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Central State Hospital: Views from a notorious asylum

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February 2, 2016 · 12:14 pm

4 years after 2-year-old’s death, mother facing criminal charges

Four years ago this month, the body of a missing 2-year-old turned up in a Liberty County drainage canal. He was face down in the water, but Jonathan Thomas Sturdy hadn’t drowned. To this day, authorities can’t say for certain what – or who – killed the child.

But Jonathan’s mother is scheduled to appear in court Monday to answer charges related to his disappearance. A grand jury recently accused Kayla Ann Aubart, 32, of cruelty to children and contributing to the delinquency of a minor, charges that could send her to prison for five to 20 years.

Read the full story here.

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Outside work creates conflicts, controversy for medical examiner

970113 ATLANTA, GEORGIA: Forensic pathologist Chris Sperry talks into a tape recorder as he performs an autopsy on January 14, 1997 at GBI headquarters in Atlanta. (Photo by MARLENE KARAS/AJC Staff)

Dr. Kris Sperry, Georgia’s chief medical examiner, performs an autopsy at GBI headquarters. (Photo by MARLENE KARAS/AJC Staff)

 

By Alan Judd

Dr. Kris Sperry took the witness stand, exuding the full authority and credibility of the state of Georgia.

Without hesitation, the chief medical examiner testified that Henry Glover died from a bullet to the back, fired by a high-powered rifle. “Any competent forensic pathologist,” Sperry said, would see the evidence the same way.

But Sperry hadn’t examined Glover’s body. He hadn’t studied the bullet, because none was found. And his opinion, like a surprising number of others he presents in court, was far from unanimous.

Sperry wasn’t even testifying in Georgia. On Aug. 29, 2013, he was in New Orleans, appearing as an expert witness against a former police officer accused of murder after Hurricane Katrina. For stating his opinion that day, Sperry earned a fee of $5,000.

It was one of more than 500 cases since 2003 in which Sperry acted as a paid forensic consultant — all while employed full time by the Georgia Bureau of Investigation.

Sperry’s role as expert-for-hire doubles his $184,000 state salary and often takes him out of the medical examiner’s office at GBI headquarters. It also exposes him to conflicts of interest and, at times, undermines his medical and scientific judgment, an investigation by The Atlanta Journal-Constitution found.

The newspaper examined court filings, depositions and trial transcripts from more than five dozen cases. Time after time, lawyers and other adversaries accuse Sperry of tailoring conclusions to suit his paying customers.

“He’s a hired gun,” said Rick Simmons, the defense attorney in the New Orleans case.

“It’s about money,” said George McGriff, another lawyer who challenged Sperry.

Sperry, 60, the chief medical examiner since 1997, oversees investigations into thousands of deaths each year: homicides and suicides, as well as those from accidents or natural causes. An opinion from Sperry or one of his 13 deputies can have profound consequences. Whether a killer faces charges or whether an insurance company pays a deceased person’s beneficiaries may hinge on the medical examiners’ conclusions.

Sperry, though, gives the impression of a detached, somewhat eccentric scientist lost in his work. He indulges an academic fascination with tattoos and sports facial hair invariably described as walrus-like. And yet he is so aware of his status as an expert witness that he can immediately cite how many times he has testified in court (704 on Oct. 31 last year, for instance).

Sperry is “a doctor of national reputation and accomplishment,” said his boss, GBI Director Vernon Keenan. “He operates on an extremely high plane of expertise.”

Sperry declined to be interviewed.

In a memo to Keenan about the Journal-Constitution’s inquiry, Sperry said he remembers few details about his work outside the GBI. When those cases conclude, he told Keenan, he shreds his files.

Keenan dismissed criticism of Sperry as “the back and forth of professionals.”

But in the New Orleans case, for one, four other pathologists attacked Sperry’s conclusions as relying on supposition, not sound forensics. One called his theories on Glover’s death “junk science.”

“Are there people who go out and stretch the truth for the benefit of their private business? Yes,” said Dr. Vincent DiMaio, the longtime medical examiner in San Antonio, Texas, and the author of several influential forensic-science books, who criticized Sperry’s work in New Orleans. “Usually, these are not people who are employed as medical examiners.”

‘A lot of cases’

For reviewing documents and writing reports, Sperry bills his clients $500 an hour. Depositions run at least $1,500. For courtroom testimony, he charges $7,500 a day, (up from $5,000 two years ago), plus travel expenses.

No professional organization or government agency regulates such rates. But interviews with other pathologists suggest Sperry’s fees — like his caseload — rank among the highest in the country.

“Some people make a lot of money because they’re good,” said Dr. Steven Karch, a pathologist in Oakland, California, and a frequent expert witness. “Some make a lot of money because they hustle and do a lot of cases.”

Either way, Sperry’s private caseload rivals that from his state job.

