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by Paige Pfleger, WPLN/Nashville Public Radio

This article was produced for ProPublica’s Local Reporting Network in partnership with WPLN/Nashville Public Radio. Sign up for Dispatches to get stories like this one as soon as they are published.

A group of Tennessee lawmakers is calling for an audit of the use of seclusion inside juvenile detention facilities, and the removal of a Knox County superintendent, following reporting from WPLN and ProPublica.

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Our investigation found kids have been locked alone in cells in the Richard L. Bean Juvenile Service Center in Knoxville more often than other facilities in the state, sometimes as punishment and sometimes for an indeterminate length of time. The Tennessee Department of Children’s Services is the licensing agency for the Bean Center and documented the improper use of seclusion for years. Yet it continued to approve the center’s license to operate without the facility changing its ways.

“The Department has a constitutional duty to the legislature to enforce state laws and a moral obligation to children to ensure that youth in state-licensed facilities are being treated humanely and in accordance with Department guidelines,” state Sen. Heidi Campbell wrote.

A letter from 14 Democratic lawmakers demands “immediate response and action” from the Department of Children’s Services. (Obtained by WPLN and ProPublica)

The letter, signed by 14 Democrats, calls the findings “alarming.” It characterizes comments by the superintendent, Richard L. Bean, as having created a “culture of lawlessness.” Those comments include Bean saying, “What we do is treat everybody like they’re in here for murder.”

The letter went on to say that “any juvenile detention facility administrator who openly defies state detention rules” should “soon find themselves out of a job.”

After receiving the letter, DCS wrote to WPLN and ProPublica: “Earlier this week, Commissioner Quin and DCS leaders began taking steps to immediately address the concerns outlined in the report about the Bean Center. The matter is being treated with urgency and is a priority to the Department.”

In inspection reports obtained by WPLN and ProPublica, one child told DCS inspectors that he was secluded after he forgot to bring his books to class. “Staff will put you in seclusion if they don’t like you,” he told the inspector. Another child said he was secluded but didn’t really understand why.

“I can’t let the kids run the place,” Bean said about putting children in seclusion. “Sometimes you get a kid, you put him in his room, and he cuss and call you everything in the books. It’s hard to let him out.”

Bean has been in charge of the detention center since 1972. When asked if he was worried about getting in trouble with DCS or the state, Bean said, “If I got in trouble for it, I believe I could talk to whoever got me in trouble and get out of it.”

Lawmakers are also requesting an audit of all of Tennessee’s juvenile detention facilities. They draw a connection to problems exposed by a previous WPLN and ProPublica investigation into Rutherford County’s facility, as well as scrutiny of the Wilder Youth Development Center.

They call for the department to immediately intervene to prevent young people from being locked alone in cells, and they say DCS should develop a “more aggressive” enforcement policy to prevent the misuse of seclusion in the future.

WPLN and ProPublica shared the letter to officials at the facility, including Bean, and requested comment; they did not immediately respond.

by Megan O’Matz, graphics by Lucas Waldron

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

Any number of odd, zigzag examples can be used to make the case that legislative districts in Wisconsin are excessively gerrymandered.

There’s the pistol-shaped 31st Assembly District, held by a Republican, that was drawn with a western border that splits the Democratic city of Beloit in two.

There’s suburban Milwaukee’s 14th Assembly District, which stretches south, then east, then southwest, then east and again south, isolating Democrats and thereby limiting the Democratic vote in neighboring districts held by Republicans.

And in the northwest corner of the state, there’s the 73rd Assembly District, which resembles a Tyrannosaurus rex after a remap wiped out a reliable bloc of Democrats and added more rural conservative areas. The result: After 50 years of Democratic control, a Republican won in 2022.

Yet when the Wisconsin Supreme Court hears arguments next week in a widely watched lawsuit arguing that the existing maps fail to meet standards set out in the state constitution, that kind of political engineering will not be the focus.

Instead, much of the debate will center on exactly how to interpret the word “contiguous.” And the map shapes that are likely to get attention have elicited comparisons to Swiss cheese.

Fifty-five of the state’s 99 Assembly districts and 21 of 33 in the Senate contain “disconnected pieces of territory,” according to the most recent petition filed with the state Supreme Court by 19 Wisconsin voters. The suit seeks to have the state’s maps declared unfair and redrawn.

Some sections of the state’s maps “look like a 2-year-old drew them,” said Democratic Rep. Jodi Emerson, who represents the city of Eau Claire in northwestern Wisconsin.

In the interior of her district, the 91st, sits a free-floating chunk that actually belongs to the turf of the adjacent lawmaker, Republican Karen Hurd.

68th and 91st Districts

This island, part of the Town of Washington, is in the Republican-held 68th Assembly District but is surrounded by the city of Eau Claire in the Democratic-held 91st Assembly District.

That may seem odd, but what is often left unsaid in discussions of Wisconsin maps is that the islands are not random parcels created by mapmakers to advantage Republicans at the behest of a Republican legislature. Rather, the irregular blobs largely follow municipal maps that reflect the history of Wisconsin cities and villages adding to their tax base by annexing bits of land in nearby areas. The practice often leaves towns with irregular maps and legislative districts with holes and satellites.

The plaintiffs, who are Democratic voters, claim that the legislative district boundaries violate Article IV, Section 4 of the state constitution, which says Assembly members must be elected from districts consisting of “contiguous territory.”

But the same section of Article IV also requires that Assembly districts “be bounded by county, precinct, town or ward lines.”

Senate districts, which are each made up of three Assembly districts, are governed by Section 5. It says they must consist of “convenient contiguous territory.”

So, which trumps which? Contiguity or municipal lines?

"This is the only case I’m aware of where contiguity has been the focus of a challenge,” said University of Colorado Law Professor Doug Spencer, an expert in redistricting. “This could give the new Supreme Court in Wisconsin a way to overturn the maps on neutral grounds."

Much is at stake. The case could decide the future of Wisconsin state politics, with possible ramifications for such hot-button issues as abortion and voting rights.

One election law expert, after reviewing the constitution, saw the Senate language as more straightforward to challenge. Section 5 does not mention a need for Senate maps to be bounded by any kind of government or municipal lines. It only mentions contiguity.

That language is “more of a slam dunk” for the plaintiffs, said Michael McDonald of the University of Florida’s political science department, where he studies mapping issues.

GOP legislators who oppose the suit argue in one legal brief that insisting all parts of a district must physically touch flouts prior court rulings and “is absurd and unworkable.”

Marooned on a Voting Island

The U.S. Supreme Court ruled in 1964 that state legislative districts should have roughly equal populations, while federal law prohibits drawing lines that dilute the voting power of minorities. In addition to those parameters, states have adopted their own principles, which frequently include keeping districts contiguous.

The rationale behind contiguity is to create local districts where lawmakers live near and share common concerns with their constituents.

Contiguous means “you can draw a district without ever having to lift up your pencil,” Spencer explained.

But that’s not Wisconsin’s method.

According to the legal complaint, the majority of Wisconsin’s Assembly districts are noncontiguous — each consisting of between two and 40 disconnected pieces of territory. Two-thirds of the state’s Senate districts are noncontiguous — each with between two and 34 disconnected pieces.

Consider just a few of the Assembly districts referenced in the case.

2nd and 88th Districts

The 88th District, which features eastern sections of Green Bay as well as more rural areas, includes two detached islands surrounded by the 2nd District. Those islands correspond to the boundaries of two towns. The islands don’t seem to benefit either party. Both districts are represented by Republicans.

48th and 79th Districts

In Dane County, the Town of Burke is made up of disjointed tracts, resulting in noncontiguous boundaries for the town. Tiny portions of the town are in two different Assembly districts, both held by Democrats.

3rd and 5th Districts

It’s not unusual to see district maps that include islands so small they encompass a block, a few homes or even a single residence. In Outagamie County, boundary lines for the Town of Buchanan create a one-house-wide hole in the Republican district that contains the rest of the city of Kaukauna.

47th District

The Town of Madison, which had noncontiguous boundaries and was part of the 47th Assembly District, ceased to exist in 2022 when it was absorbed by the cities of Madison and Fitchburg. Yet the resulting islands in the legislative district remain. The district is notable for its large number of people living in noncontiguous areas.

Population estimate based on analysis of census data by Marquette University Law School redistricting researcher John Johnson. High Stakes on the Highest Court

Wisconsin’s maps have long been a contentious political topic, even becoming an issue earlier this year in a fiercely competitive race for a seat on the state Supreme Court, a contest that attracted tens of millions of dollars in campaign donations and outside spending.

The liberal-leaning candidate, Janet Protasiewicz, won, tipping the balance of the court to the left for the first time in 15 years. During the race, she expressed her support for legal abortion and her concern that the legislative maps were “rigged.”

One day after Protasiewicz’s Aug. 1 swearing-in ceremony, the group of Democratic voters filed suit, challenging the maps as “extreme partisan gerrymanders.” The high court declined to hear arguments about how the maps created a political advantage and, instead, narrowed the case to two arcane issues. One was “contiguity.” The other was “separation of powers,” centering on whether the prior Supreme Court overstepped its authority last year when it adopted the Legislature's maps despite a veto by the state’s Democratic governor, Tony Evers.

When Protasiewicz and the liberal majority decided in favor of hearing the case, conservatives on the court didn’t hide their displeasure.

“Redistricting should not be an annual event,” griped Chief Justice Annette Kingsland Ziegler in a written dissent. She added that the decision to focus solely on contiguity and separation of powers, which are state Constitutional issues, was “an attempt to dodge appellate review.”

Another justice, Rebecca Grassl Bradley, expressed her dismay with the case by liberally citing Lewis Carroll’s “Alice’s Adventures in Wonderland” and its sequel.

“Through the Looking Glass we go,” she wrote of what she considered to be a purely political, madcap exercise.

As the court date approaches, Republican legislators have been calling for Protasiewicz’s impeachment, claiming she’s biased. But she has said she won’t prejudge the issue and won’t recuse herself.

So far, Republicans haven’t acted on the impeachment threat. But even talk of such an extreme measure shows how significant the maps’ case is.

If redrawn, districts could become more competitive and less safe for incumbents — perhaps changing the power balance in the state capital. Republicans could lose complete control of the Legislature or, even if they retain power, lose their opportunity to gain a supermajority that would allow them to override Evers’ vetoes. A weakened state GOP could also be less helpful in 2024 to any Republicans who seek to again dispute presidential election results in Wisconsin, a swing state.

John Johnson, a Marquette University researcher who studies redistricting, noted that, ironically, it was Democrats who favored noncontiguous districts three decades ago.

Back then, maps drawn under the oversight of a Democratic legislature had created islands. Wisconsin Republicans at the time favored the dictionary definition, embracing “literal contiguity,” according to a key 1992 federal redistricting case that has been cited in the current controversy.

A federal three-judge panel, considering broader issues, didn’t endorse the islands but tolerated them, noting that the distance in the Democratic plan between the towns and the islands was slight.

The court held that “compactness and contiguity are desirable features in a redistricting plan,” but “only up to a point.”

Reaching “perfect contiguity and compactness,” the judges feared, would require “breaking up counties, towns, villages, wards and even neighborhoods.”

