A Hanging Offense

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

The girl's body was slumped against the back of her bathroom door, a bedsheet knotted tightly around her neck. Instead of a warm, vibrant chocolate skin, hers was the grays and blues of impending death. Her stomach was distended, her eyes unfocused.

Joyce Robinson was the first one to spot her. The mental health technician began screaming, yelling for help, for someone to call 911. Cecilia's body fell before her; Robinson wrestled the sheet off and began CPR, with the help of other techs.

It was three days before Christmas, 1996, a little after 8 p.m., and 14-year-old Cecilia Garrett had gotten into a shouting match with other girls on her unit at the Devereux Treatment Center, a nonprofit mental health facility in League City. Told to sit by herself for a while until she calmed down, she stayed alone in a common room before deciding to go to her bedroom.

Cecilia, shown at a young age, grew up in the Chicago 
projects.
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 officials encouraged Cecilia to write in her 
journal.
Tifenn Python
Devereux officials encouraged Cecilia to write in her journal.
There were a lot of missed connections in Cecilia's 
attempts at family therapy by phone.
Tifenn Python
There were a lot of missed connections in Cecilia's attempts at family therapy by phone.

Heading down the hallway, past the nurses station, she slammed the door shut to her room and walked to her bed, where she ripped off a sheet. She knotted one end, tossed it over the top of her bathroom door, shut the door and tied the other end around her neck.

A few minutes later, Robinson entered the room to check on Cecilia and found her hanging.

Devereux personnel hustled about, sending the other girls to their rooms. An emergency medical service team and the League City police arrived. EMS came in without an oxygen tank. A Devereux employee was finally sent to bring it in off the ambulance. For a while Cecilia's color got better, closer to normal. Then it wasn't. Finally, they decided to take her to the hospital emergency room.

About an hour later, Cecilia Garrett was pronounced dead. She'd entered Devereux as a 12-year-old just two years before. She left on a gurney.

There was no obituary or news story about Cecilia in the Galveston County Daily News or the Houston Chronicle the next day or the days after. Her body was sent back to her parents in Chicago. It was like Cecilia Garrett had never been here. It was like she'd never been at all.


The Cecilia Garrett who arrived at the Devereux treatment facility in January 1995 was, by all accounts, a troubled child: aggressive, self-destructive and a victim. A friend of her father's allegedly raped her when she was nine years old. That was the same year her adoptive father moved out, and the same year Cecilia may have started using marijuana, although her parents deny that. Cecilia would cut herself on the arms and legs and had attempted suicide by slitting her wrists. A product of the South Chicago projects, Cecilia, who was big for her age, was more than the local public school system and her parents, Gladys and Victor, could handle. She was hospitalized at Hartgrove Hospital in Chicago -- she even got an extension to stay there longer while the school district looked for someplace else to put her -- but she was running out of time.

The Devereux treatment facility in League City, Texas, is 1,000 miles away from the South Side projects Cecilia called home. Devereux sends representatives to Chicago to tout its facilities, and the Chicago school system was interested. Hartgrove Hospital was a prime feeder to Devereux, said Ron Winkler, who was a Devereux intermediary signing up clients. Cecilia's treatment would be paid for with state money doled out through the Chicago schools. This was important because her parents didn't have much of anything, not even a telephone.

But still Cecilia's parents hesitated. She would be so far away. Gladys, who'd given birth to Cecilia on September 6, 1982, and Victor, who'd adopted her and her brother on September 27, 1988, didn't like it that they wouldn't be able to see their daughter regularly. Both were afraid to fly and, in any case, didn't have the money to travel back and forth. How would family counseling take place?

But something had to happen; something had to change. Cecilia had been to school only one day in all of 1994, according to Josie Winston, case manager with Chicago's alternative schools program. "She had been in the hospital, I believe, four times, psychiatrically hospitalized in 1994; and in 1993, I'm not sure what her attendance was, but I believe that she had been a chronic truant during 1993." She hadn't actually had too many special ed services from the schools, Winston said, because she was not there. "She's wandering the streets."

