By A.G. Moore 9/14/2012
You may want to stop reading now, because this is a post about despair—despair over the intransigent culture of abuse and neglect that prevails in New York States’ care of the disabled.
I started reviewing the record of the New York State Commission on Quality of Care (CQC) and Advocacy for Persons with Disability. My review was prompted by research I’d been doing on Letchworth Village.
In the early 1970s Geraldo Rivera broadcast an expose on Letchworth. Outrage followed. Patients were transferred; buildings were shuttered; the case was closed. The New York Commission on Quality of Care (CQC) was established—and so began its long record.
The reports date back to 1978 and continue to 2011. In some instances it is possible to read a full report; in some instances only a summary is available. Amongst the recitation of abuse and neglect, of patient “elopement” resulting in grievous misadventure, are mixed the names of deceased residents. These residents lost their lives to mismanagement and indifference. In many cases to outright cruelty.
The names of deceased I retrieved from CQC reports are: Simon Paz, Henry McGee, Patrick White, Agnes Moro, Mia Martine, John Meginn, Pedro Montez, Jason Price, Rita Finn, Alex Zolla, Faye Trina, Molly Reed, Janice Sherman, Jeffrey Roland, Richard Sanders, Mark Monroe, Eileen Alenza, Frank Darby, Fred Zimmer, Alphonse Rio, Aaron Maxwell, William S.,Cheryl J., Jerry Smith, John Dawson, Christopher Dugan, Florence Austin, Hilda Norton, Joseph Kirsh, Ramon Luz, Francis Helms, Joseph Conway, Wayne Thomas, Joan Stalker, Jacob Gordon.
Those listed above are just some that died while under the supervision of a New York State facility. Not included in this list, for example, is Jonathan Carey, whose caretaker killed him by sitting on him. Nor is there on the list the name of Michael Taylor, a quadripalegic who drowned in a bathtub when his caretaker left him unattended.
According to a 2011 New York Times article, approximately 1200 disabled patients had died in the previous decade under New York State supervision. Of these deaths, one out of every six was unexplained.
Back in 1978, when the CQC was first established, a hearing was held to consider the charges of the Rockland County Medical Examiner that over medication had caused the deaths of many Letchworth Village residents. When the CQC commissioners questioned the Rockland coroner, he was not able to provide specifics about individual cases. Slides he had used for analysis were deemed unacceptable. The M.E.’s determination was rejected and he was discredited.
That was the end of the inquiry. No investigation was conducted to explain the controversial deaths. No names were given of people who might have been responsible for those deaths. And this pattern of not assigning individual responsibility is evident over 30 years of CQC reports. Sometimes a name surfaces, but overwhelmingly CQC’s recommendations are grimly repetitious: increase staffing; improve supervision; upgrade training….
One fact that is apparent in the CQC transcripts is, the state bureaucracy entrusted with the care of the disabled was not up to its task. While it seems there may have been some well-intentioned individuals who conducted site examinations and sought reform, overall there appears to have been a willingness to see the inept machinery of the bureaucracy grind on.
This year Governor Cuomo created a new agency, The Justice Center for the Protection of People with Special Needs, which is intended to take a more aggressive, enforcement oriented approach to its mission of disability oversight. Sounds like a good thing, doesn’t it? Except for one fact: the person appointed to head the new agency is one and the same as the person who oversaw so many of those CQC reports: Clarence Sundram.
Mr. Sundram may be very well-intentioned; he may be a competent administrator. But he’s had his chance. If the governor wants change, then do it right. Change begins at the top. Mr Sundram was unable to reform the state bureaucracy on his previous watch. Why take a chance on him now?
At this point in history, I don’t think we can blame the state, Governor Cuomo or Clarence Sundram for tragedies that continue to occur in state facilities. We know—we have known—for a very long time what’s going on. We’ve been told, over and over again and yet we have not demanded that true change take place.
If we are searching for someone to blame for crimes perpetrated on the defenseless disabled among us, then we have to take a long honest look in the mirror and point the finger at ourselves.