Nicki Colma
Sprigg
April 11, 2002 -
November 26, 1998
At the age of 15, Nicki
Colma Sprigg, died, in a wheelchair only six days before she was to receive
an operation that would have saved her life. It was Thanksgiving day!
In 1990, a Superior
Court Judge ruled that Nicki was being neglected by her mother. On January
30, 1992, Nicki was taken to Harbor Healthcare & Rehabilitation Center
in Lewes Delaware. It took eight months for her to be seen by Dr. Kirk
Dabney who measured the curvature of her spine at 33 degrees. An appointment
was made for
her for six months
later:
"She will continue
to have reevaluation on a six-month basis with X-rays of her spine and
pelvis"
Kirk Dabney
- Sept. 14, 1992
Dr. Kirk Dabney would
not see her again for eight years. In the last years of her life, efforts
were FINALLY made to get Nicki the surgery she so badly needed.
Unfortunately, that surgery would not come in time to save her life. The
people who took her away from her mother due to neglect, neglected her
to death.
Here is a time line
of how things happened:
February 5,
1998: A D.C. judge learns that Nicki is not fitting
into her wheelchair because of her curved spine. The judge questions why
surgery has not taken place.
February 17,
1998: The judge orders the D.C. Child and Family Services
Agency to visit Harbor Healthcare.
March 2, 1998:
An agency investigator discovers Dabney hasn't examined Nicki's spine since
1992. The surgeon sees Nicki that afternoon and finds the curvature of
her spine now measures 90 degrees, a 57-degree deterioration.
March 13, 1998:
Dabney writes to the District to say he wants to schedule surgery.
April 17, 1998:
The judge says Nicki is in a "desperate, delicate condition." Nicki is
examined by three orthopedic surgeons.
July 1, 1998:
A District social worker calls Dabney's office and learns that he is waiting
for the D.C. agency to sign approval forms for the surgery. The social
worker says she asks Dabney's office to fax her the forms.
July 7, 1998:
The social worker tells the judge that two doctors believe Nicki's "life
would be prolonged with the surgery." The worker says she has not yet received
the forms from Dabney's office.
August 10,
1998: Dabney reexamines Nicki's spine and finds the
curvature has worsened to 100 degrees.
September 18,
1998: Saying that the social worker is not returning
his messages, Dabney tells the agency he is "extremely concerned" that
Nicki's surgery is not yet scheduled; he says delays might result in the
District being considered "negligent."
November 26,
1998: At age 15, Nicki is found dead in her wheelchair,
six days before her scheduled surgery on Dec. 2.
During the six years
that Nicki was at the mercy of guardians who were SUPPOSED to protect
her and work in her best interest, but, failed her. Nicki SHOULD
have been scheduled
IMMEDIATELY for the surgery that would have
saved her life. Instead, her body has been described as her back having
pitched sideways, slowly and pain-
fully, until she
was sitting at a right angle with her head tipped at the
side of her body:
"We really
didn't pay attention to the children who were sent to live outside the
District,
and that's
sad for me to say, because I was involved. By the time we started
to look at
that facility and others, and scrutinize what was going on with
Nicki, it
was too late" Pablo Ruiz-Salomon, a former social worker at the
D.C. Child
and Family Services Agency who supervised Nicki's foster-care
case during
the last year of her life"
In the years between
1993 and 2000, 229 D.C. children died while in protective custody of CPS,
Nicki was only one of those children. What happened to her brought to the
attention the many ways in which the system fails to protect abused and
neglected children. Nicki even had a court appointed attorney and was visited
only twice during her six years at Harbor Healthcare & Rehabilitation
Center. It is hard to find placement for disabled foster children and officials
are often forced to look to places where nursing homes and other institutions
have built special wings to take advantage of the need for placement of
these children:
"The kids were
basically dumped. They were stashed and forgotten"
Jerome G.
