children under one roof was exactly the model the country was moving away from. The goal was to replace big institutions with a network of community-based homes.
But in Florida, a lobbyist for the company urged legislators to carve out an exception for “transitional” programs with tiered levels of care and more people living together than was typically allowed. The change — which only benefited Au Clair — also later helped justify higher rates of pay from the state than what other programs received.
By 1997, Au Clair had changed its name to AdvoServ and expanded to about 130 children at schools in Delaware and Florida. That year, it faced two crises.
On April 2, Mazik telephoned relatives of a 14-year-old student to tell them the boy had died of an apparent seizure at Carlton Palms.
A caller to the state’s abuse hotline a few months later reported that the boy, Jon Henley, hadn’t received immediate medical care for the seizure, and that staff had neglected him.
Investigators from the county sheriff’s office and state Department of Children and Families discovered a roommate had told staff that Henley was shaking their bunk bed early that morning, but workers had done nothing to help him. One staffer said she just told the boy — who was face down — to be quiet because she thought he was masturbating. Workers were supposed to check on his wellbeing every 15 minutes all night. But he was found dead at wake-up time, 7:30 a.m., still face down.
Henley had autism and took medication to prevent convulsions. But an autopsy found it present in his blood at levels far below the “therapeutic range” typically needed to control seizures.
Ultimately, despite signs of potential lapses in care, the sheriff’s office did not file criminal charges and state investigators closed their inquiry with no finding of mistreatment. The facility faced no repercussions.
Henley, a joyful child whose loved ones called him “Prince Jon Jon,” had gone to Carlton Palms because his St. Thomas, Virgin Islands, school district wasn’t equipped to teach him. “If they had the accommodations on the island for him we would have never sent him there,” his aunt Laurice Simmonds-Wilson recalled.
When he died, she said, Carlton Palms officials said the company would pay for a casket and arrange to return his body to St. Thomas.
Family members only recently learned through ProPublica’s inquiries about the state investigation and allegations that Henley had not received proper care. The family didn’t even know an autopsy was conducted. “We feel we were lied to and fooled for all of these years,” Simmonds-Wilson said. “Jon Jon deserved justice. Period.”
A former staffer said Carlton Palms administrators had offered little information about what happened to the well-liked student, even to workers. “I was confused,” said Susan Knoll, who was a behavior analyst there at the time. “They didn’t tell us, which seemed strange.”
AdvoServ officials, in a statement, said Carlton Palms cooperated with the investigations, which found no wrongdoing, and that “[w]hen incidents like this occur, we responsibly address them.”
Just a month after Henley’s death, the next crisis hit: The New York Times published a scathing story on Mazik’s schools and his influence on federal welfare reform.
The story — which didn’t mention Henley’s death — revealed New York inspectors had once discovered children at the Delaware Au Clair school living in trailers that smelled of urine and feces. One weeping deaf boy, the story said, had been confined for hours in a wrap mat that had cut off his circulation.
“I cried all the way back on Amtrak,” a New York official told the Times.
The story also detailed how Mazik had maneuvered to dip into a stream of foster care funding by urging federal lawmakers to strike the word “non-profit” from a section of the 1996 welfare reform legislation signed by Bill Clinton.
Mazik quickly sent a letter to Delaware officials blasting the story. “Because of your involvement,” he wrote a top licensing official, “I want to provide you with some facts to help alleviate any discomfort you may feel as a result of the Times piece.”
But any worries Mazik might have had proved unfounded. The company experienced no major fallout and proceeded with plans to enter a new market. AdvoServ would soon become the largest provider of group homes for developmentally disabled adults in New Jersey.
Mazik’s circumstances seemed to reflect the company’s growing prosperity. He kept homes in Delaware and Florida, shuttling between them in his private plane. He collected fine art, cigars and wine and increased his real estate holdings. He also developed other business ventures, launching a video surveillance company that supplied his group homes and schools.
AdvoServ’s expanding portfolio of programs routinely used mechanical restraints, such as the wrap mat or cuffs — which other operators were abandoning — to manage agitated residents. The company battled fiercely to fend off any limits on such measures.
In 2003, New Jersey lawmakers introduced a state bill to curtail restraints in residential programs, particularly those serving people with developmental disabilities or brain injuries. The measure was inspired by Matthew Goodman, a 14 -year -old who had died of pneumonia after being repeatedly restrained while living at another operator’s group home.
At an assembly committee hearing on the bill, then-AdvoServ CEO Judith Favell passionately defended the tactics. “I believe that restraints should be used to assist in decreasing a behavior problem,” she said. “In my experience, the abuses involved in restraint are, indeed, rare.”
Favell also met with the committee’s chairwoman, Democrat Loretta Weinberg. Two weeks later, one of Mazik’s companies donated $2,200 to Weinberg’s campaign. Mazik gave another $25,000 to the state Democratic Party’s senate political action committee — the first installment of nearly $125,000 he would give the party over the next four years.
Weinberg’s assembly committee went on to pass a weakened version of the measure with fewer limits, and a restraint bill did not gain traction in the state senate.
Weinberg, now a state senator, told ProPublica she agreed to the compromise bill not because of AdvoServ, but because she didn’t think stronger legislation could pass and had heard from parents who supported restraints. “I have never in my 20-some years in public life sold a vote,” she said.
In the end, the company got its way: The effort at reform fizzled.
A few years later, the restraint issue resurfaced — this time on the national level. In 2009, Congressional lawmakers introduced the first of what would become a series of bills to restrict the use of restraints on public school children.
AdvoServ pushed back, using heavyweights such as former HealthSouth lobbyist Eric Hanson — who was later joined by former Congressman Jerry Weller. The company has paid the lobbyists’ firm nearly $1 million over the past decade.
The legislation was reintroduced repeatedly but stalled, never achieving significant Republican support.
Two opponents of the restrictions were the most vocal, a former Senate staffer said: One was the controversial Rotenberg Center. The other was AdvoServ.
AdvoServ has proven as adept at working over the state agencies that deliver it clients — and the millions of dollars that follow them — as it has the political process. The company’s relentless advocacy in Delaware kept a stream of residents flowing to its facilities even after two sets of regulators raised alarms about children hurt in its care.
In 2011, Delaware’s agency for foster care and children’s mental health took a bold step: It decided to stop sending kids to AdvoServ.
Nearly every day at AdvoServ, residents are strapped into mechanical restraints, which were considered so inhumane that the United Kingdom banned them in asylums in the 1800s. They have also been mostly abandoned in the U.S.
Workers force a person trying to hurt themselves or others to lie down.
Workers force a person trying to hurt themselves or others to lie down.
Workers force a person trying to hurt themselves or others to lie down.
They tie down the person's wrists and ankles with straps.
They tie down the person's wrists and ankles with straps.
They tie down the person's wrists and ankles with straps.
They fold big flaps across the person’s body.
They fold big flaps across the person’s body.
They fold big flaps across the person’s body.
They use seatbelt-like straps to close the mat, and turn on a fan so the person won’t asphyxiate.
Agency officials objected to mechanical restraints and thought kids were staying too long in what should have been short-term placements. AdvoServ had also resisted even telling regulators about all restraints — a move that one official in an email called an effort “to prevent any oversight of their practice.”
AdvoServ leaders responded to the agency’s decision with “intense outreach,” emails show, urging it to reconsider and promising the company was making improvements. But state workers saw no such improvements.
“I have checked with others here in the Kids Department, who have been on site there in recent months,” wrote Vicky Kelly, director of the agency’s family services division, in 2012, “and they don’t report evidence of these changes.”
Even the state psychiatric center for adults was cutting back on restraints at federal officials’ insistence. But AdvoServ was “unbending” in its commitment to them, another of Kelly’s emails from that year said. “So the state is in a precarious position right now,” she wrote, “in agreeing that restraint is prohibited for adults, yet still allowed for youth with serious disabilities.”
As foster care officials continued to avoid placing kids with AdvoServ, Delaware lawmakers took up a bill to prohibit using mechanical restraints on public school students and limit holds with bare hands.
That posed a problem for AdvoServ because Delaware public schools referred more children to the company’s homes than the state’s child welfare agency did, sending about 20 boarding students and 10 day students a year. Each student brought in substantial revenue: Six-figure bills are typical and, for one AdvoServ student, the state and local agencies paid a combined $383,000 per year.
AdvoServ — whose Delaware lobbying firm was led by prominent former state Rep. Bob Byrd — pushed for a loophole in the restraint measure involving schoolchildren: The company wanted providers to be able to seek waivers if they thought mechanical restraints were needed for a particularly challenging resident.
A state lawmaker told an education official that because of AdvoServ’s intervention, the bill would go nowhere without the waiver provision, according to state school officials and the director of the state Developmental Disabilities Council.
In June 2013, the restraint bill passed with the exception AdvoServ had sought. (It has not, to date, sought a waiver.)
Soon after it won that battle, the company faced a new one with state education officials. They, too, had objected strongly to mechanical restraints on students, which the company was phasing out. While officials hadn’t barred schools from sending kids to AdvoServ, company executives perceived a downtick in the number of schoolchildren referred to the company’s program in 2013.
AdvoServ responded by ramping up pressure on state bureaucrats.
“One of my clients represents AdvoServ,” former Delaware Controller General Russell Larson wrote in an email to top education leaders in August 2013. “I would love to meet with you to find out if there’s anything I can tell my client to help them improve their service.”
Education officials told him they were already talking with AdvoServ directly. Unsatisfied, AdvoServ brought its concerns to Gov. Jack Markell’s office two months later — threatening to leave the state if school referrals didn’t pick up, emails show.
As AdvoServ tried to muscle state leaders into line, rank-and-file staffers at Delaware’s education department expressed frustration.
“They HAVE gotten new referrals,” one education official wrote to another after learning of the company’s complaints to Markell. “I wish they would own the problems they caused for themselves and acknowledge the inordinate amount of time we have devoted to them to help them remain open!”
Amid the wrangling between the company and school officials, a rash of complaints about mistreatment in AdvoServ homes rolled in, with seven landing between November 2013 and July 2014. “It is out of control,” a state licensing official lamented to another.
In one case, an AdvoServ worker threw scalding water on a resident, causing first-degree burns. Employees, including a supervisor who had left the home to play video games with a friend, sought to cover up what happened by claiming a cup of hot water had fallen off a dresser when the resident was trying to injure herself, records show. Workers didn’t take her to a doctor right away. Instead, they popped her burn blisters and falsified an injury report.
They later told authorities what they had done was “typical” behavior at AdvoServ. The workers resigned or were fired. The company said they lacked credibility.
In another case, a Delaware worker covered a boy’s face with a folded-up pillowcase to prevent him from spitting, leaving him gasping for breath. That led to one of three citations from the state last year for improper restraints.
In August 2014, the state education department approved keeping AdvoServ on the list of places public schools could send schoolchildren for the next three years.
Education officials said last week the decision was based on improvements the company had made, as well as parents’ and school districts’ positive comments.
After the scalding incident and other problems, Delaware’s foster agency gave one AdvoServ school a “warning of probation,” an action two steps before license suspension. The agency required AdvoServ officials to hire a consultant to help it improve safety at all its Delaware facilities.
Though the agency still wasn’t referring kids there, AdvoServ met all the requirements. This past May, state licensing authorities lifted their warning.
AdvoServ was, once again, a residential school in good standing.
While AdvoServ largely succeeded in smoothing over conflicts in Delaware, it faced what looked like a greater threat in Florida: 14-year-old Paige Lunsford had died from a treatable medical condition and state investigators wanted to know why.
A tip to the state’s abuse hotline five days after Lunsford’s death on July 6, 2013, implicated Lunsford’s care at Carlton Palms, as well as workers’ use of restraints on her.
The caller said Lunsford had been in “too much restraint for longer than necessary” and that the restraints may have made her underlying medical problems worse. Records of her care, the caller said, went missing the morning after she died.
Carlton Palms hadn’t notified the agency of Lunsford’s death, though it was supposed to immediately report any incident where abuse or neglect was suspected.
Child welfare investigators and detectives descended on the remote campus to interview employees. They discovered a tangle of conflicting accounts.
Lunsford’s parents said Carlton Palms’ doctor, Dr. Robert Lynch, had initially told them she was rushed to the hospital, where she collapsed and died, state records show. Yet medics said that when they arrived at Carlton Palms, she was already dead.
Tom Shea — the center’s director — told investigators that overnight, Lunsford had rocked herself to sleep in the restraint chair and staffers carried her to her bed.
But workers said Lunsford had endured multiple mechanical restraints on her last night while vomiting as many as 25 to 30 times — “like water out of a sink,” one staffer told investigators. Workers tied her arms and legs to a bed while she lay on her back.
Then, in one of the night’s most harrowing moments, they decided to move her to a restraint chair in the hallway. They said Lunsford, down to 69 pounds, fought back so hard it took six of them to wrestle her into the chair — where she was bound in six places. They said she never slept.
Her caregivers said they sought help from the program’s top nursing and behavioral staff, but no one directed them to call an ambulance.
After a nearly eight-month investigation, state child protection officials cited Carlton Palms for medical neglect and for inadequately supervising Lunsford, singling out Lynch and head nurse Bonnie Clugston.
“[W]rongful death due to medical neglect is probable,” one state report concluded.
The state health department found Clugston, the facility’s head nurse, had violated state law by failing to get Lunsford emergency medical help. (The department has not made a similar finding for Lynch.)
In its statement, company leaders said they “fundamentally disagree” with the child protection agency’s conclusions and are awaiting the health department’s determination in Lynch’s case. AdvoServ also said it stands by Shea’s account of Lunsford’s last night and that the video deletion was accidental.
“Paige’s death was very tragic and heart-wrenching for us all, and it still hurts quite a bit,” said Bacon, AdvoServ’s chief operating officer. He declined to answer specific questions about Lunsford.
Clugston and Lynch resigned, the company said. Shea retired in the spring. Lynch did not return messages left at his office. Clugston could not be reached.
Lunsford’s parents filed a lawsuit in May 2015 against Carlton Palms and certain staff members, alleging negligent medical care.
The job of figuring out what sanctions, if any, should be levied against Carlton Palms fell to the Agency for Persons with Disabilities, the same department that had sought, then dropped, a year-long moratorium.
As before, officials there chose not to halt admissions or levy fines.
“[A]s my staff previously discussed with you, the Agency is willing to forego the imposition of administrative fines at this juncture and allow your facility to apply those resources instead to complying with the expectations outlined herein,” the agency’s director, Barbara Palmer, wrote in a letter to AdvoServ almost 10 months after Lunsford’s death.
The state required more upgrades to the facility’s video monitoring, including letting regulators call in for access to remote feeds, and an overhaul of how the program managed medical cases. Officials also mandated that the company retrain workers on restraints and that company officials meet regularly with regulators.
Three months after Palmer’s letter, as the Miami Herald prepared to publish a story about Lunsford, another alarming incident took place at Carlton Palms.
A boy broke his arm while staffers were restraining him in a wrap mat, according to state records. They didn’t take him to the hospital for five hours. He had surgery to insert pins in his upper arm, then landed back in the hospital days later with an infection after Carlton Palms workers didn’t properly care for the wound.
The Agency for Persons with Disabilities finally imposed an informal moratorium, pledging not to refer any residents to Carlton Palms.
The ban lasted five months, during which the state agency still allowed the facility to admit an out-of-state resident, according to the company.
“It is important to understand that the moratorium was not a punitive measure, it was done out of an abundance of caution to allow the agency and AdvoServ to work through any potential issues,” the company’s statement said. “We fully support the process.”
AdvoServ also paid a $10,000 penalty, the maximum allowed by law.
Today, AdvoServ appears poised for more growth. The company is expanding into Virginia.
In 2009, Mazik sold a majority share in the company to California-based GI Partners — which recently sold the company again to another private equity firm, Wellspring Capital Management in New York. AdvoServ says Mazik no longer has any ownership stake in the company.
Mazik did not respond to questions sent to him. In a letter, his lawyer said that since the 2009 sale, Mazik “has had no operational or managerial role regarding day to day operations” of the company.
Critics of Carlton Palms worry it has grown so big that regulators can’t effectively oversee it. The facility cares for nearly 30 percent of all Floridians who need such services. Finding so many beds elsewhere would be difficult.
When the Agency for Persons with Disabilities filed its complaint asking for a moratorium in 2012, it acknowledged a concern that suspending or revoking Carlton Palms’ license “could unnecessarily disrupt the lives of the existing residents.” The agency shut down two residential providers for people with similar disabilities to those at AdvoServ in the past year. But Carlton Palms dwarfs them in size and influence.
In a statement, the Agency for Persons with Disabilities objected to the idea that it is unable to properly oversee Carlton Palms. It said, however, “closure of a facility is always the Agency’s last resort … and is only done in cases where a provider is either unwilling or unable to correct identified problems.”
When AdvoServ executives gave me a tour of Carlton Palms last summer, the placid campus gave no indication of the previous year’s turmoil.
We traveled in a golf cart over wide grassy lawns past skinny palms and live oaks draped in Spanish moss, visiting tidy classrooms and silent halls in dorm-style buildings. Only about 20 of the facility’s roughly 200 residents were in view.
Company officials said the rest of their clients were at vocational assignments or off-campus trips such as to a bowling alley. About 80 residents do landscaping and janitorial work for minimum wage at sites, it turns out, that include buildings owned by Mazik’s leasing company in downtown Mount Dora.
The golf cart rolled past a chapel by a fountain, a field where residents play flag football, and a squat modular unit that serves as the administrative building. We saw teenage boys listening to a lesson about managing money, and, in another building, girls with more severe physical impairments doing crafts.