In June 2015, state medical examiner Kris Sperry testifies that Theresa Parker's jawbone showed signs of blunt force trauma during Sam Parker's motion for a new trial hearing in Judge Jon "Bo" Wood's courtroom at Walker County Superior Court in Lafayette, Ga. Parker was convicted of killing his dispatcher wife, Theresa, in 2009, but her body wasn't found until 2010.

Dr. Kris Sperry testifies in a criminal trial in 2015. (Photo by Chattanooga Times Free Press.)

He appeared in court 13 times as the state medical examiner between 2010 and 2014 — and 42 times as a private expert. He performed 208 full autopsies for the medical examiner’s office while accepting 158 outside cases for review.

Sperry is like any other hourly worker in state government, Keenan said: he puts in 40 hours each week, “either actually at work or in a combination of work and leave.”

“After that,” Keenan said, “it’s his free time.”

At times, however, Sperry conducts private business on the public’s time.

The Journal-Constitution examined Sperry’s weekly time sheets for the past five years. On 67 days, Sperry reported working at least eight hours for the state when, according to other documents, he spent time out of the office giving depositions or testifying in court for private clients.

On 13 of those days, Sperry recorded a full day at the GBI but actually was in court out of state.

For example, Sperry testified as an expert witness in Charleston, West Virginia, on Jan. 10, 2013. But his time sheet showed nine hours at his state job: 8:30 a.m. to 6 p.m., with 30 minutes off for lunch.

A GBI review prompted by the Journal-Constitution’s inquiry found numerous inaccuracies in Sperry’s time sheets, Keenan said last week. The agency docked Sperry 226 1/2 hours — about 5 1/2 weeks — of vacation time and other accumulated leave to make up for the discrepancies.

Sperry signed the time sheets beneath a warning that false statements violate the law. The penalty is one to five years in prison.

Keenan said Sperry often filled out the forms late and from memory. “I have no doubt this was a result of sloppy record keeping.”

 

‘Conflict of interest’

In each deposition and at every trial, one question stands out: Is Sperry an impartial medical examiner, or a paid courtroom advocate?

At least twice, the Journal-Constitution found, Sperry provided clients with opinions that contradicted deputy medical examiners whose findings he had at least implicitly approved.

“That’s procedurally, governmentally, professionally unacceptable,” said Dr. Cyril Wecht, the longtime medical examiner in Pittsburgh. “I’ve never heard of anything like that, ever, ever, ever.”

One case involved Elsie Goedhals, 40, who died shortly after a 14-hour flight from South Africa to Atlanta. Dr. Keith Lehman determined she died of natural causes: a pulmonary embolism resulting from deep vein thrombosis in her leg.

Goedhals’ insurance policy paid only if she died in an accident. Her family sued the insurer, claiming the embolism occurred accidentally because of the long flight. Refuting Lehman’s opinion was critical. So Goedhals’ family hired Lehman’s boss — Sperry — as their expert witness.

Sperry testified that determining the manner of death is “terribly imperfect” and “an opinion situation.”

“It really does depend on the definition of accident,” he said.

A lawyer for the insurance company asked Sperry how often he gets paid to re-evaluate cases that originated in his office.

“It’s very, very rare,” he said.

“Would you consider that a conflict of interest?” the lawyer asked.

“Not unless I was in disagreement with, say, for instance, Dr. Lehman,” Sperry said. “I think he and I are in complete agreement with this.”

In truth, they did not agree.

Asked whether the death could have been accidental, Lehman testified: “I wouldn’t consider it such, based on the criteria we use.”

Sperry told Keenan he recalls nothing about the case.

 

Credibility

In February 2005, Sperry completed a report on the death of a jail prisoner in Ocala, Florida. Thomas Duncan, 37, got into a fight with jail officers, who covered his head with a mesh device called a “spit mask” and strapped him into a chair. A doctor said Duncan died after a lack of oxygen caused irreversible brain damage.

Sperry placed no blame on the jail officers. He said Duncan suffered a heart attack because he was “struggling violently and actively resisting.”

Five months later, Sperry finished another report on the death of another prisoner, this one in Stillwater, Oklahoma. Mary Giannetti, 39, got into a fight with jail officers, who restrained her face down on the floor until she stopped breathing.

Sperry’s conclusion: Giannetti’s death was a homicide, caused by “inappropriate restraint procedures.”

In Florida, Sperry was an expert witness for the county sheriff; in Oklahoma, for the dead woman’s family.

As a paid expert, Wecht said, “I’m not bound” to favor a client’s position. “You’ve got to be honest to maintain your credibility.”

An Ohio case in 2013 stretched the limits of Sperry’s credibility.

He was an expert witness for a physician fighting the suspension of his medical license. The doctor had said an elderly patient’s vision was good enough to retain his pilot’s license; in reality, the man was legally blind. A few months later, during a charity event, the man was giving rides in his airplane when, without warning, it crashed. The man died, as did all five passengers.

The National Transportation Safety Board could not determine what caused the crash, but cited a contributing factor: the doctor’s “failure to accurately assess and report the pilot’s visual deficiency.”

