The Echo

In 1997, the same year that Au Clair changed its name to Advoserv, the family of Carlton Palms resident Jon Henley received devastating news.

Tuesday, April 8 1997, The Orlando Sentinel published the obituary of St. Thomas resident, the minor, Jon Henley, age 14.  At right is the official published accounting of Jon Henley's death. It is his obituary.

However, in 2015 Heather Vogell and ProPublica published a much more thorough review of Jon Henley's final hours:

First Victim, Jon Henley Tue, Apr 8, 1997 – Page 2 · The Orlando Sentinel (Orlando, Florida) · Newspapers.com

On April 2, Mazik telephoned relatives of a 14-year-old student to tell them the boy had died of an apparent seizure at Carlton Palms. A caller to the state’s abuse hotline a few months later reported that the boy, Jon Henley, hadn’t received immediate medical care for the seizure, and that staff had neglected him. - https://www.propublica.org/article/advoserv-profit-and-abuse-at-homes-for-the-profoundly-disabled

This is a summary of Vogell's reporting of this incident:

While preparing her story, Vogell reached out to Laurice Simmonds-Wilson. Prince Jon Jon, as his family affectionately called him, had been sent to Carlton Palms because his school district in the Virgin Islands was unable to provide the appropriate setting for him. Prince Jon Jon had autism and seizures.  On April 2, 1997, Ken Mazik called his family to inform them he had died as the result of an "apparent seizure." Carlton Palms paid for his casket and the cost of returning his body to the Virgin Islands.

In 2015, through Vogell, Simmonds-Wilson learned for the first time that there had been an investigation in Prince Jon Jon's death. A few months after Jon Jon's death, the state abuse hotline received a complaint - Jon Henley had not received immediate medical care for his seizures and had been a victim of neglect. The investigation found:

• His roommate reported that Jon Jon was shaking in his bed early in the morning. Staff failed to help him.
• Jon Jon was laying facedown in his bed. One staffer admitted telling the boy to be quiet because she assumed he was masterbating.
• Workers were supposed to check on Jon Jon every fifteen minutes. However, he was found at 7:30 am, dead, still lying facedown in his bed.
• Jon Jon's autopsy revealed that his blood titers for his anti-seizure medication were far below therapeutic levels. 

Yet, Vogell would discover that, "ultimately, despite signs of potential lapses in care, the sheriff's office did not file criminal charges and state investigators closed their inquiry with no finding of mistreatment. The facility faced no repercussions."

Advoserv offered this statement: "Carlton Palms cooperated with the investigations, which found no wrongdoing, and that '[w]hen incidents like this occur, we responsibly address them.'" 

"When incidents like these..." How many had there been? How many were to come?

Simmonds-Wilson would opine differently. Her family had never been notified that an autopsy had been performed on her beloved nephew. According to Vogell, the family felt they had had been deceived. 

Countdown to the end. It wasn't Carlton Palms' finest hours. The documented and confirmed episodes of abuse are consistent with the creation of a beast so large it cannot be contained. One could opine that facility was akin to doctor mills, except these patients didn't leave but for extreme circumstances. And, to be fair, there were families who deeply believed their loved one was receiving the best care possible. It is not our intention to deprive those families of their beliefs or their support for Bellwether. There will  always be two sides to this story. At least. What Echo has attempted to do is capture what is fact. It's been an effort in restraint. There has been no room for leads and rumors that haven't been substantiated through mainstream channels. Often, there has been difficulty getting agencies in Maryland and Florida to acknowledge Requests for Information and Freedom of Information Act requests. The failure of the departments in each state have stymied our research. However, this blog has consistently relied on accounts previously printed in superior publications, written by trained journalists, fact checked with diligence, and ultimately attributed to these writers and publishers. We owe these reporters and publishers a debt of gratitude.