Victor and Gladys Garrett themselves had a lot of problems. Their home life was tumultuous, punctuated by Victor's drinking problems and his occasional physical abuse of Gladys. Cecilia later told counselors that he hit her as well, but her father denied that. He was taken to jail once for hitting his son after a teacher called to say the boy had been disobedient in class. Cecilia had a younger sister and an older brother, and as he got older the brother was frequently in trouble because of drugs. Victor Garrett said he moved out because of his wife's adultery and because the kids would tear up the apartments they were staying in until landlords didn't want them anymore, and he was tired of moving. He got a place nearby and would visit them in the mornings. Later in 1995, Victor Garrett would begin drawing social security disability after being diagnosed with depression.

While insisting that most of Cecilia's behavior put Cecilia herself at risk, Winston also acknowledged the girl's aggressiveness, as when she kicked in the door at a friend's house. "We're talking about a child who had slashed up several people and had no remorse about it." In fact, it was Cecilia slashing her brother in the face that brought about her most recent hospitalization.

Winston agreed with the Garretts that it would be better for Cecilia to be placed close to home, where they could be involved in her treatment. Of the eight or nine facilities she contacted, Winston said, only one other than Devereux would take the preteen. An all-girls school, it had the advantage of being much closer to Chicago, but it wouldn't have any openings until later in January. In Illinois, none of the facilities was a lock-in, and as officials of those schools rejected Cecilia they told Winston they thought the girl needed long-term care in a secure facility.

Meanwhile, back at Hartgrove, Cecilia was not doing well. Even under medication the 12-year-old was extremely aggressive toward the staff and other students on the unit, Winston said. She was put in seclusion. Winston started looking for a school with a stronger psychiatric component.

In the end, with no other options readily available, Winston and the Garretts decided to trust Cecilia to Devereux, a facility known for taking on children and adolescents with all of Cecilia's problems and more.

The parents came down for a tour at Devereux's expense, momentarily overcoming their fear of flying. What they found was a mental health center divided into units, some mini-hospitals, others less restrictive. On Unit 4, to which Cecilia was assigned when she died, there were 22 patients, a mix of males and females ranging in age from 12 to 21, two to a room, the girls on one side, the boys on the other.

According to therapist Patti Thompson, Cecilia's admitting process into the Devereux hospital unit did not go smoothly:

"She spit in the doctor's face that admitted her. Her dad either tried to slap her or slapped her, called her a 'fucking bitch' and a 'ho.' "

Diagnosed as having a bipolar personality, Cecilia was heavily medicated for the first year with lithium, Haldol, Tegretol and Depakote. She was also diagnosed with a conduct disorder.

At the end of that year, Cecilia's behavior had improved and she was moved to a residential unit at Devereux. On an in-house rating scale of one to six, Cecilia was now a five and ready to begin building life skills, Devereux concluded.

But shortly after the switch, Cecilia encountered problems. At the last minute, her pass entitling her to a home visit for Christmas was canceled; her new psychiatrist said he needed more time to assess her. Her rating dropped to level two. In January 1996, according to Devereux records, Cecilia said, "My temper, I just blow up, saying the wrong thing, cutting myself, doing drugs, cutting people and hurting people."

Cecilia's new doctor was Mohammad Saeed, who was to achieve some measure of fame in June 2001 for his involvement in the case of Andrea Yates, the Houston mother who drowned her five children in the family bathtub. Saeed had taken Yates off the medication she'd been on shortly before the time she grew increasingly psychotic and killed her children.

In Cecilia's case, Saeed dropped her from the medication she'd been receiving as well. He concluded that the earlier diagnosis of bipolar personality was incorrect, that instead she was suffering from a conduct disorder and a narcissistic personality disorder.

Early in 1996, Cecilia and a new girl who'd entered the Devereux program teamed up to sexually attack a smaller girl on the unit. The victim's parents reported the case to police, and then Devereux operations director Melba Lindberg reported it to the state. Devereux told Cecilia to write up a statement without any legal representation; she was prosecuted and listed as a juvenile sex offender and was required to meet monthly with a probation officer. In the space of 30 days, Cecilia's rating level once again dropped, this time from a five to a one.

There were two reports of Cecilia being sexually abused at Devereux. On one occasion it was alleged she was fondled under her blouse; on another, a male patient reportedly put his hands down her pants.