Sperry presented an alternate version.

A bad heart, not bad vision, incapacitated the pilot, Sperry testified. The plane crashed, he said, because the passengers couldn’t fly it when the pilot lost consciousness.

Sperry’s opinion drew harsh criticism from a hearing officer for Ohio’s state medical board. He wrote that Sperry had no training in accident reconstruction, did not examine the aircraft, and had no idea what happened in the cockpit. He said he “did not find Dr. Sperry’s testimony credible and, therefore, placed little to no weight on his testimony.”

Sperry’s memo to Keenan said his opinion “had no relationship” to the hearing officer’s decision to uphold the doctor’s suspension.

The same was true, he said, in the New Orleans murder case.

glover car

‘Junk science’

What was left of Henry Glover arrived at the morgue in five red biohazard bags.

Glover, 31, had been burned far beyond recognition in the back seat of a white Chevrolet beside the Mississippi River in New Orleans, straight across from the French Quarter. It was Sept. 2, 2005, four days after Hurricane Katrina struck and the levees broke.

The red bags contained a skull, some body tissue, and a lot of debris.

“Most of it,” said Dr. Dana Troxclair, a medical examiner in New Orleans, “was just charred pieces of bone.”

X-rays revealed what looked like metal embedded in the tissue — bullet fragments, Troxclair guessed. For two hours, she and her supervisor sifted through the remains, but everything crumbled in their fingertips.

A bullet, Troxclair said, would not have deteriorated that much, even in the intense heat of the car fire.

“We came to the conclusion that it was pieces of the car,” she testified. “It could be anything. But we were sure it wasn’t a piece of a projectile.”

Federal prosecutors accused a New Orleans police officer, David Warren, of killing Glover. Convicted in 2010, Warren received a 25-year prison sentence.

An appeals court ordered a new trial, however, and prosecutors called in Sperry to bolster their most damaging assertion: that Warren, armed with a rifle on a second-story balcony like a sniper in a war zone, shot Glover without cause.

Eight years to the day after Katrina hit, Sperry took the witness stand.

As in other cases, Sperry began by reciting his professional experience. As Georgia’s first chief medical examiner, he said, he oversees “all of the homicides and decomposed bodies” and other complicated cases. He claimed particular familiarity with wounds from high-powered rifles because those weapons kill people so often in rural Georgia.

Sperry testified that he reviewed X-rays from the autopsy and four photographs taken before the car was set afire. One picture showed Glover’s body face down in the back seat of the white Chevrolet, with an apparent blood stain on his white T-shirt between his shoulder blades. A larger stain seems to have saturated the right side of the shirt.

glover body

Henry Glover’s body was photographed in the back seat of a car before the vehicle was set on fire in New Orleans. (Photo provided by U.S. Justice Department.)

The picture, Sperry said, showed that a bullet passed through Glover’s body, back to front — even though his front was not visible.

“At a minimum,” Sperry said, the bullet cut through Glover’s heart, his left lung, and his aorta and other major arteries.

The X-rays, Sperry said, displayed a snowstorm effect of innumerable bullet fragments, appearing white in the reversed image. The “snowstorm,” he testified, “should tell any competent forensic pathologist without any other information that they’re dealing with a high-velocity rifle wound. It’s unique and specific.”

The prosecutor asked whether Glover’s body could have absorbed metal from the car during the fire.

“That concept is preposterous,” Sperry said. “That does not exist in medical science. I mean, in a very simple way, an analogy is if … you order a steak, a pepper-covered steak at a restaurant, the pepper is not down inside the steak. It’s on the outside because that’s where it stays. It doesn’t penetrate. And, the human body, human tissues do not melt and re-form and surround stuff. That’s preposterous.”

Other experts were incredulous over Sperry’s conclusions.

“You can’t make a diagnosis of high-velocity gunshot wound … just on the basis of an X-ray,” Dr. Jerry Spencer, the former chief medical examiner for the Armed Forces Institute of Pathology, testified.

Karch, the Oakland pathologist, agreed. “Any attempt to do so,” he wrote in a statement to the court, “is little more than junk science.”

Perhaps the most damning repudiation came from DiMaio, the retired medical examiner in San Antonio. DiMaio first documented the snowstorm phenomenon in 1985 in his book “Gunshot Wounds,” a definitive pathology text.

DiMaio testified that the X-rays did not show a snowstorm at all. And with the body so decimated, he said, no one could tell whether a bullet killed Glover, much less its path through his body.

“What did the entrance wound look like? You don’t know, because you haven’t seen it. What did the exit look like? You don’t know. Did it actually exit, or was it just under the skin and when the body burned it just fell into all the debris? You don’t know.”

U.S. District Judge Lance Africk, presiding over the pre-trial hearing, asked whether this was a routine disagreement among professionals, or something more fundamental.

