Report critical of O.D. Heck

PHOTOGRAPHER: Bob Conner

A state investigation into the 2007 death of Jonathan Carey has found various problems in the way he was dealt with at the state’s O.D. Heck Developmental Center in Niskayuna, going beyond the circumstances of the homicide that killed him.

Although the investigation found otherwise, Jonathan’s father, Michael Carey, said its factual findings clearly show a connection between the failings of O.D. Heck procedures and practices and the death of his son, who was a 13-year-old with autism and mental retardation.

Edwin Tirado, one of two Heck aides who was with Jonathan and another boy on a Feb. 15 outing, was convicted later that year of killing Jonathan, and is imprisoned for manslaughter.

Tirado killed Jonathan by improperly restraining him in a vehicle, and then he and the other aide tried to cover up the crime.

According to documents prepared by the state Commission on Quality Care and Advocacy for Persons with Disabilities (CQC) and provided to the O.D. Heck director: “While it is our overall finding that the child’s death was the direct result of the actions of the staff involved and not caused, either directly or indirectly, by any failure on the part of your agency, we did identify several problems in the care which the child received [at O.D. Heck].”

Carey said that statement shows a continuing state cover-up, because the facts uncovered by the CQC investigation do show that O.D. Heck’s failure to address problems likely contributed to Jonathan’s death.

Those problems include Tirado’s having worked 197.5 hours in the two weeks prior to the homicide, including 117 hours of overtime. This in and of itself created a dangerous situation, Carey said. A previous incident involving Tirado’s negligent attitude toward the disappearance of a patient, and lying about that matter to supervisors, should have prompted his dismissal, Carey said.

Evidence also shows that a seatbelt buckle guard may not have been installed in the vehicle Jonathan was riding in, although it should have been. Jonathan had a tendency to unbuckle his seat belt, evidence showed, and apparently had done so when Tirado attempted to restrain him. O.D. Heck did have buckle guards in its possession, evidence showed, and Carey said his family gave one to the institution for Jonathan’s use.

And there appears to be a 26-minute gap from when the aides returned and notified supervisors, and the 911 call. Carey said there is no doubt that Jonathan was dead by that time, but the supervisors did not know that and should immediately have called 911. When calls were made to the abuse hotline, one apparently contained false information about the circumstances of Jonathan’s death.

Carey said the cover-up of his son’s death would likely have succeeded except that the other boy told the truth to Niskayuna police who responded with emergency personnel, prompting the criminal investigation.

Carey is also critical of state oversight of a private school where Jonathan had resided previously, and was abused in a misguided effort to toilet train him, according to his father.

Carey said a state inspector general’s report will soon be released that is likely to be highly critical of CQC’s regulation of that school and its cover-up of the wrongdoing there. He said he believes CQC Chairman Gary O’Brien resigned Friday because he is implicated in that report.

O’Brien could not be reached for comment. CQC spokesman Gary Masline said he didn’t know why O’Brien resigned, and referred questions to the governor’s office.

Erin Duggan, a spokeswoman for Gov. David Paterson, said the governor is aware of the Carey family’s complaints against O’Brien. She said O’Brien’s resignation was submitted and accepted last Friday, and declined further comment on it.

Kara Smith, a spokeswoman for the state Office of Mental Retardation and Developmental Disabilities, which runs O.D. Heck, declined to respond in detail to the CQC findings about Heck. She said there were no findings of a cover-up, and that OMRDD is considering changes to overtime rules and other policies addressed in the investigation. But the blame lies with Tirado and the other aide as individuals, she said, and not with OMRDD itself.

Carey, however, said there are fundamental problems with state oversight over public and private-sector institutions, and several hundred questionable deaths every year involving caregiver negligence or worse. State authorities routinely fail to call police in cases where there may have been criminal wrongdoing, he said.