Miller, who was chief of Child and
Family Services
from 1995 to 1997
Nicki was sent to
live at the Harbor Healthcare And Rehabilitation Center at a cost of $65,000.
a year, which was paid for by medicaid. During that time, D.C. agency social
workers were responsible for reporting to the judge about Nicki's condition
and her progress:
"It was always
worrisome, sending these children out of the District. You have to rely
on
the agency
to keep track of them, and they just wouldn't do it"
Superior Court
Judge Gladys Kessler
On Jan. 30, 1992,
Nicki made the 101-mile trip to Lewes. She was 8 years old with the mind
of an infant, unable to walk or talk or eat on her own.
Nicki, who was eight
years old at the time she was sent to live there, had the mind of an infant
and was not able to walk, talk or eat on her own, she also suffered from
several conditions including cerebral palsy, spastic quadriplegia, scoliosis
and severe mental retardation. Willie Mackall, Nicki's grandmother, went
to visit her twice a month to make up for her own daughters absence in
her granddaughters life. She made the two hour trip by bus and would take
Nicki outside in her wheelchair, pushing her down hills and finding places
where they could spend time together.
Not too long after
Nicki had arrived, her social worker had left the case and made false statements
to the next worker:
"The case is
stable and intensive services are no longer required"
Judge Kessler was
named to the federal bench and also left Nicki's case behind. At the end
of 1994, the new case worker was no longer assigned to Nicki and had not
seen her even one time. She failed to file a report updating the new judge
in Nicki's case, Judge Colleen Kollar-Kotelly, about her case. In 1995,
Nicki was assigned a new case worker, Laura Hoffman. Laura would make one
visit to Nicki and then it would be three more years before any other Social
Worker checked on her. Laura wrote a letter to the judge and informed her
that the
facility where Nicki
was living was clean and well managed. There was no mention of her spine
or any other problems. In a few months, Nicki's case was transferred to
yet another case worker.
By the mid 1990's,
the D.C. Child And Family Services was known as one of the most chaotic
child protection agencies in the United States. A federal judge had taken
direction supervision in 1995. He named a new director with the last name
Miller and it was soon discovered that 120 severely disable district children
were living in institutions outside of their city. Miller would also discover
that case workers had not even been visiting these children:
"We had social
workers recommending that they stay in these places without ever
meeting the
kids"
Willie Mackall said
that Nicki's care had taken a turn for the worst as
the number of workers
in the pediatric ward got smaller. She said that Nicki had bedsores and
her hair was falling out from being matted on
the back of her
head, Willie put a sign:
"Please Feel
Free to Comb Nicki's Hair"
Nicki had a dislocated
hip that wasn't even noticed until Willie told the staff that she had a
bone pressing against her skin. She would receive an operation on that
hip, at a later date:
"They would
leave her in bed all day and all night. I asked, 'Where is everyone?' They
said,
'They're gone.
We were paying too much money to all of those people"
Willie tried to notify
Nicki's social worker about her condition and was always told that the
workers were out in the filed. What Willie was not aware of ws that the
Delaware nursing home licensing division had been investigating the nursing
home and had issued a 59 page report which detailed patient care violations.
There were complaints from patients saying they had to sit in their own
waste for hours and they were allowed only two showers a week due to shortages
in staff:
"You feel worse
than scum"
Resident
Before releasing
the report to be release, Delaware's director of public health had delete
22 pages of violations. This became front page news rather quickly. Senator
Robert Marshall (D), was concerned about the damaging evidence to the residents
in the nursing home and held a public inquiry. Ellen Reap, the Delaware
official who ran the licensing division said that improper influence and
back room deals that took place between state public heath supervisors
and nursing home operators were lowering the quality of care given to residents.
In spite of all the publicity, the records do not show that the city social
workers or the judge, knew about the Delaware report or the hearing.
D.C. Superior Court
Judge Cheryl M. Long had taken over Nicki's case and was furious when she
read her file. Questions were asked about why Nicki had been left in a
wheelchair that was too small for her and didn't fit the contours of her
back and why Nicki had not received the surgery she needed:
"I don't want
to see her just sit there like a bump on a log and have no life except
to get pain
meds all the
time. I don't know what their problem is. I hear one weird story after
another about
what's going on there. It doesn't make any sense"
Child And Family
Services was ordered to investigate and Clairessa D. Lattimore took on
the case. She called Dr. Kirk Dabney who told her that Nicki was scheduled
for an appointment that same day. Kirk told her that he had no idea why
there was a six year delay in his keeping appointments with Nicki. Eleven
days later Kirk wrote to the
District claiming
he didn't know the reason for the delay and that he wanted to schedule
Nicki's surgery for as soon as possible.
