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Outrage, questions and finger-pointing after disabled Missouri man is found dead in block of concrete

St. Louis Post-Dispatch - 7/2/2018

July 02--FULTON, Mo. -- One day years ago, the driver of a big yellow school bus was ambling down the road when a wiry boy standing on the sidewalk caught her attention. He had thick glasses, an energetic vibe and a cast.

"He just waved at me, and I started to cry," recalled Mary Martin, 59. "Oh, my God. Here we are and we think we are so miserable. Here he is with a broken arm and he looks as happy as he can be, waving at me."

She soon found out that the boy was Carl Lee DeBrodie, and while his spirit was off the charts, intellectual disabilities left him unable to read, write or speak. He communicated through gestures, sucking sounds and a few choice words.

"He was not dumb," said Martin, who ended up being his guardian and caretaker until he graduated from high school. "He understood everything that you said to him. Doesn't mean he listened, but he understood."

About 20 years since she locked eyes on DeBrodie for the first time, Martin continues to fight for him. She's calling for justice in his ghastly death, which has become a damning indictment of Missouri's safety net for vulnerable adults who rely on the government and its contractors for life choices and care.

Eight days after being reported missing in April 2017, DeBrodie's remains were found in a garbage can encased in a block of concrete. The makeshift tomb was squirreled away in a storage unit. He would have been 31, but police believe his death went undetected for months.

On June 1, five people affiliated with Second Chance Homes of Fulton and its employees were arrested for an array of crimes related to DeBrodie's death and disappearance. Sherry K. Paulo, 53, a manager, and her husband, Anthony R. Flores, 58, have been charged with the most serious crimes, including felony client neglect or abuse in a mental health facility, involuntary manslaughter and abandonment of a corpse. Anthony R.K. Flores, 32, Shaina A. Osborne, 29, and Mary K. Paulo face charges of making a false report or statement about a missing person.

The defendants, who are all from Fulton, have pleaded not guilty. A trial date hasn't been set. Officials said criminal investigations continued into potential federal and state health care fraud.

In addition, DeBrodie's mother, Carolyn Summers, claims in a federal lawsuit that Second Chance, Callaway County authorities and service providers in Fulton are liable for his wrongful death. The lawsuit also alleges the Missouri Department of Mental Health and its leaders violated civil rights related to DeBrodie's care.

Caregivers forced developmentally disabled Missouri man to fight to the death, lawsuit claims

Caregivers forced developmentally disabled Missouri man to fight to the death, lawsuit claims

Plaintiff's attorneys in the case, who have access to the police investigation, internal records and witness statements, believe DeBrodie was left to die at a Second Chance employee's residence and finally perished about the end of October 2016. Alarm bells were allegedly being rung about Second Chance, but if authorities had reservations about the private firm, it wasn't reflected in DeBrodie's continued placement there.

A local caseworker and nurse are accused in the lawsuit of falsifying reports, indicating they'd met with DeBrodie face-to-face at Second Chance during a time over multiple months when he was probably dead.

Second Chance employees were apparently creative in the ways they made it look as if DeBrodie was thriving.

"Carl was putting his dishes in the sink when I arrived," Sherry Paulo wrote in a daily progress note dated April 6, 2017. "I asked Carl if he would like to help with some light yard work and Carl nodded, saying, 'Yeah!'"

Finger pointing

For decades, mental health treatment has been shifting away from institutions toward community-based alternatives that allow better quality of life for clients. However, a 2006 Post-Dispatch investigation found that Missouri's system to catch abuse and neglect at private facilities for intellectually disabled residents was in some ways worse than the state's own institutions.

Broken promises, broken lives

Broken promises, broken lives

A Post-Dispatch investigation published in 2006 found that Missouri's system to catch abuse and neglect at private facilities for intellectual...

Among the findings: Caseworkers failed to meet with clients, private facilities didn't report suspicious incidents and the state failed to revoke licenses of group homes where workers committed deadly lapses.

Since then, the state has transferred much of its case management authority from regional offices to county developmental disability resource boards that also put together service plans. Today, there's more emphasis on so-called Individualized Supportive Living, which is essentially an outpatient service provided in the home of the client's choosing. The Department of Mental Health certifies and licenses those providers.

While not categorized as a group home, some supportive living service providers operate homes that have one or two other residents there. That's how Second Chance Homes of Fulton operated.