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by Tony Schick, Oregon Public Broadcasting

This article was produced for ProPublica’s Local Reporting Network in partnership with Oregon Public Broadcasting. Sign up for Dispatches to get stories like this one as soon as they are published.

Since it was founded in 1802, the U.S. Army Corps of Engineers has taken on some of the nation’s most ambitious attempts to manipulate nature for the benefit of human beings. The agency’s motto — “Essayons!” — translates from French to “Let Us Try!” And try it does.

The Corps has plunged ahead time and again with billion-dollar construction projects based on assumptions that don’t exactly pan out. In some cases, the agency goes on to spend billions more restoring the natural environment it manipulated.

We reported in late October on the Corps’ $1.9 billion proposal to remedy the fact that its 13 dams on the Willamette River in Oregon have helped drive iconic salmon to the brink of extinction.

Trouble is, that recovery plan is also based on assumptions that might not match reality. Central to what the Corps proposes is a pair of fish collectors, which the agency describes as essentially giant fish vacuums. Salmon the size of baby carrots would be whooshed into it, trapped in tanks and trucked around dams on their migration to the sea. The devices are to be built on a massive scale never before tested, and the Corps estimates a single collector could cost up to $450 million. A recent scientific review concluded that the kind of approach the Corps is pitching in Oregon won’t save salmon but “only prolong their decline to extinction.”

The Corps says it’s the best option for helping salmon while keeping dams operational for hydropower customers, boaters and other users of the Willamette systems — although many of those users say they would be fine with lowering reservoirs and curtailing hydropower if it helped fish.

The Oregon story is one example in a long line of Corps projects that have drawn criticism over the years.

In 1971, the New York Times editorial board declared “the American people are becoming increasingly fed up with the expensive, boondoggling, make‐work, environmentally destructive projects that to a large degree characterize the civilian activities of the Army’s Corps of Engineers.”

Three decades later, a Washington Post investigation found the Corps pursued “billions of dollars’ worth of taxpayer-funded water projects, many with significant environmental costs and minimal economic benefits.”

The Government Accountability Office concluded in 2006 that the Corps’ work was “fraught with errors, mistakes, and miscalculations, and used invalid assumptions and outdated data.”

ProPublica, with its partner Reveal from the Center for Investigative Reporting, has reported that the Corps knew since 1852 that levees force rivers to run higher and faster and yet persisted in using them for flood control.

When asked for a response to critics, the Corps this week issued a statement in which it acknowledged that over its long history, “there have been challenges associated with some of our projects. As an organization, we are always striving to be better.”

The agency said lessons learned from past projects have prompted changes to planning processes and the incorporation of “independent peer review.” The Corps said it’s working to modernize business methods, materials and designs while evolving in its approach to environmental and social concerns. Corps leaders are committed, the statement said, “to safely deliver projects, on time and within budget.”

Here are some examples of Corps projects that didn’t go as expected.

New Orleans Levee System Floodwaters from Hurricane Katrina fill the streets near downtown New Orleans on Aug. 30, 2005. (David J. Phillip/AP)

Year begun: 1965

Location: New Orleans

The plan: Prevent flooding during coastal storms by building a series of levees around Greater New Orleans.

What actually happened: In 2005, design flaws allowed a storm surge from Hurricane Katrina to breach the walls of the $738 million levee system that the Corps had built over the preceding four decades. The storm and flooding killed 1,392 people and caused damage totaling an inflation-adjusted $190 billion. The American Society of Civil Engineers called the levee failures “the worst engineering catastrophe in US History,” and the Corps later acknowledged its levees were “a system in name only.”

Tennessee-Tombigbee Waterway A worker watches a crane unload scrap metal along the Tennessee-Tombigbee Waterway in Columbus, Mississippi, in 2019. While the waterway hasn’t lived up to expectations in terms of traffic or economic development in parts of Alabama and Mississippi, cities including Columbus rely on it for jobs and transportation. (Jay Reeves/AP)

Year begun: 1971

Location: Tennessee, Mississippi, Alabama

The plan: Build a 234-mile artificial waterway connecting the Tennessee River to the Tombigbee River in Alabama, creating a new channel to the Gulf of Mexico and an estimated 208,000 new jobs in economically depressed areas of Alabama, Mississippi and Tennessee.

What actually happened: The Associated Press reported in 2019 that the Tenn-Tom, as it’s known, “has never come close to traffic projections used to sell it to the public, and poverty rates have increased in most of the counties it flows through in Mississippi and Alabama.” New jobs totaled 29,000, a study by Troy University found — or 179,000 less than early projections. The project cost $2 billion.

St. John’s Bayou-New Madrid Floodway

Year begun: 1986

Location: Missouri Bootheel

The plan: Control flooding in southeast Missouri with a construction project that would include levees and two giant rainwater pumps and cost $165 million.

What actually happened: The project was never completed. The Corps’ own lobbyist described the idea as an “economic dud with huge environmental consequences,” The Washington Post reported in 2006. According to earlier reporting by the Post, the Corps’ efforts were expected to drain 36,000 acres of wetlands and deliver virtually no actual flood protection.

Olmsted Locks and Dam

Year begun: 1988

Location: Olmsted, Illinois

The plan: Build a lock and dam system on the Ohio River to reduce delays on one of the most commercially trafficked water routes in the country, near the meeting of the Mississippi, Ohio, Tennessee and Cumberland rivers. The project was scheduled to be finished in 1998 at a cost of $700 million. The Corps projected the locks and dam would generate $920 million in economic benefits annually.

What actually happened: The project wasn’t completed until 2018 — 20 years later than expected. The cost, $3 billion, was four times what the Corps said it would be, and the economic benefits were $236 million, or about one-fourth the original estimate. In 2021, a collection of farmers along the river sued the federal government, claiming the project had increased the frequency and severity of flooding. The Corps sought to dismiss the suit, arguing the river’s flood pattern had not been severely altered. The case is pending.

Savannah Harbor Dredging

Year begun: 1999

Location: Savannah, Georgia

The plan: Dredge Savannah’s harbor to increase commercial shipping. When approved in 1999, the cost was pegged at $459 million.

What actually happened: The Corps was sued by environmental groups and state environmental regulators in South Carolina, where Corps officials were planning to dump potentially toxic dredge spoils. The Corps tried to get the lawsuit dismissed but eventually reached a settlement that included additional pollution controls. The effort took two decades thanks to repeated delays. Meanwhile, the cost more than doubled, to $973 million.

Florida Everglades Restoration Members of the Corps’ Jacksonville, Florida, district and the South Florida Water Management District joined other federal, state and local officials and stakeholders to break ground for the Everglades Agricultural Area Reservoir, a component of the Comprehensive Everglades Restoration Plan meant to reconnect Lake Okeechobee water to the central Everglades. (Bri Sanchez/U.S. Army Corps of Engineers)

Year begun: 2000

Location: Florida Everglades

The plan: Undo the damage done by engineering projects that degraded the famed ecosystem to half its original size. This damage occurred decades earlier, when the Corps was authorized to build levees around the Everglades and drain the wetlands. Key components of the restoration effort were to include building a massive reservoir the size of Manhattan and a series of artificial marshes meant to funnel clean water into the Everglades. The work would cost $8 billion and take 30 years to complete.

What actually happened: The Corps’ subsequent estimates put the project at $23 billion and 50 years to complete. Two decades passed before the Corps and state officials finally broke ground on the reservoir. According to the Miami Herald: “Even the Army Corps, which is building the reservoir, has signaled it’s worried about whether the finished project will meet the water quality standards it’s supposed to. If the new project missed the mark, it’s possible the ‘crown jewel’ of Everglades restoration might not work.”

Controlling Columbia River Salmon Predators A small portion of the East Sand Island, Wash., cormorant colony in May 2014. The island habitat formed from soil dredged up by the Corps. The agency then started killing the birds to keep them from eating endangered salmon. (Damian Mulinix/Daily Astorian via AP)

Year begun: 2015

Location: Mouth of the Columbia River, Oregon-Washington border

The plan: A colony of double-crested cormorants had settled on a set of islands that the Corps built up with soil it dredged from the riverbed, and the birds were feasting on endangered juvenile salmon as they tried to make their way to the ocean. To save endangered fish, the Corps decided to shoot the birds and put oil on their eggs to prevent them from hatching.

What actually happened: Killing the birds drove the colony to a bridge several miles upriver, where the cormorants ate even more salmon than before. Then the birds inundated the bridge with their droppings, causing an estimated $1 million in damage each year.

Coast Fortification in New Jersey Beachgoers cross over one of numerous large pools of water that formed on the beach in Margate, New Jersey, after heavy rains in July 2017. The water was blocked from draining into the ocean by sand dunes built as part of a storm protection program that Margate residents vigorously fought, claiming that the dunes would cause exactly the type of standing water that occurred. (Wayne Parry/AP)

Year begun: 2016

Location: Margate, New Jersey

The plan: Construct sand dunes as part of a statewide effort to fortify the coast after Hurricane Sandy in 2012, at an estimated cost of $63 million.

What actually happened: Margate residents had resisted the project, arguing that an existing retaining wall was sufficient and that dune construction would cause drainage problems for the seaside town. Their fears bore out in 2017, when water pooled behind newly constructed dunes. The town sued. During the trial, according to The Philadelphia Inquirer, a Corps official acknowledged the standing water had surpassed agency predictions and that the agency wanted to continue building, despite being at a loss for solutions. Margate Mayor Michael Becker told the Inquirer the emotional toll of the beach construction was “worse than Hurricane Sandy.” After finding that the town’s concerns were “understandable and cry out for help,” a judge ruled construction could continue if the Corps fenced off ponds and built raised walkways for residents.

Dredging the Mississippi Dredging operations to build an underwater sill in Plaquemines Parish, Louisiana, outside New Orleans on Sept. 26, 2023. A saltwater wedge slowly moving upriver from the Gulf of Mexico threatened municipal water supplies. (Gerald Herbert/AP)

Year begun: 2018

Location: Mississippi River near New Orleans

The plan: Dredge the Mississippi, deepening the 45-foot-deep channel to 50 feet at the river’s mouth to allow for more shipping.

What actually happened: After the $250 million dredging was completed in 2022, saltwater from the Gulf of Mexico started entering the river. The Corps had known for decades that its continued efforts to deepen the river channel would trigger an intrusion of saltwater, according to The New Orleans Advocate. The agency predicted an underwater dam could contain the invading saltwater, but, according to Bloomberg, this year it failed to do so. To fix the drinking water problem, New Orleans is now building a pipe to pull freshwater from farther upriver, which Bloomberg reports could cost $100 million to $250 million.

by Heather Vogell

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The U.S. Department of Justice late Wednesday stepped into a massive antitrust lawsuit filed by dozens of tenants who are accusing a tech company’s apartment software of helping landlords collude to inflate rents.

The DOJ action comes after a ProPublica investigation last year found that Texas-based software provider RealPage used algorithms to recommend rents to landlords across the country to maximize profits — a practice that experts said may violate antitrust laws.

