Internal Norfolk report shows missteps before brutal beating at mental health office. City admits no fault.
Virginian-Pilot - 6/13/2019
Jun. 13--NORFOLK -- As he yelled and stomped around the lobby of a Norfolk Community Services Board building for nearly two hours, Michael Craig appeared "agitated" and "psychotic," staffers who were there said later.
According to an internal report on the incident recently obtained by The Virginian-Pilot, many of them recognized Craig as a potential danger before he beat another client into a coma in the lobby.
Despite that, the report written by services board staff concludes Craig's violent behavior was "unpredictable and random."
And despite the communication breakdowns and missteps recounted in the report, it absolves the agency's staff of any negligence in the incident.
When shown the report by The Pilot, the services board's former compliance officer questioned how those conclusions can follow from a report filled with so many warning signs.
And a lawyer representing the victim's family, in a filing with the state contesting the findings, argues staff failed to take preventative action to deal with Craig before things escalated to violence. He says they failed again when they didn't intervene in the beating.
The Pilot attempted to reach several staff members who were mentioned in the report. All declined to speak to a reporter.
The director of the Community Services Board, Sarah Fuller, did not respond to a request for comment.
Craig, who was having a mental health crisis that morning and had a long history of instability and violent episodes, was arrested after the attack and is facing a felony charge of malicious wounding. An evaluation into his mental state at the time of the crime was ordered by a court earlier this year and is still pending.
Erick Davis, a services board client who suffers from bipolar disorder, was just there that November morning to pick up a disability check. The beating left him in a coma. After he made progress relearning how to walk in the months following the beating, he's back in the hospital after suffering a spinal injury in the course of his rehab. Doctors have now told his family he may never walk again.
A secret report
The internal investigation was completed last year by Norfolk Community Services Board staff after Davis' family filed a complaint of neglect on Nov. 16, the day after Craig and Davis met in the services board's lobby.
The report has not been made public and the city said it would charge The Pilot $34.96 for a redacted copy. The newspaper independently obtained an unredacted copy of the report and supporting documentation.
Senior staff told Davis' family in a December letter relaying the report's findings that "NCSB's duty is to protect individuals from the aggressor in accordance with sound therapeutic practice."
However, the letter continues, "the allegation of neglect on behalf of the NCSB is not substantiated."
The morning started with Michael Craig and his mother, Gaynelle Craig, arriving at the Virginia Beach Boulevard office of the Norfolk Community Services Board, the city agency that treats those with mental health conditions, intellectual disabilities or substance abuse issues who can't afford private care.
Craig was in crisis and his mother was desperate to tell anyone who would listen that she was afraid of him, and for him, and that he needed help.
He chased a man down the street within a few minutes of arriving at the office, which led his mother to call the police. When officers arrived, they told her they couldn't do anything unless he'd committed a crime.
In the report, several Community Services Board staff members said they were concerned about Craig's behavior. He's described repeatedly as yelling, agitated and psychotic.
Several recognized a potential risk and took steps to try to protect themselves and other staff.
One supervisor, Denise Brown, said she tried to call the services board's Emergency Services division so Craig could get help quicker than normal. That arm of the agency is meant to "concentrate efforts on seeing an identified crisis through to an initial level of resolution," according to the city's website.
"She reported her desire was to have (Emergency Services) come to the building to pre-screen (Craig)," the report says. "Ms. Brown stated that (Emergency Services) told her they could not send anyone to 'sit with him' but she was encouraged to have staff remain with him so that he could be compliant for his intake appointment."
But Tareka White from Emergency Services disputed Brown's account.
"Ms. White stated that Ms. Brown 'definitely did not' ask for a prescreen," the report says. "Instead, she heard Ms. Brown asking a question of what to do. Ms. White recommended redirecting him and having a person sit with him."
Apparently unable to fast-track Craig's case, staff proceeded with the standard intake procedures, which include an evaluation by staff to see what kind of help a person needs.
Supervisors decided the person evaluating Craig should keep the door open so a security guard could keep an eye on him. But nobody gave that warning or anything else about Craig's behavior to Molly LaRocco, the intake clinician, before she brought him into a room with his mother and closed the door, according to the report.
LaRocco said she was asked by someone from the front desk to "take him into her office for his intake appointment because he was 'agitated.'"
The security guard, Marsha Jordan, wrote in her report that she "sat at the doorway to keep an eye out to make sure nothing happened inside the room where the meeting was held." LaRocco says the door was closed.
