When they were assigned rooms on opposite sides of the hall at a North Florida state psychiatric hospital, that decision would eventually lead to Sean’s death.

It also would spawn five lawsuits, three adult protection investigations, two inspector general reports, two licensing probes and an administrative inquiry. The state already has paid nearly $800,000 to one whistleblower, and is facing another in court in April.

But if there were lessons to be learned from Sean’s abuse and death, administrators at the state Department of Children and Families seemed determined not to learn them. In the wake of Sean’s Jan. 12, 2021, death at Northeast Florida State Hospital, the state has faced repeated accusations from his family, attorneys, its own employees and even the local sheriff’s office of covering up its mistakes.

One hospital employee testified that her signature was falsified in records identifying staff responsible for the supervision of both Sean and Loyd. The hospital’s medical director also confirmed the falsification, acknowledging in sworn testimony that looking at copies of the phony records made her “nauseous.”

Surveillance video of the attack was either not preserved or was deliberately destroyed.

The then-director of DCF’s Adult Protective Services Department concluded in a September 2021 investigation that the hospital’s top two administrators had neglected Sean in the months before his death by failing to transfer him to a medical unit in the same hospital, and were responsible for what he endured.

“You cannot have events like this occurring in a [locked] facility and…nobody be held responsible,” Roy Carr, DCF’s then-director of Adult Protective Services, testified in a June 7, 2022, court hearing to decide whether a whistleblower deserved to be reinstated.

But for months DCF’s leaders buried the report that heaped blame on the two high-ranking administrators for Sean’s abuse. They finally concluded that while Sean had been neglected and mistreated at the hospital, no agency employee was accountable. The administrators who at one point were identified as responsible for Sean’s lacerated face, broken ribs, and the “stomping” of his abdomen and groin area — and, finally, his death — have never been disciplined.

Instead, a doctor who blew the whistle on the dysfunctional hospital was fired. The Tallahassee judge who ordered DCF to reinstate the doctor excoriated the agency for trying to pin the abuse on four low-level workers who weren’t responsible — while protecting their bosses.

“I’m beyond shocked at this, this conduct,” Leon Circuit Judge John C. Cooper declared at a hearing. “Is this the way the state treats people?”

Said Sean’s mother in a Nov. 14, 2021, email to DCF Secretary Shevaun Harris: The hospital “has yet to take responsibility for their actions because they cannot get their facts straight. This has gone on for too long.” She added: “Please help our family. We deserve answers and closure.”

The Herald is not reporting Sean’s surname at the request of his family.

In an email Friday evening, DCF’s deputy chief of staff, Mallory McManus, said agency administrators “were saddened by the death of [Sean]” but blamed it on complications of COVID-19, “as determined by the medical examiner.” Sean’s mother insists that regardless of any medical examiner opinion, the beating, not COVID, was what led to her son’s death.

McManus said the agency generally does “not comment on pending litigation.”

“Our primary focus is ensuring that patients receive high-quality services at the state mental health treatment facilities,” McManus said. She added: “The Department has participated and complied with all inquiries and investigations related to this case, and it is important to note that the Department followed all protocols and procedures and denies plaintiff’s allegations of wrongdoing.”

By reason of insanity

Records suggest neither Sean nor Loyd should have been in Unit 13-2-E of the psychiatric hospital in Macclenny, Florida, to begin with.

In the months before the attack on Sean, he had lost a quarter of his body weight, had developed a pressure sore on his back, had trouble swallowing, used a wheelchair for mobility and had been diagnosed with “failure to thrive,” a condition characterized by frailty and a decline in health. At least three of his healthcare providers said they had asked the hospital’s medical director, Yolanda Hernandez, to transfer him to the hospital’s medical ward. She repeatedly declined, records say, without explaining.

Loyd, found not guilty by reason of insanity on 2016 charges of attempted carjacking, grand theft and battery, had been “stepped down” from a state hospital built for sometimes-violent criminal defendants with mental illness to a hospital built for people with mental illness but not criminal charges. Faced with a 450-bed shortage for criminal defendants, DCF had taken to routinely moving so-called forensic patients over to hospitals for those who were civilly, not criminally, committed.