In throwing its weight behind plaintiffs in the price-fixing case, the Justice Department waded into a fraught corner of federal antitrust law that could have a wide-reaching impact not only on the way businesses use technology to drive profits but also on the marketplace consumers confront.

In the past, collusion happened with “a formal handshake in a clandestine meeting,” they wrote.

“Algorithms are the new frontier,” federal prosecutors said in their filing. “And, given the amount of information an algorithm can access and digest, this new frontier poses an even greater anticompetitive threat than the last.”

After the first federal lawsuit was filed, RealPage said it “strongly denies the allegations and will vigorously defend against the lawsuit.” The company did not immediately return a request for comment on the justice department’s filing, which opposes RealPage’s efforts to have the case dismissed.

Antitrust enforcers have struggled to apply decades-old laws to new technologies such as RealPage’s rent-setting software, which have changed the way competitors interact with one another and with customers.

But, prosecutors said, whether firms use a software algorithm or human interactions to create the scheme “should be of no legal significance.”

“Automating an anticompetitive scheme does not make it less anticompetitive,” the DOJ said.

As described in federal lawsuits filed by tenants, RealPage invited concerted action among landlords, including the sharing of nonpublic data with the software, with the purpose of raising rents, prosecutors wrote in their memorandum. The arrangement is still price-fixing regardless of whether competing landlords ever communicated with one another about prices, prosecutors said.

“Put simply, RealPage allegedly replaces independent competitive decisionmaking on prices, which often leads to lower prices for tenants, with a price-fixing combination that violates” federal antitrust law, prosecutors wrote.

Not every use of an algorithm to set price violates federal law, they noted, but it is “unlawful when, as alleged here, competitors knowingly combine their sensitive, nonpublic pricing and supply information in an algorithm that they rely upon in making pricing decisions, with the knowledge and expectation that other competitors will do the same.”

The DOJ intervention increases the legal pressure facing RealPage, a private equity-owned venture.

Tenants around the country filed dozens of federal lawsuits alleging violations of antitrust law by scores of big landlords — including some that provide student housing — after ProPublica’s investigation into RealPage in October 2022. The story revealed how landlords share proprietary data with RealPage. Legal experts said the arrangement could facilitate cartel-like behavior among landlords if they used the software to coordinate pricing.

Those lawsuits were consolidated in federal court in Nashville, Tennessee.

Together, the federal lawsuits and another filed in the District of Columbia Superior Court in early November 2023 described an elaborate system set up by RealPage to push landlords’ employees to adopt the software’s suggestions.

Twelve witness accounts, rental price and occupancy data, economic evidence and investigations “confirm the anticompetitive conduct” in the rental housing market, the federal lawsuit says.

In one news release, Realpage offered its property management clients the ability to outsource daily rent-setting and revenue oversight. “We believe in overseeing properties as though we own them ourselves,” the company said in a presentation that plaintiffs’ lawyers referenced in the lawsuit.

The lawsuit quoted one unnamed witness, a RealPage pricing advisor, saying that some pricing advisors told property management employees that they had to follow the software’s recommendations. A leasing manager at a RealPage client said, “I knew [RealPage’s prices] were way too high, but [RealPage] barely budged” when the manager asked to deviate from the suggested rent.

An update to the software tracked not only clients’ acceptance rate, but also the identity of the landlords’ staff members who had requested a deviation from RealPage’s price, the lawsuit said. Compensation for some property management personnel was even tied to compliance with the company’s recommendations, it said.

As a result, RealPage’s system hiked rent prices above competitive levels, the lawsuit alleged. Another witness, a former RealPage executive directly involved in the software’s creation, “expressed dismay with the way RealPage has enabled lessors to collectively raise rents at record pace,” the lawsuit said. The witness said the practice of setting rental rates centrally and consistently raising them had “bastardized” the company’s original supply-and-demand model.

After the company purchased its main software competitor in 2017, RealPage’s reach doubled — to comprise more than two-thirds of all revenue management use nationwide, according to the complaint. About 50 big landlords are named as defendants in the suit.

In a response to the accusations in the federal lawsuit, lawyers for RealPage and other defendants called the allegation that the software company and landlords had formed a conspiracy “implausible.” They said the complaint doesn’t show direct evidence of such an agreement, like “smoking gun” documents or recorded phone calls. “In sum, Plaintiffs have not alleged a plausible horizontal price-fixing conspiracy,” the response said.

The response accused tenants’ lawyers of trying to “create the false impression that users must obtain approval from RealPage before rejecting the software’s recommendations.” RealPage attorneys pointed to a company FAQ that said output from the software “may be followed, modified, or ignored by an apartment provider.”

It also said the fact that defendants held meetings and participated in online user groups and trade associations “does not imply collusion.”

The DOJ filing comes after the District of Columbia’s attorney general, Brian Schwalb, announced earlier this month that his office was also suing RealPage and 14 of the biggest landlords in the city “for colluding to illegally raise rents for tens of thousands of DC residents.”

In the broader Washington, D.C., metropolitan area, more than 90% of large apartment buildings — meaning those with 50 or more units — use RealPage’s revenue management software to set rents, Schwalb’s lawsuit contends. The complaint, filed in District of Columbia Superior Court, said RealPage has become “the ‘Big Tech’ company of rental housing,” promising landlords it can boost revenue by 2-7% using its software.

“Increases of this magnitude translate to millions in wrongfully inflated rents in the last four years alone,” Schwalb’s complaint says. “Every dollar of increased rent that the cartel illegally squeezes from District renters contributes to widening wealth gaps, forces hardworking residents to forgo other uses of their money, and pushes residents out of a District whose housing they increasingly cannot afford.”

The Washington suit, whose defendants include one of the nation’s biggest apartment owners, Greystar, said the use of the software marked a departure from the traditionally competitive rental market, saying that when a former high-ranking manager at Greystar was asked whether landlords use the RealPage software to collude on raising rental prices, “he responded that of course they did—it’s the entire reason landlords used the software.”

Greystar could not be immediately reached for comment.

In a statement released to media outlets at the time, a RealPage spokesperson criticized Schwalb’s lawsuit, saying, “In seeking to draw a causal connection between revenue management software like ours and increases in market-wide rents, this copycat suit repeats the inaccuracies of predecessor cases.” The statement said the complaint and others like it are “wrong on the facts and the law.”

The Washington lawsuit alleged that the system was designed to police compliance of the cartel. It cited RealPage training documents that urged clients to have the “discipline” to enact the software’s pricing suggestions 90% of the time or more. Training documents encouraged regional rental managers to beware of “‘rogue’ leasing agents who too frequently override” the software’s recommended prices. Rejections would also often trigger outreach from a RealPage pricing advisor, the suit said.

Lawmakers had urged the Justice Department to step into the dispute in letters in March 2023 and November 2022.

In late October 2023, U.S. Sen. Amy Klobuchar, who chairs a Senate panel on antitrust policy, held a hearing on competition and consumer rights in housing that included the RealPage controversy.

In testimony, University of Tennessee law professor Maurice Stucke, a former prosecutor in the Justice Department’s antitrust division, noted that in several instances, data showed property managers who used algorithms to set rent saw their revenues increase even as they let more apartments sit vacant.

“So one issue for you is can the antitrust laws effectively punish and deter this alleged anti-competitive behavior?” he said to the subcommittee. “The short answer is yes, if humans agreed among themselves to fix price, and RealPage’s pricing algorithm was then used to facilitate their collusion.”

But Stucke said that given the way opportunities for competitors to collude are changing with new technology, he urged reform to address gaps in the law. He recommended changes to the way the Federal Trade Commission considers antitrust claims and how the government reviews the mergers of firms that could reduce competition. He also said Congress should look at how it might enhance privacy laws to better protect renters whose landlords are using new technology.

Klobuchar, who has already proposed reform to antitrust laws, called Stucke’s comments “music to my ears.”

by Eli Hager

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

It was 5:30 a.m. Flashlights beamed in through the windows of the ground-floor apartment in East Flatbush, Brooklyn. Police officers and child welfare caseworkers were ordering a woman to open her front door.

When she did, the first thing she saw was that the police had their guns drawn. Her hands flew up into the “don’t shoot” position; she was well aware of the recent stories of cops “shooting first and asking later.” She prayed that her 7-year-old son was still asleep in his room.

“I was beyond scared. I literally started shaking,” said L.B., the mom, who is Black and asked to be referred to by her initials for her child’s safety and privacy.

Enabled by the police officers’ show of force, the caseworkers from the Administration for Children’s Services, New York City’s child welfare agency, entered L.B.’s apartment without a warrant that day in January 2021. Before she knew it, they were scrutinizing the contents of her refrigerator and cabinets, examining her bed and bathroom, and rifling through her personal belongings. They also had her lift up her son’s shirt so they could inspect his torso.

They found nothing. The boy was safe and unharmed, living in a clean, well-organized home with his mom and his adult sister, according to case records.

The allegations against L.B., made by an anonymous caller at 4:45 a.m. that day, were false. These included that she was a stripper (she worked at a home for people with disabilities); that she used drugs (none were found, and a drug test was negative for all substances); and that an abusive man lived with her and that she owned “machine guns” (after an exhaustive search and interrogation, both claims were deemed baseless).

In fact, L.B. has never been found to have committed any type of child maltreatment, ACS and court records show.

Yet the anonymous caller, whom L.B. believes to be a former acquaintance with a grudge, has continued to dial in to New York’s state child welfare hotline. Each time, this person or possibly people make outlandish, often already-disproven claims about her, seeming to know that doing so will automatically trigger a government intrusion into her domestic life.

And ACS obliges: Over the past three years, the agency either has inspected her home or examined and questioned her son at school more than two dozen times. Caseworkers have sought a warrant for only three of these searches, most recently in August. All of those requests have been rejected by judges, according to court records.

Still, it keeps happening, and it’s nearly always the same routine, records show. The caseworkers demand entry into her apartment, ringing her doorbell and, embarrassingly, sometimes those of her neighbors as well, at all hours of the day and night. They observe her child’s unclothed stomach and thighs, and sometimes take pictures. And they interrogate him without her consent, covering topics like whether she has sex around him.

At one point he said to her, crying, “Mom, you told me they wouldn’t come back,” L.B. said.

“I’m still trying to make it up to him,” she added, “even though I didn’t do anything wrong.”

L.B. this week filed a federal lawsuit against the commissioner of ACS and the city of New York, arguing that her Fourth Amendment right against unreasonable searches and seizures has been repeatedly violated by the agency’s warrantless incursions into her family’s private sphere. She is not primarily alleging that caseworkers committed specific unlawful acts, although several ACS staff members are also named in the suit. Rather, her contention is that three years of the same type and scope of investigation — no matter the source or credibility or repetitiveness of the accusations against her — is indiscriminately and thus unconstitutionally invasive.

Legal aid lawyers in New York had said that more lawsuits like this one might be coming after a ProPublica and NBC News investigation last year found that ACS caseworkers search more than 50,000 typically low-income households every year, obtaining a warrant less than one half of 1% of the time. (L.B. is represented by Brooklyn Defender Services as well as a private law firm, and her complaint cites our reporting.) The agency finds a safety situation requiring removal of a child from a home in only 4% of these cases.

