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This story was commissioned by the .

After Ronald Scheer was found suffocated to death by the straps of his own wheelchair, an determined his cause of death was 鈥渉anging.鈥�

Scheer, a man with developmental disabilities and mobility issues who used a wheelchair, was living at the state-run St. Louis Developmental Disabilities Treatment Center in St. Charles in June 2020 when one of his caretakers allegedly failed to secure all the safety belts keeping him in his wheelchair, according to in a wrongful death lawsuit filed by his legal guardian.

Then, the caretaker allegedly left Scheer alone despite the fact that his prescribed care plan required them to check in on him every 30 minutes and reposition him every two hours. During that time, Scheer reportedly slipped down the wheelchair, his neck fell into one of the straps and he suffocated.

Scheer鈥檚 caretakers were not held responsible for his death because a court that, as public employees, they were immune from civil suits regarding negligence on the job.

But Scheer is not the only Missourian with disabilities whose death raised troubling questions. A review of state records, court documents and department policies, as well as interviews with frontline employees working in the state, reveal a dysfunctional developmental disability system riddled of accusations of abuse, neglect, and in some cases, concerning deaths.

From 2017 through 2023, 74 people with developmental disabilities died in some sort of accident while in state care, according to state records obtained by the River City Journalism Fund. Additionally, nine homicides and seven suicides occurred amongst this population during that time, according to the records. Another 2,200 died of natural causes and 392 had an 鈥渦ndetermined鈥� cause of death.

In total, from 2017 through 2023, 2,682 people with developmental disabilities died under the care of the state of Missouri 鈥� on average, one person every day.

Lisa Goodman, a 57-year-old Warrensburg woman with developmental disabilities, is another one of those people. Two months after moving into a Kansas City group home, she choked on a hot dog given to her by her caretakers and died.

Goodman鈥檚 group home was run by an agency called the Center for Developmentally Disabled. Her disabilities meant she required a special diet with non-solid food so she wouldn't choke. Yet on this day in July 2019, her caretakers, who鈥檇 been briefed on her diet, gave her a hot dog. At the time she choked and died, the caretakers had stepped outside, despite the fact that her prescribed care plan required a caretaker to supervise her while she ate, according to multiple employees who worked with Goodman or had direct knowledge of the situation but asked to remain anonymous out of fear of retribution from their superiors.

An investigative report provided by the Jackson County Medical Examiner鈥檚 Office confirms that Goodman died from asphyxia due to choking on July 27, 2019.

Goodman was a ward of the state, meaning the state of Missouri, via a public administrator, was her legal guardian. As with Scheer and around 7,500 others with disabilities like Down syndrome or severe autism, the Missouri Department of Mental Health鈥檚 Division of Developmental Disabilities was responsible for her care and well-being through residential services. That care is paid for with Medicaid. Most of these people, including Goodman, live in private facilities contracted by the state; about 250 live in state-run facilities like Scheer, according to the department.

The Department of Mental Health declined to provide any documentation on Goodman鈥檚 death including medical records, law enforcement documents, event reports or death notifications, citing various state statutes.

The Center for Developmentally Disabled did not respond to requests for comment.

Goodman and Scheer died two and three years, respectively, after a high-profile death involving another ward of the state鈥檚 Division of Developmental Disabilities. That death sparked calls for change. But people with knowledge of the department鈥檚 workings say that never happened 鈥� and as result, people with disabilities remain at risk.

Brandy Sisk of Forrest City has a son with disabilities who was under the state鈥檚 care until she successfully fought for his return home.

鈥淭hese people are treated less than human,鈥� Sisk said.

2017 death prompts lawsuit, calls for reform

When Carl DeBrodie鈥檚 caretakers discovered him convulsing, screaming and bleeding from the nose one night in 2017, they did not call 911, according to filed by his family. Instead, they put him in a bathtub and left him under running water.

DeBrodie died that night.

He was living at a facility in Fulton operated by Second Chance Homes, a private care agency contracted by the state, according to the suit. Two caretakers at that facility, Sherry Paulo and Anthony Flores, forced DeBrodie multiple times to leave the facility and come to their home to do chores. He slept on the basement floor. At their home, DeBrodie was even forced to fight another Second Chance resident for their amusement, the lawsuit alleged.

It was on one of the nights as DeBrodie was sleeping on the basement floor of their home that he died of a seizure, according to the court documents.