“I don’t consider his opinions reliable,” DiMaio said of Sperry. “The thing is, he didn’t have enough objective evidence to reach a conclusion. That’s what I’m saying. I’m saying you can’t reach a conclusion. That’s my testimony.”

Africk ultimately excluded testimony by expert witnesses for both sides. Warren was acquitted in December 2013.

Before dismissing the expert witnesses, the judge mused about the $5,000 Sperry earned for one day in court. He asked Spencer how much he was paid.

Spencer said he charged $200 an hour. “I come pretty cheap.”

“Do you get aggravated,” Africk asked, “after hearing what Dr. Sperry is getting to be here?”

“To use his term,” Spencer replied, “it’s preposterous.”

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The sad life of Georgia FedEx shooter Geddy Kramer

Published April 30, 2014, in The Atlanta Journal-Constitution.

By Alan Judd
The Atlanta Journal-Constitution

In a culture where teenagers gladly share the most intimate details of their blossoming lives, 19-year-old Geddy Kramer was a cipher.

He had no Facebook page, no Twitter account. In his high school yearbook, former classmates say, he appeared exactly once: in his senior-class photo.

It’s almost as if he never existed.

On Tuesday, however, Kramer finally left a mark: Just before 6 a.m., dressed in black and carrying a shotgun, he walked into the FedEx distribution center where he worked in Kennesaw. He quickly shot six other FedEx employees, then turned the shotgun on himself.

Kramer’s apparent suicide brought a mystifying end to a burst of workplace violence, leaving behind few clues about the forces that motivated his attack.

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Once a national model, Georgia’s child death reviews now an empty exercise

Published in The Atlanta Journal-Constitution, March 9, 2014:

BY ALAN JUDD – THE ATLANTA JOURNAL-CONSTITUTION

By the time the local child fatality review committee took up her case, Marnee Kay Downey had been dead one day longer than she lived.

The committee, as mandated by state law, compiled the details of the 8-month-old’s life and death: Chronically malnourished, she weighed less than 10 pounds. Child-protection workers had removed her siblings from their home. And her death, on Oct. 10, 2012, was a homicide: an intentionally administered overdose of a potent painkiller intended for terminally ill cancer patients.

But the committee remained silent on perhaps the most pertinent question: Why was Marnee even with her parents? Her mother took illicit drugs during pregnancy, the child was born with drugs in her system, and her parents celebrated the conclusion of a child-neglect investigation by getting high.

The review committee’s report mentioned none of that. Nor did it suggest anything the state Division of Family and Children Services or other agencies might have to done to protect Marnee. In fact, it recommended nothing at all.

What happened after Marnee Downey died illustrates the breakdown in a critical component of Georgia’s child-protection system: the review process that is supposed to dig deep into why a child died and search for ways to prevent more deaths.

+Once a national model, Georgia’s child death reviews now an empty exercise photo

Marnee Kay Downey

Almost a quarter-century ago, Georgia became the first state to create committees for each county to examine every death of a child. Today, all other states follow a similar practice.

But Georgia’s review process, an investigation by The Atlanta Journal-Constitution found, has become an empty exercise.

The newspaper examined reports on 464 deaths that county committees submitted in 2012 to the state Child Fatality Review Panel, which oversees their work. Officials redacted significant portions of the reports: the names of deceased children and their parents, dates of birth and death, even the time of day a child died.

+Questions about deaths, but no reviews photo

Still, enough data remained to show that, in most cases, the county committees’ work was superficial and slow.

The committees have a broad mandate to study failures by government agencies and to seek changes that would correct mistakes.

But not a single report among the 464 delved into mistakes by DFCS or other agencies. Just two reports requested additional investigation by police or other authorities.

+Falling behind in death reviews photo

In cases for which the Journal-Constitution could establish a complete timeline, the committees took more than twice as long to complete reviews as the law allows. A few counties, such as DeKalb, left some cases unreviewed for a year and a half or longer and didn’t complete reports on 2012 deaths until November or December 2013. In a recent publication, the statewide panel said timely reviews “build momentum from the tragic event to effect change in the community.” But one-fourth of reviews took longer than the child’s lifetime.

Almost 500 deaths — slightly more than half of the 940 recorded among Georgia children age 17 or younger in 2012 — received no review. Many were attributed to causes that rarely raise suspicions, such as disease or premature birth. But the Journal-Constitution identified 56 deaths in 38 counties that seemed to warrant investigation. Among them were 10 homicides, eight suicides, and seven drownings. Twelve of the 56 children came from families that DFCS had previously investigated.

Perhaps most significant, almost three-fourths of all reports contained no recommendations for preventing other deaths — one of the primary purposes for the reviews. Even when reports included suggestions, they usually offered what amounted to after-the-fact, self-evident parenting advice.

When an unsupervised 2-year-old wandered away and drowned in a pond, the Atkinson County review committee said parents should “watch kids at all times near open water.” When a woman ran over her 4-year-old granddaughter in the driveway, Muscogee County’s committee suggested “buying cars with back-up cameras.” When a baby died from a methadone overdose, the Fulton County committee advised simply, “Parent education.”