We didn’t stop at the site where Lunsford’s parents had been told Carlton Palms would plant a tree in her memory, just as it had planted one for Henley.
Meral Agish contributed research for this report. Production by Emily Martinez, Rob Weychert, and Hannah Birch.
Heather Vogell reports on schools for ProPublica. Previously, she reported on test cheating in public schools at The Atlanta Journal-Constitution. Her work resulted in indictments of the superintendent and 34 others.
This story was co-published with The Daily Beast.
Over the course of her lifetime, Paula Schulte survived painful scoliosis that contorted her spine, a head injury that left her in a coma for weeks, and cancer that cost her part of a lung.
What she couldn’t survive was 11 weeks in Florida hospitals.
Schulte, 64, was living an engaged life — staying in touch daily with her daughter, Stephanie Sinclair, a photojournalist, and taking afternoon drives with her husband, Joe. When she suffered an unexpected bout of seizures in August 2012, doctors said she would need only a short hospital stay until the drugs kicked in to remedy things.
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Instead, her treatment triggered a cascade of medical mistakes.
A fall from bed broke her hip and wrist — injuries that went undiagnosed for days. A hip replacement became infected, requiring another surgery. A displaced IV pumped a caustic drug into her arm until it ballooned to the size of a melon.
Schulte died as a rare syndrome, thought to be triggered by a reaction to medication, blistered her eyelids and attacked her internal organs. Doctors said it was the type of condition they had only read about in textbooks.
A close examination of Schulte’s care shows that for all the errors contributing to her decline, neither physicians nor hospitals were held accountable for any of them. Little was done to protect other patients from similar mistakes.
Strikingly, those involved with her treatment were unaware of the totality of the missteps that contributed to her death.
“There was no justice for my mother,” Sinclair said. “There was no consequence for any of this poor care on anybody’s part. I know that added to my father’s trauma, and I know that it added to mine.”
Schulte’s case illuminates how the health care system not only fails to protect patients but often compounds the harm by hiding the truth when patients or family members try to find out what went wrong.
Over the past three years, ProPublica has gathered the stories of more than 1,000 people from all 50 states who answered a detailed questionnaire about how they or a loved one was injured during medical care, including how the providers and regulators dealt with them after an error.
Only 1 in 5 respondents said a provider or medical facility disclosed that harm had occurred — and in about half the cases, disclosure came only after pressure, such as a lawsuit or complaint. Getting an apology for a mistake or injury was even more rare: Just 1 in 8 reported receiving one.
Although ProPublica’s sample is not a statistical cross-section of the nation’s patients (participants are self-selected), the responses are consistent with what some experts call a gaping hole in U.S. health care. Again and again, patients say they are ignored or dismissed by providers who seem more interested in avoiding legal liability than in acknowledging what went wrong.
A recent study estimated that preventable harm in hospitals contributes to the deaths of between 210,000 and 440,000 patients each year. That would make medical injury the nation’s third-leading cause of death, just behind heart disease and cancer.
More than a decade ago, a landmark study by the Institutes of Medicine — “To Err Is Human” — called for a national registry to track medical harm and bring greater accountability.
That hasn’t happened. Instead, it has been largely left to individual hospitals and practitioners to address and learn from incidents of patient harm.
Only 10 states require hospitals to disclose medical mistakes or unintended outcomes to patients. More than two-thirds of states have laws granting legal immunity for apologies by providers. But apologies aren’t required, and the laws on immunity often do not shield doctors from liability if they explain what went wrong.
Dr. Eric Thomas, a patient-safety expert from the University of Texas Medical School at Houston, said ProPublica’s questionnaire reflects a troubling reality that helps perpetuate harm. It is “unacceptable that such a small percentage of people are being told” about errors, Thomas argued, but doubly so because every undisclosed error is a lost chance to improve care.
“Not only is it a matter of justice and professionalism,” he said, “but it is a matter of improving safety for future patients.”
A few hospitals have tried to break through barriers to disclosure with programs that invite patients and their lawyers to talk about errors and possible compensation before disputes escalate. Rick Boothman, who has instituted a more open approach as chief risk officer at the University of Michigan Health System, said the fear of lawsuits or professional discipline still remains a formidable obstacle.
“People can nod in agreement with the ethics of this,” he said. “And then a defense lawyer who gets paid by the hour will say, ‘Boothman is crazy. This will lead to catastrophe.’ That holds the well-meaning hospitals back.”
In fact, data from Michigan and other similar programs show that taking responsibility for patient harm reduces lawsuits, Thomas said. “One of the main reasons that people sue,” he said, “is that they’re trying to find out what happened.”
In lieu of the courts, patients or their relatives can complain about poor care to an array of entities, from state regulatory agencies to The Joint Commission, the private, nonprofit organization that accredits most hospitals.
Schulte’s family turned to state regulators. They declined to investigate, saying the alleged errors didn’t pose an urgent threat to other patients. After Sinclair wrote to the Joint Commission, the group cleared the hospitals involved but said it couldn’t divulge any details.
“All anybody cared about was covering up for themselves,’’ Sinclair said.
On the morning of Aug. 12, 2012, Joe Schulte’s phone rang as he prepared to visit his wife at the hospital. The call delivered jarring news. Somehow, Paula Schulte had fallen out of her bed in the ICU. Staffers found her crumpled on the floor.
Joe rushed to Lawnwood Regional Medical Center, a 331-bed facility in Fort Pierce, just a few minutes from the couple’s house. He filled in Sinclair, who was on assignment photographing child brides in Ethiopia.
Over the years, the family had seen Paula through multiple hospital stays. Joe met Paula in the late 1970s, when he was a successful real estate broker with a house in a hip section of South Miami. Paula was artistic, funny and spontaneous. They married 18 months later, and Paula moved with her daughter, Stephanie, then 5, into Joe’s place.
Severe scoliosis had left Paula with metal rods in her spine. She experienced constant pain and felt insecure about growing up with a crooked back. When Stephanie was a small child, she recalled, her mom spent a year in a body cast after spinal surgery.
One night in 2001, while the rest of the family slept, Paula went to the kitchen, fell and slammed her head. Doctors had to perform brain surgery and medically induce a coma for two weeks. Staples closed 6-inch-long incisions on each side of Paula’s head.
The morning she was to awake, doctors warned that Paula might not be the same, perhaps even barely functional. Stephanie and Joe watched nervously as attendants removed her breathing tube. Would she even know them?
Paula looked around and smiled mischievously. “Well, this is a bitch,” she said to peals of laughter.
“Yep,” Stephanie said to Joe. “That’s her.”
In time, though, they did notice differences. Paula occasionally had trouble with vocabulary or thinking beyond the moment. Her talent for art, however — she had studied for years on a scholarship to the University of Miami — was undiminished. She continued to produce paintings of South Florida landscapes and other subjects in the vivid colors she favored.
When Schulte was admitted to Lawnwood that August, it was for a relatively minor problem — seizures that began after a doctor took her off the medication she’d been taking since the kitchen accident. The seizures left her disoriented and unable to speak. New medications were supposed to get her out of the hospital soon.
Joe rose each morning, made coffee and breakfast, then headed to Lawnwood for a 10-hour shift by his wife’s bedside. Mostly they watched Paula’s favorite TV shows while waiting for the medication to kick in.
With every shift change, Joe briefed the new nurses on the intricacies of his wife’s care. A private nurse Sinclair had hired to coordinate her mother’s care also checked in periodically.
It was on the fourth day that Joe got the call about her fall in the ICU. Falls are a common, preventable cause of injury to patients; Medicare now refuses to pay hospitals for additional treatment required when patients suffer serious falls in their care. Hospitals have become so attentive to fall prevention that employees sometimes sit with patients around the clock.
Still, about 1 million falls occur each year in hospitals, with about 11,000 of them contributing to the patient’s death.
Lawnwood doctors and nurses knew Paula was a fall risk because she was disoriented and her gait was unsteady. They noted the risk on her armband, her chart and the door of her room. To keep her safe, a bed alarm was ordered and bed rails were supposed to be raised.
Still, the bed alarm could be a nuisance, so it was often turned off, Joe recalled. The raised rails made it harder to tend to Paula, and at times they were lowered. Joe said the rails were down the night before the fall; he’d reminded a nurse to put them up.
After the fall, hospital staffers said Paula would be fine. She had fallen on her right side and had discoloration and abrasions on her right arm, which seemed to be hurting. A scan of her head and X-rays of her right shoulder and upper arm were ordered. Paula wasn’t fully able to speak, but when the staff said there were no major injuries, Joe and Stephanie felt reassured.
More than 1 million patients suffer harm each year in U.S. health care facilities. Often, their harm isn’t acknowledged even as they live with the consequences. ProPublica set out to capture their stories. Here is what we learned.
Four days later, Paula was discharged to a nursing home, Emerald Health Care. By then she was able to communicate better. Nursing home records show that her right wrist was swollen and that she complained of pain. Joe noticed that her right foot twisted to the side.
Doctors ordered more X-rays and made a sickening realization: All this time, Schulte’s right hip and right wrist had been broken. Both would require surgery — an artificial hip and a metal plate and screws to repair her wrist.
Schulte’s primary care doctor tried to find out where the injuries had occurred. Nurses at Emerald told him Schulte hadn’t fallen at their facility and had arrived from Lawnwood with the fractures, he wrote in her medical records. The broken bones may have been missed because of Schulte’s inability to clearly communicate the source of her pain, he added.
Nurses’ notes from Lawnwood suggest the hospital may have missed clues. Schulte was “having pain with moving and turning,” and showed “generalized weakness” in her right leg, they say. She “became agitated” and “refused to complete” her range of motion exercises.
Rehabilitation notes say she needed help standing up and wasn’t able to step to the side.
When Sinclair heard about her mom’s hip, she immediately understood the situation was grave; many studies show that older people who break a hip have a significantly higher risk of dying.
Sinclair, then on a photo assignment in Ethiopia, sat in a restaurant and sobbed. She cut her work short and flew home.
Schulte’s family couldn’t imagine sending her back to Lawnwood after the fall. So they turned to St. Lucie Medical Center, a 229-bed facility nearby. She was admitted through the emergency room and assigned an orthopedic surgeon, Dr. Gerald Shute.
Shute declined to be interviewed or answer written questions about Schulte’s care. As with most surgeons, there is little public information about how his patients fare. ProPublica’s Surgeon Scorecard recently published complication rates and surgical volume for nearly 17,000 doctors who operated on Medicare patients. Shute’s volume of Medicare hip replacements is low.
On Aug. 24, 2012, the day before Schulte turned 65, Shute replaced her hip and affixed the plate in her broken wrist. She returned to Emerald Health Care five days later for physical therapy. Schulte was heavily medicated and at times agitated, according to nurses’ notes and Dr. Mark Pamer, who treated her at Emerald and provided a summary of her care to ProPublica.
Caregivers eventually noted swelling and yellow drainage from her hip incision, nurses’ notes from Emerald state. Eighteen days after he’d operated, Shute diagnosed two infections in the hip joint. Schulte returned to St. Lucie Medical Center, where Shute opened the wound, washed out the infection and deposited antibiotic beads.
Joe Schulte and Sinclair said they were told that infections “sometimes happen” — as if they are the product of random chance — a common explanation given to patients in such circumstances.
It’s true that infections are a frequent complication: The Centers for Disease Control and Prevention estimate that more than 700,000 patients a year get infections while hospitalized. Of those, about 75,000 die. Though it’s hard to pinpoint how infections are acquired, studies demonstrate that they can be prevented. The CDC, for instance, said increased vigilance led to a 19-percent drop in surgical-site infections for some procedures from 2008 through 2013.
As part of an extensive analysis of surgical complications published in July, Surgeon Scorecard reported that high-performing surgeons were able to operate on hundreds of patients with few or no infections.
To fight off Schulte’s infections, a port was installed in her chest to inject potent antibiotics. One of the drugs she was given, cefepime, can cause nonconvulsive seizures, which lack the violent irregular movements of a typical seizure but can do just as much damage to the brain.
The FDA had issued a warning that year about cefepime, saying it had caused seizures in some patients. Sinclair and Joe Schulte said they were not told about the risk.
Aug. 8, 2012: Paula Schulte is admitted to Lawnwood Regional Medical Center for a short-term stay to treat seizures.
Aug. 12: In the early morning, Schulte is found on the floor of the ICU after falling from bed. X-rays later show her hip and wrist were broken.
Aug. 24: Schulte has wrist surgery and a hip-replacement at St. Lucie Medical Center.
Sept. 12: After infections were found in her hip, Schulte has surgery to clean out the joint and introduce antibiotic beads.
Sept. 19 – Oct. 17: Recovering at a nursing home, Schulte struggles with disorientation. Her mental status dramatically declines. She is sent back to St. Lucie Medical Center.
Oct. 18: An IV pumps toxic medicine into her forearm, leaving it blackened and swollen. Doctors slice it open to drain 1 liter of fluid.
Oct. 25: With Schulte suffering from the arm injury, infections and a rare drug reaction that blistered her skin, her family chooses to remove life support.
Feb. 26, 2013: Lawnwood Regional writes to Schulte’s daughter, Stephanie Sinclair, confirming the fall from bed but saying there was no evidence of hip and wrist fractures.
Oct. 6, 2015: The Joint Commission tells Sinclair it contacted Lawnwood and St. Lucie hospitals about Schulte’s care and “determined their response is acceptable.” No details were provided.
Oct. 22, 2015: Florida state officials decline to investigate Schulte’s case, referring Sinclair to The Joint Commission.
For a third time, Paula Schulte found herself in a bed at Emerald Health Care. Sinclair said her mom was angry about the fall and infections and said every day that she just wanted to go home. While Sinclair returned to New York City, Joe spent his days with Paula, trying to cheer her up. The couple watched shows on Animal Planet.
Once again, her recovery didn’t go as expected. Nursing staff documented that Paula’s behavior became more erratic, that she had trouble expressing herself, acted confused and was hostile toward them and toward Joe, even when he tried to help her with physical therapy.
It became clear that something wasn’t right. Sinclair called Joe and heard her mother screaming in the background. Sometimes she would shout the same word over and over again, like “Hello! Hello! Hello!” or “Curtains! Curtains! Curtains!”
Pamer believed Schulte was delirious and prescribed two antipsychotic medications: Haldol, a potent drug sometimes used to sedate disruptive patients, and Zyprexa. The next day, though, a psychiatrist took her off the antipsychotics.
Pamer said Schulte’s symptoms were characteristic of several possible conditions, including delirium, brain disease or nonconvulsive seizures. Given the information at the time, he told ProPublica, there was no way to be sure about the cause. Pamer decided Schulte’s neurological condition was severe enough to send her back to the hospital.
When her ambulance arrived at St. Lucie Medical Center, records say she was disoriented, confused and agitated. Doctors admitted her with a diagnosis of “altered mental status.” Sinclair assumed her mother would go into intensive care and quickly see a neurologist. Instead, Paula’s room wasn’t in the ICU and was far from the nursing station.
That first night in the hospital, to correct low potassium levels, a nurse administered potassium chloride through an intravenous line in Schulte’s left arm.
Guidelines by the National Institutes of Health call for “extreme care” when giving potassium chloride. If the IV misses a vein or is dislodged and the drug infiltrates the arm, it can cause a chemical burn, killing tissue and causing the skin to peel away. Should an infiltration occur, the IV should be “discontinued at once,” the guidelines say.
At 4:30 a.m., a nurse noted in Paula’s record: “enlarging L FA infiltrate” — an infiltration in her left forearm. The charge nurse was called to the room, and a doctor was notified. “Will continue to monitor,” the nurse wrote. Medical records indicate the IV wasn’t pulled for 90 more minutes.
When Joe and Stephanie arrived in the morning, they were horrified. Paula was catatonic, eyes staring straight ahead. Her left arm was three times its normal size, blackened and taut like a balloon about to burst. Fluid seeped through the pores of her skin, which had partially detached from her hand in what doctors call “degloving.”
Staffers said the injury wasn’t a big deal; it happens sometimes and was treatable, Sinclair recalled being told.
Then the specialists took a look. Excess fluid had made pressure build up in Paula’s arm, choking off blood flow. They diagnosed compartment syndrome, a condition that can require amputation. Doctors did not go that far, but that evening, in the operating room, a surgeon carved long incisions in her arm down to the bone. Doctors drained a liter of fluid from the limb.
Caregivers and hospital officials didn’t offer an explanation for the injury, Sinclair and her stepfather said, and no one said it was the result of an error or a mistake. Sinclair said they called it an “unfortunate situation” and said the hospital would not bill Medicare for the treatment.
Paula lay unresponsive. In the chaos around the IV infiltration, the original reason she’d been admitted — her neurological symptoms — became secondary. Two days after being admitted, she still hadn’t seen a neurologist. Furious, Sinclair demanded that the hospital call one in.
She and Joe were present when the neurologist finally arrived. Paula’s eyes were open. The doctor moved his finger in front of her face. Nothing. He gave her several firm pinches with his fingers. She didn’t resist.
In consultation notes, the neurologist said it was “probable” Schulte had been experiencing nonconvulsive seizures. Treatment guidelines say such seizures must be addressed rapidly because they can quickly damage the brain and increase the risk of death. The neurologist prescribed an additional anti-seizure drug and said Paula needed to be closely watched, his notes state.
Sinclair blew up. She’d been asking for a neurologist for days. She stormed through the hospital, demanding a transfer. With the proper care, she believed Paula could come through. “She had survived so many things before,” Sinclair said. “We thought she could do it again.”
A helicopter ferried Paula to the University of Florida Health Shands Hospital, in Gainesville. Sinclair and Joe drove more than four hours to meet her. An infectious-disease specialist examined Paula, still unresponsive, and wrote in the medical record that her seizures likely were caused by the cefepime used to fight her hip infections. She was taken off the drug and given a new one.
