Questions Surround Death Of Boy -- State Probe Fails To Uncover Details On What Happened

Shinaul McGraw could make himself understood in two ways: He could make sounds that were not words and he could gesture with his hands.

But on the night he died, his mouth was covered with gauze and his arms and legs were bound with sheets.

The 12-year-old boy's body was found wrapped like a mummy in his sweat-soaked bed in a Lynnwood group home on the morning of June 5. He'd been tied in to prevent his getting out of the bed. He died of hyperthermia, or overheating.

Shinaul's death - and an official report failing to say how it happened - add to questions in recent months about state care for the most vulnerable of children. Other questions were raised by four deaths in a Seattle foster home and sexual abuse at an Olympia group home.

The Department of Social and Health Services, Snohomish County authorities and the group home's managers all say Shinaul's death was a terrible accident.

But Shinaul's mother and three attorneys who looked at the case say it was worse than that. The mother is considering a lawsuit. And now, the very expert who set up the New Directions group home has also accused the home of professional negligence and neglect or abuse.

Had staffers there acted properly, "Shinaul would not have passed away in the circumstances he did," says consultant Donna Dykstra. "I think there were several critical points in his stay where things could have been done differently."

Dykstra was hired by the home last year to write its plan for state funding. She was hired again this fall to review its operation.

Dykstra says the home violated its agreement with the state, failing to provide training and protocols that would have prevented the boy's death. And she says the state failed to ensure the home kept its promises on quality of care.

Mike Smith, an attorney making a separate investigation for the federally funded Washington Protection and Advocacy System, agrees: "He should never have died. He wasn't provided sufficient care and attention."

Ken Maaz, executive director of Second Chance, a nonprofit agency that runs the New Directions group home, says Shinaul died of a rare combination of seizures, fever and self-injury. Maaz says any lack of safeguards was excusable because the home had been open only eight months, and he says there was no negligence or neglect in the death.

And he pointed out, a DSHS investigation didn't find any wrongdoing on the part of the home.

Indeed, the "Shinaul McGraw Complete Report" signed by John George, regional administrator for the Division of Children and Family Services, finds no neglect or abuse. The report refers to "swaddling" while it fails to say Shinaul was wrapped as tight as a mummy. The report ends with Shinaul's arrival at New Directions, but it doesn't say what happened the night he died.

Dykstra and the attorneys say the DSHS report on the death was deficient and overly secretive, perhaps trying to protect the state from liability. They say the end of Shinaul's life and the lack of accountability for his death point out problems in the state's children services.

Self-destructive behavior

Shinaul was born with Cornelia de Lange Syndrome, a genetic condition that causes mental retardation and self-destructive tendencies. He was fitted with a helmet to protect his head when he banged it against floors and furniture. On doctors' orders, all his teeth were pulled because of the damage he was doing to his lip and mouth. And he wore splints on his arms to keep his hands from his face.

Yet Shinaul's life wasn't all tragedy, says his mother, who gave him up to foster care when he was 6 but continued to visit him.

"He was overall a very happy little boy, and very smart, and he could teach me sign language," Patrice Haagen says. "He loved going to the beach, going to McDonald's, riding a bike, fishing, camping. He loved music, country and western music."

Bill and Judy Sanderson of Monroe, Shinaul's foster parents for six years, say he loved to go on outings and play with their dog.

But the Sandersons earlier this year decided they needed a respite because of Shinaul's increasing behavioral and medical problems.

The New Directions staff took charge of him on May 13, when they picked him up at Children's Hospital in Seattle after his teeth were pulled. When two staff members arrived, they found the boy tied to a hospital bed with four leather restraints.

New Directions had opened in October 1993 as a licensed residential facility under state contract to care for six developmentally disabled children. It was supposed to be the best place in the state to try to provide for severely disabled children in a homelike setting.

But the house director and case manager had no prior experience managing such a program. And staff members say they weren't ready for the hard cases they'd promised to take.

"We weren't equipped to handle that kid," says W. Stephon Morris, a part-time residential counselor at New Directions. "That's why I was coming there on the weekends; nobody else could handle him."

Morris says Shinaul needed a bed with sideboards, but the group home didn't have one. "That's the reason he was restrained, because we didn't have the facilities there for him to sleep safely."

The home was paid $921 a month by DSHS for "one-on-one" care for Shinaul.

But Morris says Shinaul's state caseworker didn't check in much to see how he was doing. "They kind of stick him in there, then they don't keep in contact much."

Shinaul seemed to get worse during his stay, according to interview notes released by the Snohomish County sheriff's office.

He ran a fever in late May, but it was gone when he got to the doctor's office. He wanted to be held all the time. He developed an enormous thirst. He'd never liked cold drinks before; now he demanded ice.