Jones County’s committee reviewed the death of an 8-month-old whose family already was the subject of a DFCS investigation. His mother, an unemployed high-school dropout, had a history of marijuana and cocaine abuse, according to state records. Three times DFCS had substantiated abuse or neglect allegations against her. On Oct. 25, 2012, she handed the baby a whole hot dog and left him alone. He choked to death.

The committee’s recommendation: “not to feed an infant-toddler a whole hot dog.”

+Once a national model, Georgia’s child death reviews now an empty exercise photo

Melanie Ann Prichard

 
 
The performance of the review committees — made up of prosecutors, judges, police, coroners, social workers and other officials and chaired by the local district attorney — stands in contrast to the mission the statewide panel articulated in a summary of its work from 2012.

“When a child dies, we have an obligation to ask ourselves, was there something that we — as caregivers, as a community, and as a society — could have done to prevent this tragic consequence?” the panel wrote. “Did we fail this child in some way?”

The chairman of the statewide panel acknowledges a gap exists between rhetoric and reality. Cobb County Superior Court Judge Tain Kell, who has led the panel since 2012, supports a bill in the General Assembly that would transfer the panel’s operations from the Office of the Child Advocate, a division of the governor’s office, to the Georgia Bureau of Investigation.

+Once a national model, Georgia’s child death reviews now an empty exercise photo
With few resources, Kell said in an interview, the state panel cannot properly monitor the county committees’ work.

“What we do,” he said, “is only as good as the data we get.”

Marnee Downey died in Haralson County, an hour’s drive west of Atlanta. Her death, like hundreds of others, was allowed to go by with little notice, even in the small community that failed to prevent it.

 

Read the rest of the story here.

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Ga. fails children in life and in death

Published in The Atlanta Journal-Constitution, Oct. 20, 2013

The searchers found Jonathan Sturdy at 9 o’clock on a cold Saturday night. The 2-year-old’s body, face down in a drainage canal, seemed to bring his disappearance earlier that day to a simple, if tragic, resolution. Except for this: Jonathan hadn’t drowned. He was dead when he entered the water.

Questions abounded: Was Jonathan murdered? Was his mother, repeatedly accused of neglect, responsible? And, most troubling, how could so many people have known about Jonathan’s dangerous life, yet failed to help?

Jonathan Thomas Sturdy’s death, on Jan. 14, 2012, would have been sad enough under any circumstances. But what happened before he died and what has happened since tell a larger, grimmer story about the failings of Georgia’s child welfare system.

In a state with one of the highest rates of children’s deaths by abuse and neglect, those failings are epic, an investigation by The Atlanta Journal-Constitution shows.

Dozens of Georgia children die from maltreatment each year despite intervention by the state’s child protection agency. In 2012 alone, the Journal-Constitution found, workers from the Division of Family and Children’s Services, or DFCS, did not detect or did not act on signs that foretold the deaths of at least 25 children.

But DFCS is only one element of a fundamental breakdown in how Georgia protects its children.

An ever-expanding wall of secrecy surrounds DFCS cases, blocking attempts to hold the agency accountable and hampering communication and collaboration with other agencies. Neither social workers nor police officers, neither medical examiners nor inquisitive neighbors can easily see all the threats to a child’s safety. Before Jonathan Sturdy died, DFCS didn’t know what the police knew, the police hadn’t heard about what neighbors saw, and none of them had any notion of the concerns reported to social workers at a nearby military base.

Hiding details of abuse and neglect may save a child’s privacy, as DFCS contends, but not necessarily his or her life.

Few states present more dangers for children than Georgia. It is among the leaders in firearms deaths, Sudden Infant Death Syndrome, and several potentially fatal diseases, in addition to maltreatment deaths. Twice in the past quarter-century, state lawmakers adopted sweeping reforms that allowed for outside reviews of how DFCS handled children’s deaths. But as public interest ebbed, so did the impact of those reforms.

The dangers are exacerbated, the Journal-Constitution found, by investigations of children’s deaths that can be alarmingly inadequate.

The newspaper examined 2,230 deaths of children, 1 week old to age 17, reported statewide between January 2011 and July 2013. Among them, 135 were homicides and 71 suicides. Authorities said 462 children died by accident.

But the newspaper’s review suggests that as many as one in four accidental deaths actually were caused at least in part by adults’ negligent or reckless conduct. Sometimes their conduct might be considered criminal.

Of the 123 children who died from adult negligence, almost 40 were unintentionally suffocated while sleeping with parents. Even when the adults had been drinking or taking drugs, few faced the criminal charges that most likely would have been filed if they killed the child while driving impaired.

Ten of those 123 deaths occurred in fires after parents left children home alone. Eleven resulted from what was termed accidental drug or alcohol ingestion — a finding that often seems incongruous to the ages of the victims. For instance, Autumn Faith Mills of Columbia County, whose death was attributed to a methadone overdose, was 33 days old.

