A Hanging Offense

Did the Devereux Treatment Center provide the care Cecilia Garrett needed or did it drive the young teenager to her death?

But the picture of Robinson painted in the depositions is a mixed one. According to Melba Lindberg, Robinson was at best an average worker. Thompson testified that Robinson lied regularly, misappropriated the kids' money when parents would send it to them and used Devereux's tax ID number to buy items for herself when she took the kids on shopping trips and other outings. She was accused of stealing patient forms. All of which Robinson denied.

Executive director Atkinson said Robinson was a good employee sometimes but that she purchased items at Circuit City using Devereux's tax-exempt status. She said Robinson was frequently missing from her job in the classroom and that she was often in the kitchen cooking food when she was supposed to be elsewhere on the unit.

At the same time, after Cecilia's death, Devereux sent Robinson as one of its two representatives to the girl's funeral in Chicago.

Cecilia, shown at a young age, grew up in the Chicago 
Cecilia, shown at a young age, grew up in the Chicago projects.
On the night of her death, Cecilia got in a shouting 
match with other girls on her unit.
Tifenn Python
On the night of her death, Cecilia got in a shouting match with other girls on her unit.

Devereux discharged Robinson a year after Cecilia's death, saying her job performance was below par. Robinson said she was being retaliated against and that Devereux didn't cut her any slack when she incurred emotional problems because of Cecilia's death. In December 1997, Robinson sought psychiatric counseling. "I had to start taking a bunch of medication just so I could function," she said. She kept seeing Cecilia's death over and over in her sleep.

In any lawsuit involving a death, there's a postmortem of experts assembled by both sides -- in this case, independent psychiatrists were tapped.

Scoring a big one for Devereux, none of the psychiatric experts thought Cecilia should have been placed on suicide precautions right before her death based upon the reading of her charts. In the depositions, the Garretts' attorneys attempted to show that those charts didn't reveal everything that was going on with Cecilia, pointing to her journal as evidence.

Dr. Richard B. Pesikoff, testifying for Devereux, has spent more than 30 years training psychiatrists at Baylor College of Medicine. He said he didn't see anything that would indicate suicide in Cecilia's record, only that she was aggressive and would attack people. He agreed with Saeed that Cecilia was not suicidal and said Saeed was right to take her off her bipolar medication.

Pesikoff countered the criticism of Devereux for housing males and females on the same unit, explaining that most psychiatric treatment programs are coed. He questioned, however, the inclusion of patients older than 18 on the same unit with 12-year-olds.

Psychiatrist Jay Tarnow also agreed that the diagnosis of bipolar was incorrect. This was proved, he said, by the fact that the bipolar medicines weren't effective with her. He said he agreed that she suffered from conduct disorder and said post-traumatic stress disorder was also likely present.

Both Tarnow and Pesikoff said Devereux had basically done its job, an opinion not shared by plaintiffs' witness Aaron Fink. Psychiatrist Fink said Devereux should be closed or reformed.

There was a documented history of suicide attempts by Cecilia, Fink said. She was placed on suicide precautions at Devereux when she was moved from acute hospital care to the residential program, he said. In March 1995 she was on suicide precautions, and there are references in her charts that she expressed suicidal thoughts, Fink said.

Still, asked if he would have had Cecilia on suicide precautions in December 1996, Fink said no. From the records late in her stay, he said, he saw none of the indications he needed.

Fink said he found "the general clinical care provided to Cecilia was poor." There was a lack of documentation, and Saeed was signing off on cases months after the reports were generated. He said there had been "superficial and incomplete evaluation of her clinical condition" and "failure to obtain previous psychiatric records."

There was a lack of coordination between units and no evidence that Saeed had talked to the psychiatrist who treated Cecilia for her first year at Devereux, Fink said. He also called the supervision of the treatment team "inadequate."

Because of poor clinical care, Fink said, Cecilia's "hospitalization and treatment was unnecessarily extended, which led to her increased frustration, increased feeling of hopelessness and ultimately contributed to her suicide. She couldn't have killed herself at Devereux if she had been discharged earlier."

Fink said Saeed didn't know his patient, not when he made reference to Cecilia as being bright, despite having a documented IQ of 87. Also, there's a conclusion that Cecilia didn't have a drug problem despite a history of that in her charts, Fink said.

Fink said he thought Cecilia had attention deficit hyperactivity disorder, with which none of the other psychiatrists agreed. He called Saeed's diagnosis of conduct disorder incomplete.

He criticized the fact that it took progress reports three or four months to get to the parents. Devereux has maintained that Gladys Garrett would either be late or entirely miss scheduled family therapy phone calls. After a while, she began making the calls from Josie Winston's office. Fink said Devereux should have set this up from the start, since it knew the Garretts didn't have a phone.

The atmosphere at the Devereux unit was a negative one that only reinforced poor behavior tendencies, Fink said. "There was a lot of sexual acting out on the unit with very poor supervision," he said. One patient set a fire, and many children ran away from the facility, he said. While sexual acting out isn't unique to Devereux, Fink said, the TDPRS made note of the degree to which it was happening in League City.

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This is not the truth I was there I was one of the girls at group. That place is a mad house ,ive been messed up since that day

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