The lawsuit, which named the state, Second Chance Homes, the caretakers and several others as defendants, ended in to the family. Paulo and Flores were convicted on 鈥� including willfully failing to provide necessary care resulting in injury and death, healthcare fraud and falsifying a document to impede, obstruct and influence a federal investigation 鈥� and sentenced to 17 陆 years and 15 years and 8 months in prison respectively.

DeBrodie鈥檚 death was highly publicized, and calls for reform came from the Missouri Developmental Disabilities Council, a federally funded council appointed by the governor to advocate for people with developmental disabilities.

"The Council has been following Carl DeBrodie's story and has high expectations that once all investigations are completed that there will be justice for Carl and that there will be necessary systemic changes implemented so that others may avoid such a gruesome death and lived experience," their 2018 read.

However, interviews with people working in the field as well as a close look at department policy suggest those systemic changes never happened. Similarly, state and court records show that stories of abuse, neglect and death within Missouri鈥檚 developmental disability system are common.

Jessica Bax, the director of the Division of Developmental Disabilities 鈥� who, since being interviewed by the River City Journalism Fund, has been nominated by Gov. Mike Kehoe to be the next director of the Missouri Department of Social Services 鈥� and Debra Walker, a spokesperson for the Department of Mental Health, declined to discuss any specific deaths or incidents due to privacy laws, including those of Scheer and Goodman.

Rudi Keller

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Missouri Independent

However, when asked about the number of people dying in state care, Bax questioned whether the rate of deaths was actually high, pointing to the fact that the division has a steadily aging population.

State records also show 1,858 reports of verbal, sexual or physical abuse from 2017 through 2023. Bax said she thinks the high number of reports is, in some ways, a good thing.

鈥淵ou always want, if someone sees something, to say something,鈥� Bax said. 鈥淲e definitely want anyone who has any sort of concern to make sure, no matter how small they think that is, to be reporting it.鈥�

The state declined to provide further records to clarify the circumstances of any of the deaths including event reports, law enforcement reports (even on the homicides), medical records, autopsies or any other administrative documentation, citing various state statutes.

However, the Department of Mental Health said in an email that it only investigated two of the 10 most recent accidental deaths (at the time of the records request) for abuse or neglect. One investigation was ongoing and the other reportedly found no substantiated abuse.

It also investigated two of the five most recent suicides, and both found no substantiated abuse, it said. The department declined to provide records on any of the investigations it did complete.

'There鈥檚 been no changes'

Dina Lester is a registered nurse from Kansas City who worked within the system for almost 10 years. She left in 2020 partially because she was disappointed with the poor level of care and lack of change following DeBrodie鈥檚 death.

鈥淭here鈥檚 been no changes into the processes that allowed that to happen in the first place,鈥� Lester said.

In DeBrodie鈥檚 situation, multiple safeguards meant to protect him failed. None of those have been significantly amended since his death.

First, according to division policy, the abuse and neglect suffered by DeBrodie, which went on for months or perhaps years, should鈥檝e been reported and corrective action taken long before his death.

Procedures for how complaints of abuse and neglect 鈥� in addition to misuse of funds or property 鈥� should be reported and investigated are outlined in . While it鈥檚 been amended several times since DeBrodie鈥檚 death, Bax acknowledged the changes 鈥渉ave not been substantive in terms of how things were done.鈥� She said the changes were 鈥渕ore to update in terms of clarifying or reflecting our changes in structure and process.鈥�

Anna Spoerre

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Missouri Independent

Lester said the reporting system is completely flawed. She made multiple reports via email and phone about abuse and neglect and saw no change. She provided the River City Journalism Fund with screenshots of such emails. She suspects regional offices investigating reports are incentivized to say deaths weren鈥檛 preventable and abuse or neglect incidents weren鈥檛 serious enough to warrant action.

Lester believes the reported number of abuse incidents is an undercount. She鈥檚 seen abuse and neglect happen without an event report created, even when a mandatory reporter witnessed it, and she鈥檚 seen reports she believed were serious go uninvestigated.

When asked what measures are in place to ensure incidents are actually reported, Bax said staff at facilities are mandated reporters and are required to undergo training on abuse and neglect. also requires a case manager to make face-to-face visits monthly to check on residents and verify their well-being.

In DeBrodie鈥檚 case, this system failed.