More often than not, officials cannot say with certainty why children died.

State law requires autopsies in unexpected or unexplained deaths of children age 7 or younger, as well as in suspicious or unusual deaths of children and teenagers. The law also mandates the procedure for all victims of violent crimes and suicides.

Since 2011, however, no autopsy was performed in 53 percent of all children’s deaths, regardless of age. During that time, state records show, authorities designated 16 children’s deaths as suicides and two as homicides without collecting evidence through an autopsy.

Investigators could not determine the manner in which more than 300 children died: from natural causes, accidents, homicides or suicides.

Even what at first appear to be definitive findings sometimes are murky. At least 40 times since 2011, coroners or medical examiners said they could not explain a child’s death — while, inexplicably, attributing it to natural causes.

Such ambiguous conclusions complicate efforts by police to file criminal charges.
They also raise an unsettling question: How easily can adults in Georgia get away with killing a child?

‘Many red flags’
Jonathan Sturdy was barely more than an infant when his family moved from Nevada to Georgia. The Army had assigned his father to Fort Stewart, and the family rented a ranch-style house in nearby Walthourville, about 50 miles southwest of Savannah. Jonathan had wispy blond hair and bright blue eyes and, in family photos, always a smile. As a toddler, he attracted a lot of attention from neighbors.

What they often noticed, though, was Jonathan and his half-brother, who was three years older, playing at the edge of the road or standing alone outside a nearby convenience store. One woman later said she frequently took the children into her home and fed them breakfast while waiting for their mother to get out of bed.

Once, a Walthourville police officer brought Jonathan home after finding the boy, wearing just a diaper, wandering through an empty field. Jonathan’s mother said she was showering and didn’t know he had gone out.

DFCS opened an investigation after Jonathan’s mother left him and his half-brother in her car outside a grocery. The engine was running, the air conditioning on, the doors locked. The mother, police said, was nowhere to be found.

Everyone, it seemed, knew about the dysfunction in Jonathan’s family. And yet, no one stepped in.

Most neighbors said nothing about the lack of adult supervision until after Jonathan’s death. The police officer told Jonathan’s mother to buy better door locks to keep the boy inside, but he didn’t notify DFCS. The officer later said he thought the problem was “rectified.”

The episode outside the grocery brought two DFCS caseworkers to Jonathan’s house in July 2011. They met with Jonathan’s parents, Thomas Sturdy and Kayla Aubart, and “discussed safety, ” a DFCS report says. Then the agency placed the case in a status known as “diversion, ” in which caseworkers could refer the parents to counseling or other services without opening a full investigation. But the workers would not return to check on the children. Nor would they track whether the family availed itself of the offered services.

“The case was closed, ” Kayla Aubart, 29, said in a recent interview. “That was the end of it.”

The depth of DFCS’ investigation is not clear. An agency report says caseworkers consulted with military officials and the children’s pediatrician, who raised no concerns about the family. But the report, compiled after Jonathan’s death, also refers to “many red flags” suggesting trouble in the family. Among them, the report says, was Aubart’s acknowledged use of narcotic painkillers.

Aubart began complaining about chronic pain after she gave birth to Jonathan in April 2009. When Jonathan was 4 months old, Aubart wrote on Twitter: “Back hurts really bad. Can’t take it anymore.” A day later: “Feeding new baby. Back still hurts.”

The pain later led Aubart to a pain-management doctor in Savannah. He prescribed Vicodin, which often causes drowsiness and can be habit-forming. On Jan. 12, 2012, Aubart sought a prescription from another provider: a physician’s assistant at Fort Stewart’s clinic for military families.

Aubart showed up wearing what appeared to be bedclothes and with both children in tow, said Detective Tracy Jennings of the Liberty County Sheriff’s Office, who spoke with the physician’s assistant. Aubart said one of the children had accidentally flushed her Vicodin tablets down the toilet, and she needed more. The physician’s assistant was skeptical, Jennings said in an interview, and feared Aubart was in no condition to care for her children, or even drive them home safely. He referred her to a clinic that treats pain without narcotics. He also reported his concerns to Army social workers.

Military officials declined to discuss how the social workers handled the report. In a statement, the Army said it has a written agreement with DFCS to promptly share reports about suspected abuse or neglect of children in military families.

In Jonathan’s case, the Army social workers never sent the report, DFCS said. Within 48 hours, it would be too late to matter.

‘A blink of the eye’
Saturday, Jan. 14, began with an argument.

It was Thomas Sturdy’s turn to watch the children, but he wanted to spend the day at a friend’s, watching football. Aubart, who stayed home with the children all week while Sturdy worked, was angry. Sturdy left about 10 a.m., he later told police, even though only two games aired that day, and the first did not begin until more than six hours later.

Aubart said she spent the day at home with Jonathan and Brent, her 5-year-old from a relationship before her marriage to Sturdy. About 3 o’clock, she said, they all took naps. When Aubart awoke about 5, she said, Brent and a neighbor kid were in the living room, playing the video game Mortal Kombat.
Jonathan was gone.