Two weeks alter,
Clairessa went to Delaware and interviewed administrators and doctors and
she collected records that were put together by Wilson Choy, an Orthopedic
Surgeon and Harbor Health-care consultant. Wilson Choy had been the one
who had done the surgery on Nicki's dislocated hip and he said:
"This is not
a case of neglect, but a neurogenetic type that progressed rapidly"
Wilson also tried
to say that Nicki's severe curvature had only been a recent thing. Clairessa
pointed out that radiology reports which dated back to 1996, indicated
"a severe scoliotic curve to the dorsal lumbar spine". Judge Long was at
the end of her rope. During an April 17, 1998 hearing, just one month after
the investigation started she said:
"She's in a
desperate, delicate condition. Every time we get within an inch of somebody
actually ordering
a wheelchair for her, they say, 'Oh, can't do it. Gotta do a spine
operation.
Gotta do this. Gotta do that.' And they keep putting off. Putting it off.
Putting it
off. And I keep wondering, 'What in the world is going on?' "
A new supervisor
at Child And Family Services, Pablo Ruiz-Salomon, was trying to figure
out why the agency's paperwork was incomplete and lacking specific details
about Nicki's medical care and treatment. Pablo supervised the kinshop
care unit and said it was NOT set up to handle children with special
needs like Nicki had. He stated that the unit which was originally created
to oversee children who had been placed with relatives, was now a dumping
ground that was supposed to relieve heavy caseloads. Records indicated
that the six case workers who worked in the unit were each supervising
31 boys and girls and this was over double what was the court ordered limit
of 17:
"What we were
doing was putting a finger in the dike. When you came in in the morning,
you would
just hope there wasn't a fatality"
Pablo Ruiz-Salomon
Nicki's case soon
became top priority at Child And Family Services. They started to realize
that the curvature of her spine would cause damage to her heart and lungs.
Other staff members at the Harbor Healthcare Center became worried that
they would be blamed for what was going on, so they made the trip to see
the judge.
Jennifer Kihn, who
was the nurse in charge of Nicki's wing at that time said that she and
her supervisor had notified the judge that nurse had wanted to schedule
surgery for Nicki. They were unable to do so due to needing an authorization
from her legal guardian who at that time was Child And Family Services.
Jennifer said that case workers had been leaving the agency so often that
the forms were never signed:
"If she didn't
have the surgery, her lungs could collapse and her heart could fail. It
was
outrageous.
I know social workers are overwhelmed. I would never want to be one,
because it's
so hard to keep on top of everything. But too many hands were
in the pot,
and it was too confusing"
Three different Orthopedic
Surgeons had examined Nicki's spine and two of them said that she could
live a longer life with surgery. Judah Campbell, who was Nicki's case worker
at that time, told the judge that she had called Kirk Dabney and he said
he needed the approval of Child And Family Services in order to perform
the operation. Two
months later, that
approval had not yet come.
"I have had
an extreme amount of difficulty communicating with your agency. After
not receiving
any response and after leaving several messages, I was finally able
to get to
speak to Ms. Judith sic Campbell"
Kirk examined Nicki
on August 10, 1998 and her spine was worse than he had seen it before,
with a 67 degree deterioration. Kirk said he left two message with Child
And Family Services at that time and tried to talk to Judah Campbell and
had not received a return call:
"If Nicki Colma's
surgery is delayed much longer, her curve may progress to an inoperable
magnitude.
One would then question as to whether or not your agency would be
negligent
in allowing this child to have proper care. I am extremely concerned about
this
patient and
would appreciate a follow-up and a finalization"
Eventually, the surgery
was scheduled for December 2, 1998. Nicki would never receive it. Nicki
Died on Thanksgiving day of 1998. Then as if her death was not bad enough,
someone from Harbor Healthcare called Child And Family Services asking
for permission to release the body of Nicki to a funeral home. The social
worker said okay and her body was taken to the funeral home and embalmed
before anyone could request an autopsy. I have to wonder if this was done
with the full knowledge that an autopsy could reveal the manner of death
and someone was hoping to stop it from being known.