Tiffany Keipp, with Callaway County Special Services and the Department of Mental Health, and Melissa DeLap, a registered nurse, were required to conduct visits with DeBrodie. Neither of them did in the final months, and the lawsuit alleges they filed false reports claiming they did. DeLap eventually pleaded guilty to health care fraud and admitted to signing seven months worth of false reports claiming she'd seen DeBrodie when he was already dead.

Still, there have been virtually no changes to this process.

Like DeLap, Lester was tasked with performing these monthly meetings. She said they鈥檝e always been flawed.

She said she鈥檇 give a facility staff a list of things to be done, and they often just wouldn鈥檛 do them. There was no system to ensure nurse recommendations are taken and no consequences when they aren鈥檛, she said.

鈥淚t was simple stuff like calling and making a dentist appointment or a physical or going in and getting labs done,鈥� Lester said. 鈥淚 mean, it's not difficult. It wasn't rocket science, but month after month after month, the same stuff would be on the list.鈥�

Bax said the division has a monitoring process and an annual review system. She also said every case manager has at least one of their cases reviewed each year.

Lester called this 鈥渞idiculous鈥� and questioned whether it鈥檚 comprehensive enough. She also said there鈥檚 a culture of fear within the system. People who speak up about the poor level of care are retaliated against by their superiors, she said. 鈥淲hat happens is people start speaking out and complaining, and then they find a way to get rid of them and basically push them out.鈥�

The River City Journalism Fund spoke with four other nurses, caretakers and frontline staff members who wouldn鈥檛 go on the record or requested anonymity out of fear of retaliation from their superiors. They made statements similar to Lester鈥檚.

'A bureaucratic nightmare'

Randy Vought, of Independence, has seen the flaws in the system firsthand. 

Vought worked as a support coordinator and then program director at Missouri Mentor and Heritage Residential, private agencies like the ones that cared for Goodman and DeBrodie, from 1986 until he retired in 2020. His job was to advocate for people with developmental disabilities in state care, help their families navigate the system and determine the best care options.

Over his decades-long career, Vought grew disillusioned. He said many deaths 鈥渟lip through鈥� the state鈥檚 processes. (Missouri Mentor, which has merged with Heritage Residential, did not respond to requests for comment on Vought鈥檚 allegations.)

For example, state policy says that an autopsy should be done by a medical examiner if there is concern about the death. However, Vought said this happens 鈥渞arely.鈥� During the 34 years he worked in Missouri, he only heard about one time a medical examiner got involved, and that was because a facility wanted to know whether the person was using drugs before their death.

鈥淚f there is a suspicious death that occurs in Kansas City, the police do the report and then the coroner is called and a coroner makes the determination of what was the cause of death,鈥� he said. 鈥淏ut if it鈥檚 an individual in the [care of the] Department of Mental Health, that doesn鈥檛 occur.鈥�

State policy requires the facility鈥檚 staff to complete an event report after someone dies, along with other documentation given to the Department of Mental Health. Vought said, in his experience, this leads to staff providing the state with an incomplete picture.

鈥淭here are way too many agencies that are for profit, that want to make money off the backs of these individuals,鈥� he said. 鈥淭hey鈥檙e not about to turn in a report that says 鈥楬ey, our staff may have missed this.鈥� Who鈥檚 going to do that? Who鈥檚 going to admit that 鈥楬ey, my staff made a mistake, so we may be liable for the death?鈥� Nobody. Not even myself 鈥� You鈥檙e going to turn in a report that looks like your staff did everything they possibly could do. That鈥檚 what you鈥檙e going to turn in. And that鈥檚 what they do turn in, and that鈥檚 what DMH swallows.鈥�

For example, Vought said he knew of an instance where a man with developmental disabilities was put into a tub of water so hot he was scalded to death. To his knowledge, no one was criminally charged for that death.

鈥淭hey reported that he went to bed and woke up and he was in a coma,鈥� he said. 鈥淭his is crazy. Nobody just goes to bed and wakes up into a coma with third-degree burns on his body. The third-degree burns were because he was put into scalding water. You forgot that part of the report, didn鈥檛 ya?鈥� After that incident, staff were required to do temperature checks before baths, he said.

Vought said the state workers who typically review the event reports are both underqualified and overworked.

