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Legislators Demand Hearings on Illinois Mental Health Facility Where Staff Abused Patients and Covered It Up

2 years 1 month ago

This article was produced for ProPublica’s Local Reporting Network in partnership with Lee Enterprises, along with Capitol News Illinois. Sign up for Dispatches to get stories like this one as soon as they are published.

All 59 Republican members of the Illinois General Assembly are calling for legislative hearings on a state-run mental health center in rural southern Illinois, citing findings of a culture of abuse, cover-ups and poor patient care from a monthslong investigative series by Lee Enterprises Midwest, Capitol News Illinois and ProPublica.

Late last week, the members sent a letter to key Democratic committee chairs in the Illinois House and Senate asking them to schedule a bicameral public hearing on the facility.

The districts that include and surround Choate Mental Health and Developmental Center are represented by Republicans, but as the minority party in both chambers, they lack the authority to convene a legislative hearing.

On Thursday morning, several downstate GOP lawmakers reiterated their call to action at a news conference at the Capitol. Rep. Paul Jacobs, R-Pomona, whose district includes Choate, and others stressed that they want to see conditions fixed.

“The residents there can’t suffer. The most profound developmental and mental disabilities in the state can’t suffer. They have to be treated well,” Jacobs said.

In addition to the in-person hearing, the lawmakers requested access to high-ranking Illinois Department of Human Services officials who oversee the facility, including Secretary Grace Hou.

The facility is one of 13 psychiatric hospitals and developmental centers operated by IDHS across the state. Choate is located in the rural community of Anna near the Missouri border about 120 miles southeast of St. Louis. The 270-bed facility serves people with mental illnesses and developmental disabilities, including people diagnosed with “profound” disabilities and some who are nonverbal.

Since September, the news organizations have detailed startling cases of patient beatings, neglect and poor medical care, as well as coordinated efforts by staff to cover up patient mistreatment. A story published this month disclosed that patients with pica, a disorder in which people feel compelled to swallow inedible objects, had been forced to dig through their own feces to recover the items.

Over a 10-year period ending in 2021, the IDHS Office of the Inspector General fielded more than 1,500 allegations of abuse and neglect at Choate. And the state’s attorney in Union County, where the facility is located, has filed charges against at least 48 people — both patients and employees — since 2015.

Several GOP lawmakers stressed that while they want to see improvement at the facility, they want Choate to remain open. The call for hearings comes after Democratic Gov. J.B. Pritzker reiterated his position last week on the situation at Choate: Fix it or close it. Some parents of longtime Choate residents have expressed concerns about where their loved ones would go if the facility closes, including state Sen. Jil Tracy, R-Quincy, whose brother lives at Choate with more than 230 other residents.

We don’t have facilities to house them up in other parts of the state,” Tracy said. “They have the type of care that is needed by the population that resides there. As I mentioned, many of these have tried group homes, ourselves included. It didn’t work for the specific needs of my brother and several others or many others that resided there.”

Closure would also mean the loss of state jobs in far southern Illinois, an economically depressed area largely represented by Republicans.

Pritzker’s threats of closure didn’t sit well with Sen. Terri Bryant, R-Murphysboro, whose district neighbors Choate, and she called on the governor to take a more active role in finding solutions.

“When the governor says, ‘They have to fix it or I’m going to close the facility’ — he’s ‘they,’” Bryant said. “So he’s the one who has to fix it. And fixing it might mean a total and complete shake-up of the administration.”

A statement from the governor’s office said he is closely monitoring the situation and will move forward on additional reforms in the coming weeks.

In addition to the request for a hearing, the lawmakers outlined a series of steps they’d like to see immediately implemented to improve conditions. Those include the installation of cameras in common interior areas, the appointment of a new director or assistant director with expertise in turning around troubled facilities and the hiring of at least 50 new front-line and health care workers at Choate. Currently, the facility employs around 500 and has approximately 80 vacancies.

Rep. Charlie Meier, R-Okawville, whose southern Illinois district includes the state-run Murray Developmental Center, has also introduced legislation that would allow authorities to report negative findings against workers who help cover up abuse to a statewide registry, barring them from working in a health care setting in the future. Peter Neumer, the IDHS inspector general, called for this change in law last month after the news organizations reported on three Choate workers who were fired for similar misconduct — but who remain eligible to work with vulnerable populations in other health care settings. Meier also introduced legislation mandating that OIG investigations be completed within 30 days, allowing IDHS to fire employees found culpable of abuse or neglect.

In one case featured in the reporting, in which eight workers were accused of abuse or failure to report the beating of a developmentally disabled man, the OIG investigation took eight years to complete. The investigation was suspended while the case was under criminal investigation by the Illinois State Policeand during a subsequent criminal prosecution.

Sen. Ann Gillespie, D-Arlington Heights, chair of the Senate Health and Human Services Appropriations Committee, said she’d received the Republicans’ letter and is considering next steps with her Democratic colleagues. She also said she’d read the news organizations’ reports about conditions at Choate and found them “horrifying.” But she stopped short of joining the call for a special joint hearing, saying that the current committee process may be most expedient for hearing bills and concerns about the facility. Regardless, Gillespie said, problems at Choate will be addressed by the General Assembly.

Gillespie noted that improving conditions at the facility has also been named a top priority for the bipartisan Illinois Senate Women’s Caucus, which she co-chairs with Tracy.

“The knee-jerk reaction might be to shut it down, but then it becomes where do these residents go? And so we can’t do anything knee-jerk that’s going to put the residents in continued or worse danger,” Gillespie said.

IDHS has not disputed any of the news organizations’ findings.

In a statement, IDHS maintained that Choate employees provide crucial care to vulnerable patients and that those who violate the standard of care will be held accountable.

IDHS has implemented reforms at the facility including additional training, increased security, surveillance cameras for the exterior and common area, increased security and management presence in living areas, and physical improvements. The center will undergo a review by the federal monitor Equip for Equality and the OIG, as well as working with the Illinois State Police.

IDHS has also brought in an onsite liaison to report to Hou and the director of the Division of Developmental Disabilities..

“We take the longstanding problems at Choate very seriously and remain committed to providing good, quality care for residents and patients at the facility. We will continue to work with families, staff, residents, and other stakeholders to carry out the mission of helping people with disabilities and others in need across Illinois,” the statement said.

The Republicans speaking at the news conference Thursday agreed that the problems are long-standing and span multiple administrations of governors from both parties, but they called for immediate solutions.

AFSCME Council 31, the union that represents some Choate employees, said in a statement following the news conference that it welcomes the support of “anyone of good will who wants to work to improve” the facility. The union said it has for years urged legislators and IDHS to increase staffing, expand training and invest in maintenance of the buildings.

“It’s regrettable that it took disturbing media reports of past misconduct to underscore the need for improvements at Choate, but the wrongful actions of a few cannot overshadow the deep commitment of the overwhelming majority of employees to Choate’s residents and to making the facility the best it can be,” the statement said.

by Molly Parker, Lee Enterprises Midwest, and Beth Hundsdorfer, Capitol News Illinois

Texas Governor Says Most Gun Crimes Involve Illegally Owned Weapons. That’s Not True for Mass Shootings.

2 years 1 month ago

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This article is co-published with The Texas Tribune, a nonprofit, nonpartisan local newsroom that informs and engages with Texans. Sign up for The Brief Weekly to get up to speed on their essential coverage of Texas issues.

Without mentioning the Uvalde mass shooting, Texas Gov. Greg Abbott last week declared school safety a priority for the current legislative session and again dismissed calls for more laws that would restrict access to guns.

“Some want more gun laws, but too many local officials won’t even enforce the gun laws that are already on the books,” the governor said during his annual State of the State address. Without providing a source or clear data, he then asserted that “most gun crimes are committed by criminals who possess guns illegally.” Abbott proposed a 10-year mandatory minimum sentence for people who are not legally allowed to have a firearm but have them anyway.

“We need to leave prosecutors and judges with no choice but to punish those criminals and remove them and their guns from our streets,” said Abbott, a Republican.

But Abbott’s speech avoided a glaring reality: The majority of the state’s 19 mass shootings over the past six decades were carried out by men who legally acquired firearms, according to an investigation by ProPublica and The Texas Tribune published before his speech. Guns were legally obtained in 13 shootings, including two in which the shooter was not allowed to have one but took advantage of a loophole in the law that does not require background checks for firearms that are acquired from private individuals. Firearms were obtained illegally in three instances. The rest of the cases were unclear.

The news organizations’ analysis found that lawmakers failed to pass at least two dozen bills that would have prevented people from legally obtaining the weapons and ammunition used in seven of the state’s mass shootings. Such measures included requiring universal background checks, banning the ownership of certain firearms and raising the minimum age to purchase an assault weapon from 18 to 21 years old.

State lawmakers instead have loosened restrictions over the years on publicly carrying guns while making it harder for local governments to regulate them.

Brett Cross, whose 10-year-old son was among the 19 children and two teachers killed last year at Robb Elementary School in Uvalde, agreed with Abbott that criminals should not have access to guns. But, Cross said, the governor’s comments ignore the fact that the people responsible for many mass shootings did not previously have a criminal background.

“Before May 24, our shooter was not a criminal,” Cross said. “If this shooter hadn’t been able to just go in and buy those guns literally two days after his 18th birthday, then my child would still be alive.” Abbott, he said, “wants to be reactive instead of proactive, and proactive is what we need to stop these things.”

The governor did not respond to multiple requests for comment on the news organizations’ investigation or about his remarks during his State of the State address.

Little evidence exists to support Abbott’s claim, said Bill Spelman, who worked for a national police association for seven years and has spent the last 30 years teaching and researching criminal justice policy.

“To just say that most gun crimes are committed by criminals who possess guns illegally is a statement you can’t back up,” said Spelman, an emeritus professor of public affairs at the University of Texas at Austin.

James Densley, who co-founded the Violence Project, a nonpartisan nonprofit research center best known for its extensive mass shooter database, said that Abbott’s 10-year mandatory minimum sentence proposal would do little to deter mass shootings because the shooter does not survive in most of those cases and in others is already facing life in prison. In the vast majority of the nationwide cases in which it is known how the shooters obtained their firearms, they did so legally, Densley said.

Densley said different forms of gun violence require targeted approaches. For instance, restrictions on assault-style weapons and large-capacity magazines could be effective at reducing mass shootings, but less so at curbing “everyday gun violence,” he said.

“And I think politicians actually know this,” Densely said. “They understand it intuitively. But they have to say what is politically convenient to satisfy the needs of their constituents and others. And so they often conflate these different forms of gun violence to be perceived to be talking about one thing when they’re actually talking about something else.”

by Jessica Priest and Perla Trevizo

This “Climate-Friendly” Fuel Comes With an Astronomical Cancer Risk

2 years 1 month ago

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The Environmental Protection Agency recently gave a Chevron refinery the green light to create fuel from discarded plastics as part of a “climate-friendly” initiative to boost alternatives to petroleum. But, according to agency records obtained by ProPublica and The Guardian, the production of one of the fuels could emit air pollution that is so toxic, 1 out of 4 people exposed to it over a lifetime could get cancer.

“That kind of risk is obscene,” said Linda Birnbaum, former head of the National Institute of Environmental Health Sciences. “You can’t let that get out.”

That risk is 250,000 times greater than the level usually considered acceptable by the EPA division that approves new chemicals. Chevron hasn’t started making this jet fuel yet, the EPA said. When the company does, the cancer burden will disproportionately fall on people who have low incomes and are Black because of the population that lives within 3 miles of the refinery in Pascagoula, Mississippi.

ProPublica and The Guardian asked Maria Doa, a scientist who worked at the EPA for 30 years, to review the document laying out the risk. Doa, who once ran the division that managed the risks posed by chemicals, was so alarmed by the cancer threat that she initially assumed it was a typographical error. “EPA should not allow these risks in Pascagoula or anywhere,” said Doa, who now is the senior director of chemical policy at Environmental Defense Fund.

In response to questions from ProPublica and The Guardian, an EPA spokesperson wrote that the agency’s lifetime cancer risk calculation is “a very conservative estimate with ‘high uncertainty,’” meaning the government erred on the side of caution in calculating such a high risk.

Under federal law, the EPA can’t approve new chemicals with serious health or environmental risks unless it comes up with ways to minimize the dangers. And if the EPA is unsure, the law allows the agency to order lab testing that would clarify the potential health and environmental harms. In the case of these new plastic-based fuels, the agency didn’t do either of those things. In approving the jet fuel, the EPA didn’t require any lab tests, air monitoring or controls that would reduce the release of the cancer-causing pollutants or people’s exposure to them.

In January 2022, the EPA announced the initiative to streamline the approval of petroleum alternatives in what a press release called “part of the Biden-Harris Administration’s actions to confront the climate crisis.” While the program cleared new fuels made from plants, it also signed off on fuels made from plastics even though they themselves are petroleum-based and contribute to the release of planet-warming greenhouse gases.

Although there’s no mention of discarded plastics in the press release or on the EPA website’s description of the program, an agency spokesperson told ProPublica and The Guardian that it allows them because the initiative also covers fuels made from waste. The spokesperson said that 16 of the 34 fuels the program approved so far are made from waste. She would not say how many of those are made from plastic and stated that such information was confidential.

All of the waste-based fuels are the subject of consent orders, documents the EPA issues when it finds that new chemicals or mixtures may pose an “unreasonable risk” to human health or the environment. The documents specify those risks and the agency’s instructions for mitigating them.

But the agency won’t turn over these records or reveal information about the waste-based fuels, even their names and chemical structures. Without those basic details, it’s nearly impossible to determine which of the thousands of consent orders on the EPA website apply to this program. In keeping this information secret, the EPA cited a legal provision that allows companies to claim as confidential any information that would give their competitors an advantage in the marketplace.

Nevertheless, ProPublica and The Guardian did obtain one consent order that covers a dozen Chevron fuels made from plastics that were reviewed under the program. Although the EPA had blacked out sections, including the chemicals’ names, that document showed that the fuels that Chevron plans to make at its Pascagoula refinery present serious health risks, including developmental problems in children and cancer and harm to the nervous system, reproductive system, liver, kidney, blood and spleen.

Aside from the chemical that carries a 25% lifetime risk of cancer from smokestack emissions, another of the Chevron fuels ushered in through the program is expected to cause 1.2 cancers in 10,000 people — also far higher than the agency allows for the general population. The EPA division that screens new chemicals typically limits cancer risk from a single air pollutant to 1 case of cancer in a million people. The agency also calculated that air pollution from one of the fuels is expected to cause 7.1 cancers in every 1,000 workers — more than 70 times the level EPA’s new chemicals division usually considers acceptable for workers.

In addition to the chemicals released through the creation of fuels from plastics, the people living near the Chevron refinery are exposed to an array of other cancer-causing pollutants, as ProPublica reported in 2021. In that series, which mapped excess cancer risk from lifetime exposure to air pollution across the U.S., the highest chance was 1 cancer in 53 people, in Port Arthur, Texas.

The 1-in-4 lifetime cancer risk from breathing the emissions from the Chevron jet fuel is higher even than the lifetime risk of lung cancer for current smokers.

In an email, Chevron spokesperson Ross Allen wrote: “It is incorrect to say there is a 1-in-4 cancer risk from smokestack emissions. I urge you avoid suggesting otherwise.” Asked to clarify what exactly was wrong, Allen wrote that Chevron disagrees with ProPublica and The Guardian’s “characterization of language in the EPA Consent Order.” That document, signed by a Chevron manager at its refinery in Pascagoula, quantified the lifetime cancer risk from the inhalation of smokestack air as 2.5 cancers in 10 people, which can also be stated as 1 in 4.

In a subsequent phone call, Allen said: “We do take care of our communities, our workers and the environment generally. This is job one for Chevron.”

In a separate written statement, Chevron said it followed the EPA’s process under the Toxic Substances Control Act: “The TSCA process is an important first step to identify risks and if EPA identifies unreasonable risk, it can limit or prohibit manufacture, processing or distribution in commerce during applicable review period.”

The Chevron statement also said: “Other environmental regulations and permitting processes govern air, water and handling hazardous materials. Regulations under the Clean Water, Clean Air and Resource Conservation and Recovery Acts also apply and protect the environment and the health and safety of our communities and workers.”

Similarly, the EPA said that other federal laws and requirements might reduce the risk posed by the pollution, including Occupational Safety and Health Administration’s regulations for worker protection, the Clean Water Act, the Clean Air Act and rules that apply to refineries.

But OSHA has warned the public not to rely on its outdated chemical standards. The refinery rule calls for air monitoring only for one pollutant: benzene. The Clean Water Act does not address air pollution. And the new fuels are not regulated under the Clean Air Act, which applies to a specific list of pollutants. Nor can states monitor for the carcinogenic new fuels without knowing their names and chemical structures.

We asked Scott Throwe, an air pollution specialist who worked at the EPA for 30 years, how existing regulations could protect people in this instance. Now an independent environmental consultant, Throwe said the existing testing and monitoring requirements for refineries couldn’t capture the pollution from these new plastic-based fuels because the rules were written before these chemicals existed. There is a chance that equipment designed to limit the release of other pollutants may incidentally capture some of the emissions from the new fuels, he said. But there’s no way to know whether that is happening.

A redacted section of an EPA consent order covering plastic-derived fuels. The agency withheld basic information on the grounds that it is confidential business information.

Under federal law, companies have to apply to the EPA for permission to introduce new chemicals or mixtures. But manufacturers don’t have to supply any data showing their products are safe. So the EPA usually relies on studies of similar chemicals to anticipate health effects. In this case, the EPA used a mixture of chemicals made from crude oil to gauge the risks posed by the new plastic-based fuels. Chevron told the EPA the chemical components of its new fuel but didn’t give the precise proportions. So the EPA had to make some assumptions, for instance that people absorb 100% of the pollution emitted.

Asked why it didn’t require tests to clarify the risks, a spokesperson wrote that the “EPA does not believe these additional test results would change the risks identified nor the unreasonable risks finding.”

In her three decades at the EPA, Doa had never seen a chemical with that high a cancer risk that the agency allowed to be released into a community without restrictions.

“The only requirement seems to be just to use the chemicals as fuel and have the workers wear gloves,” she said.

While companies have made fuels from discarded plastics before, this EPA program gives them the same administrative break that renewable fuels receive: a dedicated EPA team that combines the usual six regulatory assessments into a single report.

The irony is that Congress created the Renewable Fuel Standard Program, which this initiative was meant to support, to reduce greenhouse gas emissions and boost the production of renewable fuels. Truly renewable energy sources can be regenerated in a short period of time, such as plants or algae. While there is significant debate about whether ethanol, which is made from corn, and other plant-based renewable fuels are really better for the environment than fossil fuels, there is no question that plastics are not renewable and that their production and conversion into fuel releases climate-harming pollution.

Under the EPA’s Renewable Fuel Standard, biobased fuels must meet specific criteria related to their biological origin as well as the amount they reduce greenhouse gas emissions compared with petroleum-based fuels. But under this new approach, fuels made from waste don’t have to meet those targets, the agency said.

In its written statement, Chevron said that “plastics are an essential part of modern life and plastic waste should not end up in unintended places in the environment. We are taking steps to address plastic waste and support a circular economy in which post-use plastic is recycled, reused or repurposed.”

But environmentalists say such claims are just greenwashing.

Whatever you call it, the creation of fuel from plastic is in some ways worse for the climate than simply making it directly from fossil fuels. Over 99% of all plastic is derived from fossil fuels, including coal, oil and gas. To produce fuel from plastics, additional fossil fuels are used to generate the heat that converts them into petrochemicals that can be used as fuel.

“It adds an extra step,” said Veena Singla, a senior scientist at NRDC. “They have to burn a lot of stuff to power the process that transforms the plastic.”

Less than 6% of plastic waste is recycled in the U.S. Scientists estimate that more than a million tons of that unrecycled plastic ends up in the environment each year, killing marine mammals and polluting the world. Plastic does not fully decompose; instead it eventually breaks down into tiny bits, some of which wind up inside our bodies. As the public’s awareness of the health and environmental harm grows, the plastics industry has found itself under increasing pressure to find a use for the waste.

The idea of creating fuel from plastic offers the comforting sense that plastics are sustainable. But the release of cancer-causing pollution is just one of several significant problems that have plagued attempts to convert discarded plastic into new things. One recent study by scientists from the Department of Energy found that the economic and environmental costs of turning old plastic into new using a process called pyrolysis were 10 to 100 times higher than those of making new plastics from fossil fuels. The lead author said similar issues plague the use of this process to create fuels from plastics.

Chevron buys oil that another company extracts from discarded plastics through pyrolysis. Though the parts of the consent order that aren’t blacked out don’t mention that this oil came from waste plastics, a related EPA record makes this clear. The cancer risks come from the pollution emitted from Chevron’s smokestacks when the company turns that oil into fuel.

The EPA attributed its decision to embark on the streamlined program in part to its budget, which it says has been “essentially flat for the last six years.” The EPA spokesperson said that the agency “has been working to streamline its new chemicals work wherever possible.”

The New Chemicals Division, which houses the program, has been under particular pressure because updates to the chemicals law gave it additional responsibilities and faster timetables. That division of the agency is also the subject of an ongoing EPA Inspector General investigation into whistleblowers’ allegations of corruption and industry influence over the chemical approval process.

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Correction

Feb. 23, 2023: This story originally misstated how much plastic ends up in the oceans each year. It is millions of tons, not hundreds of millions of tons.

Correction

March 1, 2023: A corrected version of this story misstated what happens to U.S. unrecycled plastic. Scientists estimate that more than a million tons of it end up in the environment each year. It is not known precisely how much of this plastic from the U.S. winds up in the oceans.

by Sharon Lerner

Help ProPublica Journalists Investigate the Dairy Industry

2 years 1 month ago

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Dairy farms in the Midwest produce millions of gallons of milk each month. The people working on these farms, often immigrants from Latin America, do so while facing a variety of safety risks, often for low pay. Employees are injured in machinery accidents, get trampled by cows, risk exposure to chemicals and face other workplace hazards.

In reporting our story about the death of the 8-year-old son of an immigrant worker on a dairy farm in Wisconsin, we learned that there’s little oversight of worker safety. We’ve interviewed workers who suffered debilitating injuries and were then fired and unable to access medical care. Often, records and interviews show, people are barely trained before they’re sent to work with potentially deadly animals and equipment.

Workers sometimes live with mold-covered walls, holes in the floor, no heat or air conditioning, or in other substandard conditions. In some states, undocumented immigrants are barred from obtaining driver’s licenses, yet we’ve talked with dozens who say they need to drive to get to work, putting them at risk of getting ticketed by police.

We plan to write stories that can shed light on these issues, about farms both in the Midwest and across the country. We would like your help. If you have any insights into the industry — perhaps you’re a medical provider, a state or federal employee, a workers’ compensation lawyer, an occupational safety expert, a researcher, or someone who works or grew up on a dairy farm — we would love to hear from you.

We take your privacy seriously. We are gathering these stories for the purposes of our reporting and will contact you if we wish to publish any part of your story. We are the only ones reading what you submit.

by Maryam Jameel and Melissa Sanchez

Death on a Dairy Farm

2 years 1 month ago

This story contains a description of a child’s fatal injuries.

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ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week. This article was co-published with the USA TODAY NETWORK-Wisconsin and El Faro.

The call to 911 came in a little after 11 p.m. A man said a small boy on his dairy farm had severe head injuries. He said he thought the boy had been trampled by a cow.

Ann Ingolia, a deputy for the Dane County Sheriff’s Office, was in the middle of her shift when she heard the dispatch on this warm summer night in 2019. She turned on her siren and headed over, down winding roads and rolling hills, past the farms and fields that mark the landscape of this part of south-central Wisconsin.

Lights from an ambulance and other emergency vehicles flickered over the property. When she arrived, Ingolia could see paramedics attending to a boy on the ground near the milking parlor. His head was split open.

Ingolia approached the owners of the farm. Daniel and Kay Breunig pointed out a slender man wearing jeans covered in manure and blood who was walking in circles near a windmill — the boy’s father. Daniel Breunig said workers had told him that the child had been injured. But Breunig didn’t know more because he couldn’t speak Spanish and his three workers on duty that night, including the boy’s father, didn’t speak English.

