G Lion
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A sad story!
http://www.ardemgaz.com/ShowStoryTemplate.asp?Path=ArDemocrat/2005/06/15&ID=Ar00104&Section=Arkansas
Teen cried for help, got little
Up to death in lockup, girl?s complaints discounted
BY AMY UPSHAW ARKANSAS DEMOCRAT-GAZETTE
LaKeisha Brown had slept through the night, but she awoke on April 9 exhausted.
Instead of dressing for breakfast, "Keisha" remained in her small metal-frame bed.
Her lips were pale and dry. She was thirsty.
For most of her 17 years, she had felt abandoned and unwanted. In just over two hours, she was going to die.
Employees in her dorm at Alexander Youth Services Center, a state juvenile lockup where she had lived for nearly two years, asked the nurse to check on Keisha.
Nurse Lynetta Buckley arrived about 6:20 a.m. Keisha?s eyes were closed, and she responded only after Buckley called her name and shook her.
Her pulse and respiration levels were slightly high, but Buckley said they were normal.
"Client very weak," Buckley later wrote in a report about that visit. By the time the nurse left, she thought her patient appeared more alert.
A worried employee had asked treatment supervisor Joy Cole if Keisha, who had been placed on bed rest, could eat in her room.
"Make Keisha put on her clothes and go to breakfast, because security is not to bring her any food," one employee wrote that morning in recording Cole?s orders. Two months later, an internal investigation by the state Youth Services Division would cite "credible evidence" that Cole?s supervisor, program director Joann McCoy, violated policy by telling Cole to send Keisha to the cafeteria. The report also found that nurses should have called a doctor about Keisha and that Cole dismissed an employee?s request to call an ambulance for Keisha, and found credible evidence that several employees failed to properly document her failing condition.
An investigation by the Arkansas State Police into Keisha?s death produced no evidence of criminal wrongdoing.
But state legislators want to know exactly how Keisha was treated in the hours before her death. So far, Youth Services Division officials have declined to discuss her case, citing federal patient-privacy and state youthfuloffender laws. A joint meeting of legislative committees that deal with youth services is to discuss the case today at 1:30 p.m.
Most of the adults who knew Keisha best ? employees who saw her every day ? declined the Arkansas Democrat-Gazette?s request for an interview, did not return messages or could not be located.
Officials with the state Department of Human Services, the agency responsible for Alexander, declined to discuss Keisha?s case, citing federal patient-privacy laws.
But employees at Alexander are required to keep meticulous notes, and those notes, along with medical and psychological records obtained by the Democrat-Gazette, tell the story of the end of Keisha?s life.
When Keisha was born, her mother was a 17-year-old high school dropout with a toddler. The "club life" ? with its late nights and fights ? excited Michelle Brown more than full-time motherhood.
"I just didn?t want to have another baby," Brown acknowledged.
So she sent Keisha to live with Keisha?s father and grandmother in Osceola.
Only after Keisha?s death did Brown learn through psychological reports how her decision devastated Keisha, who complained for years that her mother abandoned her.
After giving birth to her third child, Brown brought 4-year-old Keisha home to Blytheville, but Keisha?s hurt remained. In later years, she would complain that Brown beat her. Brown felt she simply disciplined a daughter who was out of control.
Brown was still staying out late, she recalls now. She dated the wrong men. Didn?t have a lot of money.
When Keisha?s older brother Tracy, then 10, waited up one night and eagerly asked his mother if she?d fought anyone at the club, Brown decided to change. She eventually became a church youth adviser and earned her General Educational Development certificate. But she couldn?t change Keisha.
There is a Polaroid picture of Keisha from elementary school days. Her hair is neatly braided as she snuggles in her young mother?s arms on a sunny Easter. She?s wearing a black dress with puffy sleeves and bright-colored flowers and holding a basket her beloved "Granny Pooh" made before Granny Pooh went to prison for selling drugs.
Nothing in the photo gives away Keisha?s secret ? that she was being sexually abused. The abuse continued into her adolescence.
At age 12, she told her mother about one incident, and they reported it to police. Police arrested a relative?s boyfriend but he was not prosecuted.
She also learned to play a game that most children couldn?t fathom. In "hide-and-go-get-it," one child would cover his eyes while others scrambled under beds and behind doors. When he found one of the hiding children, the two of them would have sex.
In those days, Brown worked 12-hour shifts at a local factory until nearly 3 a.m. Often unsupervised, Keisha was smoking marijuana daily and defying her mother. She ran away from home several times.
She called bomb threats in to school, and school officials complained that Keisha broke every rule she knew about.