Johnathan L. Arden,
the Districts Chief Medical Examiner said that the body of Nicki should
NEVER have been embalmed and that it was going to make a determination
of death very difficult. In the case of Nicki, he said it would not change
his opinion and conclusion that Nicki died, in part, due to the dramatic
curvature of her spine:
"The severe
scoliosis compromised her respiratory system. It raises some very important
issues as
to whether she was receiving adequate care"
Three months after
the death of Nicki, Delaware regulators found out that at least five other
children had died at Harbor Healthcare in ten months, between April of
1998 and February 1999. The information was turned over to the state attorney
general's office.
In February 1999,
three months after Nicki's death, Delaware regulators discovered that at
least five other pediatric patients had died at Harbor Healthcare from
April 1998 through February 1999. The regulators turned the information
over to the state attorney general's office.
Few people who were
accountable for Nicki's care were actually willing to speak publicly about
what had happened to her. An assistant attorney general stated that there
was an investigation taking place into the deaths of the other children
and Nicki:
"The investigation
is ongoing. That's all I have to say"
A interview was set
up with the cooperation of Chris Evans, Harbor Healthcare's administrator.
He then changed his mind and asked that the questions be sent in writing.
The questions went unanswered:
"Confidentiality
obligations prevent the facility from responding"
Adam Balick
- attorney for Harbor Healthcare
In July, the pediatric
ward of the nursing home closed for good. The facility said that reasons
included negative political and operating environment created by certain
parties who oppose children being taken care of in nursing homes. Kirk
Dabney didn't respond to any attempts to talk to him.
Wilson Choy stated
that he had noted a mild to moderate curve of her spine at the time of
her hip surgery in 1997. A radiologist had noted a severe curvature on
an earlier date. Wilson said that it was possible that he and the radiologist
could have different opinions about how severe the curvature was. When
asked if he knew why Kirk had not seen Nicki in six years, he said he didn't
know:
"Kids get lost
in follow-ups. No one was watching out for her"
Santosh B. Reddy,
a pediatrician for Harbor Healthcare, said that he had assumed surgeons
were monitoring Nicki's case during her six year stay:
"I guess someone
else was following up. I just don't know"
Requests for an interview
with Sondra Jackson, the last receiver named by the court to have run the
Child And Family Services, were declined. Nicki's court appointed attorney
wouldn't discuss the case and hung up the phone, though not before saying:
"I'm not going
to get into this"
Only two of the case
workers who were assigned to Nicki's case in the six years she was a ward
of the state, still work for the agency, one of them is Judah Campbell.
She chose not be questioned about the case. Of the remaining six, five
could either not be located or did not wish to be interviewed or comment
on the case. Laura Hoffman said that she doesn't remember the details of
Nicki's death and that children were put at risk because there was not
enough time to give to their cases:
"We were
inundated by cases. There was not enough time to do the things we needed
to do.
And nothing
ever came to fruition to get kids the things that they needed. Everything
took a year and a day"
Laura left the agency
after three years and no longer works in the same field of work.
Judge Long is still
on the Superior Court bench, she can't comment about the case because she
is also the supervisor for Nicki's sister. Judge Long did try to hold Child
And Family Services accountable for the death of Nicki and wanted them
to pay a small price for what they had done. Days after Nicki died, a court
hearing was held and Paul Kratchman, a Child And Family Services lawyer,
made a promise that his agency would reimburse Willie for the funeral expenses
of her granddaughter. Willie had not received the payment and 17 months
later, the judge forced the agency to pay her $3,578. to cover the costs.
For information about
preventing child abuse in the state of Delaware, click the links below.
If they can't help you, ask for someone who can. NEVER give up looking
for help for an abused child!
Call this number
to report child abuse ANY WHERE in the United States!
1-800-4-A-Child
1-800-422-4453

  
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