Ingolia wasn’t fluent in Spanish, but she considered herself proficient enough to do her job. She walked up to the boy’s father, José María Rodríguez Uriarte, and tried to talk with him.

Rodríguez was screaming for his son, Jefferson, 8. He sat on the grass and rocked back and forth. “He was literally trying to dig a hole in the ground and bury himself,” Ingolia later said. At one point, she said, Rodríguez’s “demeanor went from frantic to catatonic to back to hysterical to back to catatonic to the point where I was afraid that if a milk tanker drove by, he would run out in front of it.”

In her report, she noted that it was difficult to extract information. Rodríguez told her that he “had not seen exactly what had happened.” He took her to an area near some corrals on the property and pointed to a skid steer, a 6,700-pound machine used on the farm to scrape up manure. Ingolia tried to ask about how the boy was injured and, eventually, this is what she understood: Rodríguez had been driving the skid steer, didn’t see the boy behind him and ran him over when he put the machine in reverse.

Ingolia’s interview with Rodríguez, as halting and incoherent as it was, became the foundation of the official account of the night of July 26, 2019 — Rodríguez accidentally killed his son.

That account would be repeated by other agencies, publicized by local media outlets and remembered by farmers in the area and residents who speak only English.

It is an account that torments Rodríguez because, he said, it isn’t true.

He and the other workers who were at the farm that night, along with the friends who arrived in the hours after the boy died to console an inconsolable father, know another version of what happened. To this day, theirs is the only version that many in this community of Nicaraguans and other immigrant dairy workers have heard.

Jefferson at D&K Dairy (Courtesy of José María Rodríguez Uriarte)

What happened to Jefferson and his father is a story of an accumulation of failures: a broken immigration system that makes it difficult for people to come here even as entire industries depend on their labor, small farms that largely go unexamined by safety inspectors, and a law enforcement system that’s ill equipped to serve people who don’t speak English.

The night Jefferson died, two people in addition to Rodríguez were working on the farm. One worker told Ingolia she didn’t see what happened.

It was the other worker’s first day. Video from patrol car cameras show him standing off to the side while Daniel Breunig and then a deputy and then paramedics took turns pumping the lifeless boy’s chest. He remained there after a white sheet was draped over the body.

At some point that night, another deputy identified him as a farmhand who “did not speak very good English.” That deputy handed him a notepad, and the man wrote his name.

Nobody interviewed him, though his account could have changed the course of everything that was to come.

D&K Dairy sits on about 300 acres in the rural town of Dane, about a half hour north of Madison, the state capital. Daniel and Kay Breunig both grew up on farms, and in 1991, a couple of years after they married, they bought their own.

They lived on the property with their two adult sons in a large white farmhouse with an American flag out front. Like many farming families, they worked there, too, though they left jobs such as milking cows and cleaning stalls to their employees.

At any given time, the farm had about six immigrant workers who alternated shifts to meet the needs of an operation that milked hundreds of cows three times a day. Those who could speak some English also took on some of the farm’s day-to-day management, such as hiring and scheduling.

“I would have to say I left all of that up to the lead fellow after he was trained to oversee all the rest of the employees,” Daniel Breunig said in a deposition tied to an ongoing lawsuit over Jefferson’s death. “Just because of the language barrier.”

Workers appreciated the Breunigs’ hands-off approach, unlike some more overbearing farmers they’d previously worked for. But workers complained of cow manure and cat feces in places that were supposed to be kept clean. So many cats roamed the property that it was known to Spanish-speaking residents as “El Rancho de los Gatos,” the Cat Farm.

State officials who inspected the milking parlor in the months before Jefferson’s death noted manure on the walls and cows with dirty flanks and udders, signs that the milk was at risk of becoming contaminated. D&K’s violations of sanitary standards put it in the bottom 20% of dairy farms in the state, according to the Wisconsin Department of Agriculture, Trade and Consumer Protection.

D&K Dairy also had a reputation for frequent turnover, which meant it was often hiring.

First image: D&K Dairy. Second image: A cow barn at the farm on the night of Jefferson’s death. (First image, Melissa Sanchez/ProPublica; second image, Dane County Sheriff’s Office)

Over the decades, Wisconsin’s small farms have struggled to compete with larger, more efficient operations and to stay afloat amid fluctuating milk prices. When the Breunigs bought their farm, there were more than 32,000 dairy producers in the state. By the time Jefferson and his father arrived in 2019, about 7,900 remained. Today, some 6,100 dairy farms are left.

Farms got bigger to survive, adding more cows, more automation and more workers.

But the work is dangerous and dirty and it pays poorly. Few Americans are willing to do it. And so farm operators across the country have been turning to immigrants to scrape the manure off barn floors, herd the heavy animals from corrals to milking parlors, and attach cows’ teats to machines that pump the milk that fills gallon jugs in supermarket refrigerators.

It is an open secret in the dairy industry that many workers lack authorization to work in the U.S. They get jobs using fake papers that employers, knowingly or not, accept. “The less I know the better,” one farmer in Dane County told ProPublica.

Over the years, the workforce at Wisconsin dairies has shifted; where it was once mainly immigrants from Mexico, it now includes asylum-seekers and other immigrants from Central America. Around Dane County, many are Nicaraguan.

Until recently, Nicaraguans had migrated to the U.S. in much lower numbers than people from neighboring countries. But in 2019, as their government slid into authoritarianism and the economy faltered, thousands of people fled. More Nicaraguans were intercepted at the border that fiscal year than at any other time in the previous decade.

For some, the Breunigs’ farm was a first stop.

There are about 6,100 dairy farms in Wisconsin, including about 180 in Dane County. (Sebastián Hidalgo for ProPublica)

Rodríguez grew up in poverty, one of 16 children of farmworkers who moved from one rural community to another to work other people’s land. Eventually his parents bought a few acres of their own where they planted beans, corn and rice, and raised a few cows. He said he stopped going to school after the first grade.

He wanted something better for his sons, Jefferson, the oldest, and Yefari, who was four years younger.

For several years, Rodríguez traveled back and forth from Nicaragua to Costa Rica for work, a common migration pattern among Nicaraguans. While he was away working, his sons grew up with their mother, María Sayra Vargas, in Murra, a remote community in a coffee-growing region of Nicaragua’s Nueva Segovia state.

But Rodríguez said he was finding it harder to get a job in Costa Rica. In late 2018, he started reaching out to friends who had migrated north to ask about their experiences working in Wisconsin.

Rodríguez had been hearing from other Nicaraguans that adults traveling with children were more likely to get into the U.S. after making an asylum claim at the border.

But he and Vargas weren’t sure whether he should take Jefferson. Vargas feared something might happen to their son on the long, sometimes dangerous trek through Central America and Mexico. Rodríguez worried about how he would care for his son while working. But a friend eased his worries, explaining that while she worked, her children went to school.

Jefferson was eager to go to the U.S. A skinny, dark-haired boy, he liked to play with toy cars with his brother and exhausted his mother by running down the hallway in their small home. He was a second grader with a deep, personal sense of faith and a closeness to God that surprised even his parents. “He spoke about creation, sin, things I had never taught him,” Vargas said. “He asked so many questions I didn’t even know the answers to, or have the words to explain.”

Jefferson told his father he wanted to learn English so that, one day, he could share the word of God with the children he met in the U.S.

In late February 2019, they left Murra. Rodríguez was 29; his son, 8. There were times on the journey when they went without food or water. “It breaks your soul to know a child is going through that,” Rodríguez said. “Jefferson was braver than me. He would always tell me, ‘We will get there. We will get there.’”

A little over two weeks after leaving Nicaragua, Rodríguez said, they entered the U.S. late one night by crossing the Rio Grande in Texas, a few miles from a port of entry. He said they walked for about two hours before reaching a road, where a Border Patrol agent eventually picked them up. They spent several days in detention, he said, but were able to make an asylum claim and get released with a date to go to court, a common immigration path at the time. Soon they were heading to Wisconsin.

While his immigration case was making its way through court, Rodríguez couldn’t get a work permit. He got the job at D&K Dairy the way so many dairy workers do: using fake papers he’d purchased that showed somebody else’s name and Social Security number.

He earned $9.50 an hour and was paid by check with taxes withheld. Some days he worked six hours; others, 12. Agricultural work is excluded from many of America’s labor protections, so he didn’t receive overtime pay when he worked more than 40 hours a week. In a typical two-week period, Rodríguez and his coworkers clocked 150 hours, according to interviews and records.

The job came with free housing, a major draw for new immigrants desperate to pay down debts to smugglers who’d helped them cross the border. Rodríguez owed more than $10,000 to the man who loaned him money to get to the U.S.-Mexico border. For undocumented immigrants, who are barred from obtaining driver’s licenses in Wisconsin, there’s another benefit to living where they work: they can avoid getting behind the wheel and risking run-ins with law enforcement officers on traffic duty.

Rodríguez and Jefferson moved into one of two bedrooms in an apartment above the milking parlor, the barn where cows were milked day and night. The floors vibrated from the motor that powered the loud machinery, while the smell of manure penetrated the apartment they shared with two other workers. Rodríguez and his son shared the top bunk in one of the rooms.

José Rodríguez and his son Jefferson in a photo taken soon after their arrival in Wisconsin. (Courtesy of José María Rodríguez Uriarte)

“It was not a place for children,” said a worker who slept in the bottom bunk and grew fond of his young roommate.

No data exists on how many children live on the dairy farms where their parents work. But stories are plentiful: A worker on a small farm about an hour from D&K Dairy set up a crib in an unheated parlor so she could watch her infant as she milked cows because she could not afford child care. An interpreter in the area knows of several parents who leave their children alone in farm housing while they work overnight shifts. And with some regularity, records show, law enforcement officials encounter the children of workers when they respond to incidents at dairy farms across the state.

In a court deposition, Daniel Breunig pushed back against the notion that Rodríguez and his son lived above the parlor, saying workers only stayed there between shifts or when the weather was bad. “I wouldn’t say lived,” he said. “I would say — I mean, the property that they’re speaking of is built as a break room and a rest area.”

The Breunigs had a two-bedroom unit for their workers in another house a short walk down the road. But there wasn’t enough room for everybody, so the supervisors assigned some workers to live above the milking parlor, several former workers said. More than a half-dozen former workers and visitors to the farm said Rodríguez, his son and other workers lived there.

Breunig told deputies on the night of the accident that he didn’t know the dead boy’s name or age. He later said he’d told Rodríguez that his son could only be outside during the day, under adult supervision.

Jefferson often recorded himself singing and speaking about his deep Christian faith, including in this video taken in a loft space above the milking parlor. (Courtesy of José María Rodríguez Uriarte)

Watch video ➜

Jefferson never attended school in Wisconsin, though there were about five weeks left on the local school district calendar when they arrived. Rodríguez said he couldn’t get a day off or find someone who spoke English to help him enroll his son, but he planned to do it in the fall. He asked around about child care, he said, but couldn’t afford it.

Rodríguez knows some people think he was a negligent father. He said he had two competing responsibilities: working and taking care of his son. He couldn’t always do both at the same time.

Jefferson was often alone in the rooms above the parlor. There was no TV there, just a handful of toys: a small bus, a cow, a plastic water gun he’d use to shoot at the cats. His father gave him an old cellphone that had no service but could catch personal hot spots from other workers’ phones. Jefferson used it to call his mom and brother on WhatsApp, although their cellphone service in Murra was limited. He made videos of himself set in the wood-framed loft space, singing hymns he made up about creation, sin and Jesus Christ.

When he got bored, Jefferson would pull on a pair of oversized black rubber boots and wander downstairs to play with the cats and talk with the adults while they worked.

More than 100 children are killed each year on all kinds of farms, according to national estimates. They fall off their parents’ laps while riding on tractors, get crushed by the heavy metal buckets of skid steers, suffocate in grain silos. Thousands more are injured.

No national system tracks all farm injuries and deaths, but researchers with the federally funded National Children’s Center for Rural and Agricultural Health and Safety maintain a database of these incidents using information gathered primarily from news reports and obituaries. The week of Jefferson’s death, at least three other children were killed on farms across the country, including a 14-month-old girl who was run over by a horse-drawn wagon about an hour north of the Breunigs’ farm.

People who study farm safety discourage the use of the word “accident” because it “implies it’s an act of God. That it was random, a freak thing,” said Barbara Lee, a senior research scientist at the National Children’s Center. “If you ask anybody who understands this, you have an 8-year-old in a dangerous worksite: It’s something terrible waiting to happen.”

The federal Occupational Safety and Health Administration is responsible for investigating workplace safety. OSHA has few safety standards for agricultural work sites, and small farms get significant exemptions. Still, all employers are required to maintain workplaces that are free of hazards that can cause injury or death.

The night Jefferson died, an investigator from the medical examiner’s office called OSHA because the boy “was at work with his father when the accident occurred,” according to her report. But because Jefferson was not a worker, the investigator was told, OSHA likely would not investigate.

It didn’t. In a statement, an agency spokesperson said OSHA’s jurisdiction is limited to incidents that affect workers. “A fatality involving a non-employee, regardless of age, would not generally result in an OSHA investigation unless such workplaces also have employees where hazardous conditions, such as those that may have been a factor to the non-employee’s death also exist,” she said.

The notoriously understaffed and underfunded agency has, in recent years, attempted to inspect fewer than a dozen Wisconsin dairy farms each year. The year Jefferson died, six of the nine inspections that OSHA initiated ultimately did not take place because the farms were too small to fall under the agency’s jurisdiction; three of those six involved fatalities.

As a result, it’s usually up to local law enforcement and, sometimes, child welfare agencies to investigate deaths of and injuries to children on farms. Records show that Dane County’s child protective services division, which is charged with investigating the deaths of children due to suspected maltreatment, was notified the night of Jefferson’s death.

It does not appear the agency opened an investigation. Jefferson’s death is not listed in a state registry of deaths and other serious incidents investigated for possible abuse or neglect. Rodríguez said nobody from child protective services spoke with him. The agency denied a request for records regarding its response, citing state laws that protect juvenile records.

Lee, the researcher, said child welfare and law enforcement agencies are rarely trained in farm safety. That makes it difficult for investigators to recognize whether those deaths or injuries could have been prevented.

“Who was legally responsible for the child at the time of the injury or death? In that case it was the father,” Lee said. “But was the employer turning a blind eye to the fact that the child was spending time at night in the dark in a work environment?”

“You have an 8-year-old in a dangerous worksite: It’s something terrible waiting to happen.”

—— Barbara Lee, scientist at the National Children’s Center for Rural and Agricultural Health and Safety

In the hours after Jefferson died, the farm filled with deputies and other officials who used flashlights to inspect the darkened property. About a half-dozen of Rodríguez’s friends and acquaintances came, too.

Deputies took photographs of Rodríguez standing against a white door, his face red and puffy from crying, his mouth twisted into a grimace. They escorted him to the rooms above the parlor so he could change out of his blood-smeared shirt, pants and boots.

As the night progressed, Rodríguez tried to make sense of the investigation that was unfolding in a language he didn’t understand. He said he didn’t know then, and he wouldn’t know for several days, that authorities believed he had killed his son.

Deputies and other officials seemed to treat Rodríguez gently, records and interviews show. Several officials said Jefferson’s death was one of the saddest incidents they had ever responded to.

Rodríguez said he remembered talking briefly with Ingolia and telling her that he didn’t see what happened. He said he understood what she said in Spanish but did not think she understood everything he said. At one point, Ingolia asked for his phone number but didn’t seem to catch it; it wasn’t until one of his friends repeated the numbers in English, Rodríguez said, that she wrote them down.

At another point, Ingolia asked Rodríguez when he and Jefferson had immigrated to the U.S., as well as about the boy’s mother. She wrote in her report that the boy’s mother had returned to Nicaragua three months earlier. It wasn’t until a native Spanish speaker talked to Rodríguez the following afternoon that authorities learned Jefferson’s mother had never been in the U.S.

Rodríguez said he has no recollection of being asked by Ingolia or anyone else if he was driving the skid steer. He wonders if it was because he was so clearly devastated that they didn’t want to cause him more pain.

But “if they had asked me how I did it,” Rodríguez said, “then in that very moment I could tell them that it wasn’t me.”

That night, he asked a friend to send word back home. He wanted to tell Vargas himself that their son was dead, but knew she had no cell service where they lived.

About 5 a.m. in Murra, Vargas awoke to loud banging on her door. A woman she knew had come to deliver the news: “Your son has been killed in the United States.”

Vargas said she was in disbelief, convinced it was a cruel prank. Then her younger brother arrived. He walked toward her then stood there for a few moments, unable to speak. That’s when she knew.

She cried and screamed, then fainted.

Ingolia learned Spanish in school, taking classes starting in the fifth grade in her native Louisiana and continuing through her freshman year at the University of Wisconsin, Madison. After graduating in 1991, with a degree in history and secondary education, Ingolia used her Spanish intermittently at work, first as a correctional officer and then, after joining the sheriff’s office in 2003, as a deputy.

Although much of her job consists of traffic stops, Ingolia has interpreted for colleagues and officers at other agencies. She was commended in 2014 for her role in helping detectives investigate a stabbing involving Spanish-speaking workers at another dairy farm.

Ingolia considers herself proficient in Spanish, though she acknowledged she struggles with legal and medical terminology. “Asking someone what happened here, basic type of questions, information gathering questions,” she said in a deposition, “I have no issues.”

Deputy Ann Ingolia (Dane County Sheriff’s Office)

The Dane County Sheriff’s Office does not test the language skills of employees; they self-report their proficiency. The office has no written policies on what officers should do when they encounter people who speak a language other than English or when to bring in an interpreter, said Elise Schaffer, a spokesperson for the department.

But in general, Schaffer said, patrol deputies are supposed to put out a call to ask if any of their colleagues speak that language and, if none are available, ask for help from other agencies in the county. According to agency records, on the night Jefferson died, Ingolia was the only Dane deputy on the scene who self-reported speaking Spanish at any level.

Law enforcement agencies that receive federal funding, like the Dane County Sheriff’s Office, are required by the Civil Rights Act to ensure that their services are accessible to people who speak limited English.

In 2021, the Department of Justice settled a civil rights investigation into a Pennsylvania police department over a complaint from a Spanish-speaking resident who spoke limited English and had to rely on his young son and a co-worker to communicate with the police. Under the settlement, police agreed to assess the language skills of its bilingual officers and train staff on when to use interpreters, among other measures.

In Wisconsin, what happens in practice can vary wildly from department to department and officer to officer. Law enforcement officials routinely acknowledge language barriers when they respond to incidents on dairy farms, ProPublica found. Sometimes they call interpreters or seek the help of bilingual colleagues. Just as often, records show, deputies rely on Google Translate, workers’ supervisors, co-workers and even children to interpret for them. Sometimes they fail to even do this.

In Madison, the Dane County seat and the state’s second-largest city, department policy calls for police officers to request bilingual officers when they need interpretation or translation. If one isn’t available, officers can consider a bilingual civilian employee. As a last resort, they can turn to a certified interpreter who works over the phone.

Zulma Franco, a police detective in Madison who immigrated from Colombia as a child and whose first language is Spanish, said there is a difference between speaking enough of another language to “muddle your way” through a traffic stop and having the skills to respond to a complex, emotionally charged or high-stakes situation.

Even in the Madison Police Department, which takes pride in its Latino outreach group, Amigos en Azul, there is no way to measure officers’ proficiency in another language. As in Dane County, the city relies on officers to self-report their ability.

In contrast, the state’s court system has guidelines to ensure access and provides qualified interpreters for people who need them.

But even for experienced interpreters, a number of factors — including the speaker’s country of origin, dialect and education level — can hinder understanding. When a police officer is involved, communication can be even more challenging, especially in a crisis. The results can be life-changing: a victim’s inability to make clear what has happened to them, a suspect’s difficulty in explaining their side of the story.

(Sebastián Hidalgo for ProPublica)

As part of a broader investigation into conditions for immigrant workers on dairy farms across the Midwest, ProPublica began looking into Jefferson’s death last summer. We heard repeatedly from Nicaraguan community members that law enforcement got the story wrong. Rodríguez has consistently said, in Spanish, to friends, acquaintances and even complete strangers, that another worker accidentally ran his son over that night. That worker has also openly spoken about what happened, though the sheriff’s office never interviewed him.

In January, we found that worker.

ProPublica is identifying him by his last name, Blandón, a common surname in Nicaragua. He agreed to explain what happened on the condition we not use his full name, identify his hometown or say where he is today. A soft-spoken man, he said he doesn’t want to be publicly named because he hasn’t told his family about the incident and worries about scaring his elderly parents. As an undocumented immigrant, he is also aware of the ever-present possibility of deportation.

There is no criminal investigation into Jefferson’s death.

Blandón grew up in a part of Nicaragua that, like Murra, has seen an exodus of residents seeking opportunities in the U.S.

Unlike Rodríguez, he went to a private Catholic school and attended college. He studied civil engineering and got a job in that field after graduation. But he decided to immigrate to the U.S. because his family struggled to get ahead in Nicaragua, and he wanted to better support his parents financially.

Blandón was 27 when he entered the U.S. in the late spring of 2019 and moved to Wisconsin, where he had relatives who worked on dairy farms. He found a job on another farm that paid $8.50 an hour to milk and corral about 500 cows, duties he shared with just one other worker each shift. He said he was shown how to operate a skid steer on that farm but was still learning to use it when he quit after about a month because of the exhausting working conditions.

He then got the job at D&K Dairy. He said he was hired as a “corralero,” tasked with corralling cows in and out of the milking parlor, feeding them, and using a skid steer to clear the ground of manure. He said it was a different type of machine than the one he’d been learning to use at the other farm.

Blandón said he met Rodríguez and his son earlier on the day of the incident, during a 12 p.m. to 6 p.m. shift, in the rooms above the milking parlor. He remembered noticing that Jefferson was a chatty and active boy, but said their interaction was brief.

He said he sympathized with Rodríguez for having his son on the farm. He knows many immigrant parents have no choice but to have their children with them at work.

During that first shift, another worker showed him how to use the skid steer and perform his other corralling duties. Before he knew it, Blandón said, he was expected to return two hours later to do the job on his own. It all felt rushed, he said. “Farms need workers and they’re not going to have you practice before getting to work,” he said. “Everything is risky.”

The skid steer Blandón was operating the night of Jefferson’s death. (Dane County Sheriff’s Office)

At 8 p.m., Blandón — who said he had been assigned to live in the house down the road — returned to the farm alone for the overnight shift.

Rodríguez was in the milking parlor, along with another employee, Sandra Rosales Torres, according to Rodríguez and Blandón. Rosales declined to speak on the record with ProPublica, but, speaking through an interpreter in a deposition, she also said Rodríguez was in the milking parlor.

Blandón said it was very dark in parts of the corrals. In her deposition, Rosales said Blandón didn’t have a cellphone and asked to borrow hers to use as a flashlight. She said he told her the lights on the skid steer didn’t work.

At some point, Jefferson came down from the loft and into the milking parlor. He was wearing a blue T-shirt, swim trunks printed with an American flag design and a necklace made from a red shoelace tied around a rock he’d found on the farm. Jefferson chatted briefly with his father, asking for a towel to dry his hands, Rodríguez said. Then he wandered outside.

Blandón said he doesn’t know exactly when Jefferson appeared, but he remembers spotting the child while clearing the corrals. “I didn’t expect to see the boy in a work area,” he said.

It was difficult for Blandón to hear what was happening around him; the skid steer was loud and he was enclosed in its cabin. Blandón said he was focused on getting to the next corral quickly to clean it so that he could then move the cows on time. He began moving the skid steer in reverse to turn it toward the corral.

It all happened within seconds: The skid steer’s movement felt strange, like the ground became uneven beneath him, he said. Suddenly he saw the boy’s body in front of the machine.

In horror, Blandón ran to the parlor where Rodríguez and Rosales were milking the cows. “Accidenté a su niño,” he remembers shouting to Rodríguez. I accidentally hit your son.

Rodríguez followed Blandón outside and saw Jefferson on the ground near the skid steer. Rodríguez said he attempted to do CPR. His mouth filled with blood and what seemed like a piece of a tooth. He felt his son suck in a breath before his tiny body went limp. Rodríguez carried him back toward the milking parlor.