Cecilia was able to bounce back from her drop to a level one, learning to take care of herself better. In May 1996 she was finally allowed a weeklong visit home that included Mother's Day. In September 1996 she was named student of the month at Devereux, and in October she was given a level six, the highest rating.

By fall 1996, Cecilia and her parents expected her to be moved back to Chicago, not yet ready for their home but to a nearby group home. In a letter dated October 8, 1996, she wrote her father, urging him to stay on a sober path: "I miss you when I went home. I could tell you were proud of the way I changed. I was proud of you too. You not an alcohlic (sic) no more. I'm so proud of you." She wrote a separate letter to her mother that day, saying, "Momma these white folks be down here saying Cecilia's mother isn't working in therapy don't put your self on the spot o.k." She wrote to the Chicago school district and to Devereux officials. An October 17, 1996, letter was passed on from the clinical team to Jean Brown, the Chicago case manager assigned to handle Devereux placements. Cecilia asked when she would be leaving. "I almost been here for 2 yrs. And that's a lot." She concluded the letter with a PS saying she was watching cartoons.

When the time came for the annual reapplication for funding with the Illinois State Board of Education, which was granted, Brown noted that Cecilia was in the ninth grade, not on any medications, not having any behavioral problems in class, but that she still had trouble understanding what others said to her and in expressing herself and was emotionally delayed for her age.

Brown took the information from Devereux and processed it into the reports she was making to Chicago and the state. When Cecilia reached a level six, she noted that, but also that Cecilia was having "increased difficulties following directions and demonstrating appropriate relationship with peers."

Later in October, Cecilia got word that instead of being done by January, her case had been reassessed and now July 1997 was her new target release date.

Again, a scheduled Christmas pass was denied at the last minute. The level six rating she'd attained in October was a two by December. She exposed herself in PE class. She had a kicking fight with another girl, punched a boy and was physically restrained on December 10. She was put on room restriction for four days, which meant she couldn't talk with fellow patients.

After her pass was pulled and a few days before she died, Cecilia made a distraught call to Jean Brown in Chicago. Cecilia cried and raged, saying they'd lied to her. Robinson, who stood by her side during the call, said she was "screaming and fussing…and she wasn't going to live to see Christmas and she didn't want to be here anymore.

"I had to end the phone call and get her under control," Robinson said.


Two years after their daughter's death, in December 1998, the Garretts filed a wrongful death lawsuit in Galveston County against Devereux, psychiatrist Mohammad Saeed, therapist Patti Thompson, then-operations director Melba Lindberg, family services representative Ron Winkler, staff psychiatrist Isabela Iovino and then-unit manager Jeff Kennedy. They asked for actual damages of not more than $10 million and punitive damages in the maximum amount allowed by law.

"I think this young lady essentially was being warehoused," said James Doyle, who became the lead attorney for the Garretts. "I don't think it makes any sense for her to have received this type of hospitalization and therapy over a thousand miles away from her home and family."

According to the lawsuit, when Devereux found out there were additional funds to be had, "defendants falsely and fraudulently re-characterized Cecilia's condition and subsequently manipulated her environment, her treatment and her emotional stability such that she became increasingly depressed…Her holiday trip home was canceled owing to her worsening emotional condition, whether real, manufactured or concocted."

"Our contentions are that they pushed her buttons and they had encouraged staff to be critical in terms of their assessments," said Doyle, of the firm Doyle, Restrepo, Harvin & Robbins.

Cecilia's condition worsened and "she was once again a substantial risk for suicide," the lawsuit says. She started giving away her belongings, was moody, isolated, depressed and crying. Although Devereux promotes itself as offering specialized care for suicidal patents, these procedures were ignored or avoided in Cecilia's case, the suit says.

The night of her death, Cecilia was allowed to leave a group session unattended in an agitated state. Defendants ordered observers to stay put rather than follow her, the suit says. She was found dead a short time later.

Besides failing to protect her, the lawsuit alleges that the defendants "knowingly attempted to conceal the causes and circumstances of Cecilia's death to discourage independent investigation…and to avoid liability."