鈥淵ou鈥檙e relying on a nurse and not a medical review team,鈥� he said. 鈥淚 do think a medical examiner should be the one that really gets to determine what was the cause of death.鈥�

He said when deaths occurred under his watch, the Department of Mental Health took most of what he said at face value with very little verification.

Overall, Vought said Missouri鈥檚 developmental disability system is 鈥渃riminal鈥� and 鈥渁 bureaucratic nightmare.鈥�

Vought explained that while the state updates its rates to reflect inflation and market increases, they鈥檙e only updated when a patient first enters the agency. This means agencies are incentivized to push clients out to make space for new ones that will bring higher rates, even if it鈥檚 not in the client鈥檚 best interest. This leads to inadequate care. One of his clients, he said, had been moved around to 32 different group homes in a 12-month period before she came to him.

Vought said abuse, neglect and death has been happening in Missouri鈥檚 developmental disability system, and he believes it will continue.

As recently as 2023, deadly incidents of abuse have been substantiated.

That March, Joseph Wyckoff, a man with developmental and physical disabilities including a lack of teeth and abnormal tightening or narrowing of the esophagus choked to death in a Saline County group home, much like Goodman.

According to a filed by his family, Wyckoff鈥檚 disabilities required his caretaker to cut his food into 鈥渂ite-size pieces鈥� and encourage him to drink an adequate amount of fluids. He reportedly choked and died eating chicken, macaroni, and green beans after his caretakers allegedly failed to follow these procedures.

The lawsuit ended in voluntary dismissal by the parties after the defendants鈥� legal team argued the caretaker, as a state employee, was officially immune from claims of negligence, show.

In an autopsy of Wyckoff, the coroner : 鈥淚 viewed the body of the deceased on Saturday morning and observed food particles in Mr. Wyckoff鈥檚 mouth,鈥� adding, "It was reported by the staff that they heard Mr. Wyckoff 鈥榮noring鈥� at approximately 6:15 p.m. and I鈥檓 not sure that this time frame is accurate. Staff stated that he liked to sit 鈥榳ith a blanket over his head鈥� and that there was mottling noted when they moved him from the chair to the floor to begin CPR鈥� the opinion of this office is that Mr. Wyckoff had been deceased for a longer period of time than thought by staff鈥� I believe that the 鈥榮noring鈥� sound heard was probably Mr. Wyckoff aspirating (choking) at that time since he had a blanket over his head, no attention was given at that time.鈥�

Anna Spore

/

Missouri Independent

Unique to Missouri?

Asked whether Missouri鈥檚 developmental disability system has an abuse and neglect problem, Bax declined to answer. However, Walker stated, 鈥淭his is not unique to Missouri.鈥�

National data on abuse and neglect in other state-run developmental disability care systems is not publicly available, but reporting from states like, and reveal numerous anecdotes of alleged abuse and neglect.

In Illinois, a 2022 found that, over the course of a decade, there were 200 state police investigations into employees at developmental disability care facilities. There were also nearly 4,000 allegations of neglect and abuse investigated by the state health department鈥檚 inspector general over that time period.

Bax noted that . She hopes to use the funds on enhanced oversight, quality assurance, staff development, improving the quality of employees, and increased wages.

In 2023, Republican lawmakers to spend $900 million shoring up the Division of Developmental Disabilities, though the legislature that included $171 million to boost pay for employees serving people with developmental disabilities. The following year, then-Gov. Mike Parson for $79.4 million for the Division of Developmental Disabilities, but the legislature cut the funding before the end of session.

But people who鈥檝e worked within the system say the problems with the homes supervised by Missouri鈥檚 Division of Developmental Disabilities and Department of Mental Health go beyond a lack of funds.

Lester, the Kansas City nurse, says she believes that the state has failed to address problems that put people at risk, despite people dying in preventable ways.

Lester has a grandson with special needs. She said there鈥檚 "no way in hell" she鈥檇 put him in one of Missouri鈥檚 facilities.

鈥淣obody in their right mind would,鈥� she added. 鈥淲hen you go to the hospital, there鈥檚 some quality control in a hospital setting. If you go to have a surgery, it鈥檚 not just doctors and nurses and medical professionals playing every man for himself. There鈥檚 some sort of oversight and they have to answer to somebody. And there鈥檚 not that in this industry.鈥�

This story was commissioned by the River City Journalism Fund, which seeks to advance journalism in St. Louis. See for more information.