Meanwhile, Rosales hurried across the driveway to the Breunigs’ house. She let out a “terrifying scream,” Breunig would later recall. She said she used some of the few words she knew in English: “José’s baby.”

Breunig said he looked out and saw Rodríguez near the parlor, holding Jefferson. He ran over and called 911. A deputy from neighboring Columbia County arrived less than 10 minutes later. His headlights shone over Breunig, who knelt on the ground as he pumped Jefferson’s chest with his hands.

The boy’s head was scalped and a piece of his skull was detached. His eyes and lips were swollen. Jefferson’s boots and a red baseball cap had fallen off near the skid steer.

As paramedics and Dane County sheriff’s deputies arrived, Blandón stood nearby.

“He was saying things to me like, ‘Sandra, Sandy, I’m going to end up in jail, I’m going to die in jail, never go back to Nicaragua,’” Rosales said in the deposition. “He was very scared. … He was just waiting for a policeman to call him, but they never spoke to him.”

Another deputy identified Blandón and Rosales by asking them to write their names in his notepad. In his report, he noted that he “was not able to communicate with them, as I do not speak Spanish.”

Blandón nervously wrote his first name, middle initial, and last name in the notepad. Then he waited to be questioned.

About an hour later, he said, Breunig asked him to get back to work. The cows needed to be milked.

“He was just waiting for a policeman to call him, but they never spoke to him.”

—— Sandra Rosales Torres, a D&K Dairy worker, of the man driving the skid steer

More than three years after Jefferson’s death, Ingolia said her memory of what happened is clear. “You can never unsee what you saw,” she told us in an interview. “You can never unsmell what you smelled. And I can never unhear José screaming and trying to dig a hole in the ground.”

She said it took her a half hour to get Rodríguez to stop screaming. Finally, she said, she asked him to show her where it happened. He took her to an area near some corrals on a hilly part of the property and pointed to an orange-and-white Bobcat skid steer.

Ingolia said she didn’t know the word for skid steer in Spanish. So she tried to ask whether he hit his son with the machine.

These are the words she said she used: ¿Golpe su hijo con la máquina?”

A reporter told her what those words actually mean: Hit your son with the machine.

The word “hit” in this construction is a noun, as in a “blow” or a “hit,” and not a conjugated verb that would indicate a subject.

The sentence in Spanish has no subject. It’s not clear if she’s asking if Rodríguez hit his son, or if it was somebody else, or if it was the machine itself that hit his son.

“I did the best I could for José and Jefferson the night of the incident,” Ingolia said, “and I can't really account for what anyone else did or didn’t do.”

Does she think it’s possible that she got it wrong?

“It’s possible that I did not get the question laid out so José understood exactly what I was asking,” she said. “When I asked, ‘Did you hit the child with the machine?’ I pointed at him and the machine. I thought I made it clear I was asking, ‘Did you do this?’”

News of Jefferson’s death spread in Spanish on Facebook and WhatsApp. Latino groceries, bakeries and restaurants in the area put up donation boxes to raise money to send his body home.

People who had never met Jefferson showed up to his viewing at a funeral home in Madison. They were moved by Rodríguez’s quiet sadness. “He told me he felt an enormous frustration that he had brought his son here only to die,” said María Teresa Villarreal, who got to know Rodríguez after Jefferson’s death.

The Breunigs attended the viewing, as did Timothy Blanke, the detective on the case. He gave Rodríguez the red shoelace necklace his son had been wearing when he died.

A few days later, Villarreal saw a news article in English based on the sheriff’s office’s account of what happened. By that point, an autopsy had ruled Jefferson’s death an accident. Nobody would be charged criminally.

But Rodríguez was blamed.

Villarreal said she called Rodríguez and told him, but he had already seen it. He told her it made him feel even worse than he already did.

Abarrotes Yuremi, a small grocery store in Waunakee, Wisconsin, is frequented by Nicaraguan dairy workers and other immigrants. (Sebastián Hidalgo for ProPublica)

Rodríguez found Blanke’s card and gave Villarreal his phone number to try to set the record straight. Unlike Rodríguez, Villarreal spoke English. She said she called Blanke. “I told him, ‘Your report says José caused the accident, and it wasn’t José,’” she said. “He asked who did it. I told him it was the other guy who was there.”

In an email, Blanke called Jefferson’s death “one of the most emotionally difficult investigations of my career.” He recalled getting a call about the case and handing it off to another detective. According to a sheriff’s report, that detective tried following up with the caller in early September but never heard back. Villarreal said she was never contacted by anybody from the sheriff’s office.

The detective also talked to a bilingual county official about setting up a meeting with Rodríguez, but that meeting never happened, according to the report. It does not appear that anybody contacted Rodríguez directly.

A year after their son’s death, in August 2020, Rodríguez and Vargas filed a wrongful death lawsuit in Dane County against D&K Dairy, its insurer, and the skid steer driver, first identified as “John Doe.” The sheriff’s office is not a defendant in the lawsuit.

The case is scheduled to go to trial in June.

Rodríguez said he wants to clear his name. He also wants the Breunigs to take responsibility for what happened; he doesn’t think a new employee should have been driving a skid steer alone at night just hours after learning how the machine worked.

One of the key facts in dispute in the lawsuit is who was driving the skid steer. Rodríguez’s attorneys have questioned whether Ingolia knew Spanish well enough to understand him. In 2021, Blandón gave a statement to a private investigator working for Rodríguez’s lawyers acknowledging that he was driving, but the statement was pre-printed with the wrong name and wasn’t properly notarized. A judge struck it from the court record. Since then, lawyers from both sides have been unable to locate Blandón, who has been dismissed as a defendant in the lawsuit.

Rodríguez’s attorneys declined to comment on this story.

Attorneys for the farm and the insurance company, Rural Mutual Insurance Company, have pointed to the sheriff’s department’s report as proof Rodríguez was driving.

Meanwhile, an engineer hired by Rodríguez’s attorneys to inspect the skid steer two and half months after Jefferson died said the machine’s horn, back-up alarm and rear lights didn’t work. “Each of these systems by themselves is designed to make the skid loader more visible, or get the attention of persons near the machine,” the engineer wrote in an August 2022 report. “Had these systems been functioning, it is more likely than not that this accident would not have happened.”

Attorneys for the farm and the insurance company have said in court filings that Daniel Breunig inspected the machine twice a week, on average. In a deposition, Breunig said that, as a new employee, Blandón would have been assigned to the milking parlor that night, while Rodríguez was supposed to corral the cows and drive the skid steer.

Breunig said he had trained Rodríguez on the skid steer months earlier and that, “generally every shift he worked, he was the one pushing the cows to the milking facility and cleaning up their stalls with the Bobcat.”

Rodríguez and three other workers told ProPublica that Rodríguez’s job had always been in the parlor.

The insurance company’s lawyers have said Rodríguez has a financial incentive to claim somebody else was driving. In court filings, they said he “would be unable to recover any damages arising out of [Jefferson’s] death if Jose was driving the Bobcat. If someone else was driving the Bobcat, however, Jose could recover damages.” An attorney for the insurance company declined to comment for this story, citing the lawsuit.

In court, the farm’s lawyer has repeatedly cast doubt on Rodríguez’s credibility, in part because he used an alias to get the job, even as the Breunigs’ business depended on undocumented workers who used aliases to get hired. In his deposition, Daniel Breunig said he did not know the citizenship status of Rodríguez and his son.

Through an attorney, the Breunigs declined to comment about the accident and the operation of the farm.

In his deposition, Daniel Breunig described Jefferson’s death as “an awful tragedy.” He said that, as a father, he, too, felt Rodríguez’s pain. He said he was not aware there was another account of what happened until he heard from Rodríguez’s attorneys.

The farm ceased operations in April 2022; it’s unclear what prompted the closure, though records show that the farm had been struggling to meet state sanitary standards for years.

Jefferson’s death did not attract any additional attention from authorities.

In response to ProPublica’s findings, the sheriff’s office issued a brief statement.

“Our hearts go out to the Rodríguez family on the loss of their young son,” wrote Schaffer, the sheriff’s department spokesperson.

She said investigators would welcome any new information from any witnesses or parties who wanted to come forward. “Our goal is always to conduct a thorough and factual investigation.”

In an interview, Ingolia said she was unaware there was anybody else on the farm that night that she should have talked to.

“José never said, ‘Did you talk to [Blandón]?’” she said. “Never brought up anybody else's name.”

At one point that night, Ingolia asked Rodríguez for consent to do a blood draw to test for drugs or alcohol in his system. She said she began the question by stating that he was “the driver of the machine that killed Jefferson.” Rodríguez gave his consent, though he later said he thought the purpose of the blood draw was to prove his paternity. “I suspect that by the time I asked José about the blood test he was so inside his own head,” she said. “I don’t know if he wasn’t listening or it wasn’t sinking in.”

On an accident scene that size, she said, it would have been up to a supervisor or a detective to decide who needed to be interviewed or re-interviewed. Not her.

Ingolia said none of her native Spanish-speaking colleagues were working the night Jefferson died. She mentioned a phone-based interpretation service available to deputies, but she said it’s not always reliable in rural areas with few cellphone towers.

She knows some agencies test employees’ language skills — and pay an incentive to those who are or become fluent. The sheriff’s office doesn’t do that, she said. She isn’t sure if testing would have been helpful.

Ingolia said the case is “one of the ones that sticks with you. At the end of the day, there is a small child that is dead for no good reason. It’s a very complex situation and, you know, I’m sure José was trying to do the best he could for his family.”

Even if authorities had gotten it right, though, and spoken with Blandón the night Jefferson died, it’s unclear whether much would have changed. More than likely, Jefferson’s death would still have been ruled an accident. OSHA wouldn’t have examined conditions on the farm. Immigrant parents would continue to live and work on dairy farms with their children.

A few days after Jefferson’s death, Blandón said, he met with Rodríguez at the farm and apologized. He said he told him he was so sorry. “That I never …” Blandón paused. “That it wasn’t intentional. It was an unexpected accident. It wasn’t something I meant to do, but it was something that just happened.”

Rodríguez said he knows that what happened wasn’t intentional. He doesn’t want to see Blandón, another immigrant like him, punished. “It’s not something that just goes away. I know he didn’t do it on purpose, but …” he trailed off. “It is difficult.”

Blandón continued working at D&K Dairy for about two weeks after Jefferson died, until he found a job on another dairy farm. He wanted to get away from the horrors of that night.

For some time afterward, he said, any loud noise or sudden movement would startle him and make him want to cry. He said he talked with a psychologist, a pastor and a priest to try to process what had happened.

About a year ago, Blandón left Wisconsin. He now lives in a small city in another state and works in a different industry. He said he doesn’t want to return to work on a dairy farm but he knows that he might have to one day if he has no other option.

Rodríguez never went back to work at D&K Dairy. He works on another dairy farm nearby.

When he looks back, he said, he’s still baffled by the investigation. It’s not just that law enforcement incorrectly concluded he was driving the skid steer, he said, but that they missed the bigger picture.

“Shouldn’t they have taken a closer look at what was happening on that farm, after seeing what a disaster that place was? Shouldn’t they have paid more attention?” he asked. “Don’t the police have to do that?”

If he was still alive, Jefferson would now be 12. Rodríguez said he thinks about him daily and wonders what he would be like today. He imagines that, by now, his son would have accomplished his goal of learning English in school.

He remembers how Jefferson would tell him to work hard and save up enough money so they could return home quickly. He talked about hugging his little brother again.

Lately, Rodríguez has been thinking about going back to Nicaragua. He wants to be with the only son he has left.

The gravesite and memorial to Jefferson in Murra, Nicaragua (Courtesy of María Sayra Vargas)

Help ProPublica Journalists Investigate the Dairy Industry

Alex Mierjeski contributed research.

by Melissa Sanchez and Maryam Jameel

A Norfolk Southern Policy Lets Officials Order Crews to Ignore Safety Alerts

2 years 1 month ago

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Norfolk Southern allows a monitoring team to instruct crews to ignore alerts from train track sensors designed to flag potential mechanical problems.

ProPublica learned of the policy after reviewing the rules of the company, which is engulfed in controversy after one of its trains derailed this month, releasing toxic flammable gas over East Palestine, Ohio.

The policy applies specifically to the company’s Wayside Detector Help Desk, which monitors data from the track-side sensors. Workers on the desk can tell crews to disregard an alert when “information is available confirming it is safe to proceed” and to continue no faster than 30 miles per hour to the next track-side sensor, which is often miles away. The company’s rulebook did not specify what such information might be, and company officials did not respond to questions about the policy.

The National Transportation Safety Board will be looking into the company’s rules, including whether that specific policy played a role in the Feb. 3 derailment in East Palestine. Thirty-eight cars, some filled with chemicals, left the tracks and caught fire, triggering an evacuation and agonized questions from residents about the implications for their health. The NTSB believes a wheel bearing in a car overheated and failed immediately before the train derailed. It plans to release a preliminary report on the accident Thursday morning.

ProPublica has learned that Norfolk Southern disregarded a similar mechanical problem on another train that months earlier jumped the tracks in Ohio.

In October, that train was en route to Cleveland when dispatchers told the crew to stop it, said Clyde Whitaker, Ohio state legislative director for the Transportation Division of the International Association of Sheet Metal, Air, Rail and Transportation Workers, or SMART. He said the help desk had learned that a wheel was heating up on an engine the train was towing. The company sent a mechanic to the train to diagnose the problem.

Whitaker said that it could not be determined what was causing the wheel to overheat, and that the safest course of action would have been to set the engine aside to be repaired. That would have added about an hour to the journey, Whitaker said.

But Whitaker said the dispatcher told the crew that a supervisor determined that the train should continue on without removing the engine.

Four miles later, the train derailed while traveling about 30 miles per hour and dumped thousands of gallons of molten paraffin wax in the city of Sandusky.

Records from the Federal Railroad Administration, the agency responsible for regulating safety in the railroad industry, show that Norfolk Southern identified the cause of the October derailment as a hot wheel bearing. Whitaker said this bearing was on the same engine that originally drew concerns.

A spokesperson for the FRA said the agency’s investigation into the derailment is ongoing. The agency did not say whether it was examining the role of any Norfolk Southern officials in deciding to keep the damaged engine on the train. It’s still unknown what role, if any, the help desk played in the final decision.

This month, 20 miles before Norfolk Southern’s train spectacularly derailed in East Palestine, the help desk should have also gotten an alert. As the train rolled through Salem, it crossed a track-side sensor. Video footage from a nearby Salem company shows the train traveling with a fiery glow underneath its carriage.

If, like the Sandusky train, this one was dangerously heating up, a key question for investigators will be whether the help desk became aware and alerted the crew, and if it did, why the crew was not instructed to stop. The NTSB told ProPublica it is reviewing data from the Salem detector and those before it on the train’s route.

Norfolk Southern declined to say whether members of the train’s crew received an alert before the derailment and, if they did, whether the help desk told them to disregard it. The company did not address questions about its policy giving its help desk leeway to ignore such alerts. A spokesperson said that the company’s detector network is a massive safety investment, and that its trains rarely require troubleshooting.

ProPublica asked officials at the six other large freight railroad companies whether they have similar policies allowing employees to disregard such alerts. CSX and Burlington Northern Santa Fe said they don’t, and Canadian National said that no one can instruct a crew to continue traveling when they receive an alert “requiring them to stop the train.” Union Pacific, Canadian Pacific and Kansas City Southern did not respond.

While some employees and outside experts say there are times in which such policies safely benefit business operations, union officials believe they are emblematic of Precision Scheduled Railroading, the most controversial — and profitable — innovation that’s come out of the country’s seven biggest railroads, the so-called Class 1s, in the last decade. It prioritizes keeping rail cars and locomotives in constant motion.

Gabriel Sandoval and Danelle Morton contributed reporting.

by Topher Sanders and Dan Schwartz

Help ProPublica and The Salt Lake Tribune Investigate Sexual Assault in Utah

2 years 1 month ago

If you need to report or discuss a sexual assault in Utah, you can call the Rape and Sexual Assault Crisis Line at 801-736-4356. Those who live outside of Utah can reach the National Sexual Assault Hotline at 800-656-4673.

The Salt Lake Tribune has partnered with ProPublica, a nonprofit investigative newsroom, to investigate sexual assault in Utah, and we’d like to hear from survivors and others with knowledge about this topic to help guide our coverage.

We’re reporting on sexual assault by health care professionals, an issue we highlighted in our story about a Provo OB-GYN who was sued by nearly 100 women who said he sexually assaulted them during treatments. You can fill out our confidential form below to tell us about other practitioners and health care institutions you think we should report on.

Salt Lake Tribune reporter Jessica Miller has written multiple stories about sexual assault, including at Brigham Young University, and ProPublica has worked with survivors across the country to tell their stories. We hope our continued coverage of this issue will lead to further impact.

We appreciate you sharing your story, and we take your privacy seriously. We are gathering these stories for the purposes of our reporting, and we will contact you if we wish to publish any part of your story. We may not be able to look into every tip, but we appreciate each one we receive and they will help shape our reporting.

If you would prefer to use an encrypted app, see our advice at propublica.org/tips. You can reach reporter Jessica Miller by email at jmiller@sltrib.com.

by Jessica Miller, The Salt Lake Tribune

94 Women Allege a Utah Doctor Sexually Assaulted Them. Here’s Why a Judge Threw Out Their Case.

2 years 1 month ago

This story discusses sexual assault.

This article was produced for ProPublica’s Local Reporting Network in partnership with The Salt Lake Tribune. Sign up for Dispatches to get stories like this one as soon as they are published.

At 19 years old and about to be married, Stephanie Mateer went to an OB-GYN within walking distance of her student housing near Brigham Young University in Provo, Utah.

She wanted to start using birth control, and she was looking for guidance about having sex for the first time on her 2008 wedding night.

Mateer was shocked, she said, when Dr. David Broadbent reached under her gown to grab and squeeze her breasts, started a vaginal exam without warning, then followed it with an extremely painful examination of her rectum.

She felt disgusted and violated, but doubt also creeped in. She told herself she must have misinterpreted his actions, or that she should have known that he would do a rectal exam. Raised as a member of The Church of Jesus Christ of Latter-day Saints, she said she was taught to defer to men in leadership.

“I viewed him as being a man in authority,” Mateer said. “He’s a doctor.”

It was years, Mateer said, before she learned that her experience was in a sharp contrast to the conduct called for in professional standards, including that doctors use only their fingertips during a breast exam and communicate clearly what they are doing in advance, to gain the consent of their patient. Eventually, she gave her experience another name: sexual assault.

Utah judges, however, have called it health care.

And that legal distinction means Utahns like Mateer who decide to sue a health care provider for alleged sexual abuse are treated more harshly by the court system than plaintiffs who say they were harmed in other settings.

The chance to go to civil court for damages is an important option for survivors, experts say. While a criminal conviction can provide a sense of justice, winning a lawsuit can help victims pay for the therapy and additional support they need to heal after trauma.

Mateer laid out her allegations in a lawsuit that she and 93 other women filed against Broadbent last year. But they quickly learned they would be treated differently than other sexual assault survivors.

Filing their case, which alleged the Utah County doctor sexually assaulted them over the span of his 47-year career, was an empowering moment, Mateer said. But a judge threw out the lawsuit without even considering the merits, determining that because their alleged assailant is a doctor, the case must be governed by medical malpractice rules rather than those that apply to cases of sexual assault.

Under Utah’s rules of medical malpractice, claims made by victims who allege a health care worker sexually assaulted them are literally worth less than lawsuits brought by someone who was assaulted in other settings — even if a jury rules in their favor, a judge is required to limit how much money they receive. And they must meet a shorter filing deadline.

“It’s just crazy that a doctor can sexually assault women and then be protected by the white coat,” Mateer said. “It’s just a really scary precedent to be calling sexual assault ‘health care.’”

Mateer in 2008, the year she first saw Dr. David Broadbent, an OB-GYN, in advance of her wedding night (Courtesy of Stephanie Mateer)

Because of the judge’s ruling that leaves them with a shorter window in which to file, some of Broadbent’s accusers stand to lose their chance to sue. Others were already past that deadline but had hoped to take advantage of an exception that allows a plaintiff to sue if they can prove that the person who harmed them had covered up the wrongdoing and if they discovered they had been hurt within the previous year.

As a group, the women are appealing the ruling to the Utah Supreme Court, which has agreed to hear the case. This decision will set a precedent for future sexual assault victims in Utah.

Broadbent’s attorney, Chris Nelson, declined an interview request but wrote in an email: “We believe that the allegations against Dr. Broadbent are without merit and will present our case in court. Given that this is an active legal matter, we will not be sharing any details outside the courtroom.”

States have varying legal definitions of medical malpractice, but it’s generally described as treatment that falls short of accepted standards of care. That includes mistakes, like a surgeon leaving a piece of gauze inside a patient.

Utah is among the states with the broadest definition of medical malpractice, covering any acts “arising” out of health care. The Utah Supreme Court has ruled that a teenage boy was receiving health care when he was allowed to climb a steep, snow-dusted rock outcrop as part of wilderness therapy. When he broke his leg, he could only sue for medical malpractice, so the case faced shorter filing deadlines and lower monetary caps. Similarly, the court has ruled that a boy harmed by another child while in foster care was also bound by medical malpractice law.

Despite these state Supreme Court rulings, Utah legislators have so far not moved to narrow the wording of the malpractice act.

The lawsuit against Broadbent — and the questions it raises about the broadness of Utah’s medical malpractice laws — comes during a national reckoning with how sexual assault survivors are treated by the law. Legislators in several states have been rewriting laws to give sexual assault victims more time to sue their attackers, in response to the growing cultural understanding of the impact of trauma and the barriers to reporting. Even in Utah, those who were sexually abused as children now have no deadline to file suits against their abusers.

That isn’t true for sexual abuse in a medical setting, where cases must be filed within two years of the assault.

These higher hurdles should not exist in Utah, said state Sen. Mike McKell, a Utah County Republican who works as a personal injury attorney. He is trying to change state law to ensure that sexual assault lawsuits do not fall under Utah’s Health Care Malpractice Act, a law designed to cover negligence and poor care, not necessarily deliberate actions like an assault.

Utah Sen. Mike McKell introduced a bill that would clarify that sexual assault claims should not be considered medical malpractice, removing legal obstacles for survivors who have been assaulted by health care workers. (Leah Hogsten/The Salt Lake Tribune)

“Sexual assault, to me, is not medical care. Period,” he said. “It’s sad that we need to clarify that sexual assault is not medical care. But trying to tie sexual assault to a medical malpractice [filing deadline] — it’s just wrong.”

“Your Husband Is a Lucky Man”

Mateer had gone to Broadbent in 2008 for a premarital exam, a uniquely Utah visit often scheduled by young women who are members of The Church of Jesus Christ of Latter-day Saints.

Leaders of the faith, which is predominant in Utah, focus on chastity when speaking to young, unmarried people about sex, and public schools have typically focused on abstinence-based sex education. So for some, these visits are the first place they learn about sexual health.

Young women who get premarital exams are typically given a birth control prescription, but the appointments can also include care that’s less common for healthy women in other states — like doctors giving them vaginal dilators to stretch their tissue before their wedding night.

That’s what Mateer was expecting when she visited Broadbent’s office. The OB-GYN had been practicing for decades in his Provo clinic nestled between student housing apartments across the street from Brigham Young University, which is owned by The Church of Jesus Christ of Latter-day Saints.

The Provo, Utah, office building where Broadbent once practiced (Leah Hogsten/The Salt Lake Tribune)

So Mateer was “just totally taken aback,” she said, by the painful examination and by Broadbent snapping off his gloves after the exam and saying, “Your husband is a lucky man.”

She repeated that remark in her legal filing, along with the doctor’s advice for her: If she bled during intercourse, “just do what the Boy Scouts do and apply pressure.”

“The whole thing was like I’m some object for my husband to enjoy and let him do whatever he wants,” Mateer said. “It was just very violating and not a great way to start my sexual relationship with my new husband, with these ideas in mind.”

Mateer thought back to that visit over the years, particularly when she went to other OB-GYNs for health care. Her subsequent doctors, she said, never performed a rectal exam and always explained to her what they were doing and how it would feel, and asked for her consent.

She thought about Broadbent again in 2017, as the #MeToo movement gained momentum, and looked him up online. Mateer found reviews from other women who described Broadbent doing rough examinations without warning that left them feeling the same way she had years before.

