State backs jail actions in 2010 death

Gwen Chamberlain

The New York State Commission of Correction’s (SCOC) investigation into a November 2010 suicide that happened in the Yates County Jail concludes that jail employees did not contribute to a teenage boy’s death.

Although the report implicates Soldiers & Sailors Memorial Hospital, officials there say the hospital has been deemed in compliance with state and federal regulations connected to incidents related to the death of Aaron Shehu, who hung himself in the jail on Nov. 26, 2010.

These findings paint a different picture than the details alleged in a lawsuit filed by Aaron’s adoptive parents against the county, four individual corrections officers, jail administrator Lt. Clay Rugar, Sheriff Ron Spike, an unnamed registered nurse, Cayuga Medical Center and an Ithaca doctor.

Walter Wiggins, the attorney for Aaron’s adoptive parents, Xhem and Nancy Shehu, says the commission’s conclusions don’t mean much to him and his clients because, he says, “In my career I don’t remember seeing a government body accepting responsibility, ever.”

Wiggins says the family is suing the county, corrections officers and jail administration because they all had reasonable grounds to believe he would take his life — and they were all in a position to do something about it.

“My information comes from the parents and their information came from the boy,” says Wiggins.

Aaron Shehu died in the dark early moments of Nov. 27, 2010 after he tied a sheet around his neck in his jail cell.

Just two days before, on Nov. 25, which was Thanksgiving day, he had called his parents and told them he was hearing voices in his head, according to the legal documents Wiggins has filed on the couple’s behalf.

The commission report says Shehu talked with an unidentified nurse in the jail who told him she would meet with him again after the holiday, according to the 30-page report.

That report concludes that the corrections officers in the Yates County Jail — the same ones being sued by the Shehus — acted to save his life.

The report is not connected to the lawsuit. It is the result of the agency’s investigation into Shehu’s death.

While the commission’s report points to actions of the nurse and a social worker at Soldiers & Sailors Memorial Hospital as contributing to the events that led to the 17-year-old boy’s death, and makes several recommendations for an investigation into the hospital’s discharge procedures, a federal and state review of the hospital’s actions cleared it of any responsibility.

The first finding of the commission’s 30 page report says: “Had Aaron Shehu received adequate and appropriate mental health evaluation, treatment and case management from Soldiers & Sailors Memorial Hospital John Kelly Behaviorial Health Services, both hospital and jail-based, his suicide may have been prevented.”

Neither the hospital nor the social worker are implicated in the parent’s lawsuit.

Wiggins says that’s because the hospital didn’t really become involved until after the teen died.

Further, Wiggins says he doesn’t remember seeing the notation about the social worker’s role in the events.

Loree MacKerchar, a spokesperson for S&S, said hospital officials found errors of fact and incorrect assumptions in the commission’s report upon its release in June, but the report was not changed. The report recommended that the New York State Department of Health (DOH) investigate the quality of care provided to Aaron by Soldiers & Sailors Memorial Hospital, including his unauthorized discharge on July 6, 2010 without documentation of an order made by a licensed physician or physician’s assistant.

An onsite review was conducted at the hospital in August by the DOH and on Dec. 9 the hospital received a letter stating that Soldiers & Sailors Memorial Hospital was in compliance and met New York State and federal standards.

MacKerchar says hospital officials are not aware of any investigation into actions by a registered nurse or licensed social worker employed by the hospital.

More investigations

The SCOC’s report includes recommendations for investigation by the New York State Education Department, Office of Professions into the conduct of A. T., a licensed clinical social worker for malpractice, gross incompetence, gross negligence and practicing outside the scope of LCSW and into the conduct of M.S., RN for malpractice, gross incompetence, gross negligence and failing to execute a physician’s order in her nursing care. The two individuals are referred to by their initials only in the SCOC report.

Several pages of findings in the report, obtained by The Chronicle-Express through a Freedom of Information request, have been blacked out because the information is protected by laws regarding confidentiality of medical data.

However, the legal complaint filed as the lawsuit by Aaron’s adoptive parents, includes more details such as:

• A psychiatric history of hallucinations and prior admissions to Cayuga Medical Center in Ithaca

• A statement that he had been removed from his biological parent’s custody when he was three months old because of neglect and physical abuse and that he was diagnosed with shaken baby syndrome, causing traumatic brain injury, which resulted in seizures.

• Aaron had been hospitalized in the juvenile psychiatric unit at Cayuga Medical Center

How he came to Yates County

How and why Aaron — 16 at the time — came to Freedom Village’s program for at-risk youth in Lakemont in January 2010 is not clearly revealed in either document, likely protected within the redacted portions of the commission report.

But his connections to Freedom Village, and, according to the commission report, his desire to confront another youth there led to his arrest and detention at the Yates County Jail.

According to Freedom Village documentation summarized in the report, “Shehu was portrayed as a low-functioning young man whose intelligence scores marked him as being borderline mentally retarded. It was made clear that, among his other behavioral problems, Shehu had been suicidal. His parents thought he often acted out for attention and that he was not genuinely suicidal.”

The commission report says Aaron’s behavior, which included references to his desire to die and attempts at putting things around his neck or threatening to hurt himself, ultimately led to Freedom Village authorities concluding that their programs were not suitable for “a very low-functioning, impulsive young man who felt very hopeless.” He was returned to his parents’ custody.

The parent’s lawsuit, filed on Nov. 1, 2011, says Aaron ran away from Xhem and Nancy Shehu’s home on May 4, 2010 after the parents confronted him about stealing medication from his mother. He was located by Tompkins County Sheriff deputy and taken to Cayuga Medical Center, where he was admitted on May 5, 2010.