Once when police hauled her to jail for disorderly conduct, she snorted cocaine she had in a plastic bag in her cell in hopes officers wouldn?t find it.
As her life spiraled out of control over the next three years, she became suicidal, and went in and out of psychiatric and juvenile detention facilities.
One day when she was 15, Keisha failed to show up for cosmetology class, and Brown tracked her to a crack house. She waited outside all day, yelling at approaching customers and screaming at the dealers that they wouldn?t make any money as long as Keisha remained inside.
When Keisha finally came out, Brown called police.
"I can?t stand you. I can?t stand you," Keisha screamed at her mother. "Why did you call the police?"
The answer, though clouded by anger at that moment, was clear to Brown.
"It just got to the point that every time I turned around, I had to go look for her," Brown recalled. She could no longer handle Keisha, who by then was 200 pounds and taller than her mother. "I always said I didn?t ever want to find her in no ditch."
After bouncing from a juvenile detention facility to home and then back again, Keisha was sent to Alexander in April 2003.
Maybe, just maybe, Brown thought, they could protect Keisha from herself.
Like Keisha, the Alexander facility has a troubled past.
It is the state?s largest juvenile lockup, and workers there handle nearly 140 of the worst young offenders at a time.
Over the years, the inmates have complained that employees kicked, slapped and even threatened them with death. Others killed themselves while there.
One boy, known for days to be suicidal, was able to hang himself with a bed sheet because his guard didn?t check on him. Another boy hanged himself in the same cell just a few months later ? just as the state hired Cornell Companies Inc. to take over the facility and fix problems there.
In 2002, the U.S. Department of Justice found that dozens of problems remained. Though most have been resolved, state officials have said it will be at least six more months before all are fixed.
In September 2003, Keisha was transferred from Alexander to another facility after a fellow inmate accused her of a sexual attack. Keisha later pleaded guilty to rape.
She returned to Alexander for the final time Nov. 3, 2003.
Eventually, Keisha?s behavior began to change. By late 2004, written complaints about her aggressive behavior stopped. Her suicide attempts stopped, too.
She earned her GED and mailed black-and-white copies of her certificate to relatives.
She finally began to think about her future, beyond her planned May 1 release, and hoped to someday help other girls like her, an idea she put into a poem in November:
The revelation of God?s plan is oh so near.
It?s come to me, but not in a dream, I?m suppose to help others as part of a team.
We will start up a home for other lost souls.
To teach them God?s Word, and help them reach goals.
So when someone else finds their self in my place, They can turn to the Lord, and seek His face.
No matter how bad your situation may be, Remember Jesus saved a hopeless case like me.
Brown, who lived about three hours away, visited her daughter for the first time in almost two years just a few weeks before Keisha died. She hadn?t visited sooner because she didn?t want Keisha to think she approved of her past behavior.
But now she felt Keisha had found some answers and might someday lead a normal life. Just when they had begun mending their relationship, Brown would later say, Keisha died because the medical staff brushed aside her complaints.
The medical staff at Alexander had a forced familiarity with Keisha.
In late 2004 and into 2005, Keisha regularly asked for medical attention.
But the nurses who staffed the facility until 10 every night and on-call doctors didn?t believe she was sick, according to their notes. Psychiatrist Richard Livingston described Keisha as "hysterical."
On Dec. 30, 2004, Keisha spent most of the day at Alexander?s school crying and screaming that her back hurt. The same day she wrote a three-page letter begging for help.
... My medical conditions are being neglected and ignored. I have taken the proper commands for some attention. I?ve been complaining for exactly one week about my back being hurt.
Nurse Kimberly Colclough received the handwritten grievance and typed a response.
The nurses, Colclough wrote, found nothing wrong with Keisha.
About a week later, Dr. Robert Choate, a North Little Rock pediatrician on contract with Alexander, examined Keisha. Choate ordered her to see a psychologist in hopes of curbing her continuous complaints.
"She was counseled that her chart had more complaints than I?ve seen from any other client," Choate would later write in her medical records. "She has lost all credibility with the staff."
The medical staff tested Keisha for a possible urinary tract infection, her records show, but ordered no other tests.
For four weeks, Keisha quit asking for help.
But by February, she renewed her almost daily requests for medical attention.
BACK PAINS.
Having asthma attack.
Chest & back pains Been coughing & wheezing a lot today.
In early February, Choate refused to see Keisha. He later wrote that her requests for attention "appear to be manipulative and not valid."
On Feb. 6 she again filed a grievance.
I?ve been writing sick calls about my chest and breathing. [A]ll the nurses has been telling me they can not do anything. I?ve been hurting like this since Wednesday and the doctor refused to see me.