In the months before Loyd was transferred from a forensic hospital to Northeast Florida State in February 2020, he was accused of striking a nurse in the face, causing severe injuries; punching and kicking three other staffers the same day, requiring eight staff and handcuffs to subdue him; and threatening to “knock out” another patient, Sean’s family alleged in court pleadings.

In July of that same year, court pleadings say, Loyd attacked another patient in the shower, “causing severe bleeding and facial disfigurement.”

Nevertheless, DCF declared him “stable,” and appropriate to be transferred to a less-secure civil commitment hospital.

The day before he attacked Sean, according to testimony, Loyd threatened to kill people and to “go ape and beat everybody.” He made good on some of his threats: Records say he threw punches at security workers, and it took four of them to subdue him. One staff psychologist, Darah Granger, was so afraid of Loyd that day, she testified, that the hospital posted security for a meeting she had with him.

The protection did not extend to patients. In sworn testimony, Granger said having a security guard would “agitate the other 30 patients on the unit” — some of whom “have delusions about people in uniform.” Staff also didn’t want to signal to other patients that Loyd was “somehow different.” And the hospital didn’t have enough security, in any case.

Despite orders that both men be given at least one-on-one supervision throughout the day, Loyd ran out of his room naked the next day and attacked Sean in his bed for what the hospital security chief later told an investigator was “several” minutes. The Sept. 22, 2020, assault was so violent, the family says, that Sean required plastic surgery to reconstruct his face. Still, hospital administrators waited about three hours before sending him to a nearby acute care hospital, medical records show.

Although the video of the attack is long gone, the hospital’s security chief described what it showed, according to the testimony of a Florida Department of Health investigator. Her agency was asked to investigate two nurses initially blamed for the assault. The investigator said in a deposition she was told the video showed Loyd threw a chair and other items from a room and “stripped down...nude” before entering Sean’s room. A picture showed “the bruising” Sean sustained. And, Hawkins said, “his face was bloody.”

DCF had a habit of destroying evidence of a crime, according to Baker County Sheriff’s Office emails obtained by the Miami Herald.

‘Altered, damaged, destroyed, concealed’

Northeast Florida State Hospital is a 613-bed state-run psychiatric facility on a red-brick campus about 35 miles west of Jacksonville. It’s nearly 65 years old, and shows its age.

It was designed to treat Floridians with chronic and severe mental illness, stabilize them, and then return them to their communities for continued treatment and supervision. Some residents remain indefinitely.

It was not intended to house criminal defendants or those found not guilty of violent crimes by reason of insanity, as was Loyd. Northeast Florida State doesn’t have armed guards, pepper spray, handcuffs or barbed wire.

Florida law requires that jail inmates deemed incompetent be moved to a psychiatric hospital within 15 days. But one of the state’s dirtiest little secrets is that it has hardly ever had the capacity to treat in a secure facility, such as Florida State Hospital in Chattahoochee or North Florida Evaluation and Treatment Center, in Gainesville, all the men and women diverted from the criminal justice system due to mental illness.

As a consequence, Florida’s county jails for decades have borne the brunt of housing and treating criminal defendants with serious psychiatric disorders.

In the fall of 2020, when Sean was attacked, DCF’s wait list for forensic beds had crept up to about 450, according to records obtained by the Herald.

Dr. Richard Herstein, who oversaw the state’s three psychiatric hospitals from December 2020 through December 2021, told the Herald DCF’s solution has been to quietly move patients like Loyd from secure forensic hospitals into civil commitment facilities like Northeast Florida, and commingle them with patients like Sean, who could scarcely defend himself.

Dr. Yolanda Hernandez, Northeast Florida’s medical director, acknowledged in sworn testimony that some of the forensic patients she evaluated — and rejected — for admission were “scary”. But, Hernandez added, DCF had set aside 172 beds at the hospital for forensic patients, and “We have to have those beds filled.”

“You take patients who probably shouldn’t be here because the forensic wait list is so long, right?” the lawyer for Sean’s family, Ryan Andrews, asked Hernandez in a July 2023 deposition in the family’s lawsuit against the state.

“Likely, yes,” she replied.