Then in December 2021, she spoke out on “Mormon Stories,” a podcast where people who have left or have questioned their Latter-day Saint faith share their life stories. In the episode, she described the painful way he examined her, how it left her feeling traumatized and her discovery of the reviews that echoed her experience.

“He’s on University Avenue, in Provo, giving these exams to who knows how many naive Mormon 18-year-old, 19-year-old girls who are getting married. … They are naive and they don’t know what to expect,” she said on the podcast. “His name is Dr. David Broadbent.”

After the podcast aired, Mateer was flooded with messages from women who heard the episode and reached out to tell her that Broadbent had harmed them, too.

Mateer and three other women decided to sue the OB-GYN, and in the following weeks and months, 90 additional women joined the lawsuit they filed in Provo. Many of the women allege Broadbent inappropriately touched their breasts, vaginas and rectums, hurting them, without warning or explanation. Some said he used his bare hand — instead of using a speculum or gloves — during exams. One alleged that she saw he had an erection while he was touching her.

Broadbent’s actions were not medically necessary, the women allege, and were instead “performed for no other reason than his own sexual gratification.”

The lawsuit also named as defendants two hospitals where Broadbent had delivered babies and where some of the women allege they were assaulted. The suit accused hospital administrators of knowing about Broadbent’s inappropriate behavior and doing nothing about it.

After he was sued, the OB-GYN quickly lost his privileges at the hospitals where he worked. Broadbent, now 75, has also voluntarily put his medical license in Utah on hold while police investigate 29 reports of sexual assault made against him.

Prosecutors are still considering whether to criminally prosecute Broadbent. Provo police forwarded more than a dozen reports to the Utah County attorney’s office in November, which are still being reviewed by a local prosecutor.

A spokesperson for Intermountain Health, the nonprofit health system that owns Utah Valley Hospital, where some of the women in the suit were treated, did not respond to specific questions. The spokesperson emphasized in an email that Broadbent was an “independent physician” who was not employed by Utah Valley Hospital, adding that most of the alleged incidents took place at Broadbent’s medical office.

A representative for MountainStar Healthcare, another hospital chain named as a defendant, denied knowledge of any allegations of inappropriate conduct reported to its hospital and also emphasized that Broadbent worked independently, not as an employee.

“Our position since this lawsuit was filed has been that we were inappropriately named in this suit,” said Brittany Glas, the communications director for MountainStar.

Debating Whether Sexual Abuse Is Health Care

For the women who sued Broadbent, their case boiled down to a key question: Were the sexual assaults they say they experienced part of their health care? There was a lot hanging on the answer.

If their case was considered medical malpractice, they would be limited in how much money they could receive in damages for their pain and suffering. If a jury awarded them millions of dollars, a judge would be required by law to cut that down to $450,000. There’s no cap on these monetary awards for victims sexually assaulted in other settings.

They would also be required to go before a panel, which includes a doctor, a lawyer and a community member, that decides whether their claims have merit. This step, aimed at resolving disputes out of court, does not block anyone from suing afterward. But it does add cost and delay, and for sexual assault victims who’ve gone through this step, it has been another time they were required to describe their experiences and hope they were believed.

The shorter, two-year filing deadline for medical malpractice cases can also be a particular challenge for those who have been sexually abused because research shows that it’s common to delay reporting such assaults.

Nationwide, these kinds of malpractice reforms were adopted in the 1970s amid concerns — largely driven by insurance companies — that the cost of health care was rising because of frivolous lawsuits and “runaway juries” doling out multimillion-dollar payouts.

Restricting the size of malpractice awards and imposing other limits, many argued, were effective ways to balance compensating injured patients with protecting everyone’s access to health care.

State laws are generally silent on whether sexual assault lawsuits should be covered by malpractice laws, leaving courts to grapple with that question and leading to different conclusions across the country. The Tribune and ProPublica identified at least six cases in which state appellate judges sharply distinguished between assault and health care in considering whether malpractice laws should apply to sexual assault-related cases.

An appellate court in Wisconsin, for example, ruled in 1993 that a physician having an erection and groping a patient was a purposeful harm, not medical malpractice.

Florida’s law is similar to Utah’s, defining allegations “arising” out of medical care as malpractice. While an earlier ruling did treat sexual assault in a health care setting as medical malpractice, appellate rulings in the last decade have moved away from that interpretation. In 2005, an appellate court affirmed a lower-court ruling that when a dentist “stopped providing dental treatment to the victim and began sexually assaulting her, his professional services ended.”

Similarly, a federal judge in Iowa in 1995 weighed in on the meaning of “arising” out of health care: “Rape is not patient care activity,” he wrote.

But Utah’s malpractice law is so broad that judges have been interpreting it as covering any act performed by a health care provider during medical care. The law was passed in 1976 and is popular with doctors and other health care providers, who have lobbied to keep it in place — and who use it to get lawsuits dismissed.

Broadbent’s name has been removed from the directory outside his former office suite. (Leah Hogsten/The Salt Lake Tribune)

One precedent-setting case in Utah shows the law’s power to safeguard health care providers and was an important test of how Utah defines medical malpractice. Jacob Scott sued WinGate Wilderness Therapy after the teen broke his leg in 2015 when a hiking guide from the center allowed him to climb up and down a steep outcrop in Utah’s red rock desert.

His parents are both lawyers, and after they found that Utah had a four-year deadline for filing a personal injury lawsuit, court records said, they decided to prioritize “getting Jacob better” for the first two years after the accident. But when Scott’s suit was filed, WinGate argued it was too late — based on the shorter, two-year deadline for medical malpractice claims.

Scott’s attorneys scoffed. “Interacting with nature,” his attorneys argued, “is not health care even under the broadest interpretation of … the Utah Health Care Malpractice Act.”

A judge disagreed and threw out Scott’s case. The Utah Supreme Court unanimously upheld that ruling in 2021.

“We agree with Wingate,” the justices wrote, “that it was acting as a ‘health care provider’ and providing ‘health care’ when Jacob was hiking and rock climbing.”

Last summer, the women who had sued Broadbent and the two hospitals watched online as lawyers debated whether the abuse they allegedly suffered was health care.

At the hearing, attorneys for Broadbent and the hospitals argued that the women should have pursued a medical malpractice case, which required them to first notify Broadbent and the hospitals that they wanted to sue. They also argued to Judge Robert Lunnen that the case couldn’t move forward because the women hadn’t gone before a pre-litigation panel.

Attorneys for Broadbent and the hospitals argued, one after the other, that the painful and traumatic exams the women described arose out of health care treatments.

“Accepting the allegations of the complaint as true — as we must for purposes of this proceeding — we have to assume that [Broadbent] did something that was medically unnecessary, medically inappropriate,” argued David Jordan, a lawyer for Intermountain Health.

“But it doesn’t change the fact that it’s an act performed to a patient, during the patient’s treatment,” he said. “Because that’s what the patient is doing in the doctor’s office. They’re there for treatment.”

The attorney team for the women pushed back. Terry Rooney argued that if Broadbent’s actions fell under medical malpractice laws, many women would be knocked out of the case because of the age of their claims, and those who remained would be limited in the amount of money in damages they could receive.

“That’s really what this is about,” he argued. “And so it’s troubling — quite frankly it’s shocking to me — that we’re debating heavily the question of whether sexual abuse is health care.”

The judge mulled the issue for months. Lunnen wrote in a September ruling that if the allegations were true, Broadbent’s treatment of his patients was “insensitive, disrespectful and degrading.”

But Utah law is clear, he said. Malpractice law covers any act or treatment performed by any health care provider during the patient’s medical care. The women had all been seeking health care, Lunnen wrote, and Broadbent was providing that when the alleged assaults happened.

Their lawsuit was dismissed.

“I Felt Defeated”

Brooke, another plaintiff who alleges Broadbent groped her, remembers feeling sick on the June day she watched the attorneys arguing. She asked to be identified by only her first name for this story.

She alleges Broadbent violated her in December 2008 while she was hospitalized after experiencing complications with her first pregnancy.

Brooke, one of the women suing Broadbent, says the OB-GYN groped her when she was in the hospital after having complications with her first pregnancy. (Leah Hogsten/The Salt Lake Tribune)

The nearest hospital to her rural town didn’t have a special unit to take care of premature babies, and her doctors feared she might need to deliver her son six weeks early. So Brooke had been rushed by ambulance over a mountain pass in a snowstorm to Utah Valley Hospital.

Brooke and her husband were terrified, she said, when they arrived at the Provo hospital. Broadbent happened to be the doctor on call. With Brooke’s husband and brother-in-law in the room, Broadbent examined her late that evening, she said, listening to her chest with a stethoscope.

The doctor then suddenly grabbed her breasts, she recalled — his movements causing her hospital gown to fall to expose her chest. She recounted this experience in her lawsuit, saying it was nothing like the breast exams she has had since.

“It was really traumatizing,” she said. “I was mortified. My husband and brother-in-law — we just didn’t say anything about it because it was so uncomfortable.”

Brooke voiced concerns to the nurse manager, and she was assigned a new doctor.

She gave birth to a healthy baby a little more than a month later, at the hospital near her home.

Hearing the judge’s ruling 14 years later, Brooke felt the decision revealed how Utah’s laws are broken.

“I was frustrated,” she said, “and I felt defeated. … I thought justice is not on our side with this.”

If the Utah Supreme Court rules that these alleged sexual assaults should legally be considered health care, the women will likely refile their claims as a medical malpractice lawsuit, said their attorney, Adam Sorensen. But it would be a challenge to keep all 94 women in the case, he said, due to the shorter filing window. Only two women in the lawsuit allege that they were harmed within the last two years.

The legal team for the women would have to convince a judge that their claims should still be allowed because they only recently discovered they were harmed. But based on previous rulings, Sorensen believes the women will have a better chance to win that argument if the civil suit remained a sexual assault case.

Regardless of what happens in their legal case, the decision by Brooke and the other women to come forward could help change state law for victims who come after them.

Last week, McKell, the state senator, introduced legislation to clarify that civil lawsuits alleging sexual assault by a health care worker do not fall under Utah’s Health Care Malpractice Act.

“I don’t think it’s a close call. Sexual assault is not medical care,” he said. “I know we’ve got some bizarre rulings that have come down through our courts in Utah.”

Both an association of Utah trial lawyers and the Utah Medical Association, which lobbies on behalf of the state’s physicians, support this reform.

“We support the fact that sexual assault should not be part of health care medical malpractice,” said Michelle McOmber, the CEO for the Utah Medical Association. “Sexual assault should be sexual assault, regardless of where it happens or who’s doing it. Sexual assault should be in that category, which is separate from actual health care. Because it’s not health care.”

MountainStar doesn’t have a position on the bill, Glas said. “If the laws were to change via new legislation and/or interpretation by the courts, we would abide by and comply with those new laws.”

But lawmakers are running out of time. With only a week and a half left in Utah’s legislative session, state senate and house leaders have so far prioritized passing new laws banning gender-affirming health care for transgender youths and creating a controversial school voucher program that will provide taxpayer funds for students to attend private school.

Utah lawmakers were also expected to consider a dramatic change for other sexual assault victims: a bill that would remove filing deadlines for civil lawsuits brought by people abused as adults. But that bill stalled before it could even be debated.

Brooke had been eager to share her story, she said, in hopes it would help the first four women who’d come forward bolster their lawsuit against Broadbent. She later joined the case as a plaintiff. She read in their lawsuit about one woman who complained about him to the same hospital seven years before she did, and about another woman who said Broadbent similarly molested her two days after Brooke had expressed her own concern.

“That bothered me so much,” she said. “It didn’t have to happen to all these women.”

Brooke doubts she’ll get vindication in a courtroom. Justice for her, she suspects, won’t come in the form of a legal ruling or a settlement against the doctor she says hurt her years ago.

Instead, she said, “maybe justice looks like changing the laws for future women.”

Help ProPublica and The Salt Lake Tribune Investigate Sexual Assault in Utah

If you need to report or discuss a sexual assault in Utah, you can call the Rape and Sexual Assault Crisis Line at 801-736-4356. Those who live outside of Utah can reach the National Sexual Assault Hotline at 800-656-4673.

Mollie Simon contributed research.

by Jessica Miller, The Salt Lake Tribune

Regulators Overhaul Inspections of Hospice Providers

2 years 1 month ago

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In late January, amid intensifying scrutiny of the quality of care provided by the American end-of-life care industry, the Centers for Medicare and Medicaid Services has reformed how it inspects hospice providers. The changes, detailed in a 196-page document, went into effect immediately.

Under the new protocol, inspectors must sample data from multiple locations where the hospice operates and evaluate a broader range of metrics. These include records on the hospice’s inpatient care, bereavement practices and reasons patients are leaving the service alive. “An unusually high rate of live discharges could indicate that a hospice provider is not meeting the needs of patients and families or is admitting patients who do not meet the eligibility criteria,” the revised rules note.

The rules also include directives for inspectors to evaluate the abuse and neglect of patients — an issue that has long plagued hospice providers, according to investigations from both the media and the Department of Health and Human Services Inspector General’s Office. In fact, surveyors are now required to consult news reports, previous complaints and patient reviews about the hospice in question before they begin an inspection.

In November, a ProPublica-New Yorker investigation exposed the way easy money and lax regulation have transformed a charity movement into a $22 billion juggernaut rife with exploitation. It also described an alarming network of entrepreneurs propping up for-profit hospices in Nevada, Texas, Arizona and California. State and federal licensing data showed that addresses in Phoenix, Houston, Las Vegas and Los Angeles were reportedly home to dozens — sometimes hundreds — of hospice startups, many with the same owners.

The overhaul of the inspection requirements is the most concrete reform to date to emerge from the recent push for and discussion surrounding greater oversight of the American end-of-life care industry.

The demands continue to grow. Last week, a bipartisan coalition from the House of Representatives sent a public letter to CMS Administrator Chiquita Brooks-LaSure calling for a crackdown on fraud and abuse of the hospice benefit.

“As you know, ProPublica and The New Yorker published an article on November 28, 2022 detailing horrific allegations of fraud ​​from newly certified hospices that run the gamut of wasting taxpayer dollars to putting vulnerable patients in danger,” the letter states. “The various instances of gaming the system and harming patients raises a number of questions about how the hospice benefit is currently implemented and how the federal government can better partner with stakeholders and state agencies to stop this going forward.”

The letter from the House is the latest instance of lawmakers asking CMS to protect dying patients and their families. In December, three weeks after the publication of the ProPublica-New Yorker exposé, a bipartisan group of senators sent their own letter to Brooks-LaSure noting that “further evidence of apparent Medicare fraud cannot be ignored.”

Both sets of lawmakers have requested briefings from CMS on the agency’s plans to penalize bad actors and what additional authority, if any, it will need from Congress to carry them out.

“Hospice can be an important part of a patient’s care, but only if it is operating as intended,” the representatives wrote in the letter sent last week. “We stand ready to work with CMS to ensure that this continues to be a safe option for patients while ensuring that congressional oversight is carried out.”

Industry leaders have echoed these concerns. In an effort hailed by experts as “unusual and impressive,” the national trade associations for palliative care providers have banded together to advocate for more regulation. Just last week, the groups met with Brooks-LaSure to discuss a joint list of 34 recommendations for strengthening program integrity. At the meeting, the trade groups spoke to CMS about developing a list of “red flag criteria” that would trigger additional scrutiny before hospice owners could start billing Medicare. The groups also reiterated their suggestion that the agency implement a targeted ban on new hospices in high-growth areas.

A CMS spokesperson told ProPublica that the agency “takes the oversight role of the Medicare hospice program seriously and is aggressively focused on reducing and eliminating fraud, waste and abuse.”

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by Ava Kofman

School District Pays Legal Fees After Banning Mothers From Reading Sexually Graphic Passages at Meetings

2 years 1 month ago

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A group of conservative Georgia mothers on a quest to ban library books has won a key victory against a school district that sought to limit their ability to recite graphic passages from those books at school board meetings.

Forsyth County Schools agreed this month to pay $107,500 in legal fees to the group, called the Mama Bears. Like many conservatives nationwide, the Mama Bears have taken to trying to get books removed from school libraries by reading sexually explicit passages aloud at school board meetings.

The agreement to pay legal fees stems from a late January consent judgment and injunction against the school district. The Mama Bears’ July 2022 lawsuit against the district detailed how Forsyth’s school board banned one mother from attending its meetings. The woman, Alison Hair, had insisted on reading sexually explicit material aloud before the board.

“The hope is that other elected officials, people who are on school boards and thinking about running for school board, or school officials that interact with them like superintendents, see this result and are more careful when they are tempted to censor other parents in the future,” said Del Kolde, a senior attorney with the Institute for Free Speech, a D.C.-based nonprofit that opposes campaign finance restrictions and represented the Mama Bears pro bono.

The January injunction prevents the district from enforcing what a federal judge called its “respectfulness requirement,” which school board members used as grounds to prohibit the Mama Bears’ read-alouds. The policy also had prevented the public from personally addressing board members and the superintendent or from using profane, uncivil or abusive remarks.

A spokesperson for the Forsyth County School District said its leaders are considering a revision to the policy, which most notably would eliminate language that speakers must conduct themselves in “a respectful manner.” It would also eliminate a rule that speakers not address board members individually nor be loud and boisterous. The revised proposal makes clear that law enforcement may get involved should speakers make physically threatening remarks, hateful racial epithets or other comments that would result in a meeting disruption. The board is set to vote on the new policy tonight

Kolde said emails discovered in the course of the lawsuit showed how school officials worked to make it harder for parents to criticize them.

In a March 24 email, Forsyth County Superintendent Jeff Bearden wrote to the board and a district spokesperson: “We must stop the ‘playing to the audience, pep rally mentality.’ One way to do that is limiting the amount of time for public participation.” He went on to suggest cutting total public participation at each meeting to 15 minutes.

Days earlier, Jennifer Caracciolo, the district’s communications director, urged the board to “take back the purpose” of the meetings.

“We must get back to our BOE meetings being about the work of the district and not about providing a public platform,” she wrote.

In a statement, the district said the emails Kolde cited were sent 11 months ago: “A lot has happened since they were sent, including this lawsuit which was settled between both parties. As such, as a district, we have moved forward from this issue.”

Individual school board members declined to comment on the settlement itself.

Cindy Martin, a mother of four and chair of the Mama Bears, said the group, dissatisfied with the district’s refusal to remove titles from shelves, continues to challenge books at meetings. The lawsuit, she said, was a victory even for people who disagree with their cause.

“The message is, you are servants of the American people, and you cannot silence those you serve,” Martin said in an email. “The freedom to speak is essential for our constitutional republic to survive. Government officials must always respect it and uphold it, even when it's speech they don't like.”

Kevin Goldberg, an attorney and First Amendment specialist with the nonprofit free-speech advocacy group Freedom Forum, said the Mama Bears’ victory could lead to even more challenges of restrictions on what people can say at school board meetings and who can be banned from them.

“It’s going to embolden other individuals and groups to stand up to school boards,” Goldberg said. “Because now they’re seeing one organization come out of this with success.

“This is a loss for the school board and, frankly, it’s a success for free speech.”

by Nicole Carr

Settling With Kushner Companies Was Hard. Getting Money to Former Tenants May Be Harder.

2 years 1 month ago

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A decade ago, Jasmine Cox was living with her young son in the Cove Village rental complex in Essex, Maryland, just east of Baltimore, when she started experiencing a plague of problems. The bedroom ceiling started leaking one day, then maggots started coming out of the living room carpet, and then raw sewage started flowing out of the kitchen sink, she said. She stopped cooking to keep food away from the sink. With so much black mold around, her son started needing an inhaler. When she moved out soon afterward, the landlord, Westminster Management, sent her a $600 invoice for a new carpet and other repairs.

The experience haunted her for years. So she was hit with a welter of emotions when she recently received a letter at her new home from the Maryland attorney general, alerting her that she could apply for restitution from Westminster, the property management arm of Kushner Companies, the family real estate company of Jared Kushner, former President Donald Trump’s son-in-law and a former senior adviser to the president. She has started going through old SD cards and photo-storage apps to find pictures of the apartment woes to submit with the claims form that accompanied the letter. “We were living in a biohazard,” she said. “I’m just glad something has come about to compensate people, to clear things up.”

The letter and claims form are part of a massive, highly unusual effort on the part of the attorney general’s office: trying to alert some 30,000 people who lived in Westminster Management’s 17 Baltimore-area complexes during the past decade that they may be eligible for restitution. In 2017, the office launched an investigation of the company following a report co-published by ProPublica and The New York Times Magazine on the company’s aggressive pursuit of current and former tenants over allegations of unpaid rent and poor upkeep of many of the units, which New Jersey-based Kushner Companies started buying in 2012 and has mostly sold off in recent years.

Last September, the office’s Consumer Protection Division announced a settlement with Westminster: a $3.25 million fine and the promise of uncapped restitution to tenants of the complexes who could show that they had suffered serious maintenance troubles that Westminster was slow to address. Under the settlement, Westminster would also automatically reimburse tenants and former tenants for excessive fees they had been charged over the years in addition to their rent.

Now comes the hardest part: finding the tens of thousands of people who resided at the Westminster Management properties to let them know about their chance at restitution, a task made all the more challenging by the high levels of transience at the complexes. Just 8,700 of the 30,000 people who were mailed claims forms by a claims administrator since mid-December are still living at the complexes.

“Some people won’t be reachable,” acknowledged then-Attorney General Brian Frosh in an interview with The Baltimore Banner when the settlement was announced in September. “Some people will say, ‘Oh my God, I can’t take days off work again to go do this, I mean what am I going to get out of it?’” He guessed that fewer than half of eligible tenants will participate in the process.

By the end of January, 281 claims had been filed. “It’s a little lower than we expected,” said Attorney General Anthony Brown, who took office last month.

The attorney general’s office is contacting tenants to confirm that they’ve received the claims form, according to spokesperson Aleithea Warmack. Any money left over from the initial $800,000 slice of the settlement set aside for tenant restitution will go to a fund to pay for attorneys for people facing eviction, according to recent legislation. If the restitution exceeds $800,000, the company will have to pay that amount on top of the $3.25 million penalty.

Among those the state and Westminster have so far failed to reach is Andre Willingham, a longtime resident of Dutch Village, a complex on the northern edge of Baltimore. The 58-year-old, who is on disability from injuries sustained from years working as a restaurant cook, has lived at the complex with his family for nine years, but he said he had not received anything in the mail.

If he had received it, he said, he would have filed a claim, listing the problems he experienced in the family’s two-bedroom unit, for which they pay $1,100 in rent: rodents, a broken toilet, no heat. But he worried about the fact that he did not have documentation of the problems. “It’s a sad thing they’re just coming out with it,” he said.

Separate from the restitution process for maintenance problems, which requires submitting a claim by Dec. 19, many tenants will be receiving reimbursements for fees they were improperly charged by Westminster. This will not require them to send in claims forms; the company is required to compile a list of eligible tenants by May and send them payments by August.

Those claims alone will likely total several hundred thousand or even a million dollars, Brown estimated. The attorney general’s office will follow up in early 2024 to confirm that payments were successfully deposited or, if not, to make sure former tenants who are owed money are located. Current and former tenants will also have a second opportunity to seek damages for the improper fees in a class-action lawsuit that won a successful appeal last month.

The claims process for maintenance-related issues is somewhat more cumbersome — and the first stage relies on Westminster. The company will make an initial determination of how much compensation claimants are owed. If the tenants are not satisfied, they can elect to have their case heard in court or remotely by retired state Judge Nathan Braverman, who was retained by the attorney general’s office as a special master in the cases, according to Brown. “The rules of evidence are relaxed,” Brown said, adding, “You don’t have to prove any amount of damages — it’s presumed that you suffered damages.”

It’s an approach that he believes his office is the first in the country to implement. “We really think that it’s novel, and we think it can be an effective way to really get recovery for these aggrieved renters.”

But how many current and former tenants will actually take advantage of this process remains an open question, and one that will have a big impact on how much money Westminster is actually required to pay out.

For one tenant, the process has so far proved disappointing. Bonita Barrett, a retired grocery worker, contended for years with a slew of maintenance problems in her unit at Dutch Village, including leaks, mold, and a lack of heat. She was excited to receive the letter and claims form, and checked off most of the 10 upkeep problems listed as eligible for compensation before mailing it off. “They was thieves,” she said. “I hope we get what we deserve.”