I feel my medical concerns are being ignored.
"That was Keisha?s standard response with every complaint that she brought to us, whether it was a stubbed toe or shortness of breath," Choate said in a phone interview Monday.
Three days after Keisha filed the grievance, Colclough wrote Choate: "This is becoming a problem because she is crying in tears every morning that she can?t get out of bed or walk to the kitchen. She is also missing groups and gym. ... I have multiple staff approaching me daily on her situation. I have been instructing staff that she is to continue to participate in everything and to be held accountable for her behavior if she doesn?t... it is becoming very time consuming for me."
But Keisha kept on.
I am short of breath at all times even worse when I lay down.
Chest is tight. Having difficulty breathing.
Chest & back aches hurts when I breathe.
Eventually, Keisha?s therapist confronted her, warning that her behavior could "negatively affect" her expected May 1 discharge.
Within a few days, Keisha stopped asking to see the nurses.
From Feb. 17 until her death, Keisha requested medical attention only twice, once for dry skin and once for a broken tooth.
But she told her family she was still ill.
On Feb. 19, three days after her last written complaint about her back and breathing, Keisha wrote her Granny Pooh.
Things are getting a little shaky for me. I plan on hanging in there though. ... I been sick a lot lately. These nurses suck here. My back hurts a lot. When I breathe a certain way it hurts in my left rib.
They tell me I?m not hurting but I stay strong anyhow.
In the end, when Keisha lay dying, no one with authority to get medical help believed her.
But other employees became concerned about Keisha?s condition in the days before her death.
The night of April 7, as Keisha stood in line to walk back to the dorm after softball, she stumbled and fell. Though she never lost consciousness, she seemed very sleepy.
Nurse Colclough found Keisha lying on the ground, face up and unable to move.
"I found nothing out of the ordinary," Colclough wrote in an e-mail to her bosses.
When Keisha nearly fell again, employees drove her to the infirmary.
Colclough told employees everything seemed fine.
"I was unable to find any physical findings of a serious medical problem that would render LaKeisha motionless, unconscious or unresponsive," she wrote in an e-mail.
Employees took Keisha to the dorm. She did not come out of her room that evening, not even to shower or write letters as she usually did.
Cole, the treatment supervisor, and Colclough told employees they thought Keisha was just trying to attract attention.
Keisha spent most of the next day on a bench in the school office. Employees described her as "very sick." To librarian Tressa Matthews, Keisha seemed pale and unable to move. Cole again instructed employees to give Keisha no special treatment.
The administrative assistant to the medical staff would later tell investigators that Matthews called and asked that Keisha receive medical attention. But, the assistant said, the medical staff thought it was "just another complaint from client Brown."
That evening, Keisha collapsed in the cafeteria. Case manager Mary Taylor started to write a report about Keisha?s worsening condition but Cole told her not to, according to the internal investigation.
When two nurses arrived, they found Keisha sitting on the sidewalk, breathing fast. As she had more than a month before, Keisha said her chest felt tight, that she was short of breath, and this time, dizzy.
The nurse recorded her vital signs, including her pulse at 100 and her respiration at 30. A normal pulse in a resting adolescent is between 60 and 90; the normal respiratory rate is between 12 and 16.
Nurses did not notify Choate on April 7 or 8, he said.
"I would have liked it if they had, but, once again, I have to rely on their judgment," Choate said.
He believes that he and the nurses provided Keisha with good medical care. They had no idea, he said, that she might be suffering from blood clots in her legs.
A preliminary autopsy report shows that those bloods clots likely traveled to her lungs and killed her.
"Even with good care people get sick," Choate said. "Her nurses and me cared for her more than her family did."
Dr. Barry Brenner, who heads the emergency department at the University of Arkansas for Medical Sciences, said in an interview that Keisha?s respiration and pulse oxygen level, which was 95 percent, were alarming.
Vital signs exceeding normal levels combined with complaints of shortness of breath and chest pains often signal heart problems or pneumonia, said Brenner, who never evaluated Keisha but discussed aspects of her condition at the Democrat-Gazette?s request.
"Because of the pulse/ox and the respiratory rate, you get an evaluation in the emergency room, which includes a chest X-ray, an EKG and a blood gas," Brenner said. "I bet something would have been wrong on those things.
"But you don?t know unless you look."
The night before Keisha died, no one looked.
Instead, the nurse gave Keisha two puffs from her asthma inhaler, put her on bed rest and left.
7:20 a.m.: Shift supervisor Eva Davis walked with Keisha as she shuffled the 350 feet to the cafeteria. Twice they stopped so Keisha could rest.