During the intake interview, LaRocco said in the report, Craig was "actively psychotic, hearing voices, and difficult to engage in the process. ...Due to these factors and having a sense of uneasiness with being in the same small room with (Craig), Ms. LaRocco did not conduct the Intake assessment and led him out of her room after about 20 minutes."
Later, while they were filling out financial forms, a staff member reported that Craig "made threatening comments on several occasions and his mother, who was also in the office, verbalized her fear of him." She ended up completing much of the paperwork without Craig in her office.
Despite previous requests from supervisors to keep an eye on Craig, the security guard left "to conduct rounds" while Craig was still yelling and walking around the lobby. She returned as Craig was beating Davis, according to her account in the report.
Once the attack started, neither the security guard nor any staff laid their hands on Craig to try to stop the violence, the report said.
The report said that Craig's mother was "the only one who put their hands on him when he was 'violently' hitting, kicking, stomping and swinging chairs at" Davis.
This matches a description of the event from Gaynelle Craig, Michael Craig's mother, who has told The Pilot that staff and the security guard ran away from her son and that she was the only one trying to stop the beating of Davis.
The report says this is in keeping with staff members' training, and echoes statements made to The Pilot in November by Fuller, the department director, that the agency's policy is one of non-intervention in violent incidents.
However, the services board's own written policies include explicit instructions that both guards and staff are to intervene in such crimes.
Calls for change
Over the course of several pages, staff members explain they had seen Michael Craig's agitation and psychotic behavior for nearly two hours and tried to get him immediate help.
Craig's mother said repeatedly she was afraid of him, and at least one staffer didn't feel comfortable being in a room with him.
However, the report concludes that Craig's violent attack was "unpredictable and random."
The services board acknowledges that the assault happened, but says staff were not negligent in their dealings with Craig and "utilized their resources to put interventions in place within the boundaries of the service setting."
Those "interventions" include the security guard providing "additional security for the intake clinician" and the call for help to Emergency Services. But the guard merely sat in a waiting area while the clinician interviewed Craig in a separate room, with the door closed contrary to supervisors' advice. And though staff differed on what was said in the call to Emergency Services, it didn't result in any immediate help for Craig.
Sally Carroll, who spent 5 1/2 years as the services board's compliance officer, said that while the report seemed to be thorough, she didn't agree with the findings and said the fact that an incident happened at all betrays a level of neglect.
"Why wasn't he separated? Or why wasn't the lobby cleared of clients in the two hours they were there?" Carroll asked. "There seems to be insufficient communication between staff to ensure safety."
She also said that the Norfolk Community Services Board staff and leadership don't seem to be up on the agency's own policies.
So what has changed since the incident?
The December report says Norfolk police officers are now posted in the lobby. Supervisors and peer counselors are helping to manage clients as they come in, and staff are diverting people to different waiting areas based on the services they are seeking.
They've added adult coloring books and snacks to the waiting areas.
They are giving staff at the facility "mental health support and crisis debriefing."
And that's about it.
There is no mention of any discipline, policy changes or retraining.
To the outside world, Norfolk's response to the incident has been silence. They've refused to answer questions about the incident, first claiming incorrectly they couldn't talk about it due to medical privacy, and then saying potential litigation was the reason. No lawsuit has been filed.
Don Scott, an attorney representing Davis' family, filed a petition in April asking for a hearing in front of a human rights committee of the state department that oversees community services boards to challenge the report's findings.
That hearing was closed to the public on June 4, despite requests from Scott that it remain open. Officials with the Office of Human Rights said the committee's decision will be relayed to Davis' family and the Norfolk Community Services Board within 10 days of the hearing.
Asked about his response to the services board's report, Scott said in an interview that he "can't believe they have the nerve and the gall to actually clear themselves" of responsibility.
Scott argues in the filing that the department is in violation of regulations meant to ensure the safety of clients and that by failing to treat Craig, services board staff contributed to his escalating behavior and the beating of Davis.
"I think the documents speak for themselves, that the NCSB response was inadequate," Scott said when reached by phone. "Both Mr. Davis and Mr. Craig were failed that day by the Community Services Board."
In the filing, Scott is asking for more training, more oversight and more concrete and immediate steps to deal with agitated and potentially violent clients.
"Now, it's not about pointing fingers. It's about how do we correct it."
In the meantime, The Pilot is awaiting 10 years' worth of reports about incidents in CSB offices -- more than 3,500 of them -- which it requested under the Freedom of Information Act in November. The city initially said that it would charge the newspaper $56,500 for the public records, but has since agreed to cap the price at $5,000.
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