ProPublica’s investigation tracked the case of Ronisha Ferguson, a Bronx mother who sued the city of New York after ACS removed her children from her because she refused to let caseworkers search her apartment without a warrant. (Court records indicate that the city this August agreed to settle that case with Ferguson.)

In response to a detailed list of questions, an ACS spokesperson did not address any aspect of how the agency has handled L.B.’s case. She said that ACS is required under New York law to investigate all reports of child maltreatment that are forwarded from the state hotline, including ones that are anonymous, and that every investigation must include “evaluating the home environment.” The agency has “no discretion” if the hotline operator deems the call worth passing along, she said.

L.B.’s attorneys counter that caseworkers, once they have observed a child to be safe, actually do have discretion under state law not to conduct the same full search that they have completed before. Continuing to follow these procedures over and over causes concrete harm, they say.

L.B.’s child now suffers from severe anxiety, a doctor’s note confirms, which she said is the direct result of ACS’ constant intrusions. (He has even asked her to have the doorbell dismantled.) Her employment has been affected, including when she had to take multiple months of unpaid leave to make sure that she was available for her son. Her landlord has complained to her that the situation is troubling other tenants, causing her to consider moving to a different neighborhood even though she has lived in her apartment for a decade.

Yet for a long time, it was a struggle for her to fight back. When caseworkers arrived at her door, she’d allow them to enter in part because they had the power to remove her son from her custody. They also never told her, she said, that without her consent, they would need a warrant.

They often told her that letting them in was the only way to get them to stop coming, she said.

Finally, in 2022, a co-worker convinced her that she had the right to say no. Anxiously, she started doing just that.

That February, ACS, for the first time, applied for a warrant, stating in court papers that L.B. now knew her rights but that her home still needed to be entered “immediately at any hour.” But a judge, after learning about the case’s history and realizing that L.B.’s child had been observed in his home multiple times and interviewed multiple times with no evidence that any of the allegations against his mom were true, and that all of this was causing him trauma, denied the agency’s request. (The order additionally instructed ACS to refer the matter to the Brooklyn District Attorney’s Office for investigation of an apparent pattern of false hotline calls.)

The judge told ACS that its procedures “have to be adjusted when following them is more likely to do harm,” adding that “showing up in the middle of the night is traumatic; taking off kids’ clothes is traumatic.”

Yet caseworkers kept trying to get inside L.B.’s home whenever they received anonymous reports, including a patently false claim that she lived in a bar with multiple small daughters. She kept saying no.

They applied for a warrant again. A second judge denied them, calling the whole matter a “horrible intrusion” as well as a “waste of state resources.”

So ACS took a different tack: showing up at her son’s school and calling him to the office to interrogate him there, without her knowledge let alone consent. Caseworkers did this repeatedly for many months, making him miss class, and without telling him that he was free to leave at any time.

He used to love school — his gifted and talented program, culinary arts, using the computers, playing ball outside, seeing his friends. But now he often tells L.B. that his chest hurts so he has to stay home.

He has been especially sensitive about having to lift up his shirt for strangers, she said. And about the other kids who have started to tease him about it all. He comes home crying.

Advocates for families facing ACS investigations like L.B.’s point to two pieces of legislation that the New York State Assembly could pass next year. One would create a “family Miranda warning” that caseworkers would have to read to parents at their door, informing them of their right to deny entry into their home and to have a lawyer present.

That bill nearly became law this past spring but failed in part due to opposition from ACS, as ProPublica reported.

The second is an “anti-harassment in reporting” bill that would seek to reduce false and malicious calls to the state child welfare hotline by no longer allowing these tips to be anonymous. Under the current law, anyone can report any parent without so much as leaving a name or phone number.

The new legislation would require that callers at least provide basic details about themselves so caseworkers can follow up, gather more information, make sure the accusation has some basis and consider how intrusive of an investigation is needed. Hotline and ACS staff would still be legally required to keep the caller’s identity confidential.

The ACS spokesperson said the agency is “very concerned about false and malicious reporting and the impact it has on families.” She also said ACS “supports eliminating most anonymous reporting,” with rare exceptions including when it is a child calling the hotline.

L.B., whose son is now three years older than when these searches started, agrees.

by Maya Miller and Robin Fields

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

This story is part of a partnership with Scripps News.

In North Carolina, lawmakers outraged that breast cancer patients were being denied reconstructive surgeries passed a measure forcing health insurers to pay for them. In Arizona, legislators intervened to protect patients with diabetes, requiring health plans to cover their supplies. Elected officials in more than a dozen states, from Oklahoma to California, wrote laws demanding that insurance companies pay for emergency services.

Over the last four decades, states have enacted hundreds of laws dictating precisely what insurers must cover so that consumers aren’t driven into debt or forced to go without medicines or procedures. But health plans have violated these mandates at least dozens of times in the last five years, ProPublica found.

In the most egregious cases, patients have been denied coverage for lifesaving care. On Wednesday, a ProPublica investigation traced how a Michigan company would not pay for an FDA-approved cancer medication for a patient, Forrest VanPatten, even though a state law requires insurers to cover cancer drugs. That expensive treatment offered VanPatten his only chance for survival. The father of two died at the age 50, still battling the insurer for access to the therapy. Regulators never intervened.

These laws don’t apply to every type of health plan, but they are supposed to provide protections for tens of millions of people. AHIP, a trade group that used to be known as America’s Health Insurance Plans, said new mandates are costly for consumers and states, “tie insurers’ hands and limit plan innovation” by requiring specific benefits. Nevertheless, its members take steps to make sure they are following these mandates, the trade group said.

State insurance departments are responsible for enforcing these laws, but many are ill-equipped to do so, researchers, consumer advocates and even some regulators say. These agencies oversee all types of insurance, including plans covering cars, homes and people’s health. Yet they employed less people last year than they did a decade ago. Their first priority is making sure plans remain solvent; protecting consumers from unlawful denials often takes a backseat.

“They just honestly don’t have the resources to do the type of auditing that we would need,” said Sara McMenamin, an associate professor of public health at the University of California, San Diego, who has been studying the implementation of state mandates.

Agencies often don’t investigate health insurance denials unless policyholders or their families complain. But denials can arrive at the worst moments of people’s lives, when they have little energy to wrangle with bureaucracy. People with plans purchased on HealthCare.gov appealed less than 1% of the time, one study found.

ProPublica surveyed every state’s insurance agency and identified just 45 enforcement actions since 2018 involving denials that have violated coverage mandates. Regulators sometimes treat consumer complaints as one-offs, forcing an insurer to pay for that individual’s treatment without addressing whether a broader group has faced similar wrongful denials.

When regulators have decided to dig deeper, they’ve found that a single complaint is emblematic of a systemic issue impacting thousands of people.

In 2017, a woman complained to Maine’s insurance regulator, saying her carrier, Aetna, broke state law by incorrectly processing claims and overcharging her for services related to the birth of her child. After being contacted by the state, Aetna acknowledged the mistake and issued a refund.

That winter, the woman gave birth to a second child, and Aetna did it again. She filed another complaint. This time, when the state made Aetna pay up, it also demanded broader data on childbirth claims. Regulators discovered that the insurer had miscalculated claims related to more than 1,000 births over a four-year period. Aetna issued refunds totaling $1.6 million and agreed to pay a $150,000 fine if it failed to follow conditions listed in a consent agreement.

It was a rare victory. The potential fine, though, constituted less than .002% of the $6.63 billion in profit recorded by Aetna’s parent company, CVS Health, that year.

Aetna spokesperson Alex Kepnes said the company resolved the matter in 2019 to the state’s satisfaction. Kepnes declined to answer why the insurer failed to fix the issue after the first complaint.

Watch the Scripps News Report “Hope Denied”

Patients often don’t know what care they’re entitled to under state mandates. And one survey found that 86% of people with health insurance don’t know which government agency to call for help. Knowing how to navigate the system can make all the difference to patients socked with giant medical bills.

In December 2022, Samantha Slabyk felt a sudden sharp pain in her lower right abdomen. The San Marcos, Texas, resident took herself to an outpatient emergency clinic, but after a CT scan revealed she had appendicitis, doctors sent her in an ambulance to a nearby hospital. “Everyone indicated that this was an emergency situation that needed to be dealt with promptly,” Slabyk said.

Texas has long had a law requiring insurers to cover medical treatment needed by patients in emergencies. Yet that month, her insurer, Ambetter, wrote in a letter that it would not pay the $93,000 bill because the appendectomy took place at an out-of-network facility.

Slabyk was studying to be a physician’s assistant and had been an EMT. Her fiance’s brother-in-law worked in medical billing and gave her advice on how to push back, as did her mom — whose cancer diagnosis meant she often interacted with health insurers. These connections and experiences gave Slabyk an unusual grasp of her rights and how the system works. Still, every time she reached someone at Ambetter, she felt like she was being stonewalled. Slabyk felt lost.

You can find more information about your state's laws on the Centers for Medicare & Medicaid Services website.

By June, she was so fed up she decided to submit a complaint to the Texas Department of Insurance. Five days later, she received a call from an Ambetter employee apologizing and saying they would process the procedure as an emergency and pay up.

Centene, Ambetter’s parent company, did not respond to emailed questions or a phone call seeking comment. (The state informed Slabyk it closed the complaint.)

“I was around a lot of people who were knowledgeable and giving me very good advice,” Slabyk said. “And so if you’re just like, on your own, not in the health care system whatsoever, I mean, I just, I can totally see giving up.”

California had to pass not one but two laws to compel insurers to pay for infertility treatments. And one lawmaker said insurers are still saying no often enough that he’s considering introducing a third.

After legislators began requiring such coverage in 1990, some health plans took a narrow view. They refused to pay to preserve eggs, sperm or reproductive tissue for patients facing treatments for diseases like cancer that could impair their fertility. Some patients were delaying chemotherapy to try to get pregnant beforehand or going into debt to pay for treatments out-of-pocket. Regulators forced insurers to pay in some cases, but elected officials worried that other patients were being denied this care.

State Sen. Anthony Portantino worked with colleagues to amend the law in 2019, clarifying that these treatments must be covered. Even so, insurers have been putting up roadblocks.

“Some of the insurers are taking a very strict approach that it has to be chemo,” said Portantino, who is a Democrat. For instance, patients who need cancer surgeries that could leave them infertile have faced denials.

Portantino said he plans to work with California’s largest health insurance regulator to clarify that fertility preservation must be covered more broadly. If that does not work, he said he will turn to legislation once again.

Other regulators are trying to bolster enforcement on the front end. Health insurers submit annual filings to the states where they operate, detailing the treatments and services the company will and won’t cover. Regulators check these policies to figure out whether an insurer is complying with state mandates. In Vermont, the insurance department is using federal grant money to work with an outside company to improve these reviews. Through staff training and education, the department hopes to catch insurers not following state laws before Vermont residents face wrongful denials.

Not all health plans have to follow state mandates. About 65% of employees who get insurance through their jobs work for companies that pay directly for health care. Those companies often hire insurers solely to process claims. Known as self-funded plans, they are regulated by the federal government and exempt from state coverage requirements. Employers increasingly are turning to these types of plans, which tend to be cheaper, partly because they don’t have to cover care that states require. (The federal government also imposes coverage mandates, but state laws can be more robust.)