Davis urged Keisha to eat at least a little food and drink her orange juice. Eventually, Keisha ate a few bites, her head resting on the table the whole time.
Arkansas State Police Special Agent Mike Dawson would later note that McCoy, the program director and second in command at Alexander, told him Keisha "ate good" that morning.
Just before 8, Davis and Keisha left the cafeteria.
Keisha was too weak to make it back to her dorm room. So employee Fannie Holt directed her to the gym, 50 feet closer.
As they walked, Keisha could barely breathe. Once at the gym, she crawled onto a green-andyellow gymnastics mat while other girls played basketball.
"Keisha baby, are you OK?" a 16-year-old friend asked.
"I?m cold. I?m cold," Keisha responded in a faint whisper.
Keisha was covered in chill bumps, and her teeth chattered. Friends covered her with jackets.
Keisha?s lips were white and cracked, just as they had been the day before. The skin around her eyes was pale. Her dark hands looked purplish-blue.
At an employee?s request, nurse Buckley brought Keisha?s asthma inhaler and again checked Keisha?s vital signs, though no one recorded them.
Buckley gave Keisha 400 milligrams of Ibuprofen ? the equivalent of two pills. In Keisha?s chart the nurse noted that the medication was for "minor pain/fever/toothache."
About 20 minutes later, Davis asked Holt to take Keisha back to the dorm.
Once outside, Keisha collapsed.
9:15 a.m.: Three employees and an inmate carried Keisha to the infirmary.
At first, some staff were unconcerned. A video surveillance tape shows three employees near her feet, laughing and talking for several minutes.
But her condition quickly deteriorated.
As she lay on the couch, she tugged at her clothes, gasping for air and moaning.
Her pulse and blood pressure dropped.
Her breathing became labored.
Her lips and fingernail beds were white.
She lost consciousness.
"Keisha," the employees called.
Nothing.
One of the nurses called Choate at 9:22 a.m.
As they discussed Keisha?s vital signs, the nurse suddenly said, "Doctor, I think she?s gone."
"Have you called 911?" Choate asked.
9:28 a.m.: Nurse Buckley called 911. Though standing orders from a doctor and the facility?s written nursing protocols require staff to give a patient oxygen and an adrenaline shot during a respiratory emergency, the medical records show they did neither.
Keisha had no pulse.
She wasn?t breathing.
Her eyes rolled back. Her face was cold.
One employee suggested nurses try CPR.
But nothing brought Keisha back.
In written reports about that morning, some employees would remember the last moments of Keisha?s life in the infirmary.
As she lay dying, Keisha thrust herself into a near sitting position, grabbed employee Kenneth Cooperwood?s pants leg, gasped loudly and collapsed ? the last time she ever reached out for help.
About this story
The day of Keisha Brown?s death was reconstructed with information from employee incident reports filed April 9 at Alexander Youth Services Center, interviews in the Arkansas State Police investigative file, interviews in an internal Youth Services Division investigative report, written nursing guidelines for the facility and multiple medical records detailing Keisha?s care. More details were pulled from a logbook that employees write in every 10 minutes to explain what is happening in the girls dormitory at Alexander.
The reporter also viewed a black-and-white video surveillance tape from Alexander that had no audio. It showed Keisha in the cafeteria and in the gymnasium. Once she arrived at the infirmary and was placed on a couch, the camera showed Keisha only from her calves down. The newspaper depended on incident reports and interviews to reconstruct that scene.
Supervisors Joy Cole and Joann McCoy and nurses Kimberly Colclough and Lynetta Buckley did not return messages for comment. Other employees who were there with Keisha declined to comment, did not return messages or could not be located.
Information about Keisha?s life came from her family and friends and from her psychological records for the past five years. Details about her requests for medical attention and subsequent treatment were culled from her medical records, nurses? progress notes, physician notes, Keisha?s written requests for medical care and e-mails and memos written by the medical staff.
In all, the newspaper interviewed about a dozen people who knew Keisha, who were familiar with the case or who are medical professionals, and reviewed thousands of documents, most of which came from Keisha?s Department of Human Services file. The file included all of Keisha?s medical, psychological, legal and disciplinary records while she was in the juvenile justice system.
The Human Services Department declined to release its file to the Arkansas Democrat-Gazette, but Keisha?s mother, Michelle Brown, requested a copy and gave it to the newspaper.
Michelle also gave the newspaper an unredacted copy of the internal investigation into Keisha?s death. Subsequently, the Human Services Department released the same report.