The introduction of sometimes-violent forensic patients, combined with the lack of adequate security, made Northeast Florida a more dangerous place. The hospital’s chief of security, Anthony Dees, said in July 2023 sworn testimony that the hospital experiences 10 to 15 incidents each week where one patient assaults another, or staff.

The hospital could segregate forensic patients from civil commitments in different units, but DCF won’t allow it, Hernandez, a psychiatrist, said in July 2023 sworn testimony, because it costs more. “The ward staff and the security officers, they all had special perks because of the risk they took” when working in wards exclusively with criminal defendants, she said.

When confronted with the resulting violence, the Baker County Sheriff’s Office struggled to hold offenders to account, the sheriff’s office claimed, because DCF habitually hinders outside investigations.

In a May 25, 2022, email, the head of the office’s detective division, Lt. David C. Mancini, Jr., said his department would “refer the [hospital] staff to the Florida Department of Law Enforcement” the next time his detectives were “called to an incident and the crime scene has been cleaned up.”

“It cannot be expected that any Sheriff’s Deputy be asked to respond to [Northeast Florida State Hospital] and conduct a criminal investigation with the facts, evidence, witnesses, or even the victims in some cases [being] altered, damaged, destroyed, concealed, manipulated, vanished, or dead when [hospital] personnel find it appropriate to report the crime to BCSO.”

Mancini added: “This email is public record, and I want public record to reflect and remember how infuriating I find this to be as the lead investigator on [a recent] murder investigation.”

Failure to thrive

Sean’s mother called her son “a big dude.” He stood six-foot-three and weighed 288 pounds before he became ill. He played football, baseball and basketball, and took his share of hits and sharp elbows.

He had married, divorced and was the father of two. A graduate of University High in Orlando, he was studying art and theater at Valencia Community College, was heavily involved in his church and writing Christian music when, in the spring of 2016, according to his mother, his behavior became increasingly erratic.

Doctors initially suspected he had developed bipolar disorder, but eventually diagnosed an unspecified neurological condition, possibly from a traumatic head injury.

In March of 2018, after his family concluded they could no longer care for him, Sean was committed to Northeast Florida with diagnoses of dementia and traumatic brain injury, records show. He weighed 282 upon admission, court pleadings say. By December 2019, he had dwindled to 213.

It was against this backdrop that Dustin Williams, an advanced practice registered nurse assigned to oversee Sean’s care, began lobbying Hernandez, the medical director who had sole authority, to transfer Sean to a more intensive medical ward, according to testimony. In several investigations, Hernandez denied ever getting such a request.

Williams eventually became so frustrated with management that he filed a whistleblower lawsuit in 2020. It was settled by the state for about $800,000.

In the two days prior to Sean’s beating, Loyd “refused to take his medication and accused people of holding him hostage,” according to a pleading from Sean’s family’s lawsuit. “He kicked another roommate out of his room and they bowed up ready to fight.” He accused other residents of stealing his belongings. He called himself “Word of God.” He threatened to beat any roommates. DCF records obtained by the Herald show Loyd had been “targeting” Sean.

The day before the assault, Darah Granger, the hospital psychologist, recommended that Loyd “be transported to a secure facility,” she said in sworn testimony. “Mr. Loyd currently requires a higher level of security than available in this civil hospital,” she wrote, according to her deposition.

Granger’s recommendation was ignored. Instead, she said in her sworn testimony, staff tried to place him in a quiet room, an unlocked space where patients practiced yoga.

Sometime after 4:30 a.m. on Sept. 22, 2020, Loyd asked his two supervisors to leave his room so he could change, according to testimony. He then “stormed out of the door naked” and attacked Sean in his bed.

“No one would intervene,” testified Donna Hawkins, a state Department of Health investigator, because staff was afraid of touching a physically imposing naked man.

Sean suffered, among other things, lacerations to his left eye and forehead. Two months later, doctors found two rib fractures and a collapsed lung, a DCF abuse report said. Hospital staff said it looked like Sean had been “bull stomped.”

Sean’s mother said she saw her son’s bruised and purple body during a video call a day or so after the attack. “I was horrified,” she said. “It was heart-shattering for me to see my child like that.”

Following a report about the broken ribs from a nearby hospital to DCF’s abuse hotline, Northeast Florida State administrators finally moved Sean to a medical wing. But he died Jan. 12, 2021, after contracting COVID and pneumonia. His family says medical records show he had become so frail after the attack that he could not fight the conditions.