But last week, Barrett got a call from a New Jersey number in response to her claims form. The woman on the line told her that she was eligible for $200 in compensation, which Barrett found insultingly inadequate for everything she had dealt with over the years. “$200? That’s nothing compared to what I went through,” she said. “You’re just going to offer us something to say you’re doing something. They’re just trying to give us the cheapest amount they can.” (In response to questions, Kushner Companies Chief Operating Officer Peter Febo wrote: “Westminster takes the Consent Order seriously and continues to comply with it in all respects. The mechanics and details of the claims process were agreed to between the Consumer Protection Division and Westminster.”)

Barrett said the woman told her that she could not qualify for a larger sum because she did not have evidence of the extent of the problems; the woman noted that Westminster’s records showed 16 completed work orders for her unit. But, Barrett said, that didn’t address how long it often took to complete that work.

On the call, the Westminster representative told Barrett that if she was unsatisfied with the $200 settlement, she could appeal to the special master. But that struck Barrett as unappealing. Wasn’t the purpose of this extended process to keep tenants from having to fight Kushner Companies again? The attorney general’s office had designed the appeal process to be as consumer-friendly as possible, but that’s not the impression she got from the call.

“She said you can go to court, but how long would that take? That could take as long as they did here,” she said. “It took them long enough to get to where we are now.”

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If you think you’re eligible to receive settlement money and want more information, you can call the claims administrator at 410-581-0800. If you are a tenant with a complaint you’d like the attorney general’s office to look into, you can call the housing unit within the Consumer Protection Division at 410-528-8662.

by Sophie Kasakove, The Baltimore Banner, and Alec MacGillis, ProPublica

How One Mom Fought Washington’s Special Education System — and Won

2 years 2 months ago

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In September, Megan Cummings sat down at a conference table across from four Tacoma, Washington, school officials who could determine the course of her son’s education.

ElijahKing, 14, had run away from his middle school earlier that week during an argument with a classmate. Cummings believed the group, which managed her son’s special education plan, wanted to discuss how to better support him. ElijahKing swiveled nervously in a chair beside her.

Instead, the Tacoma Public Schools educators told Cummings that ElijahKing couldn’t come back. He would be sent to a school for children with complex disabilities, one of a network of private special education programs that serve about 500 public school students.

ElijahKing turned away from the group, his eyes welling up.

Cummings had read online reviews accusing the school’s staff of mistreating kids. She pleaded with the district officials to give ElijahKing a second chance, but it was too late. He had already been enrolled in the new school.

Like other parents, Cummings was confronting a flaw in Washington’s special education system: It has failed to monitor the private schools that serve some of the state’s most vulnerable kids, leading to a wide range in the quality of the programs. Some are highly sought-after schools offering intensive therapy and instruction tailored to specific disabilities. Others, as The Seattle Times and ProPublica recently documented, have faced years of complaints about understaffing, lack of curriculum and a reliance on restraint and isolation to control student behavior.

The disparity among schools forces parents to take extraordinary measures to find a way around the system’s flaws. Some of them hire lawyers to help shepherd their kids toward the best schools — or keep them out of the worst.

“A lot of the advocacy comes down to resources and who has power and can get an attorney,” said Carrie Basas, the former director of the Washington State Governor’s Office of the Education Ombuds. “You have families that understand there are places they can lobby hard for, instead of having their kids sent somewhere else.”

Cummings — a single mother of two children with disabilities who had recently been homeless — didn’t have power or resources. But she did have one thing in common with many of the parents who take on the system: an unyielding determination to defend her child’s education.

Underfunded and Inequitable

Programs like the one ElijahKing was enrolled in, known as “nonpublic agencies,” are meant to offer more intensive services that districts say they can’t provide in public schools.

School districts often work with families to find the right educational setting. Some parents seek out — and push districts to pay for — highly regarded nonpublic agencies that can cater to their students’ disabilities. Others, like Cummings, want their kids integrated in their neighborhood schools with additional support, but districts steer their kids to poorly performing nonpublic agencies instead.

To some extent, this push and pull exists in every state. The federal Individuals with Disabilities Education Act allows families to settle disputes about their child’s special education through a due process hearing, where a school district can be ordered to provide certain education services or to place the child in a specialized school.

But Washington’s weak oversight, and its increased reliance on separate schools for students with disabilities, makes educational inequities particularly acute here. That system exposes disadvantaged kids to programs with the worst reputations. Though the state and school districts spent at least $173 million on the programs over the five school years ending in 2021, the state has few academic standards and no centralized system for tracking key measures like how often the schools restrain students.

ElijahKing was being sent to one of the schools with the worst reputations, the Northwest School of Innovative Learning. School districts have complained to the state for years about problems there, including classrooms being led by unqualified aides instead of certified special education teachers, a recent Seattle Times and ProPublica investigation found. The school has also faced allegations of abuse, including an incident, caught on surveillance video, in which a teacher put a 13-year-old boy in a chokehold.

And former staffers reported feeling pressured by the school’s owner, Fairfax Hospital, and its parent company, Universal Health Services, to skimp on staffing and resources while enrolling more students than staff could handle.

In 2019, a speech language pathologist visited the Northwest School of Innovative Learning and found a school “in disarray,” including this teacher resource room. The school director responded that the room was off-limits to students and the building had many unused areas. (Courtesy of Andrea Duffield)

The company previously defended the program in a statement to the Times and ProPublica, saying administrators take seriously the responsibility of addressing students’ complex needs. It denied that Northwest SOIL understaffed campuses and declined to comment on specific allegations of abuse, but said “restraints and seclusion are always used as a last response when a student is at imminent risk of hurting themselves or others.”

Though the state releases only limited demographic data to protect student privacy, the figures that are available — for larger schools — point to disparities in which children get access to better schools. Among the larger schools, Northwest SOIL stands out, with one of the highest proportions of low-income students. It also has above-average shares of homeless students and Black students, an analysis of 2020-21 school year data shows.

Fairfax, the largest private psychiatric hospital in Washington, attributed Northwest SOIL’s student composition in part to the demographics of nearby districts that send the most students to the school, including Tacoma and Olympia, which have lower median household incomes than other parts of Western Washington. But Northwest SOIL also has a campus in Redmond, one of the state’s wealthiest cities.

The company’s response, however, doesn’t fully explain the demographic differences because districts can send their students to any nonpublic agencies that cater to the child’s disabilities and have space for them.

Tania May, head of special education services at the state Office of Superintendent of Public Instruction, acknowledged inequities in the system and said the agency wants to increase funding to create more public programs and decrease the reliance on nonpublic agencies.

Washington’s special education system is underfunded overall — a shortfall of nearly $500 million a year, according to state education officials. Following the Times and ProPublica’s reporting, state education officials are considering sweeping reforms to state laws that would give districts more resources to serve students with disabilities.

ElijahKing’s mother felt like she had no control over her son’s academic circumstances, and she didn’t know how to demand better schools, get more resources or take legal action to steer her son toward respected programs.

But some parents did.

“An Attorney Walks in, Everyone Is Shaken”

As the system’s problems overwhelmed Cummings, Mike Hipple and Sam Read were also struggling to get their daughter, Hillary, who has autism, the services she needed in Seattle schools. By sixth grade, she would come home with a backpack full of incomplete worksheets, signaling to Hipple and Read that she wasn’t getting help at school.

Mike Hipple and Sam Read hired a lawyer to get their daughter, Hillary, transferred to the Academy for Precision Learning, where she could get more intensive support. (Ken Lambert/The Seattle Times)

The college-educated, middle-class couple had joined several Facebook groups for parents of children with disabilities and met monthly with others to discuss parenting strategies — support that can be elusive for parents like Cummings, who doesn’t own a car and has at times lacked internet access.

In late 2019, a parent in one of Hipple and Read’s support groups suggested they hire an attorney.

It often costs more than $50,000 and takes months of wrangling to bring a case to the hearing stage, special education attorneys say, although parents can recoup attorney fees if they win.

“We were terrified to get a lawyer because we aren’t super wealthy people,” said Hipple, a freelance music photographer and editor. They knew they didn’t have money for a lengthy legal battle, but they did have the time to learn about the system and push back against the district.

It took just one demand letter from their lawyer, which cost about $4,200, to get the district to pay for Hillary’s transfer to the Academy for Precision Learning, a nonprofit with two campuses and 97 students in Seattle’s University District.

Tuition, plus the cost of a one-on-one aide and a board-certified behavioral analyst, often exceeds $100,000, which the couple hoped the district would pay for. Seattle schools countered by proposing other programs, but Hipple and Read said that one was too small and that the other catered to children with disabilities that seemed more severe than Hillary’s.

“We’re privileged. We have the time, space and luxury to get it done,” Hipple said. “The parents who are working three jobs don’t have that.”

Hillary Hipple-Read is thriving at the Academy for Precision Learning. (Ken Lambert/The Seattle Times)

Seattle Public Schools declined to comment on the students’ individual experiences, citing federal student privacy laws. District officials said they would not respond to questions about students, even if parents signed release forms.

Hiring an attorney doesn’t automatically get a student into their parents’ preferred school, but the legal pressure gives parents more power in special education decisions.

“An attorney walks in, everyone is shaken,” said Chris Willis, special education director at the Orting School District, calling the dynamic one of the “foundational failures” in special education. In his nearly three decades of special education experience, Willis found that most parents don’t seek advocates — who can offer free advice — or attorneys. “Some don’t really engage or perhaps know about their legal rights,” he said.

Lawyers, for instance, can steer districts toward acclaimed out-of-state private schools that cost hundreds of thousands of dollars. In the 2020-21 school year, at least 15 students in Washington got placements that cost more than $300,000.

Theresa DeMonte’s son has severe autism and an intellectual disability but didn’t appear to be making any progress in Seattle schools. So DeMonte, a lawyer at a downtown Seattle firm, hired a special education attorney and in 2017 requested a hearing before a judge.

Her son needed round-the-clock support, but Washington has no residential schools that qualify for state special education funding. DeMonte researched top autism programs around the country and suggested the New England Center for Children in Massachusetts, a school staffed by board-certified behavior analysts that offers therapeutic activities and an indoor pool.

The district ultimately agreed to cover her son’s tuition, plus travel costs for multiple visits each year. Seattle spent as much as $412,000 a year on the school, records show.

“He was placed there because I’m a good advocate and I hired a very good attorney,” said DeMonte. “There’s no doubt in my mind that a lot of children’s needs aren’t being met because they don’t have access to the same resources.”

“He Just Needed the Chance”

For a long time, ElijahKing was one of those children.

In 2017, Cummings was living in a homeless shelter and her minimum-wage retail job was in peril because of the time she had to spend attending to ElijahKing’s educational needs. He wasn’t making progress in school, and when he had outbursts, educators routinely called the police, who took him to a local hospital.

Cummings couldn’t afford mental health care for ElijahKing, but she’d heard that the state would pay for in-patient treatment if he was in the foster system. So, she made a painful choice: Cummings let the hospital call Child Protective Services, which eventually placed him at Ryther, a state-supported mental health facility. “It was the hardest decision,” she said.

After returning to her care in 2019, ElijahKing spent nearly two years in a public school for children with behavioral disabilities in Seattle. But when the program shut down at the end of the 2021-22 school year, Seattle Public Schools suggested placing him at Northwest SOIL.

By then, Cummings had moved to Tacoma, where she had found stable housing. ElijahKing transferred to nearby Hilltop Heritage Middle School, the first “normal” school he’d attended in years, as he described it to reporters.

Then he got into the argument at Hilltop while he’d been briefly left without a one-on-one aide. As the situation escalated, ElijahKing reacted by running from school, darting across a busy street.

That’s when Tacoma Public Schools enrolled him in Northwest SOIL. Feeling she had no other option, Cummings kept him home.

In the weeks that followed, Tacoma recommended four other private programs, but none felt appropriate for her son. Some were an hour’s drive from her home, and though the district would handle transportation, Cummings didn’t want ElijahKing so far away. She wanted him in his neighborhood school with more support.

Tacoma Public Schools also declined to comment on students’ experiences, even with a privacy waiver. “Our goal is to always find the least restrictive learning environment for students,” the district said in a statement. “This looks different for every student and requires some flexibility.”

Without the support groups that others, like Hipple and Read, had turned to, Cummings went to the local library to look up laws on special education. She called the governor’s education office and asked a local nonprofit for help. Neither effort panned out. Eventually she found an article describing a student being restrained and isolated at another school, along with the name of a local attorney, who connected Cummings with Cedar Law, a Seattle-based firm that specializes in educational disputes. Lara Hruska, a managing partner at Cedar Law, agreed to take the case pro bono.

Lara Hruska, managing partner at a Seattle-based law firm, stepped in to help ElijahKing’s mother persuade the district to keep him in a local school. (Ellen M. Banner/The Seattle Times)

“She was stuck and needed a lawyer to unstick the situation,” Hruska said. Cedar filed an expedited request for a hearing. After weeks of legal proceedings, Tacoma agreed to bring ElijahKing back to Hilltop Heritage.

Cummings managed to buck a system that has sent hundreds of students to Northwest SOIL in the past few years, Hruska said: “She was extraordinary in her ability to disrupt that pipeline.”

Though the dispute kept him out of school for two months, ElijahKing reenrolled in November. A bashful teen with more to say about video games than school, ElijahKing simply said his return to Hilltop Heritage was “really good.” He made friends, he said, and looks forward to school most days.

Within a week, his teachers discussed transitioning him from a special education classroom to a few general education courses, where he’d study alongside nondisabled classmates, Cummings said. In January, he won an award recognizing him as one of the school’s most responsible and respectful students. Cummings described ElijahKing’s potential — he could catch up to his peers, graduate, maybe go to college.

“He’s so bright, I’m telling you,” she said, the same appeal she’d made to district officials just months earlier. “He just needed the chance.”

ElijahKing said he was happy to be back at the first “normal” school he’d attended in years. (Kevin Clark/The Seattle Times)
by Lulu Ramadan and Mike Reicher, The Seattle Times

Senators Demand Answers About “Alarming” Reports of Excessive and Risky Artery Procedures on Veterans

2 years 2 months ago

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Just hours after ProPublica, in collaboration with The Wichita Eagle, revealed serious allegations of illegal kickbacks and alleged patient harm at a veterans hospital in Kansas, the state’s U.S. senators urged the Department of Veterans Affairs to contact impacted patients and say whether the involved doctors and medical device company have been held accountable. The U.S. congressman who represents the hospital’s district is also calling for answers.

In a letter sent on Thursday, “regarding the alarming reports of lapses in patient safety and improper use of taxpayer dollars,” the Republican senators, Jerry Moran and Dr. Roger Marshall, asked the VA for a “full timeline and accounting” of the agency’s knowledge of, and response to, the allegations, and to reach out to all veterans who had received care at the catheterization lab of Robert J. Dole Veterans Affairs Medical Center in Wichita between 2011 and 2018. During this period, according to a whistleblower lawsuit filed in 2017, representatives from Medtronic, the world’s largest medical device maker, treated health care workers to steakhouse dinners, Apple electronics and NASCAR tickets, and in turn, the company secured a lucrative contract with the veterans hospital.

Medtronic’s representatives also allegedly “groomed and trained” doctors at the hospital, who then deployed the company’s devices, even in cases when it was not medically necessary. The doctors in question were contract workers, paid hourly by the facility, according to the lawsuit, and thus were incentivized to do longer and more complex interventions, which would increase their payment.

In several of the procedures, the doctors deployed more than 15 devices at a time, deviating from best practices, according to an internal investigation. One used 33.

“I want to say the term ‘egregious’ was used,” former facility director Rick Ament testified last December in a deposition for the whistleblower suit.

These procedures were performed to treat blockages in the legs, a common medical condition that is also known as peripheral artery disease, which affects more than 6.5 million Americans over the age of 40. Each time a physician inserts a foreign device in a patient during one of these interventions, it carries a risk of complication, which can include clots or even require amputation.

An internal investigation at the Wichita hospital uncovered a number of clinical failings, including over-aggressive procedures and a disregard for best practices. It also found, according to an internal email, that amputations had increased sixfold during the time period in question. A VA spokesperson would not say whether those outcomes were linked to overuse of the devices and said that the agency’s review has found no “quality of care” issues yet. The review is expected to last several months. (Read the VA’s full statement in response to ProPublica’s story.)

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In 2018, the director of the Wichita facility shut down interventional radiology procedures at the hospital and shared the findings of his internal investigation with the VA’s Office of Inspector General. The next year, according to an investigation memo that was unearthed in the whistleblower suit, the OIG found that employees at the hospital “may have received improper gratuities, in the forms of paid lunches, dinners, etc., from sales representatives from Medtronic.”

Even though the VA has been aware of the allegations of kickbacks and excessive device use for about five years, the agency did not publicly acknowledge these findings outside of the lawsuit until ProPublica reached out. It is unclear if the VA has reached out to any patients who underwent these procedures during the time frame in question. ProPublica contacted more than half a dozen veteran community groups in the Wichita area, and none were aware of the allegations nor the internal investigation.

Following the publication of ProPublica’s story, U.S. Rep. Ron Estes, a Republican who serves the Wichita region, expressed concern and pushed for accountability within the VA. “The VA needs to get to [the] bottom of these serious allegations,” he said in an email. “Veterans in our community should reach out to my office here in Wichita with any issues they face.”

The Kansas senators urged the agency to inform impacted patients of the “steps VA has taken to assess the quality of the care they received there, and provide them with contact information for appropriate officials who can answer any questions or concerns they might have.”

Moran, the ranking member of the Senate Veterans’ Affairs Committee, and Marshall, a doctor who served seven years in the Army Reserve, are also demanding answers to the following questions:

  • What steps did the VA take to “remove the contract employees in question from patient care duties, report them to appropriate authorities, hold them accountable for their malfeasance, and prevent them from practicing not just at the Dole VAMC but also at any other VA facilities or through VA’s community care networks”? (A VA spokesperson told ProPublica that neither it nor the hospital had taken formal action against the medical providers.)

  • What steps did the VA take to “hold the contractor, Medtronic, accountable for the role they played in this incident”? (The VA found evidence that indicated the facility had purchased a large number of devices from Medtronic, which resulted in increased costs. The VA did not respond to ProPublica’s questions related to the reasons for the excessive purchase of devices, citing the ongoing whistleblower case and investigation by the OIG. The agency said that the Wichita facility no longer purchases Medtronic equipment and supplies for complex vascular procedures on lower extremities, but that it continues to purchase other types of the company’s products.Medtronic declined to respond to ProPublica’s questions, citing the ongoing litigation. “These allegations are false and Medtronic is defending against these claims in court,” said Boua Xiong, a spokesperson for the company. Medtronic did not respond to ProPublica’s request for comment in response to the letter from the Kansas senators.)

  • What steps did the VA take to “identify and prevent similar incidents from occurring elsewhere in the VA healthcare system”?

  • What are the agency’s “plans to communicate with veterans in Kansas and across the country about this issue”?

Aside from more details on the agency’s investigation, the senators have also asked the VA to assure patients at Wichita’s veterans hospital that “their safety is VA’s paramount concern,” and to “inform those who are understandably questioning whether it is safe for them to continue seeking care there of their right to request care in the community.”

Gary Kunich, a VA spokesperson, said that the agency had received the letter and that it is “working on a prompt and complete response to Senator Moran and Senator Marshall.”

Do You Have Experience With Peripheral Artery Disease? Have You Had a Procedure on Your Leg? Tell Us About It.

by Annie Waldman

What to Know About the Earned Income Tax Credit

2 years 2 months ago

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The earned income tax credit (EITC) put an average of $2,043 back in recipients’ hands and helped lift millions of children above the poverty line last year.

Thirty-one million people applied and received the credit last year, according to the IRS. But a fifth of taxpayers who are eligible for the credit still don’t claim it. Here’s what you should know about the earned income tax credit and eligibility.

What Is The Earned Income Tax Credit (EITC)?

Tax credits help reduce how much you owe or can help give you a refund. The earned income tax credit is meant to help working people with low or moderate incomes.

You can receive as much as $6,935 in tax credit, depending on your status. It’s for this reason that the EITC is one of the most popular tax credits, even if it’s one of the least understood.

Who Can Get the EITC?
  • Individuals: If you’re filing taxes as a single filer without kids, you must have made $16,480 last year or less to claim the credit.
  • Parents: If you have a kid or have taken a young family member into your home, you should see if you qualify for the EITC. See the table below to see income requirements.
How Do I Figure Out if I Qualify for the EITC?

The best way to figure out if you qualify for the EITC is to use the IRS’ EITC Assistant, an easy-to-use online guide that will ask you yes-or-no questions to determine if you’re eligible.

There are a few basic qualifications for the EITC:

  • You must have been a U.S. citizen or legal resident all year.
  • You must have resided in the U.S., including U.S. military bases, for more than half the year.
  • You must have earned income from wages, a salary or a business.

To qualify for the EITC, you must not exceed the earned income limits. For the 2022 tax year, your adjusted gross income cannot be more than:

Earned Income Tax Credit Adjusted Income Caps

For the category that you’re in, this is the maximum you can make before exemptions and deductions to claim the credit.

Filing Status Zero children One child Two children Three or more children Single filer or head of household $16,480 $43,492 $49,399 $53,057 Married, filing jointly $22,610 $49,622 $55,529 $59,187

There are special qualifying rules for U.S. military members and clergy members.

Who is a qualifying child?

If you are claiming a child as part of the EITC, they must be a “qualifying child.” The full IRS guidelines on whether your child is a “qualifying child” are here, but let’s review the basics. Your child must:

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  • Be your child (including adopted, step and foster children); sibling (including half and stepsiblings); or a descendant of your child or sibling, such as a grandchild, niece or nephew.
  • Have been younger than 19 at the end of 2022 or younger than 24 if they’re a full-time student. They also must be younger than you. If they do not meet these age requirements, they must have been permanently disabled at any point in the year.
  • Have lived with you in the United States for more than half the year.
  • Have a valid Social Security number.
Will I Be Audited if I Claim the EITC?

As ProPublica has reported, people who claim the EITC are audited at a higher rate than those who do not claim it. While you are more likely to be audited if you claim the EITC, the audit rate was still less than 1% in 2019. In the 2021 fiscal year, 38% of audits were of filers who claimed the credit, according to the IRS’ Data Book. Here are some tips for what to do if you’re audited.

One reason for the high rate of audits is that people often claim the credit in error. But also, a decade of budget cuts at the IRS mean there are fewer people to review audit documents. It’s much more expensive for the IRS to audit wealthy taxpayers, and it claims it can’t do so without more funding. That may soon change. The Inflation Reduction Act, passed by Congress in August 2022, will provide the agency with $80 billion over the coming decade, allowing the IRS to increase its audits of the wealthiest Americans.

However, in fiscal year 2022, millionaires were audited at nearly the same rate as EITC recipients, according to TRAC, a nonpartisan, nonprofit data research center.

When Will I Get My Tax Refund?

If you take the credit, by law, the IRS cannot issue your refund before mid-February 2023. However, the IRS says that taxpayers who claim the EITC can expect their refund around Feb. 28 if they’ve filed online, chosen to receive their refund by direct deposit and have no issues with their tax return.

You can always check the status of your return on the IRS’ Where’s My Refund page.

About this guide: ProPublica has reported on the IRS, the Free File program and other tax topics for years. ProPublica’s tax guide is not personalized tax advice. Speak to a tax professional about your specific tax situation.

Kristen Doerer is a reporter in Washington, D.C. Her writing has appeared in PBS NewsHour, The Guardian and The Chronicle of Higher Education, among other places. Follow her on Twitter at @k2doe.

by Kristen Doerer for ProPublica

Louisiana to Drop Lawsuits Against Katrina Survivors Over Recovery Grants

2 years 2 months ago

This article was produced in partnership with Verite, WWL-TV and The Times-Picayune | The Advocate, which was part of ProPublica’s Local Reporting Network in 2022. Sign up for Dispatches to get stories like this one as soon as they are published.

The state of Louisiana is dropping thousands of lawsuits against homeowners who received grants to elevate their homes after hurricanes Katrina and Rita in 2005 but used the money to make repairs instead.