The Shehus say Auguste Duplan, M.D. discharged Aaron from Cayuga Medical Center in Ithaca against their concerns that he might try to hurt one of them or himself. Duplan is named in the lawsuit.

Aaron’s contact with law enforcement in Yates County began when he ran away from home again and was arrested in Yates County by New York State Police on May 17, 2010 after he allegedly stole two vehicles to return to Freedom Village.

The SCOC report says Aaron was attempting to get to Freedom Village with the intent to hurt a youth there who had reported the suicidal gesture that resulted in Aaron being dismissed from Freedom Village.

He was arraigned in Milo Town Court by Judge John Symonds and remanded to Yates County Jail on $10,000 cash/$20,000 bond.

The arresting officer told jail officials he was concerned about Shehu’s safety.

Constant Supervision

During the booking procedure at 12:24 a.m. May 18, a Yates County corrections officer documented the recent history of suicide attempts and threats and instituted constant supervision, according to the report. He was placed under constant supervision, which Sheriff Ron Spike describes as one-to-one contact with a corrections officer.

Another suicide screening was completed on June 13, and the corrections officer noted signs of depression and calm behavior with the additional comment, “But does not wish to harm himself.”

Constant supervision was continued.

Over the course of the next five months, corrections officers conducted a number of suicide screenings on Aaron.

On July 5, when an officer stated he was concerned about the teen, another screening was conducted and within two hours, he was taken to Soldiers & Sailors Memorial Hospital at 12:55 a.m. on July 6.

After an unsuccessful attempt to find a placement for him in a forensic psychiatric facility, he was discharged to the jail by the social worker, A.T.  at 11:05 a.m. The commission report states only New York State licensed physicians and physicians assistants may discharge patients fromm hospital emergency departments.

He was taken back to the jail and constant supervision status continued until 2:55 p.m., when it was stopped by nurse M.S.

The commission report calls this action by the nurse, “flagrantly incompetent care rising to a level of professional misconduct.”

The nurse was not an employee of the jail, but of Soldiers & Sailors Memorial Hospital, working in the jail under a contract between the two entities. Now, the jail employs its own registered nurse, according to Spike. The jail also contracts with S&S for psychiatric services which include social work services.

Corrections officers reported that Shehu was teased by other minors in the jail during his time there. Officers gave orders for them to stop and moved Shehu to a separate housing area. He was moved 15 times, according to the report.

According to information found in the SCOC report, Aaron’s parents visited him one time between May and November. Wiggins says they maintained contact through phone calls and saw him during court appearances.

Wiggins said Aaron’s parents attempted to get a judge to move Aaron to a setting where he could get proper treatment.

Incidents continued until Thanksgiving Day 2010.

Thanksgiving 2010

On Nov. 25, 2010, Aaron called his adoptive parents and said he was hearing voices in his head again and that he had reported this fact and his thoughts of suicide to the nurse, according to the lawsuit document.

The legal document alleges that the nurse visited him and “took no measures to secure Aaron Shehu’s transfer to a secure hospital or some other appropriate place of confinement; arrange for a 24-hour watch to be maintained... and make certain he ingested his anti-depressant medication.”

At 11:30 p.m. Nov. 26 Aaron said he was “doing good” when an officer was making rounds and stopped to talk with him.

“In reviewing the security videotape and security log book, Shehu was adequately supervised at 30 minute intervals,” the SCOC report states.

The tape also showed teen inmates in neighboring cells tossing knotted sheets toward Aaron’s cell and drawing them back in to their own cells.

At 12:07 a.m. Nov. 27, an officer discovered Shehu suspended by a sheet from his cell gate.

Aaron had committed suicide by tying his bed sheet to the bars and the other end around his neck.

Officers were able to untie the sheet from his neck. They started CPR when no pulse or respiration was detected. They used an Automatic External Defibrillator, which advised no shock, but to continue CPR. They continued CPR until Penn Yan Volunteer Ambulance arrived.

Aaron was  pronounced dead at S&S at 1:15 a.m. Nov. 27.

“The whole thing is tragic,” says MacKerchar, adding, “It just shows how unpredictable these diseases are.”

Spike, who said he could not comment specifically on the lawsuit, did comment on the commission report, saying he was pleased with the findings that concluded the way corrections officers managed Aaron’s case was “99.9 percent right.”

The same laws that prevent the medical and mental health details about Aaron’s case from being revealed to the public prevent such information also keep being shared with jail staff, according to Spike. With more medical and mental health issues being factors for people who are arrested, that poses a challenge for the jail personnel.

A tragic life

Aaron’s life began and ended with tragedy, according to Wiggins. Being taken from his biological parents as an infant, and then later being sexually abused by a mental health worker responsible for his and his younger brother’s care are just two examples of the trials the boy endured, says Wiggins.

“This kid had so many strikes against him,” says Wiggins, adding, “My hope is some good will come from this process. Perhaps we can help others from being abused.”

The SCOC report recommends the New York State Commission on Quality of Care and Advocacy for Persons with Disabilities conduct an investigation into the case, including the services in Tompkins County, and an inquiry should be made into the delivery of services by the state Office of Mental Retardation and Developmental Disabilities through the Broome County Developmental Disabilities Services Office.

The singular recommendation made to the Yates County Sheriff’s Department is to direct staff to comply with a regulation regarding key control. This recommendation stems from the inability of the corrections officer in the control area on the night of Aaron’s death to locate a key to the secure location of the cut-down tool.

This tool would have been used to cut down the sheet that Shehu used to hang himself. The commission determined the corrections officers’ actions to release the sheet from Shehu’s neck without using the cut-down tool were sufficient.