This story was published Wednesday, June 15, 2005
http://www.ardemgaz.com/ShowStoryTemplate.asp?Path=ArDemocrat/2005/06/15&ID=Ar00104&Section=Arkansas
Teen cried for help, got little
Up to death in lockup, girl?s complaints discounted
BY AMY UPSHAW ARKANSAS DEMOCRAT-GAZETTE
LaKeisha Brown had slept through the night, but she awoke on April 9 exhausted.
Instead of dressing for breakfast, "Keisha" remained in her small metal-frame bed.
Her lips were pale and dry. She was thirsty.
For most of her 17 years, she had felt abandoned and unwanted. In just over two hours, she was going to die.
Employees in her dorm at Alexander Youth Services Center, a state juvenile lockup where she had lived for nearly two years, asked the nurse to check on Keisha.
Nurse Lynetta Buckley arrived about 6:20 a.m. Keisha?s eyes were closed, and she responded only after Buckley called her name and shook her.
Her pulse and respiration levels were slightly high, but Buckley said they were normal.
"Client very weak," Buckley later wrote in a report about that visit. By the time the nurse left, she thought her patient appeared more alert.
A worried employee had asked treatment supervisor Joy Cole if Keisha, who had been placed on bed rest, could eat in her room.
"Make Keisha put on her clothes and go to breakfast, because security is not to bring her any food," one employee wrote that morning in recording Cole?s orders. Two months later, an internal investigation by the state Youth Services Division would cite "credible evidence" that Cole?s supervisor, program director Joann McCoy, violated policy by telling Cole to send Keisha to the cafeteria. The report also found that nurses should have called a doctor about Keisha and that Cole dismissed an employee?s request to call an ambulance for Keisha, and found credible evidence that several employees failed to properly document her failing condition.
An investigation by the Arkansas State Police into Keisha?s death produced no evidence of criminal wrongdoing.
But state legislators want to know exactly how Keisha was treated in the hours before her death. So far, Youth Services Division officials have declined to discuss her case, citing federal patient-privacy and state youthfuloffender laws. A joint meeting of legislative committees that deal with youth services is to discuss the case today at 1:30 p.m.
Most of the adults who knew Keisha best ? employees who saw her every day ? declined the Arkansas Democrat-Gazette?s request for an interview, did not return messages or could not be located.
Officials with the state Department of Human Services, the agency responsible for Alexander, declined to discuss Keisha?s case, citing federal patient-privacy laws.
But employees at Alexander are required to keep meticulous notes, and those notes, along with medical and psychological records obtained by the Democrat-Gazette, tell the story of the end of Keisha?s life.
When Keisha was born, her mother was a 17-year-old high school dropout with a toddler. The "club life" ? with its late nights and fights ? excited Michelle Brown more than full-time motherhood.
"I just didn?t want to have another baby," Brown acknowledged.
So she sent Keisha to live with Keisha?s father and grandmother in Osceola.
Only after Keisha?s death did Brown learn through psychological reports how her decision devastated Keisha, who complained for years that her mother abandoned her.
After giving birth to her third child, Brown brought 4-year-old Keisha home to Blytheville, but Keisha?s hurt remained. In later years, she would complain that Brown beat her. Brown felt she simply disciplined a daughter who was out of control.
Brown was still staying out late, she recalls now. She dated the wrong men. Didn?t have a lot of money.
When Keisha?s older brother Tracy, then 10, waited up one night and eagerly asked his mother if she?d fought anyone at the club, Brown decided to change. She eventually became a church youth adviser and earned her General Educational Development certificate. But she couldn?t change Keisha.
There is a Polaroid picture of Keisha from elementary school days. Her hair is neatly braided as she snuggles in her young mother?s arms on a sunny Easter. She?s wearing a black dress with puffy sleeves and bright-colored flowers and holding a basket her beloved "Granny Pooh" made before Granny Pooh went to prison for selling drugs.
Nothing in the photo gives away Keisha?s secret ? that she was being sexually abused. The abuse continued into her adolescence.
At age 12, she told her mother about one incident, and they reported it to police. Police arrested a relative?s boyfriend but he was not prosecuted.
She also learned to play a game that most children couldn?t fathom. In "hide-and-go-get-it," one child would cover his eyes while others scrambled under beds and behind doors. When he found one of the hiding children, the two of them would have sex.
In those days, Brown worked 12-hour shifts at a local factory until nearly 3 a.m. Often unsupervised, Keisha was smoking marijuana daily and defying her mother. She ran away from home several times.
She called bomb threats in to school, and school officials complained that Keisha broke every rule she knew about.