For patients, this can mean fewer protections from denials.

When 57-year-old Sayeh Peterson, a nonsmoker, was diagnosed with stage 4 lung cancer, her doctors ordered genetic testing to identify the cause. Those tests revealed that a rare gene mutation was, in fact, the culprit for Peterson’s disease and gave doctors the information they needed to create a treatment that targeted the mutation. Her state, Arizona, requires insurers to cover such testing, but Peterson’s UnitedHealthcare plan was self-funded by her husband’s employer, so the law didn’t apply. She and her husband were left with more than $12,000 in bills.

In response to questions, UnitedHealth spokesperson Maria Gordon Shydlo wrote that “there is not enough medical evidence to support use of all those tests.”

As Peterson undergoes a treatment plan tailored to the genetic test results, she is continuing to appeal the denials months later. “We’re told that we have this great insurance,” Peterson said. “But then they deny coverage for the testing that determined what my treatment would be. How do you even get your head around this?”

Do You Have Insights Into Dental and Health Insurance Denials? Help Us Report on the System.

Doris Burke contributed research.

by Samantha Sunne, Dannah Sauer and Lee Zurik, WVUE-TV

This article was produced for ProPublica’s Local Reporting Network in partnership with WVUE-TV. Sign up for Dispatches to get stories like this one as soon as they are published.

The village of Fenton, outside the oil and gas town of Lake Charles, covers only about 20 blocks. There’s City Hall. The library. One gas station. A small public housing complex. A Dollar General. A grain elevator. A Baptist church. Drivers headed to east Texas from central Louisiana go right through town, passing it all in under a minute.

In many ways, Fenton is like other small towns in Louisiana. But it is remarkable in one way: This village of 226 people collected more money in a single year through fines and forfeitures, primarily traffic tickets, than almost any other municipality in Louisiana, according to audits.

In the year ending in June 2022, Fenton brought in $1.3 million that way.

The fines were collected through what’s known as a “mayor’s court”: a little-known type of small town court found only in Louisiana and Ohio. In Fenton, its primary function is processing the thousands of traffic tickets written annually by a few police officers. Here, the mayor is also the judge, appointing the prosecutor and, if drivers ask for a trial, deciding their guilt or innocence.

The mayor runs the village with revenue primarily made up of those fines. The bulk of the salaries of the people in the courtroom — everyone from the mayor to the clerk — comes from fines and fees collected by the court.

This arrangement is so ripe for conflict of interest that the fairness of mayor’s courts has been challenged several times. One case resulted in a 1972 U.S. Supreme Court ruling that curtailed the power of mayors who take in a lot of money through their court.

Fenton village attorney Mike Holmes, in an email to WVUE-TV and ProPublica, said the mayor presides over court in a “neutral, impartial manner” consistent with Louisiana law.

But the village’s court records suggest something else about how it handles some tickets: Case summaries include curious notes from village employees and police officers. Some say not to “fix” tickets or reduce charges for drivers who had a “bad attitude.” Others suggest that the police chief and others have had a hand in dismissing charges, although Holmes said tickets are dismissed only at his direction.

Getting clear answers to how Fenton operates its court, and how fairly, has been difficult. Over four visits, journalists from WVUE and ProPublica reviewed court files, town meeting minutes, municipal ordinances and body camera video. We asked for three and a half years of electronic case summaries. We tried, several times, to see the court in action and to meet with the mayor, eventually observing court once and speaking with the mayor for five minutes.

Village officials offered conflicting and confusing explanations for the mayor’s role, how and why tickets are reduced or dismissed, why the town asks the state to suspend so many drivers’ licenses and how often trials are held. Their description of how the town runs its court didn’t align with state Judicial College guidance or that U.S. Supreme Court ruling.

Such irregularities demonstrate the problems inherent in this unique court system in place across Louisiana, said Joel Friedman, an emeritus professor at Tulane University in New Orleans who has taught procedural law for 46 years.

“The mayor who’s trying to raise money for the city is in charge of prosecuting these minor criminal offenses and getting fines brought back to the city,” he said. “There’s no accountability,” he added. “They can do whatever they want.”

A few people well-versed in mayor’s courts, including an attorney who was intrigued enough to write a book about them, said Fenton shouldn’t allow the mayor to preside over court.

Small Town, Big Budget

Fenton has just 226 residents, but it collected about as much money through fines and forfeitures in a single year as Louisiana’s third-largest city, Shreveport, which has a population of 187,000. (Jon Turnipseed/WVUE)

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Fenton is not unusual among small towns in Louisiana in administering justice through its mayor’s court.

Courts like this, which likely have been around since before Louisiana was a state, were carried over into the state’s modern judicial system when its constitution was updated in the 1970s, according to attorney Floyd Buras, who wrote that book on mayor’s courts. Now, they function as an informal way to handle minor offenses in about 250 municipalities, mostly small towns and villages.

Mayor’s courts operate in a gray area of Louisiana law. Like municipal courts, they handle violations of local ordinances. Municipal judges must hold a law degree and pass the bar; a mayor can preside over court without meeting any qualifications. Yet, like a municipal judge, a mayor can impose fines or sentence people to jail.

Mayor’s courts must ensure defendants have fair trials. But unlike other courts in the state, they aren’t subject to rules like the Code of Criminal Procedure that are supposed to ensure courts are run fairly and properly.

“They sort of operate in the shadow of the law,” said Eric Foley, an attorney with the MacArthur Justice Center, a law firm that litigates for civil rights in criminal justice.

Fenton’s court is the main reason the town’s revenue for the year ending in June 2022 was about five times as high as the average Louisiana municipality its size. This tiny village collected about as much through fines and forfeitures as Shreveport, the state’s third-largest city, with a population of 187,000. (The state provides no official definition of “fines and forfeitures,” but it generally refers to penalties for breaking the law and associated fees.)

The average municipality in the U.S. gets 1.7% of its revenue from fines and forfeitures, according to the Urban Institute, a Washington, D.C.-based think tank that promotes equity. In Fenton, it’s 92.5%.

That’s the highest percentage of any municipality in Louisiana, according to a survey by WVUE and ProPublica of audits on file with the state.

It’s also one of the highest percentages in the whole country. In a frequently cited review of local government data by the news outlet Governing in 2019, Fenton ranked second-highest for its share of revenue that came from fines and forfeitures.

Governing said nearly 600 jurisdictions in the U.S., including 70 in Louisiana, collected at least 10% of general fund revenue through fines and forfeitures.

Advocates for the poor say a reliance on fines, which they call “taxation by citation,” distorts the role of police departments. “It’s almost impossible to generate that much of your revenue without doing pretty abusive things,” said Joanna Weiss, co-executive director of the Fines and Fees Justice Center, which promotes what it calls equitable fines and the elimination of fees in the justice system.

Holmes, the attorney for Fenton, said fines make up an outsized share of its revenue because, like many other small towns, it doesn’t bring in much money from sales or property taxes. “While revenues fluctuate from year to year, Village of Fenton Police Department has long had an active traffic enforcement policy,” he wrote.

That enforcement is particularly active on the north side of town, where U.S. Route 165 shifts from a divided highway to a five-lane road. Just before drivers reach a welcome sign, the speed limit drops from 65 mph to 50. Police cruisers often wait nearby, in a stand of trees across from a small roadside cemetery.

That’s where Nikki Cross got her ticket last year. She was returning to Bridge City, Texas, about 70 miles away, to pick up her son after meeting a client north of Lake Charles for her sales job.

Cross said she braked when she saw the speed limit drop. She was ticketed for driving 61 mph in a 50 mph zone. “I told them I was slowing down at the time; I just didn’t slam on my brakes to get to the speed I needed to be at,” Cross said in a text message to WVUE and ProPublica.

Her fine: $210.00.

Mayor, Judge and Jury

The Supreme Court has ruled that a mayor can’t be impartial as a judge if he oversees the town’s finances and if its court brings in a substantial share of the town’s revenue, like Fenton’s does. Mayor Eddie Alfred Jr. initially told WVUE and ProPublica he doesn’t preside over court, but village attorney Mike Holmes later confirmed Alfred does after we saw the mayor sitting at the bench in September. (Jon Turnipseed/WVUE)

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Legally, there’s nothing improper about a town like Fenton collecting so much of its revenue through its mayor’s court. But when it does, court rulings say, the mayor shouldn’t both hold the town’s gavel and sign its paychecks.

In a 1972 case, a driver contesting two $50 traffic tickets in Monroeville, Ohio, argued that he had been denied a fair trial because the mayor who ruled against him was responsible for law enforcement and for producing revenue for the town. At the time, Monroeville generated 37% to 51% of its annual revenue from its mayor’s court, much less than Fenton.

The case, Ward v. Monroeville, went to the U.S. Supreme Court. In a 7-2 decision, Justice William Brennan Jr. wrote that the issue turned on “whether the Mayor can be regarded as an impartial judge.” He can’t, Brennan wrote, if he presides over court and also manages the town’s finances, and if the court generates a substantial part of the town’s revenue.

A week later, the Louisiana attorney general’s office followed up with an opinion instructing Louisiana towns with mayor's courts to assess whether they were in a similar situation as Monroeville.

Subsequent rulings have cited that Supreme Court opinion. In 1995, a federal judge in Ohio ruled that a mayor could be considered biased on the bench if just 10% of the town’s revenue came from its mayor’s court. In 2019, the 5th Circuit Court of Appeals ruled that a judge in Orleans Parish Criminal District Court had a conflict of interest when setting bail bonds because the court collected a fee based on the amount of each bond.

A training video on mayor’s courts released this year by the Louisiana Judicial College, the educational arm of the state Supreme Court, addresses this conflict of interest. It advises mayors to appoint an attorney to preside over their court if it brings in more than 10% of the town’s revenue. Some towns, including many in the New Orleans area, have done that.

But we found at least nine other municipalities in the state where staff confirmed that the mayor presides over court even though collections make up anywhere from 18% to 79% of the town’s annual revenue.

Bobby King, the prosecutor for the mayor’s court in Walker, near Baton Rouge, led that Louisiana Judicial College video training. In an interview, he said he would advise Fenton, or any municipality in its position, to appoint a magistrate. “You can’t be fair and impartial,” he said, “if you’re wanting to spend money on a park and a big part of that money comes from fines and fees.”

Yet it was not easy to determine who presides over court in Fenton. In a phone call in June, Eddie Alfred Jr., who has been the village’s mayor since 2009, was eager to talk about its traffic ticketing system. But he said he doesn’t preside over court.

Instead, Alfred said, defendants talk to Holmes, the prosecutor. If someone pleads not guilty, Holmes shows the driver a video of their violation. After that, Alfred claimed, “not one person” has maintained their innocence since he has been mayor. If they did, he said, they would go to the district court in Jennings, the seat of Jefferson Davis Parish.

When we visited Fenton in September to observe court, “Judge Alfred,” as he is referred to in court records, donned a black judge’s robe, walked down the hall from the mayor’s office and sat at the bench. No one was waiting to have their cases heard. After Holmes noted for the record that several people had missed their court date, Alfred said, “Court is now adjourned.” Afterward, he refused to speak with us and went back to his office.