His absence was not entirely unusual. Relatives described him as a wanderer, a fearless explorer despite his age.

“A blink of the eye and he’d be out the door, running down somewhere checking something out, him and his dog, ” Jonathan’s father later told a Savannah television station, WSAV.

Aubart said she immediately called her husband, who got a friend to help him look for Jonathan.

The temperature that afternoon had barely broken 50 degrees. The sun would set at 5:43 p.m. At 5:37, her husband’s search unsuccessful, Aubart called 911.

Police officers, firefighters and volunteers spread out through the neighborhood, within walking distance of the Walthourville police station. As night fell, the temperature dropped into the mid-30s. Jonathan had neither a coat nor his usual companion, a Labrador-bulldog mix named Chewy, to keep him warm.

A firefighter with a search dog followed a trail out of the family’s yard, across railroad tracks and a road, to a drainage canal nearly a quarter-mile away. His flashlight illuminated Jonathan’s body, face down in 4 feet of murky green water.

A state medical examiner performed an autopsy the next day in Savannah. Identifying no traumatic injuries, the procedure could not pinpoint why Jonathan died. But the medical examiner found no water in Jonathan’s lungs.

He hadn’t drowned.

The police opened a homicide investigation, and detectives called in both parents for lie-detector tests. They told Aubart she failed.

Later, she strongly denied any involvement in Jonathan’s death. But she related the detectives’ interpretation of the results with a strong dose of sarcasm: “I failed miserably. I should be ashamed. I killed my son.”

Missed chances
Children die in horrific ways.

Marnee Kay Downey overdosed on a pain medication intended for cancer patients. Her parents allegedly used it to get the 8-month-old to sleep. They face murder charges in Haralson County.

Alexis Long arrived at a hospital in Columbus with wounds on her face, forehead, back and legs. Some were new, others partly healed. Her hair was thin, as if someone had yanked it out. Her adoptive mother was charged with murder, accused of slamming the 20-month-old down so hard it broke a changing table and flung the girl to the floor.

Five-month-old Nicholas Womack Jr. died in his crib, covered by bites from cockroaches and rodents. A DFCS report described the family’s home, in Richmond County, as “deplorable.” The caseworker catalogued soiled diapers and spoiled food, dirty dishes in the bathtub and a kitchen sink clogged by grease and cockroaches, beds with no sheets and a broken window. “ETC., ” the caseworker added. The baby’s parents face child cruelty charges.

Like Jonathan, these children were among the 152 who died in 2012 even though DFCS had investigated maltreatment allegations involving their families in the previous five years.

The Journal-Constitution reviewed summaries that DFCS provided for 86 of the 152 deaths. The agency heavily edited the documents, removing names of deceased children and their families and many other details, such as the identities of police departments investigating the deaths. DFCS lawyers based the redactions on a 2009 state law that, in effect, repealed an earlier measure allowing public inspection of most files on children who died following the agency’s intervention.

Still, the summaries, in conjunction with other public records, such as police files, autopsy reports and a state database of death certificates, show that DFCS workers, police officers and others missed repeated chances to prevent many deaths.

In the weeks before Alexis Long died, for example, her adoptive mother posted complaints on Facebook about the girl’s tantrums. She also shared pictures that inadvertently showed many of Alexis’ earlier injuries.

The DFCS case summary says, “No one who responded to the photos and comments on Facebook questioned the (wounds) on the child.”

The summary didn’t say so, but the DFCS workers who repeatedly visited the home to oversee the adoption didn’t question the wounds, either.

Instead, “no agency workers … noted problems, ” DFCS reported after Alexis died. A home study “revealed no red flags for the family.”

DFCS officials would not comment on specific cases. Sharon Hill, the agency’s state director, said caseworkers and supervisors have improved their practices in dealing with sometimes-difficult families during difficult times.

The agency no longer places cases in diversion, Hill said in an interview, but instead uses a more rigorous screening process when it receives maltreatment reports. If caseworkers think a child is in danger, DFCS opens a full investigation, she said; when a child seems safe, workers offer “family support, ” such as counseling.

The agency has “certainly a deeper focus” on assessing risks, Hill said.

“We have been able to look at some of the dynamics in a family that makes a child unsafe, ” she said. “When it stands alone, it may appear to be benign, ” but when circumstances form a pattern of maltreatment, “it’s a lot more serious than you would think.”

Often, though, answers elude DFCS workers and other investigators.

Ten days before Jonathan Sturdy died, 4-year-old Alexis Redmond of Winder drowned in the bathtub. Her mother, Darlene Redmond, told the police that she left Alexis, who was autistic, alone for a few seconds. When she returned, Redmond said, Alexis was face down in 5 inches of water, not breathing.

The police doubted her story from the start.