Once when police hauled her to jail for disorderly conduct, she snorted cocaine she had in a plastic bag in her cell in hopes officers wouldn?t find it.
As her life spiraled out of control over the next three years, she became suicidal, and went in and out of psychiatric and juvenile detention facilities.
One day when she was 15, Keisha failed to show up for cosmetology class, and Brown tracked her to a crack house. She waited outside all day, yelling at approaching customers and screaming at the dealers that they wouldn?t make any money as long as Keisha remained inside.
When Keisha finally came out, Brown called police.
"I can?t stand you. I can?t stand you," Keisha screamed at her mother. "Why did you call the police?"
The answer, though clouded by anger at that moment, was clear to Brown.
"It just got to the point that every time I turned around, I had to go look for her," Brown recalled. She could no longer handle Keisha, who by then was 200 pounds and taller than her mother. "I always said I didn?t ever want to find her in no ditch."
After bouncing from a juvenile detention facility to home and then back again, Keisha was sent to Alexander in April 2003.
Maybe, just maybe, Brown thought, they could protect Keisha from herself.
Like Keisha, the Alexander facility has a troubled past.
It is the state?s largest juvenile lockup, and workers there handle nearly 140 of the worst young offenders at a time.
Over the years, the inmates have complained that employees kicked, slapped and even threatened them with death. Others killed themselves while there.
One boy, known for days to be suicidal, was able to hang himself with a bed sheet because his guard didn?t check on him. Another boy hanged himself in the same cell just a few months later ? just as the state hired Cornell Companies Inc. to take over the facility and fix problems there.
In 2002, the U.S. Department of Justice found that dozens of problems remained. Though most have been resolved, state officials have said it will be at least six more months before all are fixed.
In September 2003, Keisha was transferred from Alexander to another facility after a fellow inmate accused her of a sexual attack. Keisha later pleaded guilty to rape.
She returned to Alexander for the final time Nov. 3, 2003.
Eventually, Keisha?s behavior began to change. By late 2004, written complaints about her aggressive behavior stopped. Her suicide attempts stopped, too.
She earned her GED and mailed black-and-white copies of her certificate to relatives.
She finally began to think about her future, beyond her planned May 1 release, and hoped to someday help other girls like her, an idea she put into a poem in November:
The revelation of God?s plan is oh so near.
It?s come to me, but not in a dream, I?m suppose to help others as part of a team.
We will start up a home for other lost souls.
To teach them God?s Word, and help them reach goals.
So when someone else finds their self in my place, They can turn to the Lord, and seek His face.
No matter how bad your situation may be, Remember Jesus saved a hopeless case like me.
Brown, who lived about three hours away, visited her daughter for the first time in almost two years just a few weeks before Keisha died. She hadn?t visited sooner because she didn?t want Keisha to think she approved of her past behavior.
But now she felt Keisha had found some answers and might someday lead a normal life. Just when they had begun mending their relationship, Brown would later say, Keisha died because the medical staff brushed aside her complaints.
The medical staff at Alexander had a forced familiarity with Keisha.
In late 2004 and into 2005, Keisha regularly asked for medical attention.
But the nurses who staffed the facility until 10 every night and on-call doctors didn?t believe she was sick, according to their notes. Psychiatrist Richard Livingston described Keisha as "hysterical."
On Dec. 30, 2004, Keisha spent most of the day at Alexander?s school crying and screaming that her back hurt. The same day she wrote a three-page letter begging for help.
... My medical conditions are being neglected and ignored. I have taken the proper commands for some attention. I?ve been complaining for exactly one week about my back being hurt.
Nurse Kimberly Colclough received the handwritten grievance and typed a response.
The nurses, Colclough wrote, found nothing wrong with Keisha.
About a week later, Dr. Robert Choate, a North Little Rock pediatrician on contract with Alexander, examined Keisha. Choate ordered her to see a psychologist in hopes of curbing her continuous complaints.
"She was counseled that her chart had more complaints than I?ve seen from any other client," Choate would later write in her medical records. "She has lost all credibility with the staff."
The medical staff tested Keisha for a possible urinary tract infection, her records show, but ordered no other tests.
For four weeks, Keisha quit asking for help.
But by February, she renewed her almost daily requests for medical attention.
BACK PAINS.
Having asthma attack.
Chest & back pains Been coughing & wheezing a lot today.
In early February, Choate refused to see Keisha. He later wrote that her requests for attention "appear to be manipulative and not valid."
On Feb. 6 she again filed a grievance.
I?ve been writing sick calls about my chest and breathing. [A]ll the nurses has been telling me they can not do anything. I?ve been hurting like this since Wednesday and the doctor refused to see me.