About a day later, though, Joe noticed something curious: skin appeared to be peeling off Paula’s eyelids. He alerted doctors, who found patches on her back, too. The ominous symptoms were confirmed when a pathologist said Paula had a rare condition, Stevens-Johnson syndrome.
The ailment, nearly always caused by an unpredictable reaction to medication, starts with patches of blistered skin and can end with organ failure and death.
Paula had suffered seizures, a fall that resulted in undiagnosed hip and wrist fractures, two hospital-acquired infections and an IV infiltration that required her left arm to be slit open like a gutted fish. But nothing could have prepared her loved ones for what happened next.
The skin in Paula’s ears and mouth fell away. Her eyeballs became raw. Inside, doctors said, her organs were under attack.
Sinclair and Joe took stock of Paula’s suffering. They decided to let her go. At their instruction, doctors unplugged Paula from life-support. Twenty seven minutes later, she was dead.
“She squeezed my hand right before she died,” Sinclair said. “She knew what was happening.”
“Everybody’s mom is great, but my mom was a gentle soul. To die such a violent death is what hurts my dad and I so much,” she said. “We knew my mom was sick, but never in our wildest dreams did we think she would die like that.”
Charles Bosk, a sociologist at the University of Pennsylvania, has spent decades studying the way caregivers and health systems react when patients get hurt.
“When bad outcomes happen,” Bosk said, “patients first want an apology, second an explanation, and third reassurance that the hospital is taking steps to make sure no one is harmed in the same way again.”
Schulte’s loved ones say they never got a formal apology or explanation.
For weeks after Paula died, they were crippled by grief. They replayed Paula’s last two months, obsessed by the tumble of events.
They were about to confront a common scenario for patients and family members trying to come to grips with medical injuries. Bosk called it the “many hands” problem. With numerous doctors and nurses at different facilities involved in an episode of care, there is no overall responsibility.
The predicament is compounded by a prevailing ethic in health care: that patient safety is best served by a “no blame” environment. Harm is attributed to “system failures” rather than individuals. It’s as if medical providers don’t see themselves as part of the system, Bosk said.
At first, Sinclair thought an attorney could help. She assumed filing a malpractice lawsuit would be a simple matter. Despite what she regarded as the dramatic and well-documented nature of her mother’s injuries, the lawyers she contacted weren’t interested.
Malpractice cases can cost $50,000 or more to pursue. Attorneys usually take them on contingency, meaning they are paid if they win. The economics work only if potential damages are high, so a patient’s medical bills and lost future income can be more important than the merits of the case.
Sinclair met with an attorney who walked her through the math. Paula was older and didn’t have much income. “The most we could get is $50,000,” she recalls the attorney saying, “and we could spend that much on depositions and expert witnesses.”
Paula’s case also was complex, involving multiple facilities and many providers. More potential defendants could mean more expense. “We wish we could help everybody,” one lawyer wrote, declining the case. “Currently, we have no choice but to reject about 300 potential cases presented to us for every one case we can accept.”
Sinclair couldn’t believe it. “If you’re 65 years old and not bringing in a big income, they don’t value your life,” she said.
The malpractice door was shut. But Sinclair had obtained her mother’s medical records, a stack about 10 inches tall. She knew they held critical details and believed that if she could only convey the facts to the hospitals, they would see how errors had contributed to Paula’s death.
Early on, going through the records was just too hard. Sinclair was often forced to stop at details that were too painful or intimate. Eventually, she made slow progress. Her husband, Bryan, then in law school, helped her make a detailed timeline, listing events during Paula’s care down to the minute.
Not until February 2013, four months after her mother died, did Sinclair muster the courage to call Lawnwood Regional. The fall in the ICU had been the first domino to topple. She suspected that hospital officials might not know that it started Paula’s decline, or how things ended.
The hospital routed Sinclair to the risk management department. Patients who are harmed rarely meet anyone in risk management, but that department usually knows about them. Cases are often flagged for review before a patient is ever aware of it.
The traditional role of risk managers is to protect hospitals from lawsuits. In cases involving medical errors, they move to gather information and control what is disclosed. Critics call this approach “deny and defend”: Avoid acknowledging a mistake while aggressively protecting the institution.
When Sinclair called Lawnwood, she spoke to a person in the risk management department about Paula’s fall from bed and the undiagnosed hip and wrist fractures. To be explicit about the problems, she read directly from the medical records: that Lawnwood knew her mother was a fall risk, that she was unable to communicate clearly, that no one X-rayed the hip, and more.
A few weeks later, a letter from the interim risk manager arrived. It confirmed Paula’s fall but said an X-ray of her right arm “was negative for fracture” – with no mention that her right wrist hadn’t been X-rayed, as the medical records obtained by Sinclair indicate. The letter acknowledged that Paula’s hip wasn’t X-rayed but said, “There were no complaints of hip pain.”
“We are deeply sorry for the loss of your mother,” it continued. “We continue to strive to provide patient centered care and apologize if you feel our staff did not meet this goal.”
Sinclair wrote back, saying the hospital’s response left out key information. For one, her mother was speaking gibberish, so she couldn’t have complained about the broken hip. Precautions were supposed to prevent a fall in the first place, she wrote. Lawnwood’s response “answered none of our questions regarding the circumstances surrounding my mother’s care,” Sinclair said.
She added that her mother ended up dying after complications from the hip fracture, which “should give Lawnwood pause to perhaps handle such a request with compassion.” How would Lawnwood correct “this egregious and devastating wrong” and protect other families?
She never heard back.
In fact, subsequent incidents at Lawnwood suggest Sinclair was right to be worried about whether the hospital learned anything from Paula Schulte’s case. In late 2012, after Schulte died, another elderly patient fell in the hospital and suffered a hip fracture, Florida data shows.
As recently as March of this year, state inspectors cited Lawnwood after another patient fell and suffered a fracture. “There is no evidence the facility implemented measures developed to reduce re-occurrence or minimize risk of injury,” the inspectors’ statement of deficiencies said.
Officials at Lawnwood and St. Lucie Medical Center, both owned by Hospital Corporation of America, declined ProPublica’s interview requests. In an email, HCA spokeswoman Ronda Wilburn said Paula was “assessed and treated appropriately” at Lawnwood.
Wilburn said St. Lucie Medical Center had apologized for the “unfortunate IV incident” and had changed procedures after an internal review. She declined to specify what changes were made. Wilburn said the hip infections were diagnosed “several weeks” after Schulte left St. Lucie.
Sinclair considered the letter from Lawnwood’s risk manager a non-response. She felt gut-punched — too disheartened even to try asking questions about infections and the IV infiltration at St. Lucie, which she knew was run by the same corporation as Lawnwood.
Hospitals have broad leeway when it comes to deciding what to tell patients about medical errors. State laws aimed at encouraging disclosure are ambiguous or weak; hospital industry guidelines, though nominally promoting transparency, don’t require a detailed explanation.
Only 10 states require hospitals to tell patients about certain types of medical harm. None requires divulging how the harm happened, who was responsible or what steps hospitals are taking to make sure the harm doesn’t happen again. A national disclosure law, proposed by then-Sens. Barack Obama and Hillary Clinton in 2005 and modeled on the University of Michigan Health System’s program, never advanced out of committee.
The Joint Commission, the nation’s largest hospital accrediting agency, requires hospitals to inform patients about “sentinel events” — any injury that’s not related to the natural course of a patient’s illness that results in death, permanent harm or severe temporary harm.
Hospitals are also expected to conduct a “root cause analysis,” to reconstruct the event and determine how and why the harm occurred. But the hospital can “define and determine what information related to an adverse event or sentinel event should be disclosed … including whether the root cause should be disclosed,” a commission spokeswoman said in an email.
The American Hospital Association has guidelines that encourage open communication with patients, but they aren’t binding, either. Dr. John Combs, the AHA’s chief medical officer, would not comment specifically about Schulte’s case. However, he said that deflecting complaints from a family member would be out of step with today’s risk management standards.
Some hospitals are experimenting with new approaches.
Dr. David Mayer, vice president of quality and safety at MedStar Health, a Maryland-based hospital chain, is among a handful of federal grant recipients testing a program called Communications and Optimal Resolution — or CandOR — that “teaches people to be empathetic, and then, when apology is appropriate we take accountability,” he said.
“It’s not, ‘I’m sorry this happened to you,’ ” Mayer said, “It’s, ‘I’m sorry our care broke down and you were harmed by that care.’ ”
CandOR dictates that caregivers communicate immediately with patients after a bad outcome, even if it’s unclear why the harm occurred, or who was to blame. That contrasts with the more typical response in hospitals: to avoid talking to patients until any internal investigation is over, Mayer said. That can leave patients in the dark for months; if negligence isn’t determined, there may not be any communication with the patient, he said.
As in the Michigan health system’s program, financial compensation may be offered, or an explanation provided if no offer is made. Patients and their families are welcome to bring a lawyer to conversations with doctors or hospital officials, Mayer said.
Most hospitals still do things the old way; only about 100 of the country’s roughly 3,500 acute-care hospitals are trying approaches like CandOR, Mayer said.
After her mother’s funeral, when Sinclair saw the final death certificate, it set off a new round of frustrations and questions.
The document mentioned nothing about the fall that broke Schulte’s hip, the hospital-acquired injuries, missed diagnoses or infections. Though it listed several contributing factors, including Stevens-Johnson Syndrome, the certificate said the cause of death was epilepsy.
Yet Schulte’s discharge records from the Shands hospital showed — and doctors had asserted — that the seizures were resolved before she died.
Sinclair wrote the doctor at Shands who had completed the certificate. She asked to have it corrected to at least include the fall and the infections. “We just believe, out of respect for her, it should be accurate as to what actually transpired,” Sinclair wrote.
The accuracy of Schulte’s death certificate had a practical consequence. Schulte had life insurance that only paid out if her death were accidental — it was worth $100,000. Because the death certificate said she died of “natural” causes, Joe, who’d lost money in the 2008 financial crisis, didn’t have a claim.
There are numerous places where patients or their relatives can take such concerns, from state health agencies or nursing and medical professional boards to Medicare Quality Improvement Organizations. The Joint Commission also investigates complaints involving hospitals it accredits. Each agency has its own policies and jurisdictional limits.
About half of those who completed ProPublica’s questionnaire said they filed some sort of complaint. Many said they were disappointed with the outcomes, however. Some never heard back, while others reported getting generic responses asserting that the care was appropriate.
Sinclair didn’t fully understand, and struggled to navigate, the regulatory maze. Beset by grief, she didn’t file a complaint with the Florida Agency for Health Care Administration, which licenses hospitals, until June — more than two years after her mother died.
She took hours to prepare a three-page, single-spaced statement, including precise times and dates and quotes from the medical records. “As you can see, this is a very tragic series of events — rife with hospital error — resulting in devastating consequences for our family,” Sinclair wrote.
The next day, the agency sent a form letter. “Thank you for forwarding your concerns …” the letter began. While the agency “carefully reviewed” Sinclair’s complaint, it considers “current risks” to patients a higher priority, the letter said.
The agency would not be looking into the case.
About the same time, Sinclair sent letters about Lawnwood Regional and St. Lucie Medical Center to the Joint Commission. In October, four months later, two form letters arrived. They said the commission had contacted the hospitals and asked for responses concerning Paula Schulte’s care. The hospitals’ responses were found to be “acceptable,” the letters said.
“In line with our Public Information Policy, we cannot provide you with the organization’s response,” the form letters said. “This concludes our evaluation.”
Sinclair was outraged. How can the people most closely affected by the harm be entirely shut out of the conversation, she wondered.
Sinclair knew her mother wouldn’t live forever, but even photographing war and human rights abuses hadn’t prepared her for what happened in the end. The apathy she felt from medical providers and regulators only added insult to her mother’s many injuries, Sinclair said.
“We kissed her a million times in the last half hour of her life and surrounded her with love, but we could not protect her,” Sinclair said. “And who knew that the entity we were trying to protect her from was the health care system?”
Read more of ProPublica’s reporting on patient safety and patient privacy.
Image may be NSFW.More than 1 million patients suffer harm each year in U.S. health care facilities. Often, their harm isn’t acknowledged even as they live with the consequences. ProPublica set out to capture their stories. Here is what we learned.
View the responses of more than 1,000 who completed our patient harm questionnaire.
Share your story and get tips from others who’ve lived through a medical mistake.
Sign up for sources and get a guide to reporting on patient harm.
Patient safety is one of the most talked about topics in medicine today, but it’s rare to hear from patients who have been injured. Now, ProPublica has gathered more than 1,000 stories of patient harm, from all 50 states, as reported by patients or their loved ones. Their experiences – summarized here – add an important dimension to the patient safety debate, particularly when it comes to the neglect and abandonment many feel from a system that is supposed to be caring. Patients and their loved ones say they aren’t getting straight answers about what happened. They claim medical providers are not apologizing or accepting responsibility. Most of all, they assert that no one is being held accountable for the harm.
Patient harm encompasses a broad spectrum of experiences. Patient stories included surgical complications, medication errors and neglect.
Source: Includes 1,627 unique harm types reported by 1,010 people in response to the question, "What types of harm occurred?"
Most of the harm described by patients was severe: either death or permanent disability.
Source: As reported by 1,052 people in response to the question, "Type of admission." Excludes incomplete submissions.
Many patients described feeling victimized a second time by the way they were treated after experiencing harm. After placing trust in caregivers, they were surprised to encounter stonewalling, denial and blame. Only 1 in 10 people who completed the questionnaire said the hospital or other facility voluntarily acknowledged the harm. About the same proportion said the harm was acknowledged under pressure. Nearly all the rest said they were ignored or the harm was denied.
Patients expect transparency from doctors and nurses, but they often didn’t experience it. Only 13 percent said individual caregivers voluntarily disclosed the harm.
Source: As reported by 1,010 people in response to the questions, "Did the medical facility acknowledge the harm?" and "Did the medical providers responsible acknowledge the harm?" Excludes incomplete submissions.
Patients and experts often say it’s not enough to merely acknowledge harm – there should be an apology. But apologies were rare in our questionnaire, with just 13 percent saying they received one.
Source: As reported by 1,003 people in response to the question, "Did the patient and/or the patient's family receive an apology?" Excludes incomplete submissions.
Research shows the medical oversight system is fragmented and largely ineffective. Only 1 in 20 patients in the questionnaire believed their hospital or doctor faced consequences for the harm.
Source: As reported by 1,007 people in response to the question, "Did the medical facility suffer any consequences for the harm it caused the patient?" and 995 people in response to the question, "Did the medical provider (doctor, nurse, etc) suffer any consequences? " Excludes incomplete submissions.
Patient harm can occur in any health care setting, but most of the reported harm in our data occurred in a hospital.
Source: As reported by 1,010 people in response to the question, "Type of facility"
Elective care is often considered safer than emergency or urgent care because patients tend to be in more stable health. More than half of the harm reported via our questionnaire involved elective cases. This tracks with ProPublica’s findings in our Surgeon Scorecard analysis, which showed that errors and harm can and do occur even in straightforward cases.
Source: As reported by 1,010 people in response to the question, "Type of admission." Excludes incomplete submissions.
These stories are excerpted from patient and family members who responded to our patient harm questionnaire. They have not been independently verified. They have been lightly edited for brevity and clarity.
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About this data. These results represent the self-reported experiences of 1,010 people who say they or their loved ones were the victims of patient harm, collected via a detailed questionnaire. Because respondents are self-selected, instead of being randomly sampled, their responses are not necessarily representative of patients overall. Despite not being scientific, the questionnaire results do show that a lack of transparency about patient safety is widespread. Special thanks go to the Consumers Union Safe Patient Project, the Empowered Patient Coalition, the ProPublica Patient Safety Facebook group and Vox for their efforts sharing our survey.
The people interviewed for this story include Marie (in our story, we agreed to use only her middle name); Marie’s foster mothers Peggy Cunningham and Shannon McQuery; Marie’s friend Jordan Schweitzer; James Feldman, Marie’s public defender when she was charged with filing a false police report; H. Richmond Fisher, Marie’s attorney in her civil suit against Lynnwood, Washington; Golden, Colorado, police Det. Stacy Galbraith; Westminster, Colorado, Sgt. Edna Hendershot and Sgt. Trevor Materasso; Lakewood, Colorado, police detective Aaron Hassell; Kirkland, Washington, police officer Audra Weber; Lynnwood police Sgt. Jeffrey Mason, Sgt. Rodney Cohnheim and Commander Steve Rider; and Marc O’Leary, who was interviewed at the Sterling Correctional Facility in Colorado. Former Lynnwood police Det. Jerry Rittgarn declined to be interviewed. The description of his background comes from his LinkedIn profile.
We received thousands of pages of documents through public-records requests filed with the following agencies: the police departments in Lynnwood and Kirkland, Washington; the police departments in Golden, Westminster, Aurora and Lakewood, Colorado; and the prosecuting attorney’s offices in Snohomish County, Washington, King County, Washington, and Jefferson County, Colorado.
The records obtained through these requests included investigative reports filed by detectives in Lynnwood and elsewhere; crime-scene photos and surveillance footage collected by the various law-enforcement agencies; the two case reviews of how the Lynnwood police handled the investigation of Marie’s rape report; and video of Marc O’Leary being interviewed by police after his arrest in Colorado.
Words or thoughts attributed to anyone in this story are drawn from these interviews or documents.
We reviewed Marie’s civil suit against Lynnwood, which included such legal exhibits as the medical report from the day she reported being raped and case notes from Project Ladder, the transitional housing program to which she belonged.