Second Chance Homes duplex

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A duplex in 200 block of Claymine Drive in Fulton, Mo., as seen on Saturday, June 23, 2018. Carl DeBrodie lived for a time in one of the two housing units here that was operated by Second Chance Homes of Fulton. Photo by David Carson, dcarson@post-dispatch.com

David Carson

When done correctly -- and housemates are compatible -- providers say it's a good service because clients get more direct attention, which should make something such as DeBrodie's disappearance even less likely to happen. There are billing requirements, an individual care plan approved by the state, daily observation notes and other layers of monitoring to ensure safety.

Missouri Attorney General Josh Hawley's office asked a judge in June to dismiss the state from DeBrodie's wrongful death lawsuit.

"Mr. DeBrodie was not in state custody. He resided in a private facility," the attorney general's office argued in court records, adding: "The state is alleged simply to have licensed and certified Second Chance Homes as a residential care facility and to have contracted with Second Chance Homes and other entities to provide services for Mr. DeBrodie."

A spokesman for an online support group calling for more attention to DeBrodie's death said the state's argument was "reprehensible." Gabe Harris, an attorney in the wrongful death lawsuit, said the state was missing a chance to improve the system on its own.

"I am not surprised by their posturing," Harris said, "but I would still hope they'd use this as an opportunity to recognize some of the deficiencies in the care of individuals with developmental disabilities and institute new policies and procedures to ensure that nobody falls through the cracks like this again."

Family ties

DeBrodie's parents met in a group home. His father died early, and his mother lost custody of DeBrodie and his four siblings when he was about 12.


Mary Martin

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Mary Martin sits at an information booth she set up during Fulton Street Fair on Saturday, June 23, 2018, to raise awareness of Carl DeBrodie's death. Photo by David Carson, dcarson@post-dispatch.com

David Carson

That's when Mary Martin and her husband stepped up to be his guardian. Living with them in rural Callaway County, he put lots of miles on a go-kart, pushed the limits of a riding lawnmower and had his own pet horse. Martin said he seemed to enjoy having a lot of extended family running around and open access to the refrigerator and a television in his room.

"We had a blast," Martin said. "He just loved us. We loved him. It was a family, just like anybody else's. He was our child."

DeBrodie stayed there until he was 21, when he graduated from the special education program at Jefferson City High School. But Martin soon wished she hadn't let him go.

In 2008, after a failed attempt to reconnect with his mother, DeBrodie became a ward of the state overseen by Callaway County Public Administrator Karen Digh Allen. Public administrators are guardians of last resort for people deemed too incompetent by the probate court system to make their own decisions.


Image shows bruises on Carl DeBrodie

Mary Martin says she took this photo of Carl DeBrodie when he visited her home around 2009. Martin was DeBrodie's former guardian. She said the young man suffered the bruises while at Second Chance Homes of Fulton, which offered individualized supported living services certified by the Missouri Department of Mental Health.

DeBrodie wound up living at Second Chance, which provided around-the-clock support in a community setting. Early on, Martin said, she still got to have him on occasional weekends, but that ended after she complained about potential abuse. A photograph she took near Christmas in 2009 shows bruises on his arms and chest.

That same year, the Department of Mental Health logged a complaint at Second Chance that was later shared with The Columbia Daily Tribune. A direct care worker who lived at the facility was accused of threatening a client for stealing cake, yelling that if the client went into his area again, "you're gone!" Two years earlier, a medical aide was accused of threatening to beat a client for taking his cigarettes.

Jana Oestreich, an attorney appointed to represent DeBrodie's best interests about the time of the bruising, testified that he looked happy and healthy at Second Chance and that the bruises were more likely caused by bumping into things outside.

Martin tried to become DeBrodie's guardian again. When that was denied, she filed a petition to adopt him as an adult. That wouldn't give her complete control over his life, but perhaps more influence to pull him out of Second Chance.

"If that adoption would have gone through, Carl would be alive," said Mary Beck, another attorney who was appointed by the court to represent DeBrodie's best interests.

She and students under her guidance at a University of Missouri-Columbia family law clinic advocated for the adult adoption partly because DeBrodie had already lived a successful life with Martin as a child.

In his 2014 opinion, Missouri Court of Appeals Western District Judge Anthony Rex Gabbert agreed with a lower court's denial of the adoption.

"Clearly, a twenty-nine year old adult without mental limitations might find living at home with a parent to be more restrictive than living independently -- in an apartment, with a roommate, with access to a job and the community," Gabbert wrote.

"The idea that developmentally disabled adults are to be treated as much as possible like nondisabled adults is supported by federal legislation that encourages 'individualized supports' for the developmentally disabled to enable that individual 'to exercise self-determination, be independent, be productive, and be integrated and included in all facets of community life.' Thus, we cannot presume that what is best for a child is best for a mentally incapacitated adult. The proper inquiry here is what is best for Carl."