He thrashed about more, too, once bruising a worker. Shinaul would dive for the floor to bash his own face; experts now think Shinaul was hurting himself to distract from an even worse physical pain.

Two days before his death, a therapist thought she saw Shinaul have a minor seizure. Seizures can interfere with brain activity needed to regulate body temperature.

Maaz says a doctor was phoned. "We were told not to worry about it. We were worried about it. We thought that his spiking fevers and possible seizures were a problem." However, Maaz adds, "there was no evidence of problems when we put him to bed that night."

Sheriff's records show Shinaul woke up drenched in sweat and urine the day before his death. Staff members said the boy was in great discomfort all day, flailing and grunting and seeking comfort by holding onto people or objects.

The night of Shinaul's death

Shinaul was put to bed about 8:30 the night of his death. He slid out of bed every 10 or 15 minutes, hollering and thrashing about, until the shift change at 1 a.m.

Then he was left in the charge of Sherry Andrews, a part-time fill-in worker. There was supposed to be another staff person in the house that night, but he was out of town. There was supposed to be in-service training for all the staff, but Andrews had none. There was supposed to be a treatment plan for every resident, but there was none for Shinaul.

Andrews, 38, had worked with severely disabled people since she was a teenager helping out in group homes operated by her aunt and grandmother, she told investigators, and she had worked in corrections. (Andrews' phone is disconnected and she could not be reached.)

Andrews also was the roommate of the staff member who had picked up Shinaul in restraints at the hospital and had recently been bruised by Shinaul at the home.

Normal procedure was to put gauze and tape over Shinaul's damaged lower lip at bedtime and tuck the edges of his blanket under the mattress to give him a feeling of security.

Andrews decided to wrap a sheet several times around Shinaul's legs to prevent him from kicking the blanket off and sliding out of bed. But he still managed to push up toward the headboard, out of the covers and onto the floor.

At about 5 a.m., Andrews told investigators, she got the idea of wrapping a couple sheets lengthwise from the bottom of the bed, up over Shinaul's shoulders and back toward the bottom, in an inverted V shape, to keep him from scooting up.

She told police that's how she left him, secured in bed, and still awake at 7 a.m.

Andrews told police she had informed her relief staff that Shinaul was restrained in bed. They said she never informed them. The facility kept few records from shift to shift.

Staffers said they glanced at Shinaul from time to time through the morning but never really checked him. They didn't want to wake him up, they said.

None of these circumstances are mentioned in the official DSHS report on the death.

Morris went in to get Shinaul up shortly before noon. He says he was in the room for 20 minutes, tidying up and talking to the boy, before he realized he was dead.

Then Morris saw all the restraints. "I've never seen a procedure like that in a residential facility before," he says.

When he went to check the boy for breathing, Morris saw the gauze covering his upper and lower lips.

"The gauze could have prevented him from saying anything, could have prevented him from breathing," Morris says. "But they say it could have worked up there over the night. So you just don't know.

"I think everybody tried to do what was right. It was just that Shinaul wasn't in the right place."

A nightmare for mother

Jane Fantel, a Seattle attorney for the mother, says it was more than that. "One of the greatest tragedies of all is that he could communicate, but they prevented him from communicating," Fantel says.

Haagen cries at the thought. "I'm driving, I'm laying in bed, and I'm trying to put myself in Shinaul's place. How scary that must have been, and painful, and you couldn't even communicate."

In a recent shuffling of group-care services across the state, DSHS didn't renew New Directions, effective Jan. 1, 1995. But the facility has still been and is still being paid $4,757 per month for its six beds, even though many of them have been empty since Shinaul died.

State law requires all unexpected deaths in foster care to be investigated by an independent review team. George, the regional chief of children's programs, refused to name the members of the team that spent 20 hours studying the case, but a roster obtained by The Seattle Times shows four of the seven panel members are employed by DSHS.

When the panel's report was obtained under a public-records request, large portions were blacked out and critical incidents unmentioned.

"They want to protect themselves from liability," says attorney Lem Howell, who questioned the DSHS report on another death in an inquest earlier this year. "It's almost contrary to seeking after the real facts."

George said the death-review team did not find any neglect or abuse or even any contract violations by New Directions. He said the DSHS team's work is done.

Questions remain unanswered

Among the questions left unanswered, however, are: Who wrapped the final sheet around Shinaul? (Andrews denies it.) Did anyone put more tape on his mouth? (All deny it.) Why wasn't the staff trained, why wasn't Shinaul monitored, as promised?

Dykstra said after Shinaul died her concerns were so great, "I phoned John George and told him I thought there might have been abuse and neglect, and I contacted the Sheriff's Department as well, but I haven't heard back from them."

She said the DSHS report is gilded.

"There's this big gap. It's as if Shinaul didn't die."