The Garretts contend that records were changed to indicate more care was being taken with Cecilia in the days leading up to her death than actually was the case. Robinson says she was told to backdate records to show that Cecilia was on suicide precautions, which she refused to do.

Devereux officials and fellow defendants deny backdating or falsifying any of Cecilia's treatment records or telling anyone else to do so. They point out that Robinson has an ax to grind, having filed a lawsuit against Devereux after the center fired her. Another former employee, Hernandez Miller, who was fired, also said he was asked to falsify records in Cecilia's case. He also filed an unsuccessful lawsuit against Devereux following his dismissal.

The center denies leaning on Cecilia in any way in order to make her act out. Devereux says that it had no indication that Cecilia was suicidal, that any moroseness she was showing before her death was just part and parcel of the normal teenage condition. While the Garretts contend that Cecilia's own writings show she was suicidal, Devereux personnel say they wouldn't have looked at her private journal. Dr. Joan S. Anderson, another witness for Devereux, also said she wouldn't have been concerned about suicide in Cecilia's case, even based on her journal, saying that "teenagers typically write morbid stuff." She said she would have put her on close observation. She testified she thought Devereux was doing its job.

As for giving away possessions, Devereux personnel maintained that Cecilia gave no more than she normally did.

In her deposition, mental health technician Tundalayea "Cissy" Palmer testified that Cecilia told her she didn't care if she lost her pass and said it wasn't unusual since kids would sometimes jeopardize their passes if "they really didn't want to go or had mixed feelings about going."

Cecilia knew she wasn't going to be able to go back home, Palmer said. Asked why, Palmer responded: "Home environment, the issues with her brother…I think she knew that her parents couldn't provide for her." At the same time, Palmer described Cecilia as "one of our least behavioral kids…she maintained at least a level four most of the time and exhibited appropriate behavior most of the time." She said Cecilia grew up a lot at Devereux, "changing her clothing and the makeup and increasing her hygiene."

Devereux's position is it did everything it possibly could to help Cecilia.


Even a nonprofit like Devereux needs funds to keep going. From the depositions filed in Cecilia's case, it appears Devereux was experiencing some financial difficulties, even with the expensive fees it was charging.

When Saeed started with Devereux he was being paid $120,000 a year for his work on Unit 4, where Cecilia ended up. In addition he was paid by the hour for work he did on another unit with individual patients. Over time, Saeed said, the $120,000 had decreased to somewhere in the $70,000 range.

In a letter to Gail Atkinson in October 1995, Saeed wrote, "You mentioned that Devereux Hospital in League City is still suffering from financial and administrative difficulties."

In another communication with Devereux about his compensation, Saeed wrote, "Here I would like to remind that the staffing of RN [registered nurses] and LVN [licensed vocational nurses] has been and remains a serious problem on Unit 4 and 5." He also wrote: "Use of float pool nurses poses the problem of inconsistency, which is detrimental to the care of the patients…Nursing staff tells me we need at least a charge nurse and medication nurse at all times."

Family services liaison Ron Winkler said Chicago and other school districts across the country knew Devereux's full rates, which were about $10,000 a month. Josie Winston said that while in the past Devereux had required additional funding, in Cecilia's case it was willing to accept what the Illinois State Board of Education would pay for her care.

Winkler said Chicago would have about ten kids at any time in Devereux's Texas facilities. Jean Brown, the Chicago case manager assigned to handle Devereux placements, estimated the average number at 14. Based on $10,000 a month, Chicago would be paying just under $1.7 million a year to Devereux.

Funding concerns are echoed in Joyce Robinson's account of what was going on at Devereux. Although Cecilia was originally scheduled for discharge around Christmas, in October Thompson told the staff that the Illinois State Board of Education had come up with additional funding and Cecilia didn't need to leave. Robinson said therapist Thompson told a group of staffers to "push her buttons because she was a high level." Robinson said this was not an unusual instruction from Thompson for different kids.

In another meeting, operations director Lindberg made an overhead presentation, telling them, "they had lost millions of dollars because of Medicare or Medicaid," Robinson said. They were told to "chart more negative…to stop charting more positively because the agencies aren't paying for kids to be here that are doing so great. Then they don't need to be here," Robinson said.