“They listed his death as the result of COVID,” Sean’s mother told the Herald. “He didn’t die of COVID. He died of a beating at a state hospital.”

Attempts by DCF management to understand what happened were hindered by investigators’ inability to collect key evidence: Aside from the lost video, documents detailing who, if anyone, was supervising both Sean and Loyd were either confusing — one log showed the same person assigned to watch both men, which was not supposed to happen — or falsified, according to sworn testimony.

Indeed, DCF lawyers agreed to a stipulation — an agreement in court records — that “there is no admissible evidence showing which attendant was present with [Sean] during the time the incident with [Loyd] occurred or whether an attendant was with [Sean] during that time.”

Missing or doctored records were not uncommon. “There have been other incidents,” Tajuana Gentry, a hospital risk manager, said in sworn testimony, where documents “were falsified.”

The Department of Health’s separate investigation was hampered by DCF’s lack of cooperation. “All of my requests went unanswered,” testified the investigator, Donna Hawkins.

DCF’s first look into Sean’s injuries and later death was essentially finished within 45 days, before investigators even received his medical records or “evidence” from Baptist Medical Center Jacksonville or spoke with a treating nurse about reports of “bruises, broken bones….”

The investigator, according to an inspector general report, never interviewed the employees responsible for Sean’s care or other witnesses. Family members were completely ignored. A DCF supervisor blamed some of the lapses on a “malfunction” with the agency’s computer system, but did not wait for the glitch to be resolved. DCF closed its case without even knowing the cause of Sean’s death.

That DCF investigation held no one responsible, the inspector general later reported. Roy Carr, DCF’s then-head of adult protection, told the IG the investigation was “threadbare.”

Carr said the investigation reflected “poor work” and “poor management.” With the agency under pressure from Sean’s mother for someone to be held responsible, Carr ordered a new probe.

But the second investigation proved to be more fraught than the first.

Three investigations, no discipline

If the first investigation erred by holding no one accountable, the second one blamed four employees who bore no responsibility for the tragedy, a later probe concluded. The four — a nursing director, a nursing supervisor and two risk managers — were reported to the local sheriff’s office for criminal investigation, and the two nurses were referred to the state health department for discipline.

They also were placed on restricted duties, leaving the hospital even more short-staffed in patient care.

Like the first investigation, the second unraveled. Prompted by a request from the administrator for the state’s psychiatric hospitals, Richard Herstein, Carr conducted a third investigation himself. His “executive review” exonerated the four employees.

But it “verified” five allegations, including medical neglect and improper supervision, against the hospital’s two highest-ranking administrators, Yolanda Hernandez, the medical director, and Hospital Administrator Linda Williams.

“Williams and Hernandez failed to make diligent attempts to relocate [Sean] to a more appropriate setting, which was recommended for his care, and failed to protect him from the unacceptable behavior of others, which resulted in the injuries he sustained,” the new report said.

“This was a very disconcerting chain of events that happened to an exceptionally vulnerable individual,” Carr later testified.

Hernandez has denied not just rejecting requests to transfer Sean, but any other wrongdoing. “It’s because they have to blame someone,” she said in a deposition of Carr’s report that placed responsibility for the tragedy partly on her.

Herstein, who oversaw the state hospitals, asked Erica Floyd-Thomas, DCF’s assistant secretary for mental health, to immediately reinstate the four wrongly accused employees, citing a “critical” staff shortage. He also asked whether the two hospital administrators would be placed on restrictions, as the underlings had been. He was shocked by her answer.

“She told me not to interfere,” he testified.

The next three months, Herstein testified at his reinstatement hearing, he met regularly with Floyd-Thomas and Meghan Collins, then a DCF deputy assistant secretary, and repeatedly asked that the four wrongly accused workers be returned to normal duties.

On Dec. 6, 2021, Herstein wrote an email to Collins and Carr asking yet again about the four workers. Despite the two nurses being cleared, he later testified, no one had told the Board of Nursing, and one of the two said she was at risk of losing her license.

The next day, Collins called Herstein into her office, he testified. “I thought we told you to stay out of this,” he said she told him.