Other reporting included pulling transcripts of television news coverage from when Marie was raped and later charged; having court transcripts prepared from when O’Leary was sentenced in Colorado; reviewing grant documents for Project Ladder; and mining the criminal-justice literature for expert views on how rape investigations should be conducted.
We consulted police training guidelines by various organizations, including the International Association of Chiefs of Police and End Violence Against Women International.
Specific statistics:
“Rapes by strangers were uncommon — maybe about 13 percent of cases.” From the National Intimate Partner and Sexual Violence Survey, 2011
“Only about one-fifth to one-third of rapes get reported to police, national surveys show.” From National Crime and Victimization Survey, 2014 and National Violence Against Women Survey, 2006
“Between one-fourth to two-thirds of rapists are serial attackers, studies show.” From JAMA Pediatrics, December 2015 and Violence and Victims, Vol 17, 2002 by David Lisak and Paul M. Miller.
“But most recent research suggests that false reporting is relatively rare. FBI figures show that police annually declare around 5 percent of rape cases unfounded, or baseless. Social scientists examining police records in detail and using methodologically rigorous standards cite similar, single-digit rates.” From research and studies summarized in a Department of Justice-funded study, Policing and Prosecuting Sexual Assault in Los Angeles City and County, 2012 by Cassia Spohn and Katharine Tellis and from an analysis by ProPublica and The Marshall Project of FBI Uniform Crime Reporting program data, 2008–2012.
To determine the rate of rape crimes declared unfounded, or groundless, by law enforcement agencies, we analyzed Uniform Crime Reporting data collected by the Federal Bureau of Investigation. We examined five years of the “Offenses Known and Cleared by Arrest” data to smooth yearly fluctuations common in crime reporting. We excluded agencies that did not report crime statistics in any given month, as well as those that reported no crimes of any kind in a year. We also restricted our examination to only those agencies that reported at least one rape over this timespan.
To calculate the rate, we summed the number of unfounded rapes and divided it by the number of reported rapes. We ran this calculation for all departments that met our criteria on a national level. We also ran the same calculation for Washington state law enforcement agencies that cover cities of the same size as Lynnwood to account for possible variations due to the size of a jurisdiction or local laws.
If you have experience with or information about issues related to this story, email T.Christian.Miller@propublica.org.
Image may be NSFW.This story was co-published with Politico Magazine.
From his seat in the small plane flying over the largest remaining swath of American wilderness, Bruce Babbitt thought he could envision the legacy of one of his proudest achievements as Interior Secretary in the Clinton administration.
Babbitt was returning in the summer of 2013 from four sunlit nights in Alaska’s western Arctic, where at one point his camp was nearly overrun by a herd of caribou that split around the tents at the last minute. Now, below him, Babbitt saw an oil field — one carefully built and operated to avoid permanent roads and other scars on the vast expanse of tundra and lakes.
Under the deal he’d negotiated just before leaving Interior in 2000, that would be the only kind of drilling he thought would be allowed in the 23 million acres of the National Petroleum Reserve-Alaska, which, despite its name, is a pristine region home to one of the world’s largest caribou herds and giant flocks of migratory birds. The compromise was fair and, he hoped, enduring — clear-eyed about the need for more domestic oil but resolute in defense of the wilderness.
The deal lasted barely 15 years.
In February, the Obama administration granted the ConocoPhillips oil company the right to drill in the reserve. The Greater Mooses Tooth project, as it is known, upended the protections that Babbitt had engineered, saving the oil company tens of millions and setting what conservationists see as a foreboding precedent.
How ConocoPhillips overcame years of resistance from courts, native Alaskans, environmental groups and several federal agencies is the story of how Washington really works. It is a story that surprised even a veteran of the political machine like Babbitt.
As environmentalists, energy companies and politicians brawled over big symbols like the Keystone pipeline and offshore drilling in the Arctic Ocean, the more immediate battles over climate change and fossil fuels were being waged over projects like Greater Mooses Tooth — out of the public eye, away from the cable-news shout-fests and White House protests.
The fight was unfolding in the real Washington — where influence accrues across election cycles almost without regard to who’s in power. In this Washington, companies bend decisions of major import in their direction by overwhelming a bureaucracy that, after years of budget cuts, outsourcing and inattention, lacks the resources and morale to hold its own. Increasingly, industry spins the revolving door. It brings in people who learn there’s serious money to be made after leaving government jobs, by sticking around the capital and making it their career.
Big industries like oil play Washington as a long game, exhibiting a persistence too often lacking in the people in charge of safeguarding the public good. And to win the long game, to push ahead on frontiers like Greater Mooses Tooth, you need someone who is a real player.
In a city known for its status seekers, Andrew Lundquist was one of the legions who preferred to recede into the background. He was earnest, wary and remarkably unflappable. Even his appearance discouraged notice: average build, short sandy hair and a sober, almost melancholy bearing. He rarely was quoted in the press, and declined to be interviewed for this story.
He grew up in Fairbanks. His father, James, was a surgeon, who came from Minnesota to work at a new clinic in town. The family’s eight kids fished in the Chena River, built rafts, and camped out on the islands.
There’s a solidarity that comes with living in a place that’s so cold in winter your nose hairs freeze and that your tires go a little flat every morning. You get to know just about everyone. For the Lundquists, who leaned Republican, that meant being friends with both a U.S. senator, Ted Stevens, who once moved into a house they had just left, and future governor and senator Frank Murkowski and his family, who lived just up the river.
By the time Lundquist reached college age in the late 1970s, Alaska’s economy had transformed from a sprawling outpost for frontier strivers into an energy powerhouse, driven by vast reserves of oil discovered around Prudhoe Bay and pumped south through an 800-mile pipeline.
Lundquist got a degree in finance at the University of Alaska in Fairbanks, but not before a couple of short detours. He headed up north to the North Slope oil fields, where he managed a pipeline welding crew, and made a foray into the home-building business with Frank Murkowski’s son. “He wanted to see the oil fields personally — that work helped deepen his understanding,” recalled a classmate, Peter Van Flein.
Once he’d learned how to make a living with his hands, though, Lundquist headed in a much different direction — to Washington. In the waning years of the Reagan administration Lundquist took a job as a lowly go-fer in the Senate office of his family friend, Ted Stevens. “Stevens taught me really how to legislate and in a broader sense how to work in Washington, D.C.,” Lundquist would say later.
In 1995, as Republicans took control of Congress, he switched from one family friend to the other — Frank Murkowski was now a senator too, and in line to be chairman of the energy committee, overseeing Alaska’s dominant industry. Lundquist, now equipped with a law degree, was soon director of the committee’s 40-person staff.
On the Senate committee, he maintained a cordial working relationship with his Democratic counterparts, holding a Monday meeting with them no matter what was on the docket. Together, the panel worked through federal land exchanges, boundary adjustments, nuclear waste disposal and other difficult issues.
But in one area, Lundquist’s transactional exchanges with Democrats took on a harder edge: Alaskan oil. Over and over, he’d demand to know what it would take for Jeff Bingaman, the New Mexican who was the top Democrat on the panel, to open more of the North Slope to drilling. When it came to that, Bingaman recalled, “He was aggressively pursuing the agenda of his employer.”
For many in the Lower 48, the notion of expanded drilling in the Arctic had been tainted by images of sea otters and harlequin ducks coated in crude oil after the Exxon Valdez ran aground in Prince William Sound in 1989. But for many in Alaska, it had become a question of economic survival.
Since peaking in 1988 at just above two million barrels a day, production from the Prudhoe Bay fields had been declining precipitously. Without more supply, the Trans-Alaska Pipeline was at risk of clogs and corrosion — and the state’s coffers were at risk of steep deficits.
The cry went up, louder than before, to drill within the Arctic National Wildlife Refuge, the 19-million-acre expanse east of Prudhoe Bay. The refuge’s coastal plain was believed to hold far more stores of crude and less wildlife than the National Petroleum Reserve-Alaska, known as NPR-A. But, with its stunning white peaks of the Brooks Range, the refuge had long been a more potent symbol of virgin land. The expanse to the west, by contrast, had been set aside as a fuel reserve for the U.S. Navy in 1923, thus giving it its mundane name.
The agitation in Alaska was bipartisan: the Democratic governor, a Yale-educated Vietnam veteran named Tony Knowles, was also fretting about the declining flow. The job of mollifying him fell to Bruce Babbitt.
Babbitt had been the natural choice at Interior for Bill Clinton. The laconic former Arizona governor was a founding member of the Democratic Leadership Council, the centrist reform group that had given rise to Clinton, and then ran the League of Conservation Voters.
“My job is to stand at the border with a flaming sword” to defend the wildlife refuge, Babbitt once said. But he saw nothing inconsistent about offering the oil companies NPR-A as a consolation prize.
“Babbitt was enthusiastic about opening up NPR-A if it was done on the right terms, and I agreed with him,” recalled Knowles. Babbitt confirmed this account: “It was clear to me that we had to look west.”
Doing it right meant not letting the reserve end up like the North Slope around Prudhoe Bay under the anything-goes oversight of the state of Alaska, a sprawl of drilling pads, gravel mines, pipelines and roads. It meant limiting the impact on natives, particularly the Inupiat living in the village just east of NPR-A, Nuiqsut.
And doing it right meant protecting Teshekpuk Lake, at 30 miles wide the largest in the Alaskan Arctic. The lake happens to be smack in the middle of the part of NPR-A thought to have the richest oil fields, its northeastern corner. Yet this area is also so full of wildlife that it had long been considered inviolable — even by James Watt, who as President Reagan’s Interior secretary was the closest thing to an avowed enemy of the conservation movement.
Teshekpuk was the calving and summering grounds for a 60,000-head caribou herd. There were tundra swans that migrated to the Chesapeake Bay, buff-breasted sandpipers that headed for Argentina, yellow wagtails that wintered in Southeast Asia, and, trumping them all, bar-tailed godwits that flew 8,000 miles to New Zealand. Some 37,000 black brant geese, a large share of the global population, even molted at the lake.
To Babbitt, the region’s wildlife was “absolutely transcendent.” He thought he’d found a balance to protect precious watersheds and native hunting and fishing grounds. The drilling in NPR-A would emulate a low-impact project that was being pioneered by the oil company Arco just east of the reserve. Arco was managing without permanent roads, limiting itself to seasonal drilling, occasional helicopter flights, and ice roads — an underlay of crushed ice with water pumped along it that, once frozen, is scarred for traction. In spring, it melts away.
“There was a relentless endorsement by everyone in sight that this was the wave of the future,” Babbitt said. “The problem with roads is that roads beget more roads beget more roads. A road becomes a network, becomes a spider-web of landscape fragmentation and destruction, with little use for wildlife.”
He released his plan in 1998. It allowed leasing on a 4.6-million acre swath in the reserve’s northeast but expanded the protected areas that Watt had defined around Teshekpuk Lake to about 600,000 acres. It also called for a three-mile buffer along Fish Creek, a stretch close to Nuiqsut that villagers relied on heavily for fishing and hunting.
The oil companies seemed to buy in, as Arco and BP snatched up leases. And by the time Babbitt left Interior in 2000, he had reason to believe it was a settled matter.
In May of 2001, Andrew Lundquist took the podium in a banquet hall at the Hyatt Regency in Washington to tell the assembled guests about a new report on energy. He spoke in bland terms about a “substantive, forward-looking and truly comprehensive” proposal that increased “environmentally friendly exploration and production of domestic energy resources.”
Two weeks earlier, President Bush had released a 170-page plan to overhaul the nation’s energy policy. The plan had been produced by a Cabinet task force led by Vice President Cheney, just off a five-year stint as chief executive of oil-services giant Halliburton. Cheney’s imprint on the plan was not hard to discern. It called for building up to 1,900 new power plants, many of them to be fueled with coal. (The report made only passing mention of climate change.) It recommended exempting the chemicals used in hydraulic fracturing — fracking — from the Safe Drinking Water Act. It proposed opening the Arctic National Wildlife Refuge to drilling.
And it called for expanding drilling in the National Petroleum Reserve-Alaska. Specifically, “such consideration should include areas not currently leased within the Northeast corner of the Reserve” — that is, the areas around Teshekpuk Lake that Babbitt had shielded.
The report’s familiarity with the fine points of the Alaskan landscape was hardly surprising, given that its production had been managed by Andrew Lundquist. Plucked from the Senate to serve as the task force’s staff director, he ran meetings in Cheney’s absence, served as the contact point for the energy companies that clamored to influence the report, and handled the flow of drafts from more than 100 administration staffers across multiple departments. He was the hub of the action, the final word.
As he had in the Senate, Lundquist looked for areas of consensus, seeking to add some language on conservation and renewable energy. But he knew not to push too hard on that front, given Cheney’s inclinations. In a moment of candor Lundquist had explained his career strategy to a senior White House colleague. “He once said to me, ‘You’ve got to take your initiative but cover your ass — take risks but don’t get too far ahead of where your principals are,’” the former colleague recalled. “He knew how to comport himself.”
As reward for such comportment, Lundquist was promoted to White House energy policy director. He devised a plan to win House approval for drilling in the wildlife refuge, by limiting the drilling to 2,000 acres of its coastal plain. But the proposal stalled in the Senate, where Democrats hung onto a slim majority.
The Sept. 11 attacks did little to derail the administration’s energy fixation. As the White House pushed to turn the task force recommendations into law, it was besieged by demands from government auditors and environmental groups for records of meetings that Lundquist and Cheney had held with more than 150 energy companies and trade groups. Cheney fought disclosure all the way to the Supreme Court. At the heart of the fight was Lundquist, who was personally subpoenaed in April of 2002.
The subpoena would not have been legally necessary if Lundquist was still in the administration. But he was not. Just a few weeks earlier, after barely more than a year in his position, he had left it to strike out on his own.
In the early 2000s, much of Washington seemed suddenly awash in money. Luxury stores and restaurants sprouted in a landscape never known for its glamour; by decade’s end, half of the nation’s wealthiest counties were to be found in the Washington area.
The wealth was being driven in part by the post–9/11 proliferation of contractors capitalizing on the surge of spending on homeland security. But also responsible was an older Washington industry: lobbying.
Companies were learning that the spread of earmarks — specific spending appropriations tucked into larger bills — made it all the more advantageous to have lobbyists working Capitol Hill. Meanwhile, the worsening gridlock in Washington meant that ever more consequential actions were coming straight from the executive branch. Lobbyists familiar with the inner workings of the bureaucracy were highly desirable. From 2000 to 2010, money spent on federal lobbying more than doubled, to $3.52 billion, and most of this growth could be attributed to the expanding ranks of revolving-door lobbyists.
Lundquist caught this wave at the right moment. Nine months after he left the White House — Jan. 1, 2003 — he registered the Lundquist Group, LLC, with an office on New York Avenue less than a block from the White House complex.
Under a 1978 law, one of the post-Watergate reforms, former top administration officials were not allowed to lobby their old agencies within a year of leaving office. Lundquist was at risk of violating that, since his registration occurred only nine months after his departure.
ConocoPhillips' spending on lobbying in Washington spiked after the 2008 election of Barack Obama and Democratic majorities in Congress. In 2009, the company retained Andrew Lundquist's firm at a rate of $200,000 per year.
But the lines around what counted as lobbying were so gray as to make the law all but unenforceable. There was nothing to stop former officials like Lundquist from sharing intimate knowledge of the government with their new business associates, enabling lobbyists to deliver perfectly customized pitches. Challenged by reporters about whether his registration fell within the off-limits period, Lundquistasserted he had made no improper contacts with his former colleagues at the White House and Energy Department. “I stuck to the letter of the law on ethics rules,” he said.
In 2003, Lundquist reported collecting $300,000 in lobbying fees in addition to whatever he earned in other consulting — a big jump from the roughly $125,000 he was making at the White House. “Ultimately, a person has a family to support,” said Dan Val Kish, who worked with Lundquist on the Senate committee. “Money at the top levels of federal government is pretty good, but the private sector is much better.”
Halfway through 2003, after a year on his own, Lundquist, who has four children, sold his three-bedroom home in Arlington and bought a place nearly four times as big — a $1.48 million, four-bedroom, six-bathroom house with a pool on 1.75 acres in Great Falls, the affluent Fairfax County enclave further up the Potomac.
That Lundquist was in such high demand was no surprise — he was starting his business at the exact moment when Republicans were pushing for major energy legislation based on the plan he had shepherded. His clients in that first year included Toshiba Corp., which wanted to build a nuclear reactor in Alaska; British Petroleum; a Wyoming coal-mining company called Kennecott Energy; and Duke Energy, the electric utility giant. Each had a big stake in specific planks of the legislation.
His old boss Frank Murkowski was now governor of Alaska; the state became another Lundquist client. In 2004, he added Exelon, the large nuclear-power utility, and Coeur d’Alene Mines, a major silver and gold mining company whose board of directors he would join a year later. He was also on the board of an independent Texas oil drilling company, Pioneer. “There’s nothing I don’t work on in energy,” Lundquist told the Roll Call newspaper in 2004. “Energy has been a great niche for me.”
When Lundquist made it back home to Alaska now, his Washington connections followed. Most summers, he would head to Prince of Wales Island for a weekend at the Waterfall Resort, a five-star fishing outpost reachable by boat or seaplane. On paper, it was a fundraiser for breast cancer prevention and treatment in rural Alaska, a cause taken up by Nancy Murkowski, Frank’s wife, and one of personal relevance for Lundquist, whose mother had breast cancer. But it also served as a summit for oil industry leaders and Washington Republicans, who could meet in seclusion, and return home with their salmon and halibut cleaned and vacuum-packed by the resort staff.