On the night of December 22, the girls were in a common room and began talking in what Joyce Robinson considered a sexually inappropriate manner. They were talking about "jacking off boys," she said, so she sent them to their rooms.

Cissy Palmer was the mental health technician working with the group that night. She had been out at a store, and when she returned, Robinson told her what had happened. Palmer called them out for a community meeting.

As soon as they assembled, Palmer said, the girls began attacking Cecilia for telling Thompson about their private comments in her private therapy session earlier that day. They also reportedly said that Thompson had been passing this information on to other girls. Tempers escalated.

"I could see that Cecilia was the focal point. She was real upset with them, wouldn't accept direction to stop cursing from me." Palmer said she asked Cecilia if she wanted some quiet time and she said yes, while continuing to curse and call the other girls bitches and whores. The group left the room, sat outside the door and then got snacks. Palmer went in to ask if she felt better and Cecilia said no. After a while, Cecilia went to her room without saying anything more to the girls. Palmer said she went to the nurses station to tell Thompson what had happened and Robinson was there as well. After that, Palmer went to the boys' side of the unit to relieve a worker there.

Ten minutes later, Palmer said, she heard Robinson scream her name.

Joyce Robinson's account differs from those of Palmer and Patti Thompson. According to Robinson, the girl stomped off to her room and Robinson attempted to go after her but was stopped by Thompson, who told her, "Let her stew," and by Palmer, who waved her off from the day room. Both Palmer and Thompson deny doing this.

Robinson was getting ready to leave, but Cecilia's roommate was headed for her room, so she decided to go with her. She walked into the dark room and saw Cecilia's bed all torn up. There was a light under the bathroom door. Robinson turned around and put the roommate out because she couldn't see Cecilia. She pushed the bathroom door open, which was hard to do because Cecilia's weight was against it. When she finally shoved the door open, Robinson said, Cecilia's body fell in front of her.

It wasn't until August 1997 that Gladys and Victor Garrett got Cecilia's death summary report from Devereux. Saeed said he was behind on his paperwork.


Therapist Patti Thompson and Cecilia may not have been a good match. Joan Anderson, reviewing the files, said she felt that Cecilia liked Thompson in general, but that there were times when she was very angry with her.

Saeed said he talked with Thompson about how to deal with Cecilia because of her size, which made her appear older than she was.

Thompson said Cecilia would write her notes, then tell her to tear them up. She wrote poetry about death. "Cecilia had a somewhat hopeless feeling about her future at times in terms of would she make it," Thompson said.

Thompson apparently had problems meeting some state standards. For instance, in the year after Cecilia's death, Thompson, who was the therapist for half the unit, or 11 clients, did not provide any individual therapy for another patient for a six-week period in late 1997, which resulted in a citation for noncompliance with the Texas Department of Protective and Regulatory Services.

At another point, other employees accused Thompson of falsely documenting that she was providing therapy when she was actually at her chiropractor.

Psychiatrist Aaron Fink, who reviewed Cecilia's case files for the plaintiffs, said Thompson provided substandard care to Cecilia because she failed to recognize her intellectual limitations.

Thompson wasn't the only Devereux employee to attract complaints in the late '90s. Unit manager Jeff Kennedy didn't have the proper certification to be in that job. TDPRS notified Devereux that it was in noncompliance because of his lack of qualifications. He was moved laterally to another position after Cecilia's death.

On another occasion Kennedy got in trouble for spraying water on a sleeping client to wake him up. According to a document from the state licensing department, "Mr. Kennedy did admit that he used poor judgment." Yet when asked about it in his deposition, Kennedy said he could not recall the incident.

Melba Lindberg, despite being Devereux's director of operations, said in her deposition that she was unaware that Kennedy had been accused of spraying anyone with water.

Lindberg herself was cited by the state for failing to report two suicide attempts in April 1996, one a patient who slit a wrist and another who attempted to hang himself with a bedsheet over a door, just as Cecilia would do eight months later. Lindberg insisted these were not "major" attempts at suicide and thus didn't need to be reported to the state. She was instructed otherwise.