I feel my medical concerns are being ignored.
"That was Keisha?s standard response with every complaint that she brought to us, whether it was a stubbed toe or shortness of breath," Choate said in a phone interview Monday.
Three days after Keisha filed the grievance, Colclough wrote Choate: "This is becoming a problem because she is crying in tears every morning that she can?t get out of bed or walk to the kitchen. She is also missing groups and gym. ... I have multiple staff approaching me daily on her situation. I have been instructing staff that she is to continue to participate in everything and to be held accountable for her behavior if she doesn?t... it is becoming very time consuming for me."
But Keisha kept on.
I am short of breath at all times even worse when I lay down.
Chest is tight. Having difficulty breathing.
Chest & back aches hurts when I breathe.
Eventually, Keisha?s therapist confronted her, warning that her behavior could "negatively affect" her expected May 1 discharge.
Within a few days, Keisha stopped asking to see the nurses.
From Feb. 17 until her death, Keisha requested medical attention only twice, once for dry skin and once for a broken tooth.
But she told her family she was still ill.
On Feb. 19, three days after her last written complaint about her back and breathing, Keisha wrote her Granny Pooh.
Things are getting a little shaky for me. I plan on hanging in there though. ... I been sick a lot lately. These nurses suck here. My back hurts a lot. When I breathe a certain way it hurts in my left rib.
They tell me I?m not hurting but I stay strong anyhow.
In the end, when Keisha lay dying, no one with authority to get medical help believed her.
But other employees became concerned about Keisha?s condition in the days before her death.
The night of April 7, as Keisha stood in line to walk back to the dorm after softball, she stumbled and fell. Though she never lost consciousness, she seemed very sleepy.
Nurse Colclough found Keisha lying on the ground, face up and unable to move.
"I found nothing out of the ordinary," Colclough wrote in an e-mail to her bosses.
When Keisha nearly fell again, employees drove her to the infirmary.
Colclough told employees everything seemed fine.
"I was unable to find any physical findings of a serious medical problem that would render LaKeisha motionless, unconscious or unresponsive," she wrote in an e-mail.
Employees took Keisha to the dorm. She did not come out of her room that evening, not even to shower or write letters as she usually did.
Cole, the treatment supervisor, and Colclough told employees they thought Keisha was just trying to attract attention.
Keisha spent most of the next day on a bench in the school office. Employees described her as "very sick." To librarian Tressa Matthews, Keisha seemed pale and unable to move. Cole again instructed employees to give Keisha no special treatment.
The administrative assistant to the medical staff would later tell investigators that Matthews called and asked that Keisha receive medical attention. But, the assistant said, the medical staff thought it was "just another complaint from client Brown."
That evening, Keisha collapsed in the cafeteria. Case manager Mary Taylor started to write a report about Keisha?s worsening condition but Cole told her not to, according to the internal investigation.
When two nurses arrived, they found Keisha sitting on the sidewalk, breathing fast. As she had more than a month before, Keisha said her chest felt tight, that she was short of breath, and this time, dizzy.
The nurse recorded her vital signs, including her pulse at 100 and her respiration at 30. A normal pulse in a resting adolescent is between 60 and 90; the normal respiratory rate is between 12 and 16.
Nurses did not notify Choate on April 7 or 8, he said.
"I would have liked it if they had, but, once again, I have to rely on their judgment," Choate said.
He believes that he and the nurses provided Keisha with good medical care. They had no idea, he said, that she might be suffering from blood clots in her legs.
A preliminary autopsy report shows that those bloods clots likely traveled to her lungs and killed her.
"Even with good care people get sick," Choate said. "Her nurses and me cared for her more than her family did."
Dr. Barry Brenner, who heads the emergency department at the University of Arkansas for Medical Sciences, said in an interview that Keisha?s respiration and pulse oxygen level, which was 95 percent, were alarming.
Vital signs exceeding normal levels combined with complaints of shortness of breath and chest pains often signal heart problems or pneumonia, said Brenner, who never evaluated Keisha but discussed aspects of her condition at the Democrat-Gazette?s request.
"Because of the pulse/ox and the respiratory rate, you get an evaluation in the emergency room, which includes a chest X-ray, an EKG and a blood gas," Brenner said. "I bet something would have been wrong on those things.
"But you don?t know unless you look."
The night before Keisha died, no one looked.
Instead, the nurse gave Keisha two puffs from her asthma inhaler, put her on bed rest and left.
7:20 a.m.: Shift supervisor Eva Davis walked with Keisha as she shuffled the 350 feet to the cafeteria. Twice they stopped so Keisha could rest.