Most years, the charity spent more on the fishing weekend — the smallest package at the resort now costs $3,555 per guest — than it raised for its cause. By the mid–2000s, at least nine U.S. senators had attended the weekend over the previous decade. At least three had let the charity pay for their attendance, in contravention of Senate ethics rules, while several others, including then-Speaker Denny Hastert and Majority Leader Trent Lott, failed to disclose who paid for the trip.
In one picture from the event in the mid-2000s, Lundquist stood in dark rain-gear and flashed a tight smile for the camera, with Hastert and his wife on one side and Frank and Nancy Murkowski on the other. “Our top people go,” Red Cavaney, then the head of the American Petroleum Institute, told American Radio Works, a public-radio documentary unit, for a show that aired in 2006.
Back in Washington, Lundquist was a regular on the political fundraiser circuit. Over the course of his lobbying career, according to the Center for Responsive Politics, he would give more than $165,000 in contributions — 93 percent of it to Republicans. Companies expected lobbyists to devote a sizable portion of their fees to contributions to candidates that the companies needed on their side.
Lundquist’s business was growing fast. At first, he shared his office suite — decorated with portraits of Native Alaskans — with Joe Allbaugh, a jocular Oklahoman who had made his name as George W. Bush’s Federal Emergency Management Agency director during 9/11. As that partnership ebbed, Lundquist brought on George Nethercutt, a Washington state Republican who’d lost a bid for the Senate after a decade in the House, and Steven Griles, who recently served as deputy secretary at Interior after years as a lobbyist for coal, oil and gas companies.
In its first year the firm of Lundquist, Nethercutt & Griles reported collecting $1.3 million in lobbying fees, and the next year, $1.6 million. “We had tremendous skills and knowledge and great experience,” recalled Griles. “If you have those things you can succeed in Washington. If you’re honest and represent people fairly, you can succeed.”
The good times lasted only so long for Griles. He resigned from the firm in 2007, a few months before pleading guilty to obstruction of justice in connection with the Jack Abramoff lobbying scandal, charges that stemmed from his time at Interior. Griles was sentenced to 10 months in prison.
Nethercutt said it was an “uncomfortable” time for him and Lundquist. “We said, ‘This can’t stand — you’re going to have to leave.’ It was our reputations, too.”
Yet rather than tainting the firm, the disruption enabled Lundquist to reinvent it, this time as a bipartisan shop. Democrats had recaptured Congress in 2006, and Republican-leaning firms could be at a disadvantage. Lundquist brought on some Democrats and adopted a new name: BlueWater Strategies, suggested by one new hire, Eric Washburn, one-time energy staffer to then-Senate Democratic Leader Tom Daschle. An avid sailor, Washburn wanted to evoke “blue water navigation,” what you have to do when you’re far out in the ocean with no landmarks. “The idea is we’d help people navigate rough seas,” Washburn said.
Seas were in fact getting rougher for many in the fossil fuel industry. Within a year, Barack Obama would move into the White House after pledging to take on climate change — this, he said, could be “the moment when the rise of the oceans began to slow.”
And among the companies that turned to Andrew Lundquist for help was ConocoPhillips.
With more than 1.2 million acres of leases on the North Slope and a 25 percent stake in the Alaska pipeline, ConocoPhillips was on its way to becoming the largest oil producer in the state. Still, some of its ambition had been frustrated.
The Bush-Cheney years, at first, had promised to be a boon for the company, whose PAC and employees had spent more than $750,000 on the 2000 election, more than 90 percent of it for Republicans. Gale Norton, Babbitt’s successor as Interior secretary, visited the Alaskan Arctic and pronounced it a “flat, white nothingness” ripe for more extraction. In 2003, the administration announced a plan that followed the recommendations of Cheney’s task force: it would more than triple the amount of drilling in the reserve’s northeast over what Babbitt had laid out.
Crucially, under this plan, protections would be lifted on much of the area around Teshekpuk Lake. This could be done, the Bush administration vowed, without serious environmental damage, by using directional drilling and other new technologies. “We felt that a lot more could be leased,” said Henri Bisson, then Alaska director of the Bureau of Land Management, the Interior Department agency that oversees government-owned land.
Environmental groups were aghast. Even Tony Knowles, the former governor who had urged expanding drilling in NPR-A, viewed the plan as excessive. The Cheney task force “was the big change,” said Stan Senner, then the director of Audubon Alaska. “They were now willing to go into an area that every president going back to Reagan had reason to close.”
The National Audubon Society and other conservation groups filed a lawsuit, charging that the administration had failed to consider the reserve’s “international importance to migratory birds and other wildlife.” And a federal judge in Anchorage, James K. Singleton Jr., ultimately agreed, blocking the expansion.
The ruling threw NPR-A into limbo for the remainder of Bush’s second term. The drilling debate shifted to the Lower 48, where the fracking revolution was getting underway, helped by a provision in the comprehensive energy law that finally passed in 2005 exempting fracking chemicals from the Safe Drinking Water Act. It was the very provision the Cheney task force had called for in 2001.
In 2009, the Democrats were back in the driver’s seat in Washington and they were threatening to roll back the Bush rules on Alaska. To preserve its plans, ConocoPhillips had to make a new play. The oil company retained Lundquist’s BlueWater Strategies at a rate of $200,000 per year. “For Conoco, they do so much work in Alaska, that having Andrew in particular who had those really strong Alaska connections, it strengthened and reinforced what they were already looking for and seeking help on,” said Washburn, the former BlueWater partner.
Lundquist arrived on the scene too late to keep Obama’s first Interior secretary, former Colorado Sen. Ken Salazar, from producing an NPR-A plan that, on the whole, cheered environmentalists. It set aside half of the reserve for conservation and — once again — strengthened protections around Teshekpuk Lake. As Babbitt had years earlier, it also called for a buffer along Fish Creek, near Nuiqsut.
But that was just the blueprint. The real battle would come in applications for drilling. Dealing with the five federal entities that had to pass judgment on a project would be an enormous paperwork headache, but also an opportunity. You could play one group against the other as you navigated the system.
And for this, ConocoPhillips would have Lundquist’s help full time: At the start of 2013, he became the company’s senior vice president for government affairs, with a 20-person team under his command.
He left BlueWater’s office near Union Station and moved west into ConocoPhillips’s Washington office, in the heart of the K Street corridor. He gave up the boards of the mining and oil companies he’d served on, which between them had compensated him with more than $1.75 million in stock and fees over the previous seven years. And a few months later, the company filed its application to drill in NPR-A at Greater Mooses Tooth.
The name was a marketing gimmick, Alaska-style.
Moose’s Tooth, a legendary peak in Denali National Park, is 500 miles from the infinite flatness of the NPR-A’s tundra. It was also the name of a highly popular Anchorage brewpub started by some rock climbers. In short, the peak had no connection with the drill site, but it bestowed a friendly backcountry connotation.
“Got to love that name, Greater Moose’s Tooth. Only in Alaska,” Larry Archibald, ConocoPhillips’s senior vice president for exploration, had told oil-market analysts in a 2009 conference call.
With Greater Mooses Tooth (the apostrophe eventually would be dropped), ConocoPhillips was proposing the first drilling on public land in NPR-A. It was getting oil from another spot just within NPR-A boundaries, but that was on land controlled by one of the native corporations created under the Alaska Native Claims Settlement Act, not by the federal government.
The exploratory wells had been promising, Archibald told the analysts. NPR-A “keeps giving and giving nice light oil,” he said. The site was on land included in Babbitt’s 1999 lease sale, rights that ConocoPhillips had acquired from Arco. ConocoPhillips had gotten approval from the Bush-Cheney administration for a similar drilling project in 2004, when environmentalists were focused on the larger fight over Teshekpuk Lake. Now, financial conditions were finally right to proceed with production, thanks in part to a change in Alaska tax law the oil industry had secured. Because so much time had passed, the company would need to reapply.
ConocoPhillips would need approval from the Interior Department, which would rely mainly on its Bureau of Land Management (BLM), and from the Army Corps of Engineers. The U.S. Fish and Wildlife Service and the Environmental Protection Agency also would weigh in.
The stakes were high. Greater Mooses Tooth-1 would cost $890 million and add 30,000 barrels to the 200,000 barrels ConocoPhillips was producing daily in Alaska, which in 2013 had provided the company with $2.3 billion in earnings, more than a quarter of its total. More than that, it was the test of whether the Obama administration’s limits would hold, of what precedent would be set for the expanse waiting to the west.
“The GMT-1 proposal is politically sensitive at a national level,” wrote Bud Cribley, the BLM’s Alaska director, to his top staff in a memo preparing them for a teleconference with the director of the bureau, Neil Kornze, in March 2014.
And at the center of the showdown were the roads. ConocoPhillips had abandoned the roadlessapproach pioneered by its predecessor Arco — accessing sites via helicopters and ice roads, which meant restricting drilling mostly to winter. The lack of roads “destroys the economics” of the project, the company insisted. In a written response to questions for this story, a company spokesman disputed that its new approach represented a departure from the initial vision for the area. “All of the roads that have been built … were determined to be the environmentally preferred alternative,” he said.
To reach its existing site on the native corporation land within NPR-A ConocoPhillips was already building a six-mile road and a 1,400-foot bridge. This had provoked major opposition from conservation groups and the village of Nuiqsut and had, initially, been rejected by the Army Corps of Engineers. But, under pressure from the company and Alaska politicians, the Corps had reversed itself. Now, the company was proposing another road — this one 7.7 miles long, with two bridges, plus another water crossing via a culvert.
For a permanent road to function in the North Slope’s permafrost, the gravel fill needed to be piled up — between 5 and 8 feet high. This alteration of the landscape had consequences, said Sam Kunaknana, the tribal president for Nuiqsut. Caribou changed migration patterns to go around the barriers, complicating the hunting routines of villagers, who themselves found it hard to get over the roads on their snow-machines.
“We have to go further out to hunt our subsistence food, because the animals that once thrived in our area are now going further and further out,” Kunaknana said. The villagers had already given the first road a nickname: the “China wall.”
When Babbitt returned to the North Slope in July 2013, and flew over the oil fields just outside NPR-A that Arco had developed without permanent roads, he was overwhelmed.
“You talk about things, you read about them, you get all the facts and the data and all of a sudden you see it, and it’s a revelation,” he said. “It’s a brilliant summer day, the fog disappears and the sun is shining across a vast sparkling expanse. There’s almost nothing there, except a few lines in the tundra where they’ve emplaced pipelines and a few tiny remote pumping stations — it’s otherwise undisturbed as far as the wildlife are concerned.” It confirmed his earlier judgment: this was how it should be done.
Within days of Babbitt’s trip, ConocoPhillips filed its Greater Mooses Tooth application — including a permanent road. With the landscape fresh in his mind, Babbitt decided to make NPR-A his cause, even though he was now into his 70s, and was spending much of his time in Peru monitoring roadless oil and gas projects in the Amazon. He visited BLM’s Kornze at his Washington office. He called Kornze’s boss, Sally Jewell, the former REI Inc. executive who had replaced Salazar at Interior. He wrote to ConocoPhillips’s Alaska division chief, and got a noncommittal response.
In its preliminary evaluation of the Greater Mooses Tooth project in February 2014, BLM did examine the possibility of a roadless option, but on terms that seemed designed to make it look unappealing to villagers grown leery of excessive air traffic. It envisioned year-round drilling rather than the seasonal approach used at the original Arco site. It accepted the company’s projections for frequent flights to the site. And it accepted its claim that roadless development would require a 5,000-foot airstrip to accommodate a plane that could deliver a relief-well drill rig in the event of a blowout.
This draft assessment was, Babbitt said, “nothing short of fraudulent.” At a speech in Colorado a month after it came out, he said, “BLM in Alaska is coming perilously close to acting as a leasing agent of the ConocoPhillips company.”
The roadless idea was now all but a lost cause. So Babbitt and other conservationists shifted their efforts to getting a road with the least possible impact.
The company wanted to build the shortest, cheapest route possible, even though that would cut into the three-mile setback that both Babbitt and Salazar’s plans had called for along Fish Creek, a crucial watershed and locus of subsistence hunting and fishing. In this preference — “Alternative A” — ConocoPhillips had the backing of Alaska’s elected leaders in Juneau and Washington, who were desperate to get new oil flowing in the pipeline, and of two Native Alaskan corporations, which would benefit financially.
Conservation groups wanted the road to take a slightly longer, 8.5-mile route, with only one bridge, that would steer clear of the Fish Creek setback — “Alternative B.” They had the backing of the tribal council of Nuiqsut, the group led by Kunaknana charged with safeguarding local heritage.
Building the Alternative B route, the company said, would cost nearly $50 million more and throw the project into question.
The choice would be made by the federal bureaucracy. But, to judge from e-mails obtained through public records requests, there was little doubt which side was driving the process.
Again and again, ConocoPhillips’s representative in Alaska, a blunt engineer named Lynn DeGeorge, demanded meetings with the agencies that had a say. She resisted the agencies’ request to project costs for all the options, not just the one the company preferred. She ordered them not to share designs the company was submitting, and warned them not to meet without her. She asked for early looks at BLM’s assessments. She demanded to know if BLM received public records requests. She told BLM’s project manager, Bridget Psarianos, that her inability to offer a firm approval schedule was “pitiful.”
Her assertiveness was backed up by ConocoPhillips’s considerable resources — it had committed $1.7 billion to capital projects in Alaska in 2014, double the amount from two years earlier, partly to cover the Greater Mooses Tooth expansion. The company had been flush enough to give its retiring CEO, James Mulva, the biggest exit package of any U.S. executive in 2012 — $156 million. Andrew Lundquist received stock options valued at more than $7 million in his three years on staff, on top of his base salary.
The government’s representatives, by contrast, were at frequent disadvantage. In late 2013, they had to go on furlough as a result of the government shutdown forced by congressional Republicans. A few months later, BLM’s Psarianos had trouble finding a working computer from which to send out the bureau’s latest assessment. A few months after that, she had to ask DeGeorge for GIS mapping data.
Amidst all the talk about the growth of the federal government, Interior was one of several federal departments that had seen its number of full-time employees decrease between 2004 and 2012, as more and more federal spending flowed to private contractors and expanding departments like Homeland Security. Over that time Interior’s employees had some of the smallest growth in compensation in government, average increases in salary and benefits of less than one percent per year. Within Interior, BLM’s budget has barely budged in recent decades even as its duties have expanded. This is deplored even by one of George W. Bush’s three BLM directors, James Caswell. “BLM has always been and continues to be understaffed and underfunded,” he said.
Things were hardly any better at the Army Corps. Lacking resources, the Corps had to rely on ConocoPhillips for wetlands analysis, the data that would lie at the heart of the Corps’ determination. In a June 2014 e-mail, the Corps’ project manager, Hank Baij, thanked DeGeorge for “all your work” on the analysis — as though ConocoPhillips were doing the Corps a favor by being allowed to provide the crucial data. A month later, budget constraints even forced the Corps to close its field office in Anchorage.
Despite the mismatch, by the summer of 2014, it appeared that the environmentalists and tribal council might just prevail with Alternative B. Not only BLM, but also EPA and Fish and Wildlife, were leaning toward the route outside the Fish Creek setback, judging it less damaging to the creek fishery, to the watershed and to subsistence hunting, and less risky in the event of a pipeline rupture because it involved fewer river crossings.
But Alternative A was far from dead. Back in Washington, another process was unfolding.
On Sept. 17, as the Mooses Tooth decision was coming to a head, Andrew Lundquist arranged a meeting for himself and Ryan Lance, the company’s new CEO, with Deputy Interior Secretary Michael Connor. Prior to the Washington meeting, Interior and BLM staffers scrambled to prepare Connor. In their briefing paper they noted: “In recent meetings in Alaska, CP argued strenuously for Alternative A as its preferred alternative.”
A few weeks later, in late October, the BLM staff in Alaska issued its final recommendation. Alternative B, with the road outside of the Fish Creek setback, was the best option. But the final word would come from Washington, in a so-called Record of Decision issued jointly by BLM and the leadership of the Interior Department.
Interior, though, was taking its time — far longer than the usual month for a final decision, which BLM staff in Alaska attributed to the pressure from Lundquist’s team in Washington. The delay proved a blessing for the company. By slow-walking its decision, Interior gave the company an opening to persuade the Army Corps. At first blush, that seemed to be a challenge for ConocoPhillips. According to BLM employees in Alaska, representatives of the Corps had given the impression in weekly progress meetings in Anchorage with BLM that if BLM’s staff favored Alternative B, the Corps would sign on too, to avoid conflicting rulings.
But now the company put on the pressure. On Nov. 11, DeGeorge sent a lengthy letter to the Corps, suggesting a rationale for the agency to back Alternative A. “Fish Creek and the adjacent areas are important habitat for subsistence activities. However, exceptions to BLM’s Fish Creek setback are permissible,” she wrote.
A month after that, Nicholas Olds, ConocoPhillips’s vice president for North Slope operations, sent a letter to Cribley, the BLM director in Alaska. Olds hinted that the Corps was now leaning toward the company’s position. He put BLM on notice that it should be prepared to reverse its recommendation or risk having a split decision by the government that would stall the whole project.
Baij, the Corps project manager, began telling his counterparts at BLM that after contacts with company representatives he feared ConocoPhillips would file a lawsuit against the Corps if it sided with the BLM and conservationists. “ConocoPhillips was pulling out all the stops,” said Lon Kelly, then the head of BLM’s office in Fairbanks. “They were telling Hank [Baij] over and over again, you can’t make us do” Alternative B.
Baij has since left the Corps and did not return calls on the matter.. His supervisor, Michael Salyer, demurred when asked about legal threats. “What Hank was or wasn’t fretting about, I don’t know,” he said. The ConocoPhillips spokesman said, “We are not aware of any discussion with Mr. Baij about legal actions.”