Watch WVUE’s Report

Holmes later confirmed that Alfred does preside over court; when asked about the mayor’s statement to the contrary, Holmes said it “must have resulted from misunderstanding or miscommunication.” Asked why the mayor serves as judge when the village collects so much money from the court, Holmes said, “He is authorized to do so by law.”

Four lawyers who spoke with us — the law professor, the author of the book on mayor’s courts, the civil rights attorney and the prosecutor who led the Judicial College training — said they believe Fenton is violating the Supreme Court ruling.

“Our Main Income Is Traffic Tickets” (Anna Donlan/ProPublica)

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“Even if you can’t point to the mayor actually being on the record saying, ‘I have to keep up these prosecutions to maintain this funding,’ the fact that the average person put in that mayor’s shoes might feel that temptation — that’s kind of enough,” Foley said.

Actually, Fenton’s mayor has said something quite similar.

In a recording made in September and obtained by WVUE and ProPublica, Alfred can be heard telling village employees that there could be layoffs due to financial problems.

“Our main income is traffic tickets, and they ain’t getting written,” he said, according to one person who was in the meeting and another village employee who identified the voice on the recording as the mayor’s. They asked not to be named for fear of retribution. “We need to write more traffic tickets.”

Holmes, who handled our inquiries, did not respond to our request for comment on that statement.

The Cost of Being Rude

On the north side of Fenton, just before a welcome sign, the speed limit drops from 65 mph to 50. Police cruisers often wait here to catch speeders. Officers write, on average, about 16 tickets per day. (Jon Turnipseed/WVUE)

Watch video ➜

Fenton’s court records paint a picture of a justice system in which some people are punished for how they act while others are rewarded for who they know.

We found a dozen court records that include notations from officers and village employees saying not to “help” people or “fix” their tickets because drivers were rude. On a ticket for driving 71 mph in a 50: “Refused phone number, driver was very disrespectful no help.” Fine: $305.

A ticket for 81 in a 50: “Very bad attitude. Do not fix.” Fine: $490.

Video from an officer’s body camera during one traffic stop shows a woman, stopped for driving 62 mph, asking the officer to show her the radar reading and to let her go with a warning.

“What else do you guys do around this town?” she asked the officer after he handed her a ticket.

“Protect and serve,” he responded.

Her file reads, “Bad attitude.” She was fined $215.

Some tickets bear officers’ handwritten notes saying drivers had a “bad attitude.” We found a dozen court records with notations saying not to “help” people or “fix” their tickets because of their behavior. Holmes said such notes do not affect how cases are decided. (Obtained by WVUE and ProPublica. Redacted and highlighted by ProPublica.)

Holmes said notes about drivers’ behavior have nothing to do with how cases are decided. “A defendant is not punished for rude behavior during a traffic stop, but rather for objective, provable violations of law,” he told WVUE and ProPublica. Besides, he said, the vast majority of drivers decide to pay their tickets. (We spoke to several drivers with such notations in their files. Of those three, two said they didn’t contest their charges; the third said he couldn’t remember.)

Fourteen court files include notations saying a charge was dismissed after someone, often in law enforcement, had intervened. “Dismissed per Chief Alfred,” said the record for a ticket issued to someone who, according to the notation, knew a village employee.

Luther Alfred, the chief, said he sometimes gets requests to dismiss tickets and passes them on to the judge or prosecutor. Though he acknowledged that he has written “Dismiss” on paperwork and signed his name, he said he doesn’t dismiss charges himself and doesn’t have that authority.

Phillip Hattaway’s file for a speeding ticket he received in 2022 says, “Ivy Woods asked to dismiss per O’Quinn.” Woods is the sheriff of Jefferson Davis Parish, and Sgt. Vernon O’Quinn is Fenton’s police sergeant. In an interview, Hattaway said he contacted people he knew in law enforcement, asking for help. His ticket was dismissed. “It was short and sweet,” Hattaway said. “They just got it taken care of.”

O’Quinn said the department was “asked if we could provide any assistance,” and he “advised he didn’t have a problem with it and recommended to the prosecutor for dismissal.”

Asked why his name appears on court records, Woods said many people ask if he can get tickets reduced to nonmoving violations. “You’d be surprised how many tickets Fenton writes,” he said. “They’re pretty tough — they like their money.”

But he didn’t acknowledge calling in any favors, saying that the village “might be covering their butts, saying the sheriff asked.” Although he offered to elaborate later, he didn’t respond to subsequent phone calls.

In response to questions for this article, Holmes said, “Requests for consideration to amend or dismiss charges are received from myriad sources.” He didn’t answer a question about how the village decides which requests to act on.

We reached out to more than 100 drivers, including about 40 whose files said something about their behavior or why a ticket had been dismissed, and interviewed about 35. Several said they felt like they had been caught in a speed trap or said they had heard from others about Fenton’s reputation for traffic enforcement.

Fenton “most certainly does NOT operate a ‘speed trap,’” Holmes wrote to WVUE and ProPublica. Speed limits are well marked, police officers are stationed in the open, and tickets are rarely issued unless drivers are going more than 11 mph over the limit, he said.

Several drivers said they had been threatened with license suspensions or even arrest, both of which are allowed under state law.

When April Dugas called to ask for leniency on a ticket for driving 65 in a 50 mph zone, she said she was told Fenton issues warrants for unpaid tickets. “I was living in Texas in my car with no money for gas to go back,” said Dugas, who now lives in the central Louisiana city of Alexandria. “My grandma had to pay the ticket, so I wouldn’t have warrants out for my arrest.”

Holmes didn’t respond to a question about whether village employees threaten drivers with arrest if they don’t pay. He did say the village sometimes issues an arrest warrant to compel someone’s appearance in court, typically when they don’t show up for trial, but it’s “fairly rare.”

For those who miss court and don’t pay, the consequences can be severe. Fenton sent the Louisiana Office of Motor Vehicles about 750 requests to suspend driver’s licenses between 2018 and June, a number on par with much larger municipalities in the state.

Asked why Fenton does this, Holmes at first said state law requires municipalities to notify the state when someone doesn’t show up for court. He later acknowledged that’s not true and cited a two-year deadline under state law to request a suspension.

The village has asked the state to suspend some drivers’ licenses over a single unpaid speeding ticket, records show.

That’s what happened to Santina Griffin, a hairdresser in New Orleans who was stopped for driving 74 mph in a 50 mph zone on her way back from a funeral. She said she meant to ask the judge for leniency because she was lost at the time. But as a student and a single mom, she couldn’t make it back to Fenton for her court appearance.

She was surprised to hear the judge was also the mayor: “Sounds like a monopoly to me.”

Court Is In Session

Drivers who want to contest their speeding tickets must show up at Fenton’s City Hall, where mayor’s court meets once a month. (Jon Turnipseed/WVUE)

Watch video ➜

In a town the size of Fenton, visitors are conspicuous. We were especially so — four journalists toting notebooks and a video camera, driving around town, flying a drone overhead, watching police officers wait for speeders.

After checking out the town, we went to its small City Hall, where we encountered Luther Alfred, the police chief and uncle of the mayor, and O’Quinn, who came up to us to chat. We had been driving around recording video for a couple of hours by then, and they mentioned some places we had been. O’Quinn chuckled about a man who had warned us to keep our drone away from his house about 15 minutes earlier.

The people of Fenton care about three things, O’Quinn said: “Christ, family and the Fenton Police Department.”

We wanted to see how the court handled tickets written by that police department, but we saw the mayor handle cases just once in the four times we went to court.

Over the summer, Alfred had promised to talk to us when we came for the August court session. That was the first time we made the three-hour trek from New Orleans. But the mayor skipped our interview and canceled court without notice, surprising us and a few defendants waiting at City Hall.

When we went back in September, no defendants showed up. A court staffer later told us that few people come to court. Before the October hearing, we called ahead to arrange a time to review some files. A few days beforehand, court was canceled without explanation.

Last week, we gave it one last shot. This time, as our reporter pulled up to City Hall, she was surprised to see cars parked along the road. She took the only open spot, a patch of grass outside a utility building.

As a dozen defendants filtered in, Holmes, the prosecutor, fetched some chairs from the kitchen to accommodate them. He described what would happen. Tonight, he said, they were in what’s called a mayor’s court. This was an arraignment, where they would each enter a plea. He spent about 20 minutes describing their rights: You have the right to appeal to district court. You have the right not to incriminate yourself.

Holmes had told us that he offers plea deals to many drivers, and he did just that, telling them to meet him in the kitchen if they were interested.

Then he called the judge in. Alfred, wearing his judge’s robe, sat at a large wooden desk emblazoned with the village seal. Holmes called up each driver to answer to their charges before the judge. Most pleaded no contest, which means they didn’t admit guilt but accepted punishment.

When a driver wants to contest a ticket, Holmes had told us, the driver or a lawyer shows up in court, pleads not guilty and is told to return later. “A trial is conducted with all care to ensure each defendant receives due process and is treated fairly before the court,” he said.

That’s not what happened with one case that night. One man, facing a charge of failing to use his turn signal, insisted he was innocent. The mayor told him to wait so O’Quinn could find video of the stop and play it in court. The video was inconclusive, however, and the driver maintained his innocence. Holmes said if the officer were called to testify, he likely would say the driver had broken the law. But he suggested the charge be dropped, and the mayor agreed.

Under state law, mayor’s courts are required to keep a record of all trials, but we had been told there was none and that there hadn’t been a trial since at least 2018. Holmes had told us the mayor “is rarely called upon to pass judgment at trial.”

Afterward, our reporter went up to ask Holmes more questions. The mayor called her into the kitchen. He wanted to make sure she had noticed how lenient the court had been with defendants.

“We’re not without compassion,” Holmes said.

Alfred said he believes he’s a fair judge, despite all the money he collects through court. But, he said, we’d been asking a lot of questions. “Now,” he said, “we have to hire someone.”

That was the topic of discussion a week later, when the three members of the board of aldermen held their monthly meeting in the same kitchen where Holmes had arranged plea deals. “The mayor can’t be the judge,” Alfred said, “which to me does not make sense.“ A man named Hugh Cunningham, who presides over mayor’s court in a nearby town, stood up and described how he would run the court if hired.

Board members objected. “We have to pay somebody to be the judge when he was judging for nothing,” said one board member about Alfred.

For about 15 minutes, Holmes laid out why the town should appoint a magistrate: the Supreme Court ruling, attorney general’s opinions, the possible appearance of bias.

Under the law, Holmes said, it’s up to the mayor to appoint a magistrate; the board votes on that decision. It didn't take long for Alfred to make up his mind: “I think we should put it off because I think this court is fair.”

How We Reported This Story

Louisiana law requires municipalities to turn in yearly financial reports to the state auditor. Over several months, we reviewed the most recent available annual audits for all 301 municipalities and two combined city-parish governments required to file audits with the state. We compared revenue from fines and forfeitures to overall governmental revenue.