Many of those homeowners said they had been told by representatives of Road Home, the grant program, that they could use the money for repairs, according to an investigation by The Times-Picayune | The Advocate, WWL-TV and ProPublica.

“It’s about damn time,” said attorney Shermin Khan, who represented more than 50 of the 3,500 people who were sued over elevation grants.

Despite what homeowners were told, grant agreements said the money — federal grants that were managed by the state — had to be used to raise homes. Under pressure from the U.S. Department of Housing and Urban Development to recoup grants that hadn’t been spent properly, the state sued homeowners, seeking repayment of $103 million.

Many of those sued were older and poor. Several homeowners preemptively declared bankruptcy, according to their attorneys. Others failed to defend themselves in court, so the state placed liens on their properties.

Watch WWL-TV’s Report

Louisiana Gov. John Bel Edwards announced that the lawsuits would be dropped as he joined federal and New Orleans leaders Thursday morning at a community center in the Lower Ninth Ward to mark the official end of the Road Home program, 17 years after it launched. It was the largest housing recovery effort in U.S. history.

Edwards acknowledged that the $30,000 grants were “insufficient in size to actually elevate people’s homes.” At the time, it typically cost at least three times as much to lift a house and put it onto raised footings.

“It’s been a miserable thing for the state of Louisiana to pursue these individuals because we knew the vast majority of them were never going to pay,” Edwards said.

Edwards said about 5,000 people were sued or could have been for being out of compliance with grant rules. That includes grants for repairs as well as for elevation.

First image: U.S. Department of Housing and Urban Development Secretary Marcia Fudge spoke at a meeting on Thursday in New Orleans. Second image: The meeting was held at a community center in the Lower Ninth Ward to mark the official end of the Road Home program. (Photos by Brett Duke, The Times-Picayune | The Advocate)

Homeowners sued by the state were living a “nightmare,” HUD Secretary Marcia Fudge said, worried they wouldn’t be able to pass their homes on to their children.

“I decided on my watch it was going to be over,” Fudge said. “The federal government is doing something that it has never done before for the people of Louisiana.”

U.S. Rep. Troy Carter, D-La., said in an interview that the news outlets’ reporting was instrumental as he tried to convince Fudge to find a way to stop the collection efforts.

“A program that was designed to pull people out of the storm should not put them back into the storm,” Carter said. “Unfortunately, Road Home did that to many.”

Dropping the lawsuits will allow people to go on with their lives, he said. “This gives us an opportunity to at least remedy as best we can the mistakes that were made.”

The state will halt collection efforts related to all Road Home grants and drop any liens placed on homes through the litigation. But people who made partial or full payments will not be reimbursed, officials said.

“There’s only so much we can do,” Carter said. “There won’t be an opportunity for a refund if you’ve already paid back.”

The state paused collection efforts in May after the news outlets found that a law firm it hired had accelerated the pace of legal filings. By then the state had collected about $5 million from 425 families.

Homeowners Offered Grants, but No One Double-Checked Eligibility

After an initial delay, the elevation grant program was launched in 2008, when the state sent letters to 40,000 homeowners telling them they could get $30,000 each to raise their houses to reduce flooding in the future. About 32,000 homeowners participated.

Once the state Office of Community Development received an application, it sent the money to homeowners, according to testimony in one of the lawsuits by Jeff Haley. He helped administer the elevation grant program as an official with ICF Emergency Management Services, the contractor Louisiana hired to run Road Home, from 2006 to 2009.

But no one double-checked before the money went out that homeowners were eligible or that their homes needed to be elevated, said Haley, who is now with the state Division of Administration. The state simply “didn’t have time,” he said. There was pressure to “get the funds out into the community as fast as possible.”

To get $30,000 grants, homeowners signed agreements promising to elevate their homes to reduce the chance of flooding. The state changed the rules several times to expand what the money could be used for, but by then many homeowners couldn’t prove how they had spent the money. (Obtained by ProPublica, The Times-Picayune | The Advocate and WWL-TV)

The state told the news organizations that it aimed the elevation grants at people whose homes were in flood-prone areas and who had already received another Road Home grant. It was up to homeowners to determine how much they needed to raise their homes, officials said; if they learned they were already at the correct height, they should have returned the money.

But when homeowners informed Road Home representatives, sometimes in writing, that they didn’t plan to elevate their houses, some were verbally told that they could use the money for repairs, according to eight families and eight attorneys representing more than 200 homeowners.

Wallace and Kristy Styron received a $30,000 elevation grant even though their home in southwestern Louisiana’s Cameron Parish was already above the required height. After the state sued them, Wallace Styron testified that he repeatedly told a Road Home representative that he didn’t need to raise his home and even said he had submitted paperwork to prove it. But the person insisted he accept the grant, he said, telling him he could use it for repairs.

A Road Home document outlining the benefits Styron initially qualified for, dated Dec. 2, 2006, said he was not eligible for an elevation grant. Forms for two other homeowners reviewed by the news organizations said the same. Another three homeowners indicated on forms that they didn’t want the elevation money. Yet all those homeowners received grants, and all were subsequently sued for repayment.

After HUD flagged many grants for being spent improperly, the state changed the rules twice between 2013 and 2015 to allow spending on repairs and other expenses. But by then, so much time had passed that many homeowners couldn’t prove how they had used the money.

HUD considered those to be overpayments and would not close out the Road Home program until Louisiana returned the money. Though state officials told the news organizations in 2022 they didn’t want to sue their fellow citizens, they had been paying attorneys to do just that for about five years.

Days after the news outlets published their investigation, local elected officials and housing advocates called on the state to drop the lawsuits. Two weeks later, Louisiana Commissioner of Administration Jay Dardenne announced he was ordering a pause to all collection efforts. He said the state had reached a settlement in a related lawsuit against ICF over how it managed Road Home, and that negotiations had begun with HUD to accept money from that settlement instead of homeowners.

ICF did not immediately respond to a request for comment, but spokesperson Lauren Dyke said in May the firm “worked within the policies put in place by the state.”

The state plans to use $12 million from the ICF settlement to pay off its debt to HUD, plus an anticipated $20.5 million appropriation by the state Legislature and $37 million in unused Road Home funds.

Cameron Parish attorney Jennifer Jones said the elevation lawsuits were a nightmare for her clients. She won four lawsuits in which homeowners testified that Road Home representatives told them they could use the grants to fix their homes, only to be sued later for doing so.

The majority of elevation grants were for properties in lower-income neighborhoods and communities of color, as were the lawsuits that followed, according to an analysis by the news outlets.

The $30,000 the state sought from her clients “might as well be $1 million,” Jones said. “They just don’t have it.”

Gentilly homeowner Donna Hilliard was ecstatic to hear the judgment the state filed against her for her $30,000 elevation grant would go no further and the lien against her house would be canceled. She said she was intimidated into making two monthly installment payments of $250 by attorneys working for the state, but she decided to stand her ground after sharing her story with the news organizations.

Pat Forbes, executive director of the Louisiana Office of Community Development, which oversaw the Road Home program, said in May he has “no reason to believe” the state’s attorneys threatened anyone or insinuated the state would take their home.

Matthews at her home in New Orleans in April 2022 (Sophia Germer/The Times-Picayune | The Advocate)

Celeste Matthews, 68, received $30,000 to raise her Gert Town home and was later sued when she failed to do so. The same day she was featured in the news story detailing the lawsuits, the law firm representing the state notified her that it would pursue a default judgment against her, which could result in a lien on her property. Matthews was facing financial ruin.

Upon hearing the news that the state was dropping the lawsuits, Matthews said: “Thank you, Jesus, thank you. I am elated. Now I can relax.”

If you received a Road Home elevation grant and have already repaid the money, we'd like to hear from you. Contact Rich Webster at Verite.

Mark Ballard of The Times-Picayune | The Advocate contributed reporting.

by David Hammer, WWL-TV, and Richard A. Webster, Verite

Despite Decades of Mass Shootings in Texas, Legislators Have Failed to Pass Meaningful Gun Control Laws

2 years 2 months ago

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This article is co-published with The Texas Tribune, a nonprofit, nonpartisan local newsroom that informs and engages with Texans. Sign up for The Brief Weekly to get up to speed on their essential coverage of Texas issues.

It has become a mournful pattern. Following mass shootings, lawmakers in many states have taken stock of what happened and voted to approve gun control legislation to try to prevent additional bloodshed.

In Colorado, the Legislature passed universal background checks in 2013 after a shooter at an Aurora movie theater killed 12 people. After 58 people were shot dead during a 2017 concert in Las Vegas, the Nevada Legislature passed a red flag law that allows a judge to order that weapons be taken from people who are deemed a threat. And in Florida in 2018, then-Gov. Rick Scott signed a bill that raised the minimum age to buy a firearm to 21 after a teenager with a semi-automatic rifle opened fire at a Parkland high school, killing 17 people.

But not in Texas.

In the past six decades, the state has experienced at least 19 mass shootings that have killed a total of nearly 200 people and wounded more than 230 others. Yet state leaders have repeatedly batted away measures that would limit access to guns, opting instead to ease restrictions on publicly carrying them while making it harder for local governments to regulate them.

As the state Legislature convenes for the first time since the Uvalde school shooting last May, lawmakers have once again filed a slate of gun control bills. If history is an indicator, and top legislative leaders predict it will be, they are unlikely to pass.

An analysis by ProPublica and The Texas Tribune of hundreds of bills filed in the Texas Legislature over nearly the past six decades found that at least two dozen measures would have prevented people from legally obtaining the weapons, including assault rifles and large-capacity magazines, used in seven of the state’s mass shootings.

At least five bills would have required that people seeking to obtain a gun undergo a background check. Such a check would have kept the man involved in a 2019 shooting spree in Midland and Odessa from legally purchasing the weapon because he had been deemed to have a mental illness.

Seven bills would have banned the sale or possession of the semi-automatic rifle that a shooter used to kill dozens of people at an El Paso Walmart in 2019.

And at least two bills would have raised the legal age to own or purchase an assault weapon from 18 to 21 years old, which would have made it illegal for the Uvalde shooter to buy the semi-automatic assault rifles.

A state House committee that investigated the Uvalde massacre found that the shooter had tried to get at least two people to buy a gun for him before he turned 18 but was unsuccessful. Immediately after his birthday, he purchased two AR-15-style rifles and thousands of rounds of ammunition, which he used to kill 19 students and two teachers at Robb Elementary School.

“If that law had been 21, I guarantee you he would have continued to be frustrated and not be able to obtain that weapon,” said state Rep. Joe Moody, a Democrat from El Paso who served as vice chair of the House committee.

Gun violence in Texas was again in the news after one person was killed and three people were wounded Wednesday in a shooting at an El Paso mall. The shopping center abuts the Walmart where the 2019 massacre took place; the latest incident came just a week after the shooter in the earlier case pleaded guilty to hate crimes and weapons charges. Though the investigation into this week’s shooting is underway, U.S. Rep. Veronica Escobar, a Democrat who represents El Paso, responded to a tweet of support sent by Republican Gov. Greg Abbott by calling on him to enact gun violence prevention legislation during the current legislative session.

A collection of reforms are necessary to help curb the number of mass shootings — and gun violence in general — across the nation, said Ari Freilich, state policy director for the Giffords Law Center to Prevent Gun Violence.

“There is an enormous need for states to act, especially in states like Texas, where today someone with a really significant history of violence can purchase unlimited quantities of weapons of war without any kind of background check, where there’s no red flag law in place to give people close to them the tools to go into a court and help be a part of preventing violence, where young people can go out and purchase their own firearms years before they can buy their first beer,” Freilich said.

Abbott has repeatedly opposed legislation regulating guns. “There are thousands of laws on the books across the country that limit the owning or using of firearms, laws that have not stopped madmen from carrying out evil acts on innocent people,” Abbott said in a prerecorded speech to the National Rifle Association three days after the Uvalde shooting.

Since then, the governor has argued against legislation that would raise the age to purchase assault-style weapons in Texas, saying that a federal district court judge ruled last August that the Second Amendment prevents the state from barring 18- to 20-year-olds from carrying handguns. Texas is not appealing the ruling.

Eric Ruben, a law professor at Southern Methodist University, said that the widely held consensus in the appellate courts has been that restrictions on AR-15-style weapons are constitutional, as are age restrictions. Ruben said that a U.S. Supreme Court decision last June, which gave Americans a broad right to arm themselves in public, complicated the long held consensus. The ruling rejected a standard used by most lower courts that weighed whether the law advanced public safety and instead stated that governments should pass laws that are “consistent with this nation’s historical tradition of firearm regulation.”

“The appellate courts have yet to weigh in more broadly on the constitutionality of raising the age to purchase military-style semi-automatic weapons, as Florida did after Parkland, after that June decision,” he said.

Neither the governor nor Lt. Gov. Dan Patrick responded to requests for comment or detailed questions. A spokesperson for House Speaker Dade Phelan pointed reporters to previous statements in which he said he would vote against raising the minimum age to buy a firearm and that he didn’t think the House had the votes to pass such a bill.

Rhonda Hart, whose 14-year-old daughter was killed in a 2018 shooting at Santa Fe High School, said she’s been frustrated by the repeated unwillingness of Texas lawmakers to consider meaningful gun legislation.

“We’ve tried everything with them, but they just don’t want to do it,” Hart said. “I’ve said it, and I hope to God that it never becomes true, but they’re not going to care about fixing gun violence until a member of the family or they themselves get impacted.”

Below are details of selected Texas mass shootings in which at least three people were killed, starting with the 1966 massacre of 16 people at the University of Texas at Austin. The news organizations reviewed more than 700 bills introduced in the state Legislature since 1965, along with legislative reports, news clips, press releases and databases compiled by nonprofits that track mass shootings, including The Violence Project and Mother Jones.

University of Texas Tower shooting in Austin

When: Aug. 1, 1966

Victims: 16 killed, 31 injured

People stand at a monument bearing the names of those killed in the Aug. 1, 1966, University of Texas Tower shooting that left 16 people dead, during a memorial in 2016. (Jon Herskovitz/Reuters)

Description: An engineering student and ex-Marine sharpshooter killed a receptionist and two tourists on his way to the observation deck of the tower at the center of the University of Texas campus in Austin. Once there, the 25-year-old used a collection of guns to kill and injure dozens until police killed him. Police later discovered that the shooter had killed his mother and wife the night before. He left a note at his home requesting an autopsy on himself to see why he committed the crime. “Maybe research can prevent further tragedies of this type,” he wrote.

Shooter background: About five months before the shooting, a campus psychiatrist wrote in his notes that the student said he was “thinking about going up on the tower with a deer rifle and start shooting people.” But the psychiatrist did not believe he intended to carry out the shooting, according to a United Press International story published around the 20-year anniversary of the mass shooting. The student also told the psychiatrist he had physically assaulted his wife. News coverage did not specify whether the alleged assaults were reported to the police. In 1964, he had been demoted in the Marines after being court-martialed for lending money at exorbitant rates, according to a report commissioned by the governor.

Weapons: A mix of rifles, including one semi-automatic, pistols and a shotgun.

How the weapons were acquired: The college student purchased guns and ammunition from three stores on the day of the shooting, according to the report commissioned by the governor.

What happened after: During a press conference, Gov. John Connally said that he did not believe requiring people to obtain a license to own a weapon would solve gun violence. He said that even if Texas had such a law, the shooter didn’t have anything in his background to preclude him from obtaining a license to own a gun. Connally, a Democrat, said he was concerned that those who commit crimes and later plead insanity were escaping punishment.

Starburst Lounge shooting in El Paso

When: Feb. 3, 1980

Victims: five killed, three injured

Description: A 21-year-old was drinking at an El Paso bar with his brother when he started to shoot at patrons. Several of them later wrestled the gun away from him and detained him until police arrived. Later that year, the shooter pleaded guilty to five counts of murder with a deadly weapon. He is serving life in prison.

Shooter background: A report from a psychologist who evaluated the shooter after the killings said that he had previously been arrested for minor offenses but did not specify what those offenses were, according to KXAN-TV. After the shooter pleaded guilty, his attorney presented evidence that he had a drinking problem to persuade the judge to reduce his sentence. But that did not happen.

Weapons: Semi-automatic rifle.

How the weapons were acquired: Unclear.

What happened after: Texas lawmakers meet once every two years unless the governor calls a special session. Gov. Bill Clements, a Republican, did not. When lawmakers returned to the Capitol in January 1981, they passed a bill, unrelated to the shooting, that allowed off-duty peace officers to carry their weapons in public.

First Baptist Church shooting in Daingerfield

When: June 22, 1980

Victims: five killed, 10 injured

Description: A former high school math teacher walked into First Baptist Church in Daingerfield, about 135 miles east of Dallas, and fatally shot five people the day before he was to stand trial for incest. The 45-year-old then shot himself in the head just outside the church, but survived. Some in the church thought he retaliated after parishioners, several of whom worked at the same school as the shooter, refused to serve as character witnesses for him in the incest trial, Texas Monthly later reported. The court heard a defense motion for a change of venue for the trial for the mass shooting in 1982. But the shooter killed himself in a county jail cell before the proceeding concluded.

Shooter background: About 14 years prior to the killings in Daingerfield, the man had fatally shot his father in the face. The investigating coroner ruled the shooting to be an accident. Then, the year before the church shooting, a grand jury indicted the man on a charge of incest with his daughter. His son told the district attorney prosecuting the incest case that he feared his father would kill him if he testified, according to Texas Monthly.

Weapons: Two pistols and two semi-automatic rifles, along with 240 rounds of ammunition.

How the weapons were acquired: Unclear. Federal law at the time prohibited someone from possessing a firearm if they had been indicted for a crime punishable by more than a year in prison, but a national instant background check system did not yet exist to prevent this shooter from buying one, Dru Stevenson, of the South Texas College of Law Houston, told ProPublica and the Tribune.

What happened after: Lawmakers did not pass measures related to the shooting when they were next in session in 1981.

Western Transportation Systems company shooting in Grand Prairie

When: Aug. 9, 1982

Victims: six killed, four injured

Description: A 46-year-old truck driver shot workers at warehouses operated by his former employer after a pay dispute. He fled the scene in a stolen 18-wheeler and was shot and killed by police after he crashed in the city of Grand Prairie, about 13 miles west of Dallas.

Shooter background: The shooter had no prior police record, according to local law enforcement officials at the time.

Weapons: Two handguns and a semi-automatic rifle.

How the weapons were acquired: Police told the press that the weapons were “over-the-counter types and not purchased illegally.”

What happened after: When the Legislature next convened in 1983, lawmakers passed a bill banning the sale of Teflon-coated bullets capable of piercing the Kevlar bulletproof vests worn by law enforcement. The bill was not related to the shooting.

College Station rampage

When: Oct. 11, 1983

Victims: six killed, no reported injuries

Description: A 24-year-old killed six people, including his brother-in-law and sister-in-law and a state trooper who pulled him over, in a rampage that extended 160 miles between College Station and Hempstead. State troopers arrested him at a roadblock in Wharton County, according to the Texas Department of Criminal Justice. He was sentenced to death in 1984 and executed in 1987.

Shooter background: Law enforcement told news organizations at the time that the shooter blamed his in-laws for his marital problems.

Weapons: Two pistols and a revolver.

How the weapons were acquired: The Texas Court of Criminal Appeals found in 1986 that the shooter used a revolver he stole from the state trooper he killed and that he had purchased two pistols the day of the shooting. It’s unclear where or from whom he purchased them.

What happened after: Gov. Mark White, a Democrat, attended the funeral of the state trooper. He later told police officers during a meeting in Houston that he asked prosecutors across the state to speed up trials of people accused of violence against law enforcement officers, according to the Fort Worth Star-Telegram. When the Legislature next met in 1985, lawmakers passed an unrelated bill that prohibited cities from adopting any regulations regarding firearm sales, ownership and transportation. Another bill that had the support of law enforcement would have made it a crime to carry not just handguns but also long guns into a bar; it did not pass in the Senate.

Dallas nightclub shooting

When: June 29, 1984

Victims: six killed, one injured

Description: Witnesses and police said a 39-year-old man argued with a woman after asking her to dance with him. He briefly left the nightclub, returning with a gun and opening fire. A jury sentenced him on Nov. 15, 1984, to six life terms in prison. He died in prison in 2017.

Shooter background: The shooter had been convicted of assault 13 times in Belgium, as well as being involuntarily hospitalized for mental health disorders, between 1960 and 1980, according to The Dallas Morning News.

Weapon: A semi-automatic pistol with a 14-round magazine.

How the weapon was acquired: Police said the shooter was able to legally purchase the gun at a pawn shop in 1983 because he was a legal resident. U.S. officials said he was granted legal resident status only because they had failed to uncover his history in Belgium. Firearm sellers were also not required to perform background checks at the time, and the National Instant Background Check System had not yet been established.

What happened after: In response to the shooting, lawmakers passed a bill in 1985 that made individuals eligible for the death penalty if they were convicted of committing multiple murders in one incident.

Luby’s shooting in Killeen

When: Oct. 16, 1991

Victims: 23 killed, at least 20 injured

Description: A man crashed his truck into a Luby’s restaurant in Killeen, nearly 70 miles north of Austin, got out and began shooting patrons. After police responded and wounded him, the 35-year-old shooter retreated to a restroom, where he killed himself. Police said that the shooter appeared to be driven by an intense hostility toward women, given witnesses’ descriptions that he passed over men to shoot women and previous interactions reported by his female neighbors.

Shooter background: The shooter had several minor drug convictions, including one in El Paso for which he served six months of probation.

Weapons: Semi-automatic pistols.

How the weapons were acquired: The shooter legally bought both guns from a store in Nevada.

What lawmakers said: During the 1993 session, Gov. Ann Richards, a Democrat, vetoed a measure to have Texans vote on whether to permit people to carry concealed handguns in public. Richards was against legalizing the carrying of weapons in public, saying, “I am an avid hunter and believe strongly in the rights of individuals to own guns. That is not the question here. The legislation will only increase the level of violence on our streets.” In 1994, Richards lost her bid for reelection. During an interview with Texas Monthly a decade later, her campaign manager said the loss was due, in part, to her veto.

Walter Rossler Co. massacre in Corpus Christi

When: April 3, 1995

Victims: five killed, no injuries reported

Description: The gunman killed five people at Walter Rossler Co., where he had previously been employed. The 28-year-old then killed himself. Police at the time said that officials at the company angered the gunman, who had quit his job in 1994, by providing a negative reference to a potential employer. The company had also sued the gunman to recover tuition that it had paid for him to attend a college class.

Shooter background: The shooter did not have a criminal background, according to the Texas Department of Public Safety, which pointed only to two previous speeding tickets.

Weapons: A semi-automatic pistol and a revolver.

How the weapons were acquired: Police said the shooter legally purchased two handguns from a Corpus Christi gun dealer.

What happened after: On May 26,1995, Gov. George W. Bush, a Republican, signed into law a bill that allowed people 21 or older to receive a license from the Texas Department of Public Safety to carry concealed handguns in certain public places. Licensees had to complete 10 to 15 hours of training and pass an exam. They couldn’t carry concealed handguns into courthouses and schools. Businesses could also ban them from their property. The measure initially exempted people who were considered to be of “unsound mind,” but lawmakers later revised the law to allow people previously diagnosed with a mental health condition to receive a license if a doctor has cleared them. Bush could not be reached for comment.

Wedgwood Baptist Church shooting in Fort Worth

When: Sept. 15, 1999

Victims: seven killed, seven injured

Description: A 47-year-old man entered Wedgwood Baptist Church in Fort Worth and opened fire during a concert in which hundreds of teens were present; the shooter shouted obscenities and demeaned parishioners for their religious beliefs. He threw a pipe bomb before killing himself.

Shooter background: According to police, the man had no previous criminal record. A family member told the Fort Worth Star-Telegram that he had a mental illness; there was no record of him being treated at local or state psychiatric facilities.

Weapons: Two semi-automatic handguns and a homemade pipe bomb.

How the weapons were acquired: The shooter legally purchased the guns from a flea market in 1992, according to The Washington Post. A bill filed in 1991 would have made it a crime to sell firearms and ammunition at Texas flea markets.

