Thursday, May 4, 2006
Questions over
boy's death at juvenile hall
Unheard calls for help ... discrepancies in
written reports. ... What really happened the morning that Johnny
Lim died?
By
CLAUDIA ROWE
P-I REPORTER
The morning that Johnny Lim, 14,
collapsed and died in a cell at the King County juvenile detention
hall, minute-by-minute logs compiled by the guard who was supposed
to monitor him apparently were altered and basic emergency
procedures failed.
 The
teenager's death last December, blamed by the King County Medical
Examiner's Office on a spontaneous brain stem hemorrhage, is the
subject of a jury inquest scheduled for May 23 -- standard procedure
if an inmate dies in custody.
The circumstances surrounding his
death reveal a youth-holding pen manned by undertrained staff using
subpar communications equipment -- unprepared for medical or
security crises. And records of the boy's last minutes present
starkly different versions of what happened: A nurse said she found
the youth not breathing and without a pulse just after 6:30 a.m.,
the very moment the boy complained of a stomach ache, according to a
guard.
In Johnny Lim's cell, the
often-unreliable intercom system appeared to be working. The boy's
14-year-old roommate, Ezeo Ajeto-Castro, insists that he pushed it
three times, pleading for help -- "I need the nurse because my
cellmate's not feeling so good," he recalled saying -- and was
repeatedly told that someone was on the way. But for at least 15
minutes, the boy estimates, no one came.
"It took them forever," Ezeo said
during a recent interview at the detention center, where he has been
held, off and on, for car theft and other charges since December.
By department policy, a guard was
supposed to be watching the boys, making nighttime bed checks every
20 minutes on all the youths in M-hall. But a log of those rounds
indicates that the officer on duty, Chima Ijeoma, reported nothing
amiss between 6 and 6:25 a.m. -- about the time, Ezeo says, that his
roommate was vomiting, reeling and wheezing on the floor. The boy
believes Ijeoma simply failed to come by and missed the disaster
unfolding in cell M-2.
"Usually, they stop coming after 12,
or just every now and then," he said.
Seven minutes later, at 6:32 a.m.,
Ijeoma noted, "Youth pushed the call-button and requested to see the
nurse because 'My stomach is acting funny.' "
Yet Ezeo insists that Johnny never
called for help, and another form shows that nurse Rene Berg walked
into cell M-2 at 6:32 a.m. to find him "lying supine on mattress in
front of bed -- unresponsive." Johnny had no pulse, no breath and
his pupils were fixed, she wrote.
A former FBI document examiner who
worked at the Washington State Patrol Crime Laboratory for nearly 30
years said Ijeoma's cell-check log appeared to have been altered --
initially filled out to show the youths as safely in bed, then
over-written, after the fact, to record Johnny's emergency removal
at 6:44 a.m.
A second handwriting expert who has
testified in a number of court cases concurred.
"It's very suspicious-looking," said
Timothy Nishimura, the crime lab analyst, who examined a photocopy
obtained by the Seattle P-I.
The boy's death was the first at the
14-year-old detention center, and officials from the Department of
Adult and Juvenile Detention have offered few details about it.
"Overall, I'm going to say that staff
did an outstanding job for the situation they were put in," said
Reed Holtgeerts, director of the King County Department of Adult and
Juvenile Detention. "This was basically a graveyard crew that got
caught in a situation that they weren't ready for. They did an
outstanding job."
Citing the upcoming inquest,
Holtgeerts declined to comment specifically on the dorm-check log
and other documents. Ijeoma said he has been prohibited from
discussing the matter with reporters.
But Jared Karstetter, a lawyer
representing the detention officers, said Ijeoma is still employed
at the detention center and has not been disciplined. A review of
his actions the morning of Dec. 26 was "put on hold," Karstetter
said, pending the outcome of the inquest.
Essentially a fact-finding process,
the juried inquiry carries no punitive weight of its own, but
information uncovered there could be used in lawsuits.
With that possibility in mind, the
Lim family has hired a lawyer, Moni Law.
"They certainly have some serious
concerns about dereliction of duty," Law said. "The family lost a
young child who was in the custody of King County, and they simply
want to know why and whether there was a way to prevent it."
Medical experts have hedged over
whether quicker emergency care could have saved Lim. But in the wake
of his death, detention officials issued six "Action Steps." These
include increasing the frequency of first-aid training for staff and
revising emergency procedures to include crime-scene preservation.
"There was a determination that we
need to improve upon some of those areas," Holtgeerts said.
Staff at the detention hall say they
have complained for years about broken radios, faulty intercoms and
other dysfunctional systems at the $16 million facility, which was
built in 1992.
Detention Officer Jessika Orange,
filling out a consultant's questionnaire, described an emergency
involving two girls that went unnoticed by the post officer because
he couldn't hear anything over his radio. "One of my youth had to
bang on the door to get his attention," she said.
Last year, an outside evaluator
studied the facility and issued a report confirming that
"significant shortcomings were found to exist" in the youth center's
security electronics.
"Staff can't reliably communicate
emergencies or assistance requests due to overburdened, worn-out and
unreliable radios," it said.
The 240-bed detention hall and
juvenile court complex are also rife with safety risks, wrote
consultant Paul Allyn. At least one youth escaped last year as court
officers were trying to take him into custody, and inside the
detention hall itself the basketball court, classrooms, and library
lack video cameras for watching detainees.
Dorm lighting provides an easy way to
commit suicide by hanging, the Allyn report continues. And last fall
a team of educators, health experts and corrections officials issued
a report urging managers to "intensively train staff" and
"immediately focus on fire and other emergency responses."
Johnny and Ezeo, both repeat visitors
at juvenile detention, became friends during their days in cell M-2,
playing cards and working out by doing pull-ups off the top bunk.
They had much in common -- neighborhood buddies who shared their
obsession with cars, relatives who had stepped in to raise them when
their own parents could not, and a striking sense of loyalty to
friends.
When not distracting themselves from
the general boredom by making slingshot marbles out of peeled-off
wall paint, they talked about what they might do together outside,
after release.
Around 11 p.m. on Christmas night
when they went to sleep, Johnny on the top bunk and his roommate
below, everything seemed fine, Ezeo said.
But several hours later, Ezeo heard
the older boy mumbling, talking in his sleep, it sounded like, and
later Johnny stumbled toward the small sink, complaining of a
"killer headache." Ezeo, trying to get back to bed, told him to call
the nurse.
Johnny never did. Instead, the boy
recalled, he knelt over the toilet, spitting into the bowl, then
staggered a few steps and crashed to the floor.
"I just thought he was really sick or
having a seizure or something," Ezeo said. "But you can die from
seizures, so I rang the button, and I kept ringing it."
CONTRADICTORY REPORT:
Johnny Lim's death in juvenile detention
generated several official documents that
contradict one another. See some of them
here (PDF, 278K).
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