Bad for business

At least one service provider in recent years noticed more bruising on DeBrodie that led them to report potential abuse to state authorities. It's unclear how or whether the state responded.

Independent of that, attorneys representing DeBrodie's mother in the wrongful death lawsuit, who have read witness statements, believe Second Chance used corporal punishment in an irresponsible manner and didn't protect clients from assault by other residents of the home.

They claim the Callaway County Public Administrator's office and Callaway County Special Services, which is the local board in charge of case management, exchanged emails in 2016 discussing the removal of DeBrodie and two other residents from Second Chance. Internal correspondence allegedly says Second Chance owner Rachael Rowden told authorities that removing the clients would put her out of business.


Home where Carl DeBrodie is believed to have died

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The home in the 200 block of West Sixth Street in Fulton, Mo., as seen on Saturday, June 23, 2018, where Carl DeBrodie is believed to have died. DeBrodie's body was found encased in concrete in a garbage container similar to the one in front of the house. Photo by David Carson, dcarson@post-dispatch.com

David Carson

DeBrodie wasn't present at a meeting on Oct. 25, 2016, to discuss the matter because he wasn't feeling well, according to the lawsuit. A few weeks later, attorneys believe DeBrodie suffered a seizure in the private residence of Second Chance employees. Instead of taking him to the hospital or calling 911, he was allegedly put in a bathtub with the shower turned on, in an attempt to revive him.

He died soon after that, attorneys believe, and wasn't reported missing until April 17, 2017, when a different company took over the caseload at his facility.

Rowden, owner of Second Chance, has not been charged with a crime. Her attorney in the civil lawsuit didn't return a call for comment. Allen, the public administrator, said she wouldn't talk to the press because of the ongoing lawsuit and investigations.

Callaway County Special Services previously told the Fulton Sun in a statement: "We are deeply saddened about the loss of Mr. DeBrodie. Callaway County Special Services is, and has been, conducting its own review related to Second Chance homes, our staff and procedures. We are unable to comment further, at this time, due to privacy and confidentiality obligations."

'1,000 red flags'

Stresses in the support system for people with disabilities often show up in rural areas that are far from psychiatrists and other specialists. But DeBrodie died in Missouri's mental health capital.

Fulton State Hospital, the oldest of its kind west of the Mississippi River, has multiple campuses. Numerous support staff and other state workers live in the area.

And although government guardians are often stretched thin by lengthy caseloads and minimal resources, the local public administrator's office is two blocks from where DeBrodie apparently died in the bathtub.


Self storage facility where Carl DeBrodie was found

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Moore EZ Storage on the 500 block of South Westminster Avenue, in Fulton, Mo., as seen on Saturday, June 23, 2018. The body of Carl DeBrodie was found encased in concrete in a plastic garbage container inside a storage unit at the self storage facility. Photo by David Carson, dcarson@post-dispatch.com

David Carson

"Everybody is pretty much in an uproar over here with the same questions," said Scott Gaines, 46, who lives by the storage unit where DeBrodie's remains were found. "Why did it take so long for somebody to get arrested? Why didn't somebody say something? Where were the social workers? It seems like there were 1,000 red flags."

Susan Johnston, 62, said her jaw dropped when news broke about the concrete tomb, but overall, she's become desensitized.

"Mankind does not shock me anymore," said Johnston, a former Callaway County clerk, helping run a church bake sale at an annual downtown festival and carnival.

Martin also had a booth set up to promote a foundation she wants to build to help advocate for people with disabilities. Wearing a "Justice for Carl DeBrodie" T-shirt, she shook hands with anyone who would listen to her about his case and the impact he continues to have on her life.

"Carl taught me to love," she said.

Martin persuaded Sarah Robinson, 40, who runs a mobile home park, to give a small donation.

"Special needs people need special care, and he wasn't getting the care that he needed," she said. "I feel disgusted but hopeful that there will be justice and maybe the family will find some closure. I can't imagine being in that situation."

Lisa Buhr, 38, was downtown to promote her campaign for state representative for the area, which is heavily populated with mental health workers and other state employees.

"When you are running on bare bones, people lose their lives," Buhr, a Democrat from Holts Summit, said of Missouri. "There are people falling through the cracks everywhere. Not just in mental health. Not just in my district. When you look the other way, this is what happens."

2018 homicide map

2018 homicide map

Government and teacher salaries

Government and teacher salaries

Government data

Government data

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Missouri executions


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