There is no official government definition of fines and forfeitures in those audits, but the terms generally cover penalties for breaking the law and associated fees. In some places, they could include collections outside court, such as library fines and traffic camera tickets. Fenton’s attorney confirmed that its total is made up of fines and fees collected through mayor’s court for violations of municipal ordinance. A small number of municipalities’ audits did not include a line item for fines and forfeitures.

We compared all municipalities, regardless of whether they had a mayor’s court. (There is no official list of municipalities in Louisiana with mayor’s courts, but the state Supreme Court said there are about 250.) Of all the municipalities we reviewed, Fenton’s share of total revenue from fines and forfeitures was the highest.

Do you have a story to share about a mayor’s court in Louisiana? Contact Lee Zurik at lee.zurik@gray.tv or 504-483-1544.

Joel Jacobs of ProPublica reviewed the data analysis.

Correction

Nov. 22, 2023: This story originally contained an inaccurate description of what the Fines and Fees Justice Center advocates for. The organization promotes equitable fines and the elimination of fees in the justice system, not equitable fees.

by Paige Pfleger, WPLN/Nashville Public Radio

This article was produced for ProPublica’s Local Reporting Network in partnership with WPLN/Nashville Public Radio. Sign up for Dispatches to get stories like this one as soon as they are published.

With a glint in his eye, Richard L. Bean reminisces about the days when children in his detention center could be paddled.

“We didn’t have any problems then,” Bean says. “I’d whip about six or eight a year and it run pretty smooth. They’d say, ‘You don’t want him to get hold of you.’” Once, he chuckles, a kid had to be held down by four guards to be spanked.

Bean took the helm of this East Tennessee detention center — now named the Richard L. Bean Juvenile Service Center — in 1972. The laws and the science on how to treat children in detention have changed a bit since then.

Yet Bean has held on to an old-fashioned approach to his work. These days, he’s reliant on a different tool for keeping kids in line: locking them alone in cells for hours — sometimes even days — at a time.

“What we do is treat everybody like they’re in here for murder,” he says. “You don’t have a problem if you do that.”

Most of the children in the Bean Center are not in for murder — in fact, most have only been charged with a crime, but are awaiting court dates.

Listen to Richard L. Bean describe paddling kids as punishment. “Had a lot of problems since” the state made him stop, he says. (Paige Pfleger/Nashville Public Radio and ProPublica)

At 83, superintendent Bean uses a bamboo cane to give a tour of the 120-bed facility. It’s connected to the juvenile court by a maze of windowless corridors; kids are passed between the two buildings in uniforms and shackles.

It’s difficult to know how children have been treated inside the walls of institutions like this one because policies designed to protect the privacy of kids can also obscure what goes on in facilities that break the law.

That was the case at a juvenile court about 150 miles west in Rutherford County, where reporting from ProPublica and WPLN revealed that kids were being illegally detained — at rates far higher than anywhere else in the state — for the most minor crimes, or even, in at least one instance, crimes that didn’t exist. The proof was right there, being collected by the state and laid out, for years, in an annual report. Yet no one flagged that kids were being jailed at a staggering rate, and no one seemed to try to stop it.

Here at the Bean Center, records reveal different violations of the law.

What we do is treat everybody like they’re in here for murder. You don’t have a problem if you do that.”

—Richard L. Bean, superintendent of the Richard L. Bean Juvenile Service Center

Kids have been locked alone in a cell here more often than other facilities in the state, sometimes as punishment, and sometimes for an indeterminate length of time. And even as the state has implemented reforms that would have made seclusion less common, the Bean Center remained reliant on the practice.

Here too, these violations are not a secret: The facility’s licensing agency, Tennessee’s Department of Children’s Services, has been documenting this improper use of seclusion for years at Bean’s center and elsewhere. The Richard L. Bean Center has repeatedly been put on corrective action plans. Yet DCS continues to approve the center’s license to operate without the facility changing its ways.

The Rules of Seclusion

In 2016, a suit in Rutherford County challenged the use of solitary confinement in the juvenile detention center after a child was kept in solitary for days for disrupting class. Around the same time, research emerged showing that isolating children doesn’t actually improve their behavior — if anything, it could worsen it. Solitary confinement can cause psychological impacts like depression, anxiety or psychosis, and young people are especially vulnerable to those effects. The majority of suicides inside juvenile correction facilities in the United States happen when a child is isolated.

So in 2017, DCS mandated that juvenile detention centers throughout the state change the way they use seclusion, adding guidelines and a reporting requirement.

The new standards said that children kept in seclusion inside Tennessee’s juvenile detention centers could be locked into cells that are 50 square feet — about the size of a U-Haul cargo van — usually with a concrete slab for a bed and a metal toilet affixed to the wall.

A cell at the Richard L. Bean Juvenile Service Center where kids are sometimes kept in isolation (William DeShazer for ProPublica)

Importantly, the standards made clear that seclusion was meant to be a last resort and should not be used as punishment.

“Seclusion shall only be used when necessary to prevent imminent harm to themselves, another person, prevent damage to property, or prevent the youth from escaping,” the standards dictate. “Staff shall never use seclusion for discipline, punishment, administrative convenience, retaliation, staffing shortages, or reasons other than a temporary response to behavior that threatens immediate harm to a youth or others.”

Shortly after, those standards were codified into state law.

In order to have their licenses renewed, which happens annually, juvenile detention centers are supposed to abide by DCS’ standards. Every few months, a DCS inspector drops into facilities unannounced to take a tour, review documentation of the use of tools like chemical sprays, and interview a few kids. The resulting inspection reports are written almost like a journal entry and provide a glimpse of life inside juvenile detention centers.

Listen to the WPLN Story

WPLN and ProPublica reviewed eight years of those inspection reports, covering 2016 to 2023, and found multiple instances of children being locked up in seclusion — sometimes for days or more than a week — for minor rule infractions like laughing during meals or talking during class. One facility put a child in seclusion for eight days for simply having head lice, which the inspector called “a little extreme.”

And while many facilities were documented using seclusion improperly, the Richard L. Bean Center emerged as particularly prolific in its use of seclusion as a means of punishment, even years after the state standards were imposed.

Tyshon Booker was 16 years old when he says he was secluded in the Richard L. Bean Center. Now he’s 24 and incarcerated at a nearby prison, serving a 51-year sentence for homicide — a sentence the state Supreme Court recently ruled amounted to cruel and unusual punishment for juveniles like Tyshon.

But even though it was years ago, he remembers his two-year stay at the Bean Center like it was yesterday. During his 2015-2017 detention there, he says he was kept in seclusion twice for several days on end, without reprieve. He was stripped to his boxers, a T-shirt and socks before being placed in a cell alone.

Boys at the Bean Center wear orange clothing and sandals. (William DeShazer for ProPublica)

He says he had to get creative to keep his mind from spinning out.

“I learned how to make dice out of bread,” Booker says. “I made dice, roll the dice for hours. And then you’ve got to remember, we’re in solitary confinement, so I’d get hungry and I’d eat the dice. So, like, just imagine, the savage life in solitary confinement — rolling dice on a dirty floor for hours,” he recalled. “It was horrible.”

He says he would also lay on the ground of his cell with his face pressed against the cold floor, trying to yell to another kid who was locked in a solitary cell nearby.

He says it was worse than anything he’s experienced in adult prison. He thinks prison conditions are better because there’s more oversight. At the Bean Center, on the other hand? “They think, ‘Oh, they’re kids. Nobody is going to do this to kids, nobody would treat kids like this.’ So I don’t think it’s as much eyes as the penitentiary.”

In 2018 reports from visits to the Bean Center, one child said he was secluded after he forgot to bring his books to class. “Staff will put you in seclusion if they don’t like you,” he told the inspector. Another child said he was secluded but he didn’t really understand why.

They think, ‘Oh, they’re kids. Nobody is going to do this to kids, nobody would treat kids like this.’ So I don’t think it’s as much eyes as the penitentiary.”

—Tyshon Booker, former detainee at the Richard L. Bean Juvenile Service Center

The same inspector visited the facility twice in October of 2018. On Oct. 16 she wrote that the facility “continues to be in good standing with the DCS licensing” and that the facility had corrected all its problems and could have its license renewed for the year. But when she returned the next day, Oct. 17, documents show the facility was put on a corrective action plan for a list of problems, including using seclusion as punishment.

Then in 2019, an inspector returned and found that the Bean Center’s reliance on seclusion as punishment had escalated. Seclusions at the facility that year were about double what they had been the year before. In just a few months, it reported more than 160 instances of locking up children alone.

On that visit, the inspector talked to five kids. Each one of them had seen youth placed in seclusion for fighting or not following the rules. One child said he was secluded for talking back. That would break not only DCS’ standards but also the new state law. Despite documenting evidence that the Bean Center’s problem with seclusion had only gotten worse, the facility was taken off its corrective action plan and had its license approved for another year.

In an email to WPLN and ProPublica, DCS says it has multiple levers it can pull if a facility isn’t in compliance, including freezing or slowing admissions, decreasing capacity, or even refusing to approve a license. But DCS says it has never used any of those options at the Bean Center.

Inside the Bean Machine

From the outside, the one-story brick Bean Center looks more like an elementary school than a junior jail. It’s situated just a few miles from downtown Knoxville, next to an ill-kempt sports field where kids play peewee football.

Inside, colorful stripes on the walls help kids navigate the hallways, an eerie counterpart to their neon orange prison outfits and the handcuffs they sometimes wear.

Color coding in the Bean Center’s hallways helps kids know where to go. (William DeShazer for ProPublica) The facility sometimes uses handcuffs and leg shackles on the children. (William DeShazer for ProPublica. Names blurred by ProPublica.)

Bean can be found sitting behind a massive desk in his office. Where the rest of the detention center is sparse, his office is stuffed. His walls are covered in photos of himself through the years with visitors to the facility. His tenure has lasted so long that he’s run out of wall space — the photos spill out of his office and into the hallway.

The room is cluttered with memorabilia — a can of pinto beans from his family’s renowned meals with local politicians, dubbed Bean dinners; bumper stickers for the current juvenile court judge; figurines of elephants; and political tchotchkes.

He says he thinks the politicians making the rules around juvenile detention centers and seclusion don’t know what it’s like inside these facilities.

“Most people think we’re running a kindergarten,” Bean says. “We’re running the juvenile junior jail for Knox County. And there’s some tough kids — tougher than the ones in the jail, I guarantee.”

Bean doesn’t see reform laws as the state trying to do right by these kids; instead he sees it as the state making his job more difficult. He compares his relationship with the state and DCS to his marriage of 55 years.

“You have to do a lot of kissing,” he says, laughing. “A lot of, ‘Yes, ma’am.’ You can’t always have it your way in this business.”

Bean’s office (William DeShazer for ProPublica)

In 2021, when the state ruled that kids could not be secluded for longer than six hours because of the damaging effects isolation had on them, Bean didn’t shy away from telling inspectors his thoughts.

An inspector wrote in August 2021 that Bean “stated that he did not feel two to six hours was enough time to lock the youth in their rooms,” a reference to the limits in the new law. “I also asked if the facility’s policy and procedures manual had been updated to reflect the new seclusion bill requirements. … The current policy and procedure manual for the facility was last updated in 1999."