Three weeks later, on Dec. 29, 2021, Herstein was fired.

In sworn testimony, Herstein later compared his dismissal to a “perp walk”. Human resources supervisors stood over his shoulder as he packed his belongings, and tore pages out of his notebooks and diary, saying they were all “DCF business,” he said.

‘Do the right thing’

Herstein’s dismissal set off yet another round of recriminations: Collins and Floyd-Thomas had asked DCF’s inspector general to investigate Herstein for interfering with an agency abuse investigation. After Herstein was gone, the IG found he had not interfered. Herstein filed suit as a whistleblower asking to get his job back. Cooper, the Leon County circuit judge, ordered DCF to do just that, which DCF appealed.

The inspector general looked into a second allegation of tampering with an agency investigation when whistleblowers accused Northeast Florida’s attorney, Carol Alesch-Scholl, of convening a meeting to coach Hernandez on her testimony in the first IG case.

Three workers “testified that Ms. Alesch-Scholl made remarks about all of them being part of a team and that they needed to tell her what happened during the [IG] interviews so she could prepare Dr. Hernandez for her interview with the [IG],” a report said. One of the workers told Alesch-Scholl “she should be ashamed of herself” for even asking, according to the Inspector General report on the allegations involving the lawyer.

The IG report said Alesch-Scholl at first said she didn’t remember ever requesting such a meeting, and later said the meeting was to discuss something other than the Inspector General probe. Alesch-Scholl’s email, however, showed the invitation for the gathering was titled “IG investigation meeting”.

The IG concluded the allegation could be “neither supported nor refuted.” Though three workers testified Alesch-Scholl was seeking to coach a hospital administrator’s testimony, investigators granted the lawyer great deference. Alesch-Scholl, the report said, “reiterated that it was never her intent to interfere with an [IG] investigation or ask staff to divulge” their testimony.

At Herstein’s reinstatement hearing, Judge Cooper could barely contain his disgust over the agency’s handling of Sean’s death and its aftermath. “This is like a bad movie on Netflix,” he said.

“I want to know what happened, what broke down, and why are these people still being treated this way,” the judge said, referring to the four wrongly accused employees.

DCF’s lawyers told him, in effect, to mind his business: “Respectfully,” DCF’s attorney, Miriam Coles, told the judge, “their case is not before the court.”

“I know I can’t force you to do the right thing,” the judge said.

In May of 2022, the four employees absolved of wrongdoing were finally returned to full duty.

The two nurses who had been reported to the state health department for patient neglect have since left the hospital. In March of 2023, they filed a whistleblower lawsuit against DCF in Leon County, claiming the agency retaliated against them after they advocated on Sean’s behalf and fought attempts to scapegoat them for his death.

The family’s federal lawsuit over Sean’s death has not yet been set for trial. It will be heard, without a jury, before Chief U.S. District Judge Mark E. Walker. Herstein’s whistleblower lawsuit is expected to begin in Leon Circuit Court in April. While they await the appeal over his job, DCF administrators have refused to reinstate him.

Roy Carr, who had been head of adult protection, said in sworn testimony he was told the two hospital administrators cannot be held to account because they fail to meet DCF’s definition of caregiver: “A caregiver has to be an individual that provides regular and frequent care to a vulnerable adult.” He later acknowledged he has verified allegations against other facility operators. “You know, smaller facilities, like an ALF owner.”

Carr said he had done dozens of executive reviews, but the one involving Sean’s case was “the first” not to be accepted.

An unsigned and undated internal “final” review, which appears to be directly addressed to Sean’s family, acknowledged that Sean “sustained a physical injury” at the hospital and that, due to his frailty, he “should have been placed at an alternative treatment facility.” But the report added, “conclusions drawn were not able to corroborate or support direct and/or intentional malfeasance by hospital staff.”

“It would not be prudent,” the review concluded, to investigate the matter further.

As of January 2024, the wait list for forensic patients at state hospitals topped 400. And sometimes violent so-called “step down” residents remain commingled with frail and disabled patients at places like Northeast Florida State Hospital.

To this day, DCF has declined to identify anyone responsible in Sean’s beating and eventual death.

 Distributed by Tribune Content Agency, LLC.