She was investigated by the Texas Department of Health after employees filed complaints about her.

Devereux had an adult patient who died by hanging himself using a door in the year before Cecilia's death. Following this, Gail Atkinson said, some policies and procedures were changed, such as when kids could go to the bathroom and when doors could be locked, so there would be better supervision. Robinson had suggested cutting the tops off the internal doors, but that wasn't done. The fire marshal said that would violate fire codes, Atkinson said, adding, "There are many other ways that a person can hang themselves other than the door." The group also discussed throwaway gowns and sheets that would tear easily, but Atkinson said that upon talking to a number of people they decided that wouldn't be effective.

League City police reports for 1995 and 1996 show repeated calls -- more than 100 a year -- to Devereux. Some were prank 911 calls, but others included repeated claims of assault and sexual assault, as well as reports of missing persons.

Despite this, Devereux doesn't appear to have a reputation for problems in the community at large. Some of that may be owing to its influential board of directors, which in 2002 included the following from the economic development side: Tom Brooker, a developer with the South Shore Harbour Development Corporation; Jim Reinhartsen, head of the Clear Lake Area Economic Development Foundation; Tedd Olkowski, head of the Galveston County Alliance; and Doug Frazier, with economic development for the city of League City. Law enforcement showed itself on the board as well, with Pat Bittner, assistant chief of police in League City, and Gean Leonard, Galveston County sheriff.


Joyce Robinson is a crucial figure in the Cecilia Garrett story. In one of her letters home, Cecilia complained that "it's hard trying to live off these white people rules." Robinson, a fellow African-American, said Cecilia called her "Mom" and felt comfortable with her. In her deposition, Robinson was positive about Cecilia's future; she said she felt Cecilia was working hard to overcome her background and make something of herself.

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.

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.


Gail Atkinson, executive director of Devereux in Texas, did not renew Saeed's contract on June 21, 2001, which was the morning after Andrea Yates's children died. She insisted in her deposition that one had nothing to do with the other, that she had been planning for two months before not to renew his contract and had already engaged another doctor. She said Saeed had previously refused to sign his contract, that he wanted more money. She'd also learned that he was building his private practice in Dickinson "and I was worried that he was leaving us."

Chicago's Josie Winston in her deposition said that "there has been success with sending students to Devereux." She thought that Devereux would help Cecilia learn how to behave in school, to focus, to relate to authority figures, to stop the physical aggression toward other kids. She thought that Cecilia, armed with all these new behaviors, would eventually leave Devereux for a less restrictive environment and eventually earn a high school diploma.

Cecilia's death, Winston said, "was very, very traumatic for all of us. We've never had a child -- never lost a child."

Whatever their flaws, Gladys and Victor Garrett wanted Cecilia home. Gladys Garrett repeatedly asked Devereux and Jean Brown of Chicago about that. What they didn't realize was that because Cecilia wasn't committed to the institution, she could have come home anytime. In a poem written October 4, 1996, Cecilia said: "God please take me away / take me to a better place where I can stay."

Jean Brown called Cecilia's death tragic. At the time of her deposition in December 2000, she said she hadn't sent any Chicago children to Devereux since then.

Asked earlier this month if Devereux in League City was still receiving Chicago public school children, a Devereux spokeswoman said it was. In May of last year, a 17-year-old South Dakota female patient hanged herself at the Devereux center in Colorado. Asked how many deaths there have been at Devereux facilities in 13 states, the spokeswoman said that information was confidential.

In his deposition, Saeed recalled that when he was at Devereux, there was hardly any patient with a local residence. "I think most of these children come from faraway places."

Gladys and Victor Garrett are divorced now. They came together to Houston in late February. That's when Cecilia's case was settled -- February 28, 2003, more than six years after her death -- for an undisclosed amount. The money wasn't disbursed till the second week of April.

Because of the settlement, those involved in the case say they cannot talk about any part of it. (Comments from attorney Doyle in this article were made before they settled.)

So the question of how much Cecilia Garrett's life was worth remains a secret held by a small group of people.

How much Cecilia's life was valued, of course, remains an entirely different enigma.

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1 comments
yomitch3
yomitch3

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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