As the decision dragged into 2015, Bruce Babbitt was invited to dinner with Andrew Lundquist and Ryan Lance, the ConocoPhillips CEO, at Del Campo, a sleek Washington grill where the tomahawk ribeye for two goes for $119.
Babbitt accepted, warily. The company men cordially debated Alaska drilling with him — ironically, back in the day, Lance had been an engineer at Arco, where he was a leader of the roadless drilling system Babbitt had taken as a model. But they steered clear of the particulars of the impending decision. Babbitt thought about making a last-ditch pitch for his vision for NPR-A, but decided it was futile. “It was pretty much cooked,” he said.
He was right. The very next day came the ruling: the Army Corps had decided in favor of ConocoPhillips.
Under the agency’s logic, the company’s preferred route was best, essentially because a shorter road meant disturbing fewer wetlands. This confounded conservationists and the other agencies, who questioned the Corps’ reliance on ConocoPhillips’s wetlands data and who noted that the Corps had not taken into account the protections for the Fish Creek setback. Salyer, Baij’s supervisor, defended the decision and said that ConocoPhillips’ entreaties had had little impact. “I don’t think we felt a whole lot of pressure,” he said.
Interior could have contradicted the Corps by sticking with BLM’s preference. But e-mails show that it in the months after Lundquist and Lance’s visit to the department, it had chosen otherwise. In an unusual move, it had developed two versions of a Record of Decision, one for Alternative A and one for B, while waiting for the Corps’ choice.
On Feb. 13, its final Record of Decision gave ConocoPhillips the official go-ahead to drill in Greater Mooses Tooth with a road through the Fish Creek setback. Officials justified it by saying the alternatives were not so different and this would “provide a federally unified decision” with the Army Corps.
In just over a decade, Lundquist and his associates had obliterated several principles of Babbitt’s original balancing act. The land right around Teshekpuk Lake was still safe, for now. But the drilling sites in NPR-A weren’t going to be roadless; a road was going right through a key watershed and subsistence area; and tribal leaders’ wishes were being overruled.
Interior’s approval came with a highly unusual condition, as if underscoring its misgivings: ConocoPhillips would pay $8 million toward a new, yet-to-be-defined “mitigation” process that would seek to compensate for the project’s harm. “The Department looks forward to continuing to work with ConocoPhillips as it moves forward with safe and responsible energy development on the North Slope,” Assistant Secretary for Land and Minerals Management Janice Schneider, who negotiated the payment, said in a statement.
Dismay abounded. The tribal leaders in Nuiqsut took the decision as a direct affront. Not only had the agencies ruled against them, but Interior officials, after meeting with ConocoPhillips in Washington, had ordered BLM staff in Alaska to drop mitigation measures the village had requested, such as air filters for its school. “Our voice was not respected in the process,” said tribal administrator Martha Itta. The $8 million was little solace — in Alaska, such payouts often had the effect of dividing the Native community.
Like the villagers, conservation groups took it as a foreboding sign that, in the very first application it had gotten to drill in NPR-A, the Obama administration had made an exception from the plan it had itself laid out, by allowing a road through the Fish Creek setback. The Salazar plan “was a good plan in that it really did strive to balance conservation and development — but it’s only a good plan if it’s actually stuck to,” said Nicole Whittington-Evans, Alaska director for the Wilderness Society.
BLM employees in Alaska were demoralized, too, by the fact that their concerns about Alternative A had, it seemed, been sold for a price. Rather than requiring the company to take the less damaging approach, the government had settled for a payment with an undetermined purpose. “We were trying to get money out of ConocoPhillips for something we could have tried to mitigate and we decided not to,” said Lon Kelly, who has since retired from the BLM office in Fairbanks. “It was so disappointing for the Obama administration, for Sally Jewell, to go down this road.”
Babbitt, too, faulted the Interior leaders for not sticking to the BLM’s original finding in favor of Alternative B. “They should have raised their voice,” he said. “They could have defended their decision, which was done weakly, if at all.” He had little doubt what led to the outcome: “Somebody intervened in Washington,” he said.
Asked what happened at Lundquist and Lance’s visit to Interior in September, the company spokesman would only say, “A number of topics were covered at the meeting.” Interior officials declined to comment.
In the months after Greater Mooses Tooth won approval, the oil market plunged. Despite this, in November, the company gave its formal internal go-ahead for the project — with so much invested in its North Slope operations already, drilling there is relatively cost-efficient. Construction is to begin in 2016. The company has also set in motion its next application for the reserve — Greater Mooses Tooth 2, linked to GMT-1 by another road, a slightly longer one. With the world facing an oil glut for the foreseeable future, causing major cutbacks for oil projects in the Lower 48, drilling will nonetheless proceed on some of the most pristine federal lands.
Having guided Greater Mooses Tooth to a successful conclusion, Lundquist and his team moved onto the next, related goal: lifting the U.S. ban on crude exports, a step that would greatly expand the market for the company’s North Slope oil. In August, the Senate energy committee, Lundquist’s former haunt, voted to lift the ban. And in mid-December, Republicans got it inserted into the end-of-year spending deal.
Way back when his lobbying firm was taking off, Lundquist flirted with returning to government — not in the administration, but running for office himself, from Alaska. But it was hard to leave a firm that was doing so well, and a Beltway circuit that he had mastered. “He wanted to stay in the private sector,” said Nethercutt, the former congressman. “It’s kind of infectious that way — it’s a matter of the job and the sophistication. He’s run in some high-powered circles, and he got used to it.”
Of course, there was the chance that a new opportunity would present itself to Lundquist in a year or so, noted Joe Allbaugh, the former FEMA director under Bush who had shared a lobbying venture with Lundquist.
“I expect,” Allbaugh said, “that should there be another Republican president, he should be one of the first ones to be approached when it comes to energy jobs — and rightly so, because of his expertise.”
Correction, Dec. 21, 2015: This story originally misspelled the first name of Dan Val Kish.
Related stories: For more of ProPublica’s coverage of politics and lobbying, check out our ongoing series, The Breakdown.
Image may be NSFW.Early this year, as the 2016 presidential contest got underway, a ProPublica team began a long-term project to examine the political system. While many other news organizations provide excellent day-to-day coverage of the campaign, our goal is to bring light to underlying changes in the structure and operation of 21st century U.S. democracy.
Our series is called “The Breakdown,” and we mean it in both senses of the word. There’s a palpable feeling among voters that the machinery of government has failed them or has been hijacked by special interests — thus the popularity, at the moment, of some presidential aspirants with little or no experience in governing. We also mean that we seek to break down the system into some of its component parts, in order to better explain how it functions.
Bitter political division is manifest in Washington. Of course, there’s nothing new about that. Machiavelli called such conflict a trademark of all republics. The writers of the U.S. Constitution deliberately structured the government to be an arena of competing interests. You can find complaints from commentators and historians about gridlock or its colonial equivalent as far back as you want to go. But we believe that every era has its defining characteristics and it’s the place of journalism to bring them into focus.
The growing flood of cash into politics is only one piece of the puzzle. While we’re tracking the looser campaign finance rules that have enhanced the role of the wealthiest Americans, we also aim to uncover less-visible avenues of influence in government in Washington and across the nation. At the same time, we are looking beyond political contributions to find the root reasons for why Washington spins its wheels on some of the biggest challenges of our time.
So far, among other things, ProPublica has told the behind-the-scenes tale of how the oil industry plays the long game in Washington, showing how corporations and interest groups accrue influence across election cycles almost without regard to who’s in power.
We’ve also shown why some plans with bipartisan support, like a permanent funding fix for crumbling roads and bridges, don’t move ahead, because Congress gets stuck on outdated political assumptions and ideological litmus tests. We explained the kind of congressional dealing that greased the skids for a bill that would speed U.S. approval for medications and medical devices, despite warnings about risks to patients.
We upended conventional wisdom about why working-class voters in some states are moving to the right, voting for politicians who want to slash the safety net they and their neighbors depend upon.
In campaign finance, our investigation of one Texas super PAC illustrated how the free-for-all has empowered a new class of political consultants, whose methods and behavior can be as disruptive to donors as to voters. We showed how the loosening rules have greatly enhanced the influence of political committees dominated by a single donor and how executives can use the state versions of super PACs to advance their personal or corporate agendas.
We’ve also pulled back the curtain on the inside strategies of lobbying groups. For one thing, special interests are often as eager to preserve a favorable status quo as they are in getting government to take an action to their benefit. To that end, gridlock can be a feature to be encouraged, not a bug, as when the traditional higher education lobby threw in with the for-profit sector to block new regulations from the Obama administration. And sometimes lobbyists play both sides of the fence, as with a new breed in the influence industry: Democratic consulting firms that, over time, have expanded from advising political campaigns into advising industry groups on how to reach Democratic lawmakers.
And we’ve looked into the conduct of government officials, including a story that was first to raise questions about whether Hillary Clinton used her private email account to tap into an undisclosed back channel for information on Libya’s crisis and other foreign policy matters. We also held Clinton accountable for what she actually did as a U.S. senator on the banking industry, showing that her record belies her tough ‘cut it out’ talk.
In another case, we found that U.S. embassies accepted gifts from Hollywood in the form of spiffy new home theaters while the studios lobbied the State Department on copyright policy and other matters.
Our team also has created online tools to help citizens monitor what their representatives are doing now. We created an app to help readers browse and search federal campaign filings for the latest data. Separately, we’ve explained why such reports from U.S. senators are so delayed — they’ve managed to hang onto a 40-year-old paper-based system that slow-walks its filings even as presidential and House candidates have to submit documents electronically in a timely way.
Finally, we’ve provided a tool for readers to see how many votes their representatives miss, and the lame excuses they provide for their absences.
Stay with us in 2016 as we continue to dig into many more stories like these. As always, we welcome your comments and suggestions.
Related stories: Check out The Breakdown for all of our work on government and politics.
Image may be NSFW.Related story: Nursing Home Workers Share Explicit Photos of Residents on Snapchat
Date: January 2012
Facility: CareOne at Livingston
City: Livingston
State: NJ
Type of facility: Nursing home
How it became public: News story, criminal charges
Social media site: Facebook
Description: A nursing assistant photographed a resident's genitals and sent the picture to a friend, who uploaded it to Facebook. The assistant was fired. Both were charged with invasion of privacy and conspiracy. The New Jersey Attorney General's office said the worker was given probation; her friend pre-trial intervention. A spokesman for CareOne, Tim Hodges, said in an interview that the home itself reported the incident to authorities and has a "very strict policy on the use of no mobile devices or cameras in our facility. Fortunately we have not had an incident since then."
Date: October 2012
Facility: St. Ann's Home
City: Rochester
State: NY
Type of facility: Nursing home
How it became public: News story, criminal charges
Social media site: Facebook
Description: A year after she stopped working at the home, a former nurse aide posted a video to Facebook in which an elderly wheelchair-bound resident was harassed. The video showed a hand briefly tugging at the resident's hair. Voices in the video could be heard taunting her, saying among other things: "The boss lady said that if you don’t wash the dishes, she will slap the black off you…and she called you a bitch.” The aide pleaded guilty to one count of willful violation of health laws, a misdemeanor. The home's administrator Susan Murty said an investigation started immediately when an employee discovered the posting and the home worked with authorities to determine its scope. "Most of the people who work in nursing homes are really wonderful people and it’s a shame that this is what people talk about. That’s always our frustration," she said.
Date: November 2012
Facility: Brookview Meadows
City: Green Bay
State: WI
Type of facility: Assisted living
How it became public: News story, criminal charges
Social media site: Snapchat
Description: Two workers took photos and videos of nude or partially nude elderly residents and shared them on Snapchat. One picture showed a resident vomiting; another video showed a resident being assisted with an obstructed bowel, according to a criminal complaint. The employees admitted taking photos and sharing them with one another and with friends. Both pleaded no contest to misdemeanor counts of disorderly conduct and invasion of privacy through use of a surveillance device. A lawyer for the facility told the Green Bay Press-Gazette at the time the women were charged that both were screened before they were hired, and both were fired after an investigation. The current executive director declined to comment beyond saying the facility has changed ownership since the incident.
Date: December 2012
Facility: Dunmore Health Care Center
City: Dunmore
State: PA
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Instagram
Description: The name and picture of a resident with Alzheimer's disease were posted on a nursing assistant's Instagram page. The resident "was incapable of granting permission for this social media post and did not give such permission," according to a government inspection report. In its plan of correction, the home said the photo was removed from Instagram and no other residents were affected. The home's administrator declined to comment. Read more information.
Date: Around December 2012
Facility: Saint Albans Healthcare and Rehabilitation Center
City: Saint Albans
State: VT
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: not specified
Description: A video of a resident identified as having dementia was posted on an employee's social media website without the permission of the resident or family. The director of nursing services said "it was brought to my attention by (staff) that on (another staff's social media website) posted something that said 'this is why I love my job' and then there were people's feet but no faces and (Resident #3) was singing. I didn't do an investigation because there was no identifiable people and not sure if (Administrator) might have spoke to (her/him)." The home did not return multiple calls seeking comment.
Date: January 2013
Facility: Valley Convalescent Hospital
City: Watsonville
State: CA
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Facebook
Description: A nursing assistant posted a picture of a resident's hand on Facebook, with a caption akin to "I am holding her hand til she falls asleep." A comment posted below the photo by a second nursing assistant had a question that included the resident's first name. Both employees were "counseled" for not maintaining confidentiality.
Date: March 2013
Facility: Greenfield Health and Rehabilitation Center
City: Lancaster
State: NY
Type of facility: Nursing home
How it became public: News story, criminal charges
Social media site: Snapchat
Description: A nurse aide took photos of an incontinent resident's genitals covered in fecal matter and shared them with another staff member on Snapchat. He pleaded guilty to a misdemeanor count of willful violation of health laws and was given a year of conditional discharge and community service. The home's administrator, Darlene Crispell, told ProPublica that officials reported the incident immediately to the state health department and fired the staff member involved. "Our training has included the prohibition of electronic devices in the work areas as a result. We’re pretty aggressive in monitoring that. Technology is a problem for us, for everybody, these days... The resident involved was not harmed but certainly it was a serious incident."
Date: April 2013
Facility: Autumn Care of Norfolk
City: Norfolk
State: VA
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: not specified
Description: A newly hired nursing assistant posted a picture of a resident with Down's Syndrome on a social media network without consent. The employee admitted to posting the photo and said she would take it down. The employee was asked to come in and meet with the administrator but never came back to work. The home's parent company did not return two calls seeking comment.
Date: Around April 2013
Facility: Deer Crest
City: Red Wing
State: MN
Type of facility: Assisted living
How it became public: Government inspection report, news story
Social media site: Instagram
Description: A staff member took a photo of a resident on the toilet in the bathroom. The picture showed the resident's bare skin and was taken without consent and uploaded to Instagram. The staff member admitted taking the photo, was suspended and ultimately fired. The staff person also was directed to remove the photo from the social media site. The facility was found to be in compliance with state rules. It provided written reminders to all staff about its policies and procedures. Its executive director did not return multiple calls.
Date: May 2013
Facility: Sharon Health Care Pines
City: Peoria
State: IL
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: not specified
Description: A housekeeper posted a picture of a vision- and hearing-impaired resident on her social networking webpage, with the caption "This is my friend," along with the resident's first name. The employee apologized and immediately removed the photo. She said she was not aware that a person could not do such a thing without the resident's consent. The home's administrator told ProPublica that the matter was corrected immediately and that annual training is conducted "so that we’ll never have a repeat issue."
Date: July 2013
Facility: Centers for Living and Rehab
City: Bennington
State: VT
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Facebook
Description: A staff member took a picture of a resident on the commode and posted it on a social media site. The facility failed to immediately report an incident of possible mistreatment by staff to government inspectors. Spokeswoman Ashley Brenon Jowett said in a statement to ProPublica: "The employee noted in the 2013 report was the granddaughter of a resident. While visiting her grandmother (and not working), she took a photograph and posted it to her personal Facebook page. The grandmother, a resident, was fully dressed in the photo, which was taken to share the excitement of her recovery. Only those who have familiarity with the facility would have been able to discern that the resident was sitting on a commode in the photo. There was no resident or family complaint; when the post was discovered by another staff member, we self-reported the incident as a cautionary measure. The employee was advised of the sensitivity of the situation and immediately removed the image. She understood the facility’s response, was remorseful, and mortified that she could ever have been interpreted as having put her grandmother’s privacy or dignity in jeopardy. "
Date: Around August 2013
Facility: Bishop Drumm Retirement Center
City: Johnston
State: IA
Type of facility: Nursing home
How it became public: News story
Social media site: Instagram
Description: Two employees posted at least one inappropriate photo on a social media website. Officials would not detail the nature of the photos but said both "rogue" employees were fired. In a statement at the time, Bishop Drumm president and chief executive Brian Farrell said publishing photos of a resident not only violates the home's core values, "it also violates the human dignity of the resident.” He said all employees are educated about handling of personal health information, including photos. "Such behavior cannot and will not be tolerated.”
Date: September 2013
Facility: Newaygo Medical Care Facility
City: Fremont
State: MI
Type of facility: Nursing home
How it became public: Government inspection report, news story, criminal charges
Social media site: Snapchat
Description: A nursing assistant was accused of taking a photo of a female resident with Alzheimer's disease on the toilet with her private parts exposed, drawing on a picture of a penis with the caption "limp dick" and sharing it on Snapchat. She was fired and pleaded no contest to a felony charge of using a computer to commit a crime but denied wrongdoing in an interview. The facility had written up the employee twice previously for use of her cell phone and social media at work. Officials at the home did not return calls and emails seeking comment.
