Nicki Colma Sprigg
  - 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 Health Care & 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 Health Care. 

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 Health Care & 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 Health Care 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 Health Care 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 Health Care 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 Health Care 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 Health Care 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 Health Care

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 Health Care, 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.

Death occurred in the state of Delaware

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