What happened after: Speaking in Fort Worth a day after the shooting, Bush said, “If there are loopholes in the law, we ought to fix them.” Under a federal law, background checks are required for firearm sales. The law, however, applies to only licensed dealers, excluding private sellers and gun shows. When Texas lawmakers next met in 2001, Bush was president. Legislation restricting gun sales and possession failed that session. Bush could not be reached for comment.

Mi-T-Fine Car Wash shooting in Irving

When: March 20, 2000

Victims: five killed, one injured

Description: A former employee went to a car wash in Irving, about 14 miles northwest of Dallas, from which he’d been fired three days earlier. He demanded that a safe be opened and then shot his former co-workers. When police caught him the next day, the 28-year-old claimed the shooting was in response to a manager refusing to rehire him. He was convicted of capital murder in 2000 and executed in 2012.

Shooter background: After the shooting, the man confessed to having separately killed a woman who had been missing since 1999. He led police to her remains. Prior to that, at age 15, he had been convicted of assaulting his aunt with a hammer and sentenced to 18 months in a juvenile correctional facility. He had also been convicted in 1991 of three counts of burglary of a building, a felony, and sentenced to five, seven and eight years in prison. The sentences were to run concurrently. Texas Department of Criminal Justice records show he was paroled for those crimes on May 3, 1999.

Weapon: A pistol.

How the weapon was acquired: A friend gave him the gun. State law does not require background checks if guns are acquired privately.At least seven failed bills filed between 1975 and 1993 would have required a person to apply for a firearm transfer permit from either local or state police and go through a criminal background check. Had such a background check been conducted, the car wash employee would have been prohibited from acquiring a gun because of his burglary convictions.

What happened after: During the legislative session that followed in 2001, lawmakers filed four bills that would have required background checks for purchases at gun shows. Each failed. Then, in 2003, state lawmakers passed a measure that stripped cities of the authority to ban people with concealed handgun licenses from taking their weapons into government facilities. By 2004, a federal law banning assault weapons had expired. The following year, a Texas lawmaker proposed legislation to ban the sale and possession of assault weapons. It did not pass.

Sash Assembly of God shooting in Sash

When: Aug. 28, 2005

Victims: four killed, no injuries reported

Description: A man who lived across the street from Sash Assembly of God, about 100 miles northeast of Dallas, began arguing with the pastor and four others outside the church. He shot and killed the pastor and another man in the town. He also fatally shot two women who were driving by the church. The 54-year-old later killed himself after a standoff with police.

Shooter background: Prior to the shooting, a couple who lived next to the church said they called the police several times to report the man for shouting obscenities at them and firing a gun, but police never arrested him because he stayed on his property, according to the Associated Press.

Weapons: A revolver and a semi-automatic pistol. Police also found a shotgun, a rifle and ammunition in his house.

How the weapons were acquired: Unclear.

What happened after: At least three unrelated gun control bills failed to pass during the following legislative session. One would have required background checks for purchases at gun shows. Another would have criminalized the sale or purchase of more than one handgun to the same person in a 30-day period. A third would have directed court clerks to send information to the Texas Department of Public Safety about people who were judged to have a mental impairment or who had been committed to a mental institution; lawmakers later passed a similar bill in 2009.

Fort Hood shooting in Killeen

When: Nov. 5, 2009

Victims: 13 killed, 32 injured

Parishioners at Greater Vision Community Church in Killeen, Texas, cry during the altar call on Nov. 8, 2009, as a pastor offers prayers for those killed in the shooting at the Fort Hood Army post three days earlier. (Jessica Rinaldi/Reuters)

Description: A 39-year-old psychiatrist at Fort Hood carried out what is believed to be the largest mass shooting at a U.S. military installation. The 30-minute rampage ended when police shot him in the back, paralyzing him from the waist down. The shooter was convicted and sentenced to death in 2013 but remains in military prison, according to an Army spokesperson.

Shooter background: Before he was stationed at Fort Hood, the shooter had been a psychiatrist at Walter Reed Medical Center in Washington, D.C. Supervisors there repeatedly warned him that he was doing substandard work, and intelligence analysts began tracking his emails with at least one suspected Islamist militant in December 2008, according to NPR.

Weapons: A semi-automatic pistol with a 20- to 30-round magazine and a laser sight. He also carried a revolver.

How the weapons were acquired: He legally bought the pistol at a Killeen gun store after passing a background check. At least one bill that had been filed in 1993 but failed to pass would have classified the gun as a prohibited assault weapon because it had a 20- to 30-round magazine.

What happened after: Gov. Rick Perry, who was running for reelection at the time of the shooting, issued a statement saying, “We are deeply saddened by today’s events, but resolve to continue supporting our troops and protecting our citizens.” He did not offer specific actions he would take. Perry did not respond to requests for comment.

During the following legislative session in 2011, a measure that would have made it illegal to sell an assault weapon to someone under 21 also failed to pass. Texas did not experience another mass shooting until 2014, but in 2013 state lawmakers passed legislation allowing school district employees with licenses to carry firearms to serve as “school protectors” in response to the mass shooting at an elementary school in Sandy Hook, Connecticut. These employees, known as school marshals, would have to undergo 80 hours of training and a psychological exam before they would be allowed to carry guns on campus. Each gun would have to be kept in a locked safe and could only be accessed when there was an active shooter, according to a legislative analysis of the bill.

Fort Hood shooting in Killeen

When: April 2, 2014

Victims: three killed, 12 injured

Description: An Army specialist fired at fellow soldiers in a building on the post. He continued firing while driving away from the scene. The 34-year-old later killed himself when a military police officer confronted him in a parking lot.

Shooter background: An Army investigation concluded there were no clear warning signs that the shooter had violent tendencies, nor did there appear to be a single event or stressor that led to the shooting. Military officials, however, noted in their report that the day of the shooting he had been having issues with the paperwork to get time off and had gotten into an argument with someone at the battalion headquarters. The shooter’s grandfather and mother also had died months earlier. He was also thousands of dollars in debt and was being treated for behavioral health conditions, including depression and anxiety, the Army Times reported.

Weapon: A semi-automatic handgun.

How the weapon was acquired: He legally purchased the gun at the same store that sold the gun used in the 2009 Fort Hood shooting, according to Reuters.

What happened after: During a press conference, Perry declined to take a stance on whether soldiers should be allowed to carry concealed weapons on military installations. “We’ll learn lessons about what occurred here and minimize the chances of this ever happening again,” he said. Perry did not respond to requests for comment.

In the following legislative session in 2015, lawmakers allowed people licensed to carry concealed handguns to do so on college campuses. At the same time, at least four bills that would have required background checks for purchases at gun shows or between private individuals did not make it to the floor of either chamber. Other bills that failed to pass during the session would have banned magazines that accept 20 or more bullets and established red flag laws that would have created a process by which a judge who determined that a person posed a danger to themselves and others could order the seizure of their firearms for up to a year.

Attack on police in Dallas

When: July 7, 2016

Victims: five killed, 11 injured

Description: A 25-year-old former soldier targeted white law enforcement officers during a Black Lives Matter protest in downtown Dallas. After an hours-long standoff, police detonated a bomb that killed him.

Shooter background: The soldier was sent home from Afghanistan in 2014 after his commanders found he had sexually harassed a fellow soldier. Despite this, The Dallas Morning News reported, the Army released him from active duty with an “honorable” discharge, which means he left in good standing.

Weapons: An AK-style rifle and semi-automatic handguns.

How weapons were acquired: Investigators said he legally purchased the weapons online or at a gun show, according to The Wall Street Journal. At least eight bills that were filed in Texas between 1989 and 2005 would have prohibited the sale or possession of the AK-style rifle the gunman bought, classifying it as an assault weapon.

What happened after: In response to the shooting, state lawmakers passed the Police Protection Act in 2017, making assaulting a police officer a second-degree felony punishable up to 99 years or life in prison. They also set aside $25 million for law enforcement agencies to buy bulletproof vests and body armor.

Separately, lawmakers expanded the school marshal program to private schools and increased the number of marshals from one per 400 students to one per 200 students.

Measures that didn’t pass included requiring background checks in person-to-person online firearm sales and red flag laws.

Sutherland Springs church shooting

When: Nov. 5, 2017

Victims: 26 killed, 22 injured

Texas Gov. Greg Abbott attends a candlelight vigil on Nov. 5, 2017 for those killed at Sutherland Springs First Baptist Church earlier that day. (Robert Jerstad for The Texas Tribune)

Description: A 26-year-old man fired more than 450 rounds inside the church that his wife’s family attended in the town of Sutherland Springs, about 30 miles east of San Antonio. He was chased and wounded by a nearby resident and later killed himself.

Shooter background: In 2012, the shooter, who served in the Air Force, had escaped a mental health facility in Santa Teresa, New Mexico. He had been admitted to the facility after bringing firearms onto an Air Force base and threatening commanders, according to a police report obtained by The Dallas Morning News. In 2013, he was convicted by the military of two charges of domestic assault against his wife and son, which led to his dismissal. In 2014, he was charged with misdemeanor animal cruelty in Colorado’s El Paso County. The charge was dismissed in 2016 after the shooter completed probation.

Weapon: An AR-style semi-automatic rifle with a 30-round magazine. Law enforcement also found two handguns in his car.

How the weapon was acquired: Illegally. The shooter purchased the rifle more than a year before the rampage, at a sporting goods chain store in San Antonio. He lied about his out-of-state address and criminal conviction on the application. The conviction should have prevented him from buying the firearm, but the Air Force failed to report the domestic violence case to the federal background database.

What happened after: When lawmakers met in 2019, they passed a bill that clarified people licensed to carry concealed handguns could carry them in places of worship unless those places explicitly banned the practice. Another bill that would have required people to surrender their firearms if they were convicted of a crime involving family violence, had a felony conviction or had a protective order against them was left pending in a committee.

Santa Fe High School shooting

When: May 18, 2018

Victims: 10 killed, 13 injured

Description: A 17-year-old student at Santa Fe High School, about 35 miles south of Houston, entered the campus before 8 a.m. and shot a school resource officer and more than a dozen other students and teachers. He surrendered about a half-hour later. Abbott told reporters the student had written in his journal that he wanted to carry out the shooting and then kill himself. A judge found the shooter incompetent to stand trial in 2019 and committed him to a state psychiatric hospital, where he currently resides.

Shooter background: The student didn’t have a criminal history. His father told The Wall Street Journal that he believed the bullying his son endured in school led to the shooting.

Weapons: A shotgun and a revolver.

How the weapons were acquired: The shooter took his father’s legally owned guns from their home. Texas’ safe storage law allows prosecutors to go after parents for failing to secure their firearms from children 16 years old and younger, but the shooter’s family was not liable because he was 17 years old. Some of the victims’ families argued in a lawsuit that he must have illegally acquired the ammunition because he was not at least 18 years old. They reached a settlement this month with the company, Lucky Gunner, that sold ammunition to the shooter. As part of the settlement, the company agreed to verify the age of customers buying ammunition going forward.

What happened after: After the shooting, Patrick called on parents to safely secure their guns. “Your children should not be able, or anyone else, to get your legally owned guns,” he said. “This is one big step we can take.” Abbott told the press he could support legislation that required people to report to law enforcement if their guns had been lost or stolen, hired more school counselors and shortened the time that a court has to report someone’s mental health determination to law enforcement for use in the National Instant Background Check System. Such a determination should prevent a person from legally purchasing weapons. The governor issued a statement encouraging lawmakers to consider adopting red flag laws but emphasized the need for due process. No such measures passed during the 2019 legislative session. Lawmakers instead increased the number of people allowed to serve as school marshals from one per 200 students to one per 100 students. Supporters said the increase could dissuade potential school shooters. Lawmakers also bolstered school emergency plans to include the establishment of threat-assessment teams and drills to better prepare teachers and students for emergencies. The Legislature also appropriated nearly $339 million in school safety funding.

El Paso Walmart shooting

When: Aug. 3, 2019

Victims: 23 killed, 26 injured

Description: A 21-year-old man drove more than 650 miles to El Paso from a Dallas suburb, where he lived. He arrived at a Walmart at about 10:30 a.m. and fired at families fundraising outside the store. He then went inside, shooting indiscriminately at employees and customers. Prior to the shooting, he had posted a hate-filled 2,300-word manifesto online that had white nationalist and anti-immigrant themes, speaking of a “Hispanic invasion of Texas.” On Feb. 8, he pleaded guilty in federal court to hate crimes and weapons charges. He will be sentenced in June.

Shooter background: The shooter didn’t appear to have a criminal history. He’d “been diagnosed with severe, lifelong neurological and mental disabilities” and was treated with antipsychotic medication after the massacre in El Paso, his attorneys wrote in a court filing. Weeks before the shooting, his mother had called the police to say she was worried about her son owning an AK-style rifle given his age, maturity level and lack of experience handling such a firearm, CNN reported.

Weapon: An AK-style rifle and a thousand rounds of ammunition.

How the weapon was acquired: El Paso police said the shooter legally bought the weapon online from Romania and picked it up at a gun dealer near his home in Allen, Texas. At least eight state bills filed between 1989 and 2014 would have banned the rifle as an assault weapon and prohibited selling or possessing large-capacity magazines with more than 20 rounds.

What happened after: The mass shooting happened a few months after the legislative session in 2019 concluded, and the next regular session was not until 2021. Abbott held meetings to discuss possible legislative solutions to prevent another massacre but did not call a special session. The governor formed the Domestic Terrorism Task Force and directed the Department of Public Safety to, among other things, increase the number of special agents investigating criminal gangs affiliated with neo-Nazi and white nationalist groups.

Midland-Odessa shooting

When: Aug. 31, 2019

Victims: seven killed, 24 injured

Chalk messages cover a sidewalk on Sept. 1, 2019, before a vigil following a shooting in Odessa, Texas. (Callaghan O’Hare/Retuers)

Description: A 36-year-old man called 911 in Odessa, about 350 miles west of Dallas, to complain about his employer after being fired. He later called an FBI tip line and made what an FBI agent described as rambling statements “about some of the atrocities that he thought he had gone through,” according to ABC News. Police said he then hijacked a postal truck, killing the letter carrier and ditching his car. He then continued to shoot as he drove through Odessa and neighboring Midland. Police shot him dead in a movie theater parking lot in Odessa.

Shooter background: He wasn’t legally allowed to possess firearms after a court deemed him unfit because of his mental health status, according to the U.S. Department of Justice. A DOJ spokesperson declined to provide specifics.

Weapon: Semi-automatic rifle.

How the weapon was acquired: The shooter first tried to purchase a gun at a sporting goods store but was rejected because his mental health status came up in a background check, according to the DOJ. Instead, he purchased a weapon from a private seller, who was not required by law to conduct a background check. At least 13 unsuccessful bills introduced between 1975 and 2015 would have required him to undergo a background check, designated the rifle an assault weapon, and prohibited the sale and possession of the firearm and of large-capacity magazines with more than 20 rounds.

What happened after: Abbott issued eight executive orders on Sept. 5, 2019, in response to the El Paso and Midland shootings, requiring state police to standardize intake questions used by law enforcement agencies and develop clear guidance to improve reporting of suspicious activity.

Patrick called for background checks for some private sales, like those between strangers, in an interview with The Dallas Morning News. Such a bill, along with red flag laws and bans on assault weapons or high-capacity ammunition, failed during the next session.

In the 2021 legislative session, lawmakers instead passed a bill allowing Texans to openly carry handguns without a license. They separately made it a crime to lie on a background check form, created a statewide active-shooter alert system and let school marshals carry their firearms.

Robb Elementary School shooting in Uvalde

When: May 24, 2022

Victims: 21 killed, 17 injured

Students flee after an armed man entered Robb Elementary School in Uvalde on May 24, 2022. (Courtesy of Pete Luna/Uvalde Leader-News)

Description: State officials said an 18-year-old sent text messages to an online friend in Germany, including one on the day of the shooting, saying he was going to shoot his grandmother and shoot up a school. About 30 minutes later, he shot his 66-year-old grandmother in the head, stole her truck and drove about 2 miles to Robb Elementary School, crashing the vehicle in a ditch. He entered the school and began shooting, ultimately killing two teachers and 19 children in the border community about 80 miles west of San Antonio. More than an hour after he arrived at the school, federal law enforcement officials entered the classrooms and shot and killed him. FBI investigators said they didn’t believe the shooter was “motivated by a particular ideology.”

Shooter background: The shooter didn’t have a criminal history, state officials said during a news conference. He had a troubled childhood in Uvalde and was bullied at school, classmates said. He stopped attending school during the pandemic. He was also fired from his job at a Whataburger in late 2021 after a month for allegedly threatening a female coworker and “fared similarly at his next job at Wendy’s,” according to a report by a state House committee that investigated the shooting.

Weapons: Two AR-15-style rifles.

How the weapons were acquired: The shooter legally bought a rifle online the day he turned 18. On May 17, the day after his birthday, he purchased another rifle at a local gun shop. He also eventually bought 60 magazines and more than 2,000 rounds of ammunition, according to the House committee report. At least 15 bills filed in the Legislature between 1989 and 2021 that failed to pass would have made it illegal for him to purchase this type of weapon because of his age, classified the rifles as a type of banned assault weapon, or made it illegal to possess or sell large-capacity magazines with more than 20 rounds.

What happened after: Abbott rejected calls for stricter gun laws, arguing that cities and states that attempt to limit access to firearms still suffer from gun violence. Patrick described the shooting as “pure evil.” He called for more security in the state’s schools, saying on Fox News, “We have to harden these targets so no one can get in, ever, except through one entrance.” His comments echoed a statement he had made following the Santa Fe High School shooting in 2018. Some of the measures filed this year include raising the age to buy assault-style weapons, allowing honorably retired law enforcement officers or veterans to provide security to schools, and requiring metal detectors at every school entrance and a police officer on every campus. One Republican wants to amend the Texas Constitution to prohibit lawmakers from regulating firearms altogether.

Lexi Churchill, Lomi Kriel and Ren Larson contributed reporting and research.

by Jessica Priest and Perla Trevizo

Do You Have Experience With Peripheral Artery Disease? Have You Had a Procedure on Your Leg? Tell Us About It.

2 years 2 months ago

ProPublica reporters are looking into the booming business around peripheral artery disease, a condition that afflicts 6.5 million Americans over age 40. It’s caused when fatty plaque builds up in a person’s arteries, blocking blood flow to their legs. This leads to leg pain and numbness, especially when walking. The disease is fairly common, but patients may not even know they have it.

Experts say most treatments are perfectly safe. But there has been growing concern about one type of procedure — atherectomies — after researchers and doctors uncovered patterns of excessive and inappropriate use.

We have learned that some doctors may be taking advantage of high reimbursement rates and prescribing aggressive treatments even when they aren’t necessary. This could lead to a higher risk of complications, including limb amputation. (See our story on this here.)

We think this is an extremely important investigation. But to make progress in our reporting, we need to connect with patients. That’s challenging because many people may not even know they have had an atherectomy. Please help us by filling out our form if:

  • You think that you, or someone you know, has peripheral artery disease and may have had a leg procedure like an atherectomy, stent or angioplasty/balloon. (If you are unsure if you have had any of these procedures, we still want to hear from you.)
  • You are a health care worker and have a tip to share.
  • You are a medical device representative and have a tip to share.
  • You are a regulator overseeing these systems.

Commitment to your privacy: We appreciate you sharing your story, and we take your privacy seriously. We are gathering these stories for the purposes of our reporting, and will contact you if we wish to publish any part of your story.

We are the only ones reading what you submit. If you would prefer to use an encrypted app, see our advice at propublica.org/tips. If the form is not loading for you, please click here.

by Annie Waldman and Maya Miller

Steak Dinners, Sales Reps and Risky Procedures: Inside the Big Business of Clogged Arteries

2 years 2 months ago

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

On June 14, 2017, just before noon, a doctor made an incision near a patient’s groin. Kari Kirk, a representative for the world’s largest medical device company, Medtronic, looked on and began texting her colleague a play-by-play.

“Fixing both legs from the ankles,” she wrote.

It was a fairly common procedure at the Robert J. Dole Veterans Affairs Medical Center in Wichita, Kansas, performed to treat blockages in the leg vessels.

Within reach were an array of Medtronic products: tubes with blades attached to shave hardened deposits off of artery walls; stents to widen blood vessels; balloons coated with therapeutic drugs.

Each time a doctor puts a foreign device in someone’s body, it carries a risk of complication, which can include clots or even require amputation. So medical experts, research and even Medtronic’s own device instructions urge doctors to use as few as are necessary.

But, as revealed in Kirk’s text messages, this doctor took an aggressive approach.

“Just used 12 [drug-coated balloons]!!” Kirk texted her colleague.

“Does that mean I owe u $$,” he responded.

“Thats what I'm thinking!!! 🤣,” she said. “And now 14 balloons!😳”

“😜- but only one stent so far??”

“So far!”

As the texting continued, her colleague replied, “U are going to want to start going to the VA all the time.”

The messages, recently unsealed in an ongoing whistleblower lawsuit, give a window into the way money and medicine mingle in the booming business of peripheral artery disease, a condition that afflicts 6.5 million Americans over age 40 and is caused when fatty plaque builds up in arteries, blocking blood flow to the legs.

Representatives from companies are often present during vascular procedures to guide doctors on how to use their complex devices. This kind of access has the potential to influence treatment plans, as companies and their representatives profit when more of their product is used.

The suit, filed in 2017 by a sales representative for a competing medical device firm, alleges an illegal kickback scheme between Medtronic and hospital employees. According to the complaint and documents released in the suit, between 2011 and 2018, VA health care workers received steakhouse dinners, Apple electronics and NASCAR tickets, and in turn, Medtronic secured a lucrative contract with the hospital. Meanwhile, the company's representatives allegedly “groomed and trained” physicians at the facility, who then deployed the company’s devices even when it was not medically indicated.

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Independent from the whistleblower suit, internal investigators at the Wichita facility have also examined the treatment patterns of its vascular patients in recent years and found numerous cases where medical devices were used excessively. While it’s not uncommon to deploy several devices, a medical expert on the investigation team found that the VA doctors sometimes used more than 15 at a time — one used 33 — deviating from the standard of care.

“It is unconscionable — there can be no valid medically acceptable basis to cram so many devices into a human being,” wrote attorneys representing the whistleblower in legal filings from January 2023. “This is not medical treatment. This is abuse.”

Dr. Kim Hodgson, former president of the Society for Vascular Surgery and an expert retained by the plaintiff, said the findings of the internal review of patient data raise “a high level of concern regarding necessity of treatment provided,” according to case documents.

Medtronic declined to respond to ProPublica’s questions, citing the ongoing litigation. “These allegations are false and Medtronic is defending against these claims in court,” said Boua Xiong, a spokesperson for the company. Medtronic representative Kirk declined to respond to ProPublica’s request for comment.

The hospital investigation found that amputations increased sixfold in the same time frame as the procedures in question, according to internal emails, but made no conclusion about whether those two things were connected. ProPublica reached out to the VA to ask whether any patients had been harmed.

The VA is “conducting an extensive review of patient care” at the Kansas hospital, “including the number of devices used on patients — to make sure that Veterans were not harmed by any procedures,” press secretary Terrence Hayes said. So far, the VA’s investigation has found no “quality of care issues,” he said, and the investigation will continue “until every Veteran’s case has been reviewed.” (Read the full statement here.) Neither the department nor the hospital has taken formal action against the medical providers, Hayes said.

The Robert J. Dole Veterans Affairs Medical Center in Wichita, Kansas (Jeffrey Beall/Wikipedia Commons)

The medical group that had a contract with the VA for vascular interventions, Wichita Radiological Group, did not respond to ProPublica’s requests for comment, nor did the doctors named in the suit: Dr. Shaun Gonda, Dr. Bret Winblad and Dr. Kermit Rust. It is unclear from the case documents which doctors conducted which procedures. Eric Barth, an attorney for the medical group, denied the allegations in recent legal filings, calling the claims “baseless” and the lawsuit a “witch hunt.”

The lawsuit comes amid growing concern about one of these procedures — atherectomies — after researchers and doctors have uncovered patterns of excessive and inappropriate use. Recent research has found that this procedure, a common but costly treatment to shave or laser plaque from blood vessels, is not more effective than cheaper alternatives and may even be associated with a higher risk of complications including amputation. In recent years, several doctors and clinics have been investigated for allegedly taking advantage of Medicare’s reimbursement rates, and one study found that many doctors are resorting to atherectomies in the earliest stages of peripheral artery disease, against best practices that urge noninvasive treatment.