Davis urged Keisha to eat at least a little food and drink her orange juice. Eventually, Keisha ate a few bites, her head resting on the table the whole time.
Arkansas State Police Special Agent Mike Dawson would later note that McCoy, the program director and second in command at Alexander, told him Keisha "ate good" that morning.
Just before 8, Davis and Keisha left the cafeteria.
Keisha was too weak to make it back to her dorm room. So employee Fannie Holt directed her to the gym, 50 feet closer.
As they walked, Keisha could barely breathe. Once at the gym, she crawled onto a green-andyellow gymnastics mat while other girls played basketball.
"Keisha baby, are you OK?" a 16-year-old friend asked.
"I?m cold. I?m cold," Keisha responded in a faint whisper.
Keisha was covered in chill bumps, and her teeth chattered. Friends covered her with jackets.
Keisha?s lips were white and cracked, just as they had been the day before. The skin around her eyes was pale. Her dark hands looked purplish-blue.
At an employee?s request, nurse Buckley brought Keisha?s asthma inhaler and again checked Keisha?s vital signs, though no one recorded them.
Buckley gave Keisha 400 milligrams of Ibuprofen ? the equivalent of two pills. In Keisha?s chart the nurse noted that the medication was for "minor pain/fever/toothache."
About 20 minutes later, Davis asked Holt to take Keisha back to the dorm.
Once outside, Keisha collapsed.
9:15 a.m.: Three employees and an inmate carried Keisha to the infirmary.
At first, some staff were unconcerned. A video surveillance tape shows three employees near her feet, laughing and talking for several minutes.
But her condition quickly deteriorated.
As she lay on the couch, she tugged at her clothes, gasping for air and moaning.
Her pulse and blood pressure dropped.
Her breathing became labored.
Her lips and fingernail beds were white.
She lost consciousness.
"Keisha," the employees called.
Nothing.
One of the nurses called Choate at 9:22 a.m.
As they discussed Keisha?s vital signs, the nurse suddenly said, "Doctor, I think she?s gone."
"Have you called 911?" Choate asked.
9:28 a.m.: Nurse Buckley called 911. Though standing orders from a doctor and the facility?s written nursing protocols require staff to give a patient oxygen and an adrenaline shot during a respiratory emergency, the medical records show they did neither.
Keisha had no pulse.
She wasn?t breathing.
Her eyes rolled back. Her face was cold.
One employee suggested nurses try CPR.
But nothing brought Keisha back.
In written reports about that morning, some employees would remember the last moments of Keisha?s life in the infirmary.
As she lay dying, Keisha thrust herself into a near sitting position, grabbed employee Kenneth Cooperwood?s pants leg, gasped loudly and collapsed ? the last time she ever reached out for help.
About this story
The day of Keisha Brown?s death was reconstructed with information from employee incident reports filed April 9 at Alexander Youth Services Center, interviews in the Arkansas State Police investigative file, interviews in an internal Youth Services Division investigative report, written nursing guidelines for the facility and multiple medical records detailing Keisha?s care. More details were pulled from a logbook that employees write in every 10 minutes to explain what is happening in the girls dormitory at Alexander.
The reporter also viewed a black-and-white video surveillance tape from Alexander that had no audio. It showed Keisha in the cafeteria and in the gymnasium. Once she arrived at the infirmary and was placed on a couch, the camera showed Keisha only from her calves down. The newspaper depended on incident reports and interviews to reconstruct that scene.
Supervisors Joy Cole and Joann McCoy and nurses Kimberly Colclough and Lynetta Buckley did not return messages for comment. Other employees who were there with Keisha declined to comment, did not return messages or could not be located.
Information about Keisha?s life came from her family and friends and from her psychological records for the past five years. Details about her requests for medical attention and subsequent treatment were culled from her medical records, nurses? progress notes, physician notes, Keisha?s written requests for medical care and e-mails and memos written by the medical staff.
In all, the newspaper interviewed about a dozen people who knew Keisha, who were familiar with the case or who are medical professionals, and reviewed thousands of documents, most of which came from Keisha?s Department of Human Services file. The file included all of Keisha?s medical, psychological, legal and disciplinary records while she was in the juvenile justice system.
The Human Services Department declined to release its file to the Arkansas Democrat-Gazette, but Keisha?s mother, Michelle Brown, requested a copy and gave it to the newspaper.
Michelle also gave the newspaper an unredacted copy of the internal investigation into Keisha?s death. Subsequently, the Human Services Department released the same report.
This story was published Wednesday, June 15, 2005