Date: February 2014
Facility: Prestige Post-Acute and Rehab Center
City: Centralia
State: WA
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Snapchat
Description: A nursing assistant recorded a resident on the toilet and shared the video on Snapchat with another nursing assistant who was working on the opposite side of the building. In the video, the resident's face was visible while sitting on a bedside commode with her pants below the knees, cleaning herself while laughing and singing. A third nursing assistant told inspectors that use of cell phones by employees had been going on in the facility for an extended time. In a statement to ProPublica, PrestigeCare said it was an isolated incident and that it instituted new, stricter cellphone and social media policies. “Nothing is more important than the safety and well-being of our residents. When we learned about this issue last year, we took immediate steps to notify the police, along with other state authorities. We immediately placed the employee on suspension pending an investigation, and once complete, terminated her. We also met with the patient’s family and doctor to discuss what happened. We take these situations very seriously and are thankful that our own internal procedures alerted us so promptly to the issue."
Date: February 2014
Facility: Sevier County Health Care Center
City: Sevierville
State: TN
Type of facility: Nursing home
How it became public: News story
Social media site: Facebook
Description: An employee posted an "inappropriate" picture of himself posing in a resident's room. The home's administrator told WJHL-TV at the time that the home fired the employee, but took no additional legal action because there was no evidence patients were in the room when the picture was taken.
Date: March 2014
Facility: Rosewood Care Center
City: St. Charles
State: IL
Type of facility: Nursing home
How it became public: Government inspection report, news story, criminal charges
Social media site: Snapchat
Description: One nursing home assistant recorded another using a nylon strap to lightly slap the face of a 97-year-old resident with dementia. The video was posted on Snapchat. On it, the resident could be heard crying out "Don't! Don't!" as the employees laughed. They were fired, pleaded guilty to a misdemeanor count of battery and were sentenced to probation and community service. Ivy Gleeson, the nursing home administrator, told the Chicago Tribune in 2014 that the two women were fired. “In our facility, resident safety is our utmost concern,” Gleeson said. She did not return calls and emails from ProPublica seeking comment.
Date: April 2014
Facility: George L Mee Memorial Hospital
City: King City
State: CA
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: not specified
Description: Two licensed vocational nurses posted a picture of themselves on a social media site; a health chart with a resident's name was visible. A home official declined to comment, referring a call to its parent organization, which did not return calls.
Date: April 2014
Facility: Gridley Healthcare and Wellness Centre
City: Gridley
State: CA
Type of facility: Nursing home
How it became public: Government inspection report, news story, criminal charges
Social media site: Snapchat
Description: Five nursing assistants were fired and prosecuted for taking and sharing photos and videos of residents. In one, a nursing assistant was twerking (dancing in a sexually provocative way) over a resident's head. In another, a resident only wearing underwear was carried by a male nursing assistant over his shoulder. Some of the pictures involved residents who were inappropriately exposed or appeared to be deceased. One nursing assistant said pictures and videos were sent on many occasions. The facility did not report the abuse in a timely manner because the administrator told inspectors "there was no concrete evidence that it had occurred." Two of the former employees entered pleas of guilty or no contest to felony elder or dependent adult abuse; the others of failing to report the abuse, a misdemeanor. The home's current administrator said the facility changed owners on Sept. 1 and that she could not speak about prior events. A representative of the home’s operator at the time of the incident said in a statement to the Gridley Herald newspaper that the home was cooperating with authorities, took corrective action, and that its highest priority was to “ensure the best quality of care and treatment for our patients.”
Date: July 2014
Facility: Emmanuel Center for Nursing
City: Danville
State: PA
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: not specified
Description: An employee reported receiving a picture of another employee on the floor with a resident while the resident was being changed in the bathroom. The facility did not immediately try to verify the identity of the resident in the photo because only a small portion of the resident's knee was visible. The nursing home administrator and director of nursing told inspectors that their staff did not follow the employee policy on cell phone use or its policy on timely reporting of possible resident abuse. In a statement to ProPublica, Anthony Cooper, the home's administrator, said: "We have implemented a specific set of policies and procedures so as to capitalize on the benefits of social media while continuing to protect the privacy of our residents. Social Media is definitely here to stay and will continue to grow and change. It is an excellent vehicle for families to keep connected and can serve as an effective marketing tool. As long as agencies create a sufficient monitoring system it can have a more positive impact as opposed to negative."
Date: July 2014
Facility: Villa Pines Living Center
City: Friendship
State: WI
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Snapchat
Description: A resident with one leg had a picture and video of him posted on Snapchat with the word "Jerk!" written across it. The video shows a staff member kicking the resident's wheelchair and the resident kicking back, with laughter in the background. The Snapchat came from a nursing assistant and allegedly was sent to several people. The nursing assistant initially denied taking the video but later admitted it. Jennifer Johnson, the home's regional director of operations, said in a statement: "We have strict guidelines in place to govern the use of social media and cell phone communication, as well as a thorough training program that takes place both at the time of hire and on an annual basis. If we encounter a situation that we believe violates our policies, we address it immediately, thoroughly and with appropriate action. Our guidelines clearly state that an infraction may result in discipline up to, and including, termination."
Date: July 2014
Facility: Nazareth Health and Rehab Center
City: Stoughton
State: WI
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Snapchat
Description: The facility received a phone call from a community member saying that she had received a Snapchat photo of a resident who was naked, lying in bed, and surrounded by feces. A nursing assistant, who was alleged to have sent the picture, denied it, but days later, admitted to taking Snapchat pictures of residents of the facility. According to inspectors, the facility did not adequately investigate the accusations. The nursing assistant was suspended. Jennifer Johnson, the facility executive director, said in a statement: "Our first priority at Nazareth Health and Rehabilitation Center is the health and safety of our residents and staff. We therefore have thorough policies in place to regulate activity that takes place within our facility. This includes extensive guidelines on social media and cell phone use as well as, of course, standards designed to ensure the confidentiality of our residents. Employees undergo training relative to these policies when they are hired and do so routinely on an annual basis. Should an infraction occur, re-education sessions are held. Also, our guidelines clearly state that an infraction may result in discipline up to, and including, termination."
Date: August 2014
Facility: Great Barrington Rehabilitation and Nursing Center
City: Great Barrington
State: MA
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Instagram
Description: A photo of a resident's face and a video of the resident telling a joke was found on a nursing assistant's Instagram site, which was viewed by other nursing assistants and a nursing supervisor. The assistant denied that she had an Instagram site or that she posted the resident's picture on an Instagram site. The resident had no knowledge of a staff member taking his/her picture. Susan Moss, a spokeswoman for Kindred Healthcare, which operated the facility until August 2015, said, "Kindred’s policy strictly prohibits employees from taking photographs of patients without obtaining proper written permission. Appropriate disciplinary action is taken if it is determined that an individual employee violated the policy, including posting photographs of patients on social media. The Kindred organization takes its responsibility seriously and conducts regular training and reminders to ensure that the policy is clearly understood by individual employees."
Date: October 2014
Facility: Riverside North Enrichment Community
City: Ames
State: IA
How it became public: News story, criminal charges
Social media site: Snapchat
Description: A nursing assistant recorded a video showing a resident's genitals. She pleaded guilty to one count of dependent adult abuse, a misdemeanor. A spokesperson at the facility told the Ames Tribune at the time that the woman is no longer an employee. The current administrator declined to comment when reached by ProPublica, saying she was not there when the incident happened.
Date: February 2015
Facility: Nevins Nursing and Rehabilitation Centre
City: Methuen
State: MA
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Facetime
Description: While talking to a friend on FaceTime, the live video chatting service from Apple, a nurse pointed the camera at a resident. At the time of the incident, an aide was washing the resident in bed following an incontinence episode. The aide said the nurse placed the cell phone in the resident's face and demanded that he/she say hi on camera to the person with whom the nurse had been talking. Administrator Joyce Shannon said in a statement to ProPublica that "this self-reported incident was very unfortunate and we are 100 percent committed to protecting and maintaining our resident’s privacy. This was an isolated incident where a temporary agency worker acted indiscreetly around social media. The worker no longer provides care at our facility and all of our staff have received social media, confidentiality and privacy retraining. Most importantly our resident did not receive any ill effects from this incident."
Date: February 2015
Facility: Autumn Care Center (now Price Road Health and Rehabilitation Center)
City: Newark
State: OH
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Snapchat
Description: Someone from the community called the facility after being disturbed by a nursing assistant's posting on Snapchat of two residents lying in bed in hospital gowns being coached to say "I'm in love with the coco" (lyrics of a gangster rap song). As the male resident said the words, a banner appeared across his chest that said, "Hahahhahaha omg" with three laughing emoticons; as the female repeated the words, a banner across her chest said, "Got these hoes trained." The female resident's son said his mother would have been embarrassed because she had previously worked as a church secretary for 30 years. After facility staff learned of the conduct, they allowed the nursing assistant to complete her shift. The director of nursing said she did not send her home because "she didn't know the identity of the residents on the video and didn't feel it was abuse." The nursing assistant subsequently resigned. "A systemic breakdown in implementing the facility abuse policy was identified," inspectors wrote. The home's current owner, Greystone Healthcare Management, took over days after the incident. A spokeswoman said it "provides extensive, on-going training, support and oversight to insure that we provide patient centered care."
Date: April 2015
Facility: Village Creek Nursing Home
City: Fort Worth
State: TX
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: not specified
Description: A nursing assistant posted a picture of a resident with severe cognitive impairment on a social media website. The nursing assistant told inspectors that she posted the picture because the resident had on a nice hat, and she had her hair done, so they took a picture together in the dining room. "She stated it was not a bad picture." The administrator and assistant administrator both told inspectors that they were unaware of the resident's picture being posted on the nursing assistant's social media page. The home did not return calls seeking comment.
Date: April 2015
Facility: Roselawn Gardens Nursing and Rehabilitation
City: Alliance
State: OH
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Facebook
Description: A facility audit of staff members' Facebook pages revealed two staffers had photos of a resident on their personal Facebook pages. John Ingles, the home's current administrator, said he was not in his position at the time and could not provide additional details. "We have not had it happen again," he said.
Date: April 2015
Facility: Golden LivingCenter - Pierre
City: Pierre
State: SD
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Snapchat
Description: An anonymous caller told the home's executive director that a nursing assistant had sent her a photo and video of a resident in the bathtub via Snapchat. The employee was suspended but law enforcement was not notified. The executive director told inspectors she was unsure if the incident constituted abuse. In a statement to ProPublica, Erin M. Pope, chief privacy officer and assistant general counsel of parent company Golden Living, said: "Golden Living’s priority is to protect the health, safety, and confidential information of our patients and residents, and we work hard to monitor the use of mobile devices and cameras in our LivingCenters. We take any violation of privacy very seriously and must remain vigilant to ensure our employees, residents, patients and guests share our commitment to protecting confidential information."
Date: May 2015
Facility: The Waters of Scottsburg
City: Scottsburg
State: IN
Type of facility: Nursing home
How it became public: Government inspection report, news story, criminal charges
Social media site: Snapchat
Description: A nursing assistant took a picture of a resident's backside and buttocks and shared it on Snapchat. A second assistant admitted to taking a photo of another resident who was both cursing and calling people names. In September, one of the assistants pleaded guilty to a charge of voyeurism. The home's administrator referred a reporter to a corrective-action plan filed with the state. In that plan, the home said residents were assessed for mental disturbance related to the pictures but nothing negative was found. The home also re-educated staff about its cell phone policy and further restricted their use in resident care areas.
Date: June 2015
Facility: Bethany Woods Nursing and Rehabilitation Center
City: Albemarle
State: NC
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: Snapchat
Description: A geriatric certified aide took pictures and videos of a resident and posted them on Snapchat. One video showed the resident kicking his legs in the air, yelling, and on the video it stated his name and said it was after his "happy medications." In the other video, he was just lying there while the aide asked him what's wrong. She was terminated. The home's interim administrator said she has no knowledge of the incident and declined comment.
Date: July 2015
Facility: Windsor Place
City: Daingerfield
State: TX
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: not specified
Description: A picture on the social media website of a nursing assistant showed a resident in bed with only a blue bed pad covering her buttocks. The resident had her arms crossed over her breasts and her legs drawn upward. The assistant said she took the photo because the assistant director of nursing asked her to do so, in order to show a physician bruising on her body (the assistant director denied doing so.) The nursing assistant said she was not aware the photos were uploaded on her account. She was terminated. The administrator told inspectors that nurses were the only staff with permission to take pictures of the residents, and that was only if a physician requested it. The home did not return multiple calls seeking comment.
Date: July 2015
Facility: Wingate at Belvidere
City: Lowell
State: MA
Type of facility: Nursing home
How it became public: News story, criminal charges
Social media site: Snapchat
Description: Two nurses aides face charges of elder abuse for posting humiliating videos of residents on social media. According to the Lowell Sun newspaper, one video shows an elderly resident sitting on a commode while dressed and being asked about her sex life and if she smoked marijuana. Another shows the same resident sleeping when one of the aides yells in her ear, waking her up. A third shows a 75-year-old resident making noises to show her teeth with the caption, "Chuckie's Bride." The employees were fired. In a statement to New England Cable News, the home said, "The investigation revealed that the employees violated Wingate at Belvidere’s strict policies concerning patient safety and privacy of three residents and as a result, these individuals were terminated. We were able to confirm that no private health information, such as names or clinical information was captured on the videos." The home did not return phone calls from ProPublica.
Date: July 2015
Facility: Maplewood Center
City: Amesbury
State: MA
Type of facility: Nursing home
How it became public: Government inspection report
Social media site: not specified
Description: A nursing assistant posted a photograph of two residents in the facility dining room. When interviewed by inspectors, one resident was unable to respond to questions. The other did not recall being photographed and did not like the photograph and would not have liked it shown to others. The nursing assistant told inspectors that it was a known violation of residents' privacy to photograph them and said the picture was accidentally taken and posted. The assistant said the photograph and post were immediately deleted when he was notified by staff at the facility. Although staff were not allowed to have cellular telephones on the units or in resident areas, it was not enforced, the nursing assistant said. The home did not return multiple calls seeking comment.
Date: September 2015
Facility: Carillon Assisted Living
City: Newton
State: NC
Type of facility: Assisted living
How it became public: News story
Social media site: Snapchat
Description: Three personal care assistants were fired after an employee took a photo of a resident on the toilet and posted it on Snapchat. Keith Ensey, regional director of operations for Carillon Assisted Living told WBTV, "We substantiated abuse for the three team members--the person taking the picture and the two team members seen in the picture. They were fired for breaking multiple company policies involving the cell phone policy, social media policy, violation of resident's rights and also violation of privacy policies." Ensey told the station that his investigation did not uncover any other similar incidents. "It's just such an appalling act," he told the station. "And such a defenseless resident."
Date: October 2015
Facility: LifeHOUSE Vista Healthcare Center
City: Vista
State: CA
Type of facility: Nursing home
How it became public: News story, criminal charges
Social media site: Snapchat
Description: An employee took footage of a partially nude woman getting in the shower. A second employee is standing behind the resident laughing. Both were suspended and later fired. One of the employees was charged this month with misdemeanor counts of elder abuse and unauthorized invasion of privacy. Tom Allen, a lawyer for the home, told ProPublica that officials responded quickly when they learned about the video. The home was not cited by California regulators for any wrongdoing. "From my perspective, this is criminal elder abuse and we won’t put up with it and we didn’t put up with it." He said the facility was drafting new policies to deal with the issues.
Sahir Doshi contributed research to this report.
Image may be NSFW.This story was co-published with the Washington Post.
Nursing home workers across the country are posting embarrassing and dehumanizing photos of elderly residents on social media networks such as Snapchat, violating their privacy, dignity and, sometimes, the law.
ProPublica has identified 35 instances since 2012 in which workers at nursing homes and assisted-living centers have surreptitiously shared photos or videos of residents, some of whom were partially or completely naked. At least 16 cases involved Snapchat, a social media service in which photos appear for a few seconds and then disappear with no lasting record.
Read details of 35 incidents since 2012 in which workers at nursing homes and assisted-living centers shared photos or videos of residents on social media networks. The details come from government inspection reports, court cases and media reports. Read more.
Some have led to criminal charges, including a case filed earlier this month in California against a nursing assistant. Most have not, even though posting patients’ photos without their permission may violate the Health Insurance Portability and Accountability Act, the federal patient privacy law that carries civil and criminal penalties.
The incidents illustrate the emerging threat that social media poses to patient privacy and, at the same time, its powerful potential for capturing transgressions that previously might have gone unrecorded. Abusive treatment is not new at nursing homes. Workers have been accused of sexually assaulting residents, sedating them with antipsychotic drugs and failing to change urine-soaked bed sheets. But the posting of explicit photos is a new type of mistreatment — one that sometimes leaves its own digital trail.
In February 2014, a nursing assistant at Prestige Post-Acute and Rehab Center in Centralia, Wash., sent a co-worker a Snapchat video of a resident sitting on a bedside portable toilet with her pants below her knees while laughing and singing.
The following month, one nursing home assistant at Rosewood Care Center in St. Charles, Ill., recorded another using a nylon strap to lightly slap the face of a 97-year-old woman with dementia. On the video, the woman could be heard crying out, “Don’t! Don’t!” as she was being struck. The employees laughed.
And this February at Autumn Care Center in Newark, Ohio, a nursing assistant recorded a video of residents lying in bed as they were coached to say, “I’m in love with the coco,” the lyrics of a gangster rap song (“coco” is slang for cocaine). Across a female resident’s chest was a banner that read, “Got these hoes trained.” It was shared on Snapchat.