In reports and interviews, detectives said Darlene Redmond eventually gave differing accounts of how long she left Alexis unsupervised. A friend had stopped by, and Redmond spent somewhere between several seconds and several minutes with him before she returned to Alexis.

Redmond told police the friend placed Alexis on a sofa to perform CPR, pushing about two cups of water out of her lungs. But when officers checked a few minutes later, according to a police report, “no water spots were found.”

Redmond denied to police detectives that she caused her daughter’s death. She did not respond to recent requests for an interview. One recent afternoon, a woman at the house where Alexis died, who identified herself as Redmond’s niece, said the girl fell asleep and drowned “in a second” because a new medicine made her drowsy. However, toxicology tests showed Alexis had no drugs in her system when she died.

The initial police reports said officers intended to charge Redmond at least with reckless conduct and possibly with more serious offenses. But they closed the case when a state medical examiner ruled Alexis’ death was an accidental drowning “due to autism.”

The autopsy report does not mention the questions surrounding Alexis’ death or her family’s history with DFCS — five investigations of neglect since 2007.

Such information should increase “the index of suspicion” about children’s deaths, said Dr. Gregory Davis, Kentucky’s assistant state medical examiner and a pathology professor at the University of Kentucky.

“Medical examiners need to know what was happening in a decedent’s life, ” said Davis, who spoke on behalf of the National Association of Medical Examiners. “Then they have to try to determine whether it affected the death. “Context is everything, ” he said.

Medical examiners often fall back on vague findings, such as Sudden Infant Death Syndrome, giving a false impression of certainty, he said. Georgia has a higher rate of sudden infant death than all but four other states.

“That really is a fancy diagnosis for, ‘We don’t know why this child died, ‘ ” Davis said. “The intellectually honest answer is to say, ‘I don’t know.’ ”

Public pressure for an exhaustive investigation into a child’s death is rare. Many children quickly pass from memory.

Alexis Redmond is buried in a small cemetery in Barrow County, across a fence from a noisy building-materials distribution facility. Her grave, covered with gray pebbles, has no stone monument almost two years after her death. It is marked only by a small metal placard left behind by the funeral home.

Jonathan Sturdy was memorialized in a 68-word online obituary, its terseness pointedly emphasizing his abbreviated life.

A stalled case
Kayla Aubart believes Jonathan’s killer is on the loose. But she knows she is the leading suspect. She knows she is the only suspect.

“They think I did it so they’re not going to look at anybody else, ” she said. Police and social workers, she said, are “railroading me at every … turn.”

Detectives still have the clothes Aubart wore when Jonathan’s body was found. If she had killed her son, she said, those clothes would have been torn by briars and caked with mud from walking to the canal.

“How dumb are these people, really?” she said. “Did I put my hands on his neck? No. Kids sneak out. It’s the Terrible Twos. They wander. This wasn’t the first time.”

Aubart suspects a young neighbor she describes as “weird.” Police say the boy was not involved.

“He’s been interviewed and blah-de-blah-blah, ” Aubart said. “I feel he knew us and he watched us.”

Aubart’s mother, Cindy, deals blackjack at a Nevada casino. She said a customer who is psychic told her Jonathan died at the hands of a young boy. But she said authorities refuse to consider that anyone other than Kayla could have killed Jonathan, carried his body almost a quarter-mile and tossed it into the drainage canal.

“She’s lazy, ” Cindy Aubart said. “That is three football fields away. Like I told the detective: If there was a hundred dollar bill on the other end, she’d think about it.”

She added: “Kayla might not have been the perfect mother, but she would never have hurt those boys.”

Jonathan’s death brought DFCS back to his family’s home. This time, caseworkers took custody of his half-brother, Brent, and placed him in foster care. Later, the state sent the boy to live with an aunt in Wisconsin.

Kayla Aubart wants custody of Brent, and she said she did everything DFCS and the police asked of her after Jonathan died. She took drug tests and attended parenting classes. She looked for work and moved into a rundown trailer so she would be near Brent’s foster home. And she said she saw a “so-called psychologist” chosen by DFCS, but he accused her of lying about what happened to Jonathan.

“As long as they think I killed Jonathan, they’re not going to give me Brent back, ” she said. “They’re all a bunch of damn liars.”

Almost two years after Jonathan’s death, authorities cannot make a case against Aubart, or anyone else. Jennings, the sheriff’s detective, does not directly implicate Aubart. But she said: “Had he been supervised sufficiently, it wouldn’t have happened.”

With the investigation stalled, Aubart moved on with her life.

She divorced Jonathan’s father shortly after he left the Army last year. She lived briefly in South Florida. Then she joined her parents in Laughlin, Nev., a small desert town 100 miles south of Las Vegas.

Aubart has faced minor criminal charges three times since Jonathan died, once in Florida and twice in Nevada. Her most recent arrest in Las Vegas followed a fight with her new husband.

Aubart spent the night in jail. It was early September, a month after she gave birth again, to another baby boy.

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May 13, 2013 · 10:01 am