“Atherectomy is important in certain settings. But it’s being used in a way that is entirely inappropriate and it’s largely driven by the incentive structure,” said Dr. Caitlin Hicks, the lead author of the study and an associate professor of surgery at Johns Hopkins University School of Medicine.

Although different payment structures govern the care of veterans, the whistleblower lawsuit alleges that outside physicians, paid hourly by the Dole VA, were motivated to conduct longer and more complex procedures that would earn them higher payment.

Under different circumstances, the patient in the procedure room on that summer day could have been done after two hours.

But, 150 minutes in, those Medtronic representatives were still texting. At that point, more than 15 of their vascular devices had been used, including stents, balloons and those for atherectomy.

“Long case!” Kirk’s colleague texted. “Is it looking ok??”

“It is,” she said. “Thought we were done a few times! Now he’s going back in to cut again!”

A little while later, she texted: “....17!”

He texted back: “😆😆😂😂”

Hospital leaders had been scrutinizing the use of these procedures at the Dole VA for years.

In 2017, shortly after Rick Ament was hired to lead the facility, he noticed something was amiss. While the longtime hospital administrator was poring over the finances, he was alarmed to discover that the relatively small Dole VA had one of the most expensive cardiac programs in the country. As Ament dug deeper, he realized vascular interventions were the reason.

Angioplasty: A compact balloon is inserted into a blood vessel and inflated to flatten plaque against its walls.

Stent: A metal mesh tube is implanted into a narrowed blood vessel to hold open its walls.

Atherectomy: A catheter, often capped with a blade or laser, is inserted into a blood vessel and removes plaque off its walls.

(Illustrations by Now Medical Studios, special to ProPublica)

“It just did not make sense that the acuity level of our patients would generate such extreme cost variances from the norm,” he testified in December, in a deposition for the whistleblower case. “It was so significant, we needed to get to the bottom of it.”

Ament, a second generation Air Force veteran, quietly assembled a task force to investigate why the facility had purchased so many medical devices for these procedures. After they examined inventory records, calculating the total number of medical devices and the cost of devices per patient, they grew concerned.

“We were more expensive than, I believe it was, the top 10 hospitals in the VA combined,” he said. “My feeling was that we either had very, very bad providers or we had product walking out the door.”

Ament enlisted experts from other VA hospitals to help his team investigate, including an administrative officer who could understand finances and a respected interventional radiologist who could examine records. The task force gathered a list of patients from 2016 to 2018, according to internal emails, and analyzed their medical charts.

According to internal VA documents released through the whistleblower suit, the review found a number of clinical failings: Evidence-based medicine had not been followed in the majority of cases reviewed. Procedures were over-aggressive, treating lesions that should have been left alone. And there was a total disregard for established best practices for treating peripheral artery disease.

One of the experts on the investigative team explained to Ament that while it was not uncommon for doctors to use a couple of devices in one intervention, the total number of devices in many of the procedures at his facility went into the double digits, sometimes five times the expected amount.

In one encounter, a doctor deployed 33 devices in one procedure — three atherectomy devices, nine stents and 21 balloons.

This use of devices was exorbitant, Ament came to understand. “I want to say the term ‘egregious’ was used,” he testified. “It was kind of like validation, but I really wish I was wrong.”

“Did it make you concerned for patient care?” a lawyer asked during the deposition.

“It did,” Ament replied.

A member of his task force pulled data for veterans who had leg amputations due to vascular disease. Over five years, the number of veterans who had amputations increased, from about six in 2013 to 38 in 2018, according to internal emails released in the suit. The VA did not respond to ProPublica’s questions about the rise in amputations or whether it was due to complications from the procedures.

An internal VA email released in a whistleblower lawsuit

Even though Ament testified in December 2022 that he became aware of the excessive use of devices during his investigation that began about five years ago, neither he nor the VA have publicly acknowledged these findings outside of the lawsuit. It is unclear whether VA representatives informed the patients whose records were reviewed about their findings. ProPublica reached out to more than half a dozen veteran community groups in the Wichita area and none were aware of the investigation nor the allegations of overuse of vascular procedures at the facility.

The VA says that if its ongoing review finds instances of substandard care, it will reach out to affected patients and inform them about possible complications and benefits they may be entitled to. The press secretary said the review will take several months. Ament declined to respond to ProPublica’s questions, citing the ongoing case.

In 2018, Ament turned over his findings to the criminal division of the VA’s Office of Inspector General. He also shut down interventional radiology procedures at the facility’s catheter lab.

Federal agents separately opened an investigation into the same unit in the facility, looking into allegations of kickbacks.

More than 40 pages of expense reports from Medtronic, revealed in the whistleblower case, show sales representatives treating Dole health care workers to hundreds of meals over several years — lunches at Dempsey’s Biscuit Co.; business meals at the Scotch & Sirloin steakhouse; dinner at Chester’s Chophouse & Wine Bar, price per attendee: $122.39.

Federal agents obtained the receipts.

“Robert J. Dole VAMC employees may have received improper gratuities, in the forms of paid lunches, dinners, etc., from sales representatives from Medtronic,” wrote Nathen Howard, a special agent in the VA OIG, in an investigation memo from February 2019.

This kind of relationship could violate VA policy, which forbids federal employees from receiving any gifts, including meals, from people who do business or seek to do business with a federal institution. For health care workers, violating this policy could have serious implications for patients. Numerous studies have shown that even modest industry-sponsored gifts, including meals, may influence prescribing or treatment behavior of health care professionals.

The agents opened their investigation into kickbacks at the Wichita facility in response to the whistleblower lawsuit, which was filed by Thomas Schroeder in 2017. The VA OIG would not confirm or deny whether it was continuing to investigate kickbacks at the facility. The VA did not directly answer ProPublica’s questions about kickbacks at the Dole VA, but it said that every employee must complete an annual ethics training, which covers gift rules.

In recent years, Medtronic has settled a handful of other cases that have alleged kickbacks between company representatives and health care professionals.

In 2018, Medtronic’s subsidiary Covidien paid $13 million to settle claims with the U.S. Department of Justice that it paid kickbacks to health care institutions that used its mechanical blood clot devices. In 2019, the same subsidiary paid $17 million to resolve allegations that it provided in-kind marketing support to doctors using its vein products. And in 2020, Medtronic paid more than $8 million to settle claims that representatives had paid kickbacks to a neurosurgeon, including scores of lavish meals at a restaurant that the doctor owned, to induce him to purchase the company’s medication pumps.

Schroeder’s lawsuit is not the first time Medtronic’s vascular devices were named in an alleged kickback scheme. In early 2015, Medtronic acquired Covidien, and shortly after the merger, its subsidiary ev3 Inc. agreed to pay $1.25 million to resolve allegations that it had paid doctors who were “high volume users” of its atherectomy devices to act as evangelists for the company, and had provided physicians with company shares to participate in clinical trials for their tools.

The whistleblower in this earlier case, a former sales representative for the company, also alleged that the subsidiary was gaming Medicare’s payment system. Hospitals were often hesitant to conduct atherectomy procedures because of the low reimbursement rates. According to the suit, sales representatives encouraged doctors to admit patients for longer stays to reap greater reimbursements and make a profit, even though such stays were often not medically indicated.

“Medical device makers that try to boost their profits by causing patients to be admitted for unnecessary and expensive inpatient hospital stays will be held accountable,” special agent Thomas O’Donnell, from the Office of Inspector General at the U.S. Department of Health and Human Services, said in a press release for the settlement. “Both patients and taxpayers deserve to have medical decisions made based on what is medically appropriate.”

Medtronic spokesperson Xiong said that in each case, the company “cooperated fully with the DOJ to resolve its concerns and, where wrongdoing was found, took appropriate remedial action.”

Seton Hall Law School professor Jacob Elberg, a former assistant U.S. attorney for the District of New Jersey who led its health care and government fraud unit, is concerned by the frequency of such settlements in the last two decades. “There are, at this point, real questions as to whether the sanctions imposed by DOJ are sufficient to deter wrongdoing and to lead to meaningful change, especially within the medical device industry.”

Although the Department of Justice has declined to intervene in the lawsuit involving the Dole VA at this time, the case is ongoing and further depositions with Medtronic sales representatives and a former VA employee are scheduled for this month.

VA employees and doctors named in the suit declined to comment or did not respond to ProPublica’s questions about the alleged kickbacks and whether sales representatives may have influenced veterans’ treatment plans. In interviews with federal investigators, according to released transcripts, several of the employees who were questioned denied receiving frequent meals from sales representatives, contradicting Medtronic’s expense reports.

Their statements also stand in contrast to Medtronic representative Kari Kirk’s final text messages during that procedure in June 2017, which ultimately lasted more than three hours.

“Now u done??” her colleague asked.

“Just finished,” she texted. “Running to get them lunch!”

“👍🍺🎉”

Do You Have Experience With Peripheral Artery Disease? Have You Had a Procedure on Your Leg? Tell Us About It.

by Annie Waldman

How ProPublica’s Local Stories Reach the Communities We Report On

2 years 2 months ago

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

When ProPublica publishes its most ambitious journalism, we want it to be read by the largest possible audience. But, as important, we want it to reach local communities affected by what we’re covering. All of this, of course, is with an eye toward getting our findings in front of the people in a position to make changes.

In a world that’s sliced itself into increasingly separate segments, no single news organization can accomplish these goals on its own. We do best when our stories are picked up by a wide range of other outlets, from television to radio to news sites. Sadly, the local news ecosystem around the country is collapsing faster than efforts to buttress it can be undertaken. According to the State of Local News 2022 report, more than two newspapers, on average, vanish each week. The report noted that 2,500 newspapers have shuttered since 2005, and many more are expected to close in the years to come.

That’s why we were so pleased at the end of last year that two consequential stories — one about the arrest of children at an Illinois school, the other about digging up a historic Black cemetery in Virginia — appeared on the front pages of newspapers in the communities where the events happened.

ProPublica reporter Jodi S. Cohen and Chicago Tribune reporter Jennifer Smith Richards, a member of our Local Reporting Network, revealed how administrators at the Garrison School called police to report student misbehavior every other school day, on average. Over the past five school years, officers arrested students more than 100 times, which is particularly stunning because the school has fewer than 65 students in most years.

No other school district in the nation had a higher student arrest rate, according to the most recent data. That school year, 2017-18, more than half of all Garrison students were arrested.

The story ran on the front page of the Chicago Tribune, which has a statewide readership. It also hit home for those living near the school — the story ran on the front page of the Jacksonville Journal-Courier, located about 2 miles from the school.

David Bauer, the newspaper’s editor and publisher, told me in an email that a lot of people in his community “are familiar with the school in passing only; this allowed readers to look at an aspect of what goes on behind the scenes on a deeper level. It helped that the Chicago Tribune and ProPublica were involved, because it made me comfortable that the story was solidly researched and reported.”

To tell the story about Garrison, our reporters analyzed U.S. Department of Education data and obtained records from the school district that included written narratives every time police were involved in the past five years. They also relied on Jacksonville Police Department records, including arrest reports and 911 calls from this school year. While reporting in Jacksonville and meeting students and their parents, the duo repeatedly heard that the student arrests were printed as part of the police blotter in the Journal-Courier. With help from the ProPublica research team, they compiled all the arrests of students in Jacksonville printed in the newspaper during the past decade, up to last year. Our newsroom subscribes to the Journal-Courier, and reporters were able to search the archives and see the blotter items in print. We published some of those in the story, “The School That Calls the Police on Students Every Other Day.”

Even before the story ran, it had an impact. The state superintendent of education at the time, Carmen Ayala, called the frequent arrests of students at Garrison “concerning.” An Illinois State Board of Education spokesperson said a state team visited the school and confirmed an overreliance on police. As a result, the state will provide training and other professional development.

Bauer said he expected some pushback from the story, but that really didn’t happen. “There was interest in the story pretty immediately. Many people said they were unaware; a few called for immediate change and asked us to do more about what has been taking place since 2017, which we did a week later, because there had been administrative and other changes both at the school and, I believe, within the police department.

“The reality is that it’s hard for many newspapers, particularly those with smaller staffs, to take on deep-dive projects like this, but they remain a crucial part of the watchdog mission of journalism. I think that any time there can be partnerships with trusted groups (certainly ProPublica is among them) to keep readers informed, the community benefits.”

Since 2017, ProPublica has opened up four regional offices, employing 27 local reporters. (Cohen works in our Midwest office.) We’re about to open a fifth this year.

In addition, we support the work of 20 more journalists at local news organizations through our Local Reporting Network, which pays the salary and benefits of journalists working at local outlets around the country so they can embark on accountability journalism projects that they otherwise could not have done.

We do this because we believe local audiences deserve coverage that holds elected officials, businesses and other powerful institutions to account for their actions and inactions. Reports show that communities with more access to news are more likely to participate in local elections and civic matters.

The power of a local audience was clear for Seth Freed Wessler’s story about the removal of Black graves from a cemetery in southern Virginia to make way for the expansion of a Microsoft data center.

Wessler, who works in our South office, found the story as he was looking into for-profit archaeology firms and their practices when conducting work on behalf of developers to comply with federal preservation laws. He came across a local news story about an archaeology firm in Virginia that had been challenged by tribal communities over the quality of a study the firm had performed at an important historical site. Indeed, Virginia had called into question the credentials of the firm’s owner, and a former employee had filed a whistleblower affidavit alleging that the company’s work was shoddy and unethical.

In the course of their conversations, the whistleblower told Wessler about the excavation of an African American cemetery that he’d worked on. He didn’t believe the work had been done with the care it deserved, and he raised concerns that he and the rest of the crew lacked meaningful expertise about Black cemeteries. He was also disturbed that no family members of the people buried in the cemetery had been contacted or consulted.

Wessler immediately requested records about the cemetery from the state and the county. There was no indication in any of the documents that descendants had been contacted. Indeed, internal county emails revealed that Mecklenburg County, Microsoft and its consultants all sought to downplay the cemetery’s significance and to dig it up and move it with as little outside knowledge or input as possible. Wessler then tracked down living relatives of the people whose names appeared on gravestones, and he reported out the story from Virginia.

The story got national and regional attention, including on the front page of the Richmond Times-Dispatch. But meaningfully, it also was published on the front page of The Mecklenburg Sun and its sister publication, the News & Record, in the community where the graves were removed. Ironically, one of the descendents is a reporter at the Sun and hadn’t known that his great-grandfather’s grave had been excavated and moved until Wessler contacted him.

Tom McLaughlin, editor and general manager of The Mecklenburg Sun, said he ran Wessler’s story because it was a compelling read about a topic of local interest.

“Wish we had the resources to do work like this ourselves, but the reality of local journalism is that we have a daily scramble on our hands keeping up with the basics. This was a deep dive piece and an excellent one at that,” he said in an email.

“In general, I think the public’s reaction to the story was along the lines of our in-house assessment: this was an eye-opening piece for anyone who thinks everything involving local government (and trillion-dollar corporations) is done correctly and completely above board,” he wrote. “Gravesite desecration is not something that is difficult to grasp, and in our old-school, largely conservative area, I think a fair number of people are outraged by what’s happened here.”

Prior to the publication of Wessler’s article, Microsoft had reached out to the newspaper about placing a quarter-page ad to publicize its community ventures, McLaughlin wrote. The ad was canceled without explanation after the Sun published the story.

In an email, a Microsoft spokesperson said the company “made the decision to not run the ad in December as it did not feel like the right time given the sensitivities of the story and impact on the community. This was in no way retribution for the newspaper carrying the story. We believe that local media plays a crucial role in helping to raise awareness of upcoming works and are always considering how best to incorporate it as part of our community engagement.”

I asked McLaughlin what ProPublica can do to support local newsrooms. “I wish I had a better answer for you,” he said. “We do our work because we think it’s important — it sure doesn’t pay much — and I think in fairness to ourselves, the problem of suboptimal government and outright corruption (not just government either) would be much worse in our absence. This is the problem with local journalism vanishing across much of the nation.”

I couldn’t agree more. While ProPublica can’t change the economic fundamentals of local news organizations, we’re doing what we can to help ensure readers, no matter where they live, have access to accountability journalism.

by Charles Ornstein

Military Justice Reforms Still Leave Some Criminal Cases to Commanders With No Legal Expertise

2 years 2 months ago

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This article is co-published with The Texas Tribune, a nonprofit, nonpartisan local newsroom that informs and engages with Texans. Sign up for The Brief Weekly to get up to speed on their essential coverage of Texas issues.

More than a year has passed since Congress adopted reforms that promised to overhaul the U.S. military justice system. Lawmakers stripped military commanders of their authority to prosecute certain serious cases but allowed them to maintain control over other alleged crimes.

However, the reforms, which will not go into effect until the end of this year, may have created additional challenges, military experts said.

Commanders, who oversee service members but are not trained lawyers, still have control over various aspects of the system, including whether to confine soldiers ahead of trial for alleged crimes, ProPublica and The Texas Tribune found.

We spoke to two military legal experts, Geoffrey S. Corn and Rachel E. VanLandingham, about the reforms and what they mean for the future of the military justice system. Corn is a retired Army lieutenant colonel who is now a professor and directs Texas Tech University’s Center for Military Law and Policy. VanLandingham is a professor at Southwestern Law School in Los Angeles and a retired Air Force lieutenant colonel. They are both former judge advocate generals, or military lawyers. Here are takeaways from those conversations.

The ReformsWere Long Overdue

The military justice system was initially formed as a way to discipline soldiers during times of war, giving commanders unfettered authority to mete out discipline and punishment. That included determining who should be prosecuted and for what crime.

VanLandingham was largely unfamiliar with that system when she enlisted at the Air Force Academy at age 18. She remembers being sexually assaulted and harassed while at the academy but said she never reported anything for fear of being ostracized or retaliated against.

She was a senior at the academy when dozens of women reported being sexually assaulted or harassed during a three-day 1991 convention of Navy and Marine Corps aviators in Las Vegas.

The incident, which became known as Tailhook after the association that put on the event, was among the first times there had ever been focus on sexual misconduct in the military or how the military treated women in the armed services. The secretary of the Navy eventually resigned in the wake of the scandal and several admirals were censured or relieved of duty. The Navy also adopted a “zero tolerance” policy to sexual harassment.

“Tailhook was the first time that I recall that it hit me that ‘Oh, there might be a bigger problem here than just this little academy world,’” VanLandingham said. “‘That was my first time thinking, ‘Huh, is the military going to take care of me?’ But at that point, I couldn’t think about it too much because I had a five-year commitment.”

Similar scandals unfolded over the next three decades, prompting additional public scrutiny of military culture and commanders’ attitudes toward sexual assault. Congress turned up the pressure in 2013 as lawmakers like Sen. Kirsten Gillibrand of New York began to push the idea that commanders should not oversee the justice system.

But large-scale reform wouldn’t happen until 2021, one year after the disappearance and murder of Army Spc. Vanessa Guillén at Fort Hood in Central Texas. Her death, along with the deaths of several other soldiers at the post, spurred louder calls for change. Guillén was sexually harassed by a supervisor months before she was allegedly killed by another soldier. That year, an independent review committee appointed by the Secretary of the Army published a report that found evidence soldiers had underreported sexual assault and harassment at the post for fear of “ostracism, shunning and shaming, harsh treatment, and indelible damage to their career.”

“That commission actually found that there was an environment that was permissive of sexual harassment and assault, which was the first time any kind of military-related formal document actually pointed a finger at the commanders and said, ‘You allowed an environment that was conducive to this stuff,’” VanLandginham said.

The Compromise Will Change Only Some Things

In 2021, Congress made sexual harassment a separate offense in military courts, easing the path for charging soldiers. Previously, ambiguity in the law made it so that soldiers often would be charged with sexual harassment only in conjunction with other misconduct. Lawmakers also mandated that military judges, not jurors, sentence service members for all non-death penalty offenses and ordered the creation of recommended sentencing guidelines.

But the most significant change was lawmakers’ creation of a new office of military attorneys, called the Office of the Special Trial Counsel. Instead of leaving it up to military commanders to decide whether to prosecute cases related to serious offenses that include sexual assault and domestic assault, murder and involuntary manslaughter, attorneys within the new office will do that.

VanLandingham, who supports taking legal authority from commanders, believes that the new system does not go far enough because it leaves some cases in the hands of military commanders. For example, commanders continue to decide whether to prosecute offenses such as robbery, assault and distribution of controlled substances.

That disparity “makes no sense,” VanLandingham said. “It’s a product of politics versus a product of doing the right thing.”

By comparison, Corn supports maintaining commanders’ ability to decide cases in which service members are accused of crimes. He said commanders “are in those positions because they have had a career of exercising careful, thoughtful and decisive judgment.” But he said if Congress was going to take away that authority, it should have done so across the board and not only in certain cases.

“I struggle with the idea that Congress has said a nonlawyer commanding general is not competent to make decisions on whether or not an individual should be brought to trial for sexual harassment, but he is competent to make decisions on whether another defendant can be brought to trial on some other offense,” Corn said. “If I’m that other defendant, I’m saying, ‘Wait a minute, that’s fundamentally unfair.’”

The 2021 Law Wasn’t the Last Word

Congress passed additional changes in December that VanLandingham said helped address some of what had been left unfinished in 2021.

Lawmakers moved three additional charges under the purview of military attorneys. Those are sexual harassment, causing the “death or injury of an unborn child” and “mailing obscene matter,” which means wrongfully sending explicitly sexual materials like a nude photo of a child.

The new law also requires the U.S. president to remove such powers as the ability to grant immunity to witnesses and hire witness experts from commanders in cases that the new trial counsel office is handling.

Congress also passed a measure requiring the Secretary of Defense to annually report on the outcomes of cases handled by the new Special Trial Counsel office beginning no later than 2025.

All service members will also for the first time have the ability to seek judicial review of their convictions. Previously, only service members who were sentenced to several months of confinement or received a punitive discharge were eligible to ask for such a review.

Congress directed that an existing advisory committee examine what information about a case should be shared with lawyers representing victims of crimes allegedly committed by military personnel. Victims have historically had trouble accessing evidence connected to their cases.

Corn believes the change will bring more transparency for alleged victims. “If I’m a victim’s counsel, and the prosecutor is saying, ‘We have decided not to prosecute this case,’ and my client is distraught and doesn’t understand it, my ability to have access to the file to show the victim what the problems are in the case helps me do my job,” Corn said.

VanLandingham said one of the most significant changes in December was Congress’ decision to require that courts-martial jurors — known as panel members — be selected at random, like a civilian jury. Currently, military commanders select the panel members. Those rules are not expected to go into effect until the end of 2024.

The change is “huge, at least appearance-wise,” VanLandingham said. “It’s just one more step to show that, yes, all these things that have been done for hundreds of years in the civilian sector really do and can be done” in the military.

More Work Remains to Be Done

The 2021 overhaul, which included the creation of the Office of the Special Trial Counsel, won’t go into effect until the end of this year at the earliest. That’s too long, VanLandingham said: “We can invade a country in far shorter of a time frame.”

She expects Congress and the Department of Defense to want time to see how the new system works before considering other large-scale reforms.

VanLandingham said she believes the only solution is to transfer prosecutorial authority of all felony-level offenses in the military to the Justice Department, “whose prosecutors do nothing but prosecute.” Short of that, she said, commanders should be taken out of the military justice equation entirely instead of having the two-pronged system Congress created.

“You’ve created a Frankenstein system that is doubly inefficient and, I think, still leaves in place things like gross racial disparities, gross rank disparities in the administration of military injustice. It’s hard for me to even call it military justice when you have twice as many African Americans still court-martialed to this day,” VanLandingham said.

She said commanders should not be in the business of practicing law.

Corn said future reforms should focus on creating more uniform and effective training for commanders “on the ethical guideposts that prosecutors, good prosecutors, use to decide whether or not to send the case to trial.”

Still, he expects that prosecution of almost all criminal offenses will one day fall to the special trial counsel office.

“So 10 years from now, when the captain at Fort Hood who is a brigade or division commander, if you said to him, ‘Hey, did you know that 15 years ago, if you were in this job, you would decide what cases go to trial?’” Corn said. “He’d probably say, ‘That’s crazy.’”

by Vianna Davila