The woman’s son told government inspectors that his mother, who had worked as a church secretary for 30 years, would have been mortified by the video. Days after the incident, the home changed hands and is now known as Price Road Health and Rehabilitation Center. Greystone Healthcare Management, its new owner, said it “provides extensive, on-going training, support and oversight to insure that we provide patient centered care.” (The prior owner, Steve Hitchens, said the incident happened days before the home was sold and he does not recall details.)
In a statement, PrestigeCare said it fired the employee, alerted authorities and instituted new, stricter cellphone and social media policies. “We take these situations very seriously and are thankful that our own internal procedures alerted us so promptly to the issue.”
Rosewood Care Center did not respond to repeated requests for comment.
“Something hasn’t happened now unless there’s a selfie or Facebook posting about it,” said Marian Ryan, the district attorney of Middlesex County, Mass., whose office is pursuing elder abuse charges against two women who posted numerous videos of nursing home residents on Snapchat. “The use of social media is just pervasive across every aspect of society.”
ProPublica identified incidents by searching government inspection reports, court cases and media reports. Ryan said she suspects such incidents are underreported, in part because many of the victims have dementia and do not realize what has happened.
Nursing homes rarely found problematic social media postings themselves – most came to light based on tips from other staffers or members of the community, records show. Indeed, some of the Snapchat posts were not shared publicly but only with a select group of “friends,” one of whom alerted home officials or authorities.
The federal agency charged with enforcing the privacy law, the Office for Civil Rights in the Department of Health and Human Services, has not penalized any nursing homes for violations involving social media or issued any recommendations to health providers on the topic.
Deven McGraw, the office’s deputy director for health information privacy, expressed outrage when told about the incidents. “If we don’t have pending investigations on any of these cases … they would be candidates for further inquiry from our end,” she said, adding that the office also should issue guidance on social media and the privacy law.
The U.S. Centers for Medicare and Medicaid Services, which regulates nursing homes, has cited individual facilities for deficiencies related to privacy and is seeking to more explicitly address the issue as it writes new definitions of “abuse,” “neglect,” “exploitation” and “sexual abuse” in updated rules governing the homes.
“Nursing home residents must be free from abuse or exploitation,” CMS spokeswoman Lauren Shaham said in an email.
While it is impossible to know whether these incidents are increasing, ProPublica’s analysis identified 22 cases in the past two years, but only 13 in the two years before that. That could partly reflect the explosive growth of social media, and Snapchat in particular.
The incidents represent a tiny fraction of the content created by Snapchat’s more than 100 million daily active users, who view more than 6 billion videos each day. Snapchat has a Safety Advisory Board to guide its policies and products.
“This type of behavior is cruel and violates the Terms of Service promise Snapchatters make to respect other people’s rights,” the company said in a statement. “We believe that elderly people should be celebrated and cared for with respect and compassion. We have a dedicated Trust & Safety team that reviews abuse reports and takes action when they become aware of a violation, and we comply with valid legal requests from law enforcement.”
Greg Crist, a spokesman for the American Health Care Association, the nursing home industry trade group, said in an email that unauthorized photos and videos of residents are “disturbing.”
Some homes, he noted, particularly those in rural areas, do not use social media themselves so they may not realize that “many of their employees do, so they need to be vigilant and aware.” The group hosts training sessions on social media and expects to hold more in the coming year.
Joe Small’s great-grandmother, Annie Mae Martin, was videotaped without her permission at St. Ann’s Home, a Rochester, N.Y., nursing home.
A former nurse’s aide posted a video on Facebook in October 2012 showing a hand briefly tugging at the back of the woman’s hair and recording unseen staffers taunting her with insults. “The boss lady said that if you don’t wash the dishes, she will slap the black off you … and she called you a bitch,” one says. The aide, Ericha Brown, who worked at the home for less than a month in 2011, tagged other employees and added the caption: “I miss these mornings.”
Brown was arrested and charged with three counts of willful violation of health laws; she pleaded guilty to one count. In a handwritten confession, she wrote, “I deeply regret my actions and will never do anything like this again.” She did not return phone calls seeking comment.
Martin remained a resident of the home and died earlier this year at age 94.
“It was very distressing,” said Small, who held Martin’s power of attorney. “We are all going to get old one day and need assistance to help us in our day-to-day activities, and this is the way you have to be treated when you go into these establishments?”
Susan Murty, administrator of St. Ann’s Community, said the home began an investigation immediately after an employee discovered the posting and officials worked with authorities to determine its scope. “Most of the people who work in nursing homes are really wonderful people, and it’s a shame that this is what people talk about. That’s always our frustration.”
New York Attorney General Eric Schneiderman’s office prosecuted the case and also secured a guilty plea earlier this year in another case involving an aide at a nursing home in Erie County.
“We will not tolerate medical professionals who abuse and exploit the trust of nursing residents by broadcasting private and sensitive medical issues on social media,” Schneiderman said through a spokesman.
Taylor Waller, a former nursing assistant in Indiana, pleaded guilty in September to one count of voyeurism for sharing a photo of a resident’s back side and buttocks on Snapchat. She served three days in jail, she said, and is currently on probation.
In an interview, Waller acknowledged that she made a mistake but said she did not take the picture for malicious reasons and the resident didn’t even know it happened. “They just blew everything out of proportion,” she said. "It was just a picture of her butt. How many people take a picture of people’s butts?… I worked in health care for five years. Everybody takes pictures of the residents all the time. I’m not the only one.”
Waller also said that people searching for nursing homes for relatives have bigger issues to worry about than privacy violations involving social media.
“There is so much abuse that goes on,” she said. “Nursing homes are so short staffed. Every facility I worked in, every time I went in, residents would be soaked from head to toe in pee and they sat in it for hours. They were treated like animals. I understand taking pictures is bad but there are so many worse things that need to be taken care of, too.”
At Gridley Healthcare and Wellness Centre in California, a nursing assistant reported a co-worker in April 2014 for using Snapchat to send pictures of residents who were “inappropriately exposed” or who appeared to be deceased. The assistant told state health inspectors that “she was absolutely disgusted by the lack of respect this showed for human life and for a person who had passed… . It was amazing to her that a person could be so uncaring for a laugh.”
Five workers ultimately pleaded guilty to state charges of elder abuse or failure to report elder abuse. The home’s current administrator, Diana Haines, said she could not comment because she wasn’t the administrator at the time and that the home changed operators this year. A representative of the home’s operator at the time of the incident said in a statement to the Gridley Herald newspaper that the home was cooperating with authorities, took corrective action, and that its highest priority was to “ensure the best quality of care and treatment for our patients.”
Many nursing homes ban the use of cellphones on the job but have had trouble enforcing those rules.
This fall, an employee at LifeHOUSE Vista Healthcare Center near San Diego took video of a partially nude woman getting into the shower and shared it on Snapchat. A second employee is seen standing behind the resident laughing. Both were suspended, then fired. The California Attorney General’s Office on Dec. 9 charged one of the assistants with misdemeanor counts of elder abuse and invasion of privacy.
“Let’s face it, if this were my mother, I would just be furious with this. I’d be inconsolable,” said Tom Allen, a lawyer for the home. “There’s no reason for anybody at LifeHOUSE to do or condone this type of thing.”
Allen said social media poses many challenges for homes. “We’re feeling our way through this. There’s no ground rules here.”
Some homes have allowed employees to keep working after warning them about using cellphones on the job.
At Newaygo County Medical Care Facility in Michigan, a nursing assistant was written up twice for using her cellphone at work, including once for taking pictures, before she was accused of taking a picture of Mindy Mench’s grandmother-in-law, Janet Hartranft, on the toilet there in September 2013. Hartranft died in March 2014 at age 79.
This year, ProPublica has been chronicling how weaknesses in federal and state laws, as well as lax enforcement, have left patients vulnerable to damaging invasions of privacy.
More reporting like this:
The nursing assistant pleaded no contest to a charge of using a computer to commit a crime.
At the aide’s sentencing hearing, Mench said she read a letter to the court asking the caregiver to explain her actions. “I just said, ‘Why? Why did you take this picture?’ ” Mench recalled. “She never addressed anything that I said in my letter. She never even looked at me.”
Mench, who had power of attorney for Hartranft, said she has two sisters who work in nursing homes and they couldn’t explain it either.
“These people, our older generation, have served, whether they were a vet or not, they have served in our communities and in our society,” Mench said. “Look what you’re doing to them, look how you’re treating them. It’s taking advantage of the weak and it’s sick.”
In an interview, the woman who was convicted, Reida Osterman, denied taking or posting the video and said she believes another employee picked up her phone and did it. She said she pleaded no contest because “I was going through a very stressful time in my life, probably the worst time in my life ever.”
“If I could answer to the family, I would, but I can’t tell them why because I did not post no pictures of anybody,” she said. “I know for a fact I would never ever ever do anything to hurt anyone.”
Michigan lawyer Tatiana Melnik has written and spoken about the need for health care organizations to pay attention to their employees’ use of social media. Facilities need to enforce their rules, not just have them, she said.
“If there are no sanctions for misbehavior because no one is actually watching what’s happening,” she said, “staff members have no reason to actually respect the rule.”
Image may be NSFW.After 9/11, the Drug Enforcement Administration reframed its mission, warning the country that terrorists had gotten into the illegal drug trade to finance their attacks. This claim gave rise to a little-known statute in the Patriot Act, which authorizes the DEA to pursue people accused of narco-terrorism anywhere in the world, even when none of the alleged activities took place on American soil.
A recent investigation by ProPublica senior reporter Ginger Thompson, in partnership with the New Yorker, closely examines some 37 narco-terrorism cases, raising questions about whether the DEA is actually stopping threats or staging them. One of these cases involves three men accused of trafficking drugs in Mali to support a North African branch of Al Qaeda and the Colombian guerilla army FARC. But the evidence entered in the case was dubious – all provided by the DEA, using informants who were paid hundreds of thousands of dollars to lure the targets into staged narco-terrorism conspiracies.
On this week’s podcast, Thompson speaks with Julia Gatto, a federal public defender who represented one of the Malian men (who was convicted and imprisoned in New York for five years), about the sting operation that entrapped her client, the heightened political climate that led to the passage of narco-terrorism laws, and whether links between drugs and terrorism exist at all.
Oumar Issa served five years in prison on charges that he was trafficking drugs to support al-Qaeda. (Justin Clemons/AP for ProPublica)
Highlights from their conversation:
Listen to this podcast on iTunes, SoundCloud or Stitcher. For more, read Thompson’s The Narco-terror Trap and our interactive graphic The Making of a Narco-terrorist.
Image may be NSFW.A federal judge in Washington last week threw out the narco-terrorism conviction of an Afghan man whom U.S. authorities had touted as an example of the dangerous alliances between terrorists and drug traffickers. Haji Bagcho, in his mid–70s, was one of the first people prosecuted under a little-known section of the Patriot Act that made narco-terrorism a crime, even when none of the alleged activities occurred on American soil.
According to court documents, Bagcho had been under investigation by the Drug Enforcement Administration since 2006 and was eventually arrested in Pakistan in 2009. The DEA said an analysis of ledgers and other records seized from money exchange houses that did business with Bagcho suggested that the elderly heroin dealer was responsible for some 19 percent of the world’s supply of opium. And based almost entirely on the testimony of a single paid informant, who was identified during trial only as Qari, the agency alleged that Bagcho used the proceeds from his illegal narcotics business to support the Taliban.
The DEA warns that drugs are funding terror. An examination of cases raises questions about whether the agency is stopping threats or staging them. Read the story.
“It is clear that the defendant’s illegal activities as a drug trafficker and supporter of terrorists constituted an extremely serious form of criminal conduct, particularly when, as in this case, the two activities were combined,” prosecutors argued. “His conduct directly threatened the lives of American service members, their NATO coalition partners and the Afghan public.”
It turns out, however, that Qari had previously been deemed a liar. According to court records, a different U.S. government agency had designated Qari a “fabricator and/or information peddler.” That agency, which was not identified publicly, had paid Qari $10,000 for information about terrorist activities, but then decided to cut off contact with him once it determined his information “seemed unrealistic and sensational.”
Court records indicate that in 2010, the unidentified agency conveyed its concerns about Qari to an agent in the DEA’s office in Kabul. But the DEA kept up its ties to Qari and paid him some $45,000 for his work as a confidential informant, at a time when the annual gross per capita income in Afghanistan was less than $600. Prosecutors in the Bagcho case said their check into Qari’s background failed to come up with the derogatory information “due to discrepancies in the spelling of Qari’s name.”
The first trial against Bagcho ended in a mistrial when jurors could not agree on a verdict. After a second trial, Bagcho was convicted on two counts of drug trafficking and one count of narco-terrorism. In a 24-page ruling, issued last Friday, Judge Ellen Segal Huvelle vacated the narco-terrorism count against Bagcho, saying “the government violated the defendant’s right to due process by failing to turn over favorable impeachment evidence.” She wrote, “Evidence that the DEA’s Kabul office was told that Qari had been deemed a liar by another government agency, yet it still elected to use him as a witness would serve to undermine the reliability of the government’s investigation and its sources.”
Earlier this month, a story by ProPublica and The New Yorker examined some 37 narco-terrorism cases highlighted by the DEA and found that a disturbing number of them also unraveled. In most of the cases, the only evidence of a link between drugs and terrorism entered into evidence was provided by the DEA, which used paid informants to lure targets into staged narco-terrorism conspiracies.
Shelli Peterson, a federal public defender who represented Bagcho at trial, said the ruling “vindicates our belief that Mr. Bagcho did not receive a fair trial.” She said, “This result should serve as a warning to prosecutors handling other cases involving national security to ensure that they follow the rules.”
Still, it remains unclear what affect the ruling will have on the life sentence Bagcho received as a result of the drug charges alone. A hearing is scheduled for the first week in January on whether Bagcho will get either a new trial or a new sentence.
Image may be NSFW.News organizations have long chronicled problems with investigating reports of rape. Backlogs in rape kits. Cynical efforts to bury rape cases to make a police department's crime fighting statistics look better. Failures to fully exploit the powerful investigative tool of DNA.
"An Unbelievable Story of Rape," a joint reporting effort by The Marshall Project and ProPublica, reinforced some of the most basic ways police could improve their handling of rape cases. These steps offer the promise of both catching the guilty and protecting the victimized.
1. Check with police agencies where the suspect previously lived or traveled. Our reporting showed the value of this simple step. Police investigating a series of rape allegations against former NFL star Darren Sharper never contacted the authorities where he had previously lived. They were all working in isolation — allowing Sharper to rape or attack nine women in multiple states over three years.
In " An Unbelievable Story of Rape," the police in Colorado reached out immediately to their fellow agencies. And within six weeks, they had nabbed Marc O'Leary, a serial rapist now serving 327½ years in prison.
2. Use the FBI's Violent Criminal Apprehension Program (ViCAP). ViCAP is an FBI database designed to catch serial killers and rapists based on the similarity of their behavior. Using data provided by local law enforcement agencies, ViCAP searches through unsolved crimes to seek out similar patterns — say a certain knife that was used in several attacks. Then it suggests a possible match.
ViCAP may be especially useful in rape cases. First, a large number of rapists are serial offenders. One-third to two-thirds of rapists commit multiple crimes, according to studies. In contrast, only about one percent of murderers are serial killers. Also, only about half of all rape cases involve DNA. ViCAP is built to catch serial rapists who don't leave DNA. In Canada, a similar system is credited with linking together 7,000 crimes since 1995.
But in the U.S., local police don't feed much information into ViCAP. And with a paucity of information, the system rarely turns up good matches.
3. Be aware of myths regarding rape. Criminal experts talk about a hypothetical person called the "righteous victim" who was attacked during a "real rape." That's a woman with no blemishes in her past who is raped by a stranger, tries to fight him off and then promptly reports the crime to police. That victim and that crime exist. But they are not common.
The truth is, rape is a crime with all kinds of victims who respond in all kinds of ways. Women often don't go to the police right away. And they can be pastors or prostitutes. The vast majority know their attacker. Only 13 percent of rapes are committed by strangers.
Any police officer who may be involved in a rape investigation would do well to read the evidence-based findings — many of them surprising — about what rape looks like. Useful resources include the International Association of Chiefs of Police and End Violence Against Women International, a non-profit organization that trains police officers in how to conduct rape investigations. Last week, the Department of Justice released its own guidelines.
4. Listen. This is the most obvious, perhaps. Cops, like journalists and prosecutors, can have an innate skepticism about the people they encounter in their line of work. That makes some sense, for there are no shortages of liars and criminals. But it's important to simply listen to a victim's story, and then to check it out. It takes courage for a woman or a man to come forward and tell the police they were raped. Cops can respect that bravery by not allowing the small minority of people who are fabulists to poison their objectivity or diligence.
Before charging someone with a false claim of rape, be very sure that you have the evidence to make a case. There is a good reason for contemplating the prosecution of people who falsely report rape. Innocent people can be harmed. Reputations can be ruined. Precious police resources can be wasted. But police experts say the cost of routinely filing such charges can also be high. Women who fear they might be prosecuted if their reports of rape are not deemed believable may be scared off from reporting at all. Only about one-third of rapes are even reported to police — due in part to the long judicial history of dismissing women's accusations. The bottom line in dealing with suspicions of false reporting is to take the charge like any other. You have to prove that the person invented the story beyond probable cause. That means collecting evidence, witness statements and all the rest before filing such a charge.
For crisis support: Contact the National Sexual Assault Hotline (800-656-HOPE).
Related coverage: For more coverage, read ProPublica's previous reporting on an "unbelievable" story of rape, how flawed rape statistics hamper rape prevention, and the police failure to stop a former NFL star's rape spree.
Image may be NSFW.