That inspector also noticed a pattern: Instead of writing down the time the child was let out of the cell, as he was supposed to do on forms for the state, Bean would just write his initials, “RLB.”

Despite DCS’ policies and the state law dictating exactly how long kids could be kept in seclusion, Bean decided to use his own discretion. He said writing “RLB” was his way of denoting that it was up to him to decide when the children were ready to be released and rejoin the other kids. He told the inspector that he’d make that decision based on how “remorseful” a child was.

“I asked them how their attitude is,” Bean says. “I can’t let the kids run the place. Sometimes you get a kid, you put him in his room, and he cuss and call you everything in the books. It’s hard to let him out.”

The use of “RLB” instead of a specific time also made it impossible for the state to discern how long kids were being locked up alone.

A Tennessee Department of Children’s Services report from August 2021 noted that records did not always show how long children were held in isolation. (Obtained by WPLN and ProPublica. Highlighting by ProPublica.)

For those seclusion incidents that were documented properly, it was evident that Bean was keeping kids in their cells longer than he was supposed to. Most of the incidents of seclusion were “either definitively over 6 hours, or for an indeterminate amount of time,” the inspector wrote in the same report. One youth told the inspector that he had been placed in seclusion for “several weeks” for fighting.

Then in late 2021, something new happened: Bean’s seclusion numbers started dropping. It was the same year that a new law laid out the option for something called “voluntary time-out,” through which a kid can request to be left alone in their room for a few hours but is allowed to come out whenever they want to.

As the number of seclusions has fallen at the Richard L. Bean Center, the number of what inspectors called “voluntary seclusions” skyrocketed — in August of 2022, the facility reported just 44 seclusions compared with 122 the previous August.

According to the inspections, the facility also reported 344 voluntary seclusions.

“We don’t use it as punishment,” Bean explains. “So all of it’s volunteer.”

But the DCS inspector who visited that year noted that it was uncertain how voluntary the process actually was at the Bean Center.

“It is unclear whether the youth are aware that they can come out of their room by choice,” the inspector wrote. “The previous rule at the facility was that youth had to stay in their room for the remainder of the day if they chose to voluntarily go to their room.”

Bean believes he can “get out of” any trouble he may get into for his disciplinary practices. (Paige Pfleger/Nashville Public Radio and ProPublica)

Recently, Bean said he started a new rule — if a kid requests a voluntary lockup to avoid going to school, he responds by secluding them until the next morning.

“And then next morning, we say, ‘You want to go to school today?’” Bean said. “Most of them say, ‘Yeah, I want to go. I don’t want to be locked up.’”

Bean doesn’t seem to worry too much about getting caught.

“If I got in trouble for it, I believe I could talk to whoever got me in trouble and get out of it.”

Run It Like A Business

When asked what happens to inspection reports after they are filled out, DCS said that evaluation summaries “are distributed to the appropriate administrative parties and filed in the licensing record.” The department also said it provides a list of violations to the facility administrator; the administrator typically has 30 days to submit compliance documentation, which is verified by licensing staff.

DCS confirms that in the time it has been licensing juvenile detention centers in Tennessee, it has never terminated a license. And records from the Bean Center illustrate that corrective action orders can be lifted without the violation being resolved.

The department declined to comment further on why it never did more to crack down on the Bean Center.

“You can write everything into statute and create some really solid legislation, but if it’s not being used or it’s not being enforced, then what’s the next step?” asks Kylie Graves, policy director of the independent state agency Tennessee Commission on Children and Youth.

Graves said that there has been a tendency for the state to look the other way when it comes to juvenile justice in Tennessee.

A statue outside of the Bean Center celebrates “lives saved through caring.” (William DeShazer for ProPublica)

“The idea of this practice ever being used in a foster home or something like that would immediately raise flags and horrify people,” she said.

The Tennessee Commission on Children and Youth is calling for a third-party review of juvenile detention centers and the entire youth justice system. The agency points to Kentucky, which has proposed setting aside money to do just that. Several other organizations are likewise advocating for a review, including Disability Rights Tennessee, an organization that acts as a monitoring agency for juvenile detention facilities and has special access to the kids and documents inside.

“What seems like a good approach starting in January when the legislature reconvenes is to talk about putting in some type of mechanism for enforcing compliance,” says Zoe Jamail of Disability Rights Tennessee.

One proposal, Jamail says, could be a clean-up bill that would take oversight of juvenile detention facilities out of DCS’ purview, though she says she isn’t sure what agency could take that on. An audit last year found that nearly half of new DCS workers quit within their first year. That problem was compounded by an influx of kids entering the foster care system.

And the involvement of a third party could help mitigate a conflict of interest — DCS is invested in keeping county detention centers open and operating. In addition to being the licensing agency for the county detention centers, DCS also has contracts with most of those facilities to hold kids who have been convicted of a crime while they try to find placement for them.

DCS declined to comment on that arrangement.

“Most people think we’re running a kindergarten,” Bean says. “We’re running the juvenile junior jail for Knox County. And there’s some tough kids — tougher than the ones in the jail, I guarantee.” (William DeShazer for ProPublica)

It’s an arrangement that Richard Bean says is mutually beneficial — DCS pays his facility more than $175 per day per kid. He calls those kids paying customers.

Bean says that’s in addition to the $120 per day he gets from detaining kids from surrounding counties that don’t have a juvenile detention center.

Resting his chin on his cane, Bean says he doesn’t intend to slow down. He has big plans to hire more staff and get more bodies in beds — especially kids sent his way by DCS.

“I mean, you’ve got to take care of the kids,” Bean says. “But … you got to kind of run it like a business, too. I could make over one million dollars for the county.”

Meribah Knight contributed reporting.

by Topher Sanders, Jessica Lussenhop, Dan Schwartz, Danelle Morton and Gabriel Sandoval

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

Bradley Haynes and his colleagues were the last chance Union Pacific had to stop an unsafe train from leaving one of its railyards. Skilled in spotting hidden dangers, the inspectors in Kansas City, Missouri, wrote up so-called “bad orders” to pull defective cars out of assembled trains and send them for repairs.

But on Sept. 18, 2019, the area’s director of maintenance, Andrew Letcher, scolded them for hampering the yard’s ability to move trains on time.

“We’re a transportation company, right? We get paid to move freight. We don’t get paid to work on cars,” he said. “The first thing that I’m getting questioned about right now, every day, is why we’re over 200 bad orders and what we’re doing to get them down. … If I was an inspector on a train,” he continued, “I would probably let some of that nitpicky shit go.”

Haynes knew that the yard’s productivity metrics were hurting and that the repairs he ordered had a direct impact on his job security. Just that day, he’d flagged a 40-pound GPS box that was hanging by a cable off the side of a car. He worried it could snap off and fall on a colleague’s head or go hurling into a driver’s windshield. His boss greenlighted the car to leave anyway.

Haynes had started carrying a digital recorder in case he ever needed to defend himself. It captured him asking Letcher what would happen if a defect they let go wound up killing someone. The question went unaddressed as Letcher issued a warning: If they continued to hurt productivity by finding defects he deemed unnecessary, he would begin doling out punishment. He might even have to close the yard’s car shop.

“I’m trying to save your freaking jobs,” he said.

If the public thinks of America’s sprawling freight rail network at all, it typically does so when a train derails, unleashing flaming cars and noxious smoke on a community as it did this year in East Palestine, Ohio. The rail industry usually responds by vowing fixes and defending its overall record, which includes a steady decrease in major accidents. But a ProPublica investigation has found that those statistics present a knowingly incomplete picture of rail safety.

They don’t count the often-harrowing near misses, the trains that break apart, slip off the tracks or roll away from their crews with no one aboard — the accumulation of incidents that portend deeper safety risks. The government trusts the rail companies to fix the underlying problems on their own, to heed the warnings of workers like Haynes of loose hoses that could impair brakes or rotting tracks that could cause derailments. Unless those mishaps result in major injuries or costly damage, the companies don’t have to report them to anyone.

But as railroads strive to move their cargo faster, that honor system, ProPublica found, is being exploited. To squeeze the most money out of every minute, the companies are going to dangerous lengths to avoid disruptions — even those for safety repairs.

They use performance-pay systems that effectively penalize supervisors for taking the time to fix hazards and that pressure them to quash dissent, threatening and firing the very workers they hired to keep their operations safe. As a result, trains with known problems are rolling from yard to yard like ticking time bombs, getting passed down the line for the next crew to defuse — or defer.

Regulators say they can’t stop the intimidation that is feeding this dynamic. The Federal Railroad Administration can remove retaliators from working on the rails but seldom does, even if an employee alerts it to harassment in real time. Proving managers’ intent is difficult, a spokesperson said.

And the Occupational Safety and Health Administration, which enforces workplace whistleblower laws, only probes so deep. It takes the agency so long to conclude investigations that many workers, tired of waiting months for rulings, remove their complaints and sue the companies instead. Once that happens, OSHA has no legal authority to continue its investigation, barring the agency from exposing repeat bad actors or patterns in the industry’s abuse of whistleblowers.

To do what the government hasn’t, ProPublica examined 15 years’ worth of federal lawsuits against rail companies, interviewed hundreds of workers including managers, listened to hours of audio recorded by workers and pored over decades of regulatory, judicial, legislative and industry records. We identified 111 court cases in which workers alleged they had been disciplined or fired after reporting safety concerns; nearly 60% ended in settlements with the companies. Three in recent years resulted in jury verdicts of over $1 million for fired workers.

Separately, OSHA and Department of Labor administrative judges found railroad companies violated whistleblower laws in 13 cases since 2018 in which workers voiced safety concerns. Among the railroaders: one who tried to alert BNSF headquarters to broken wheels, which could have derailed trains (the company is appealing the case); two who slowed a CSX train to abide by a federal safety mandate (the company is appealing the case); and a CSX engineer who refused to work a 12-hour shift just hours after a previous shift without the period of rest required by law.

“It’s really hard to stay awake sometimes,” the engineer, Chad Hendrix, had testified, before CSX worked out a settlement with him.

The Association of American Railroads says that the industry’s sterling safety record “stands in stark contrast” to assertions made in this story. “From the day a trainee first reports on the job, railroads instill the message that every employee has a role to play in keeping themselves, their colleagues, and communities safe. Safety protocols are ingrained in daily operations, and employees are continuously empowered to report safety concerns so proactive steps can be taken to prevent a future accident,” the group said. (Read the full statement here.)

The companies mentioned in this story largely declined to comment on specific cases. (Read the full statements by Union Pacific, BNSF, Norfolk Southern and CSX.) They said they encourage their workers to voice safety concerns and tout internal hotlines where employees can do so anonymously. They say they do not tolerate retaliation.

But ProPublica found that companies retained and promoted supervisors who juries found had wrongfully terminated employees. And workers said that they had been targeted after making safety reports they thought were anonymous, or that they were ordered to stop calling safety hotlines, or that they’d simply grown apathetic, seeing hazards they had raised go unaddressed. Two BNSF employees sustained life-changing spinal injuries when their train crashed into a 6-ton tree that had fallen on the tracks; workers had warned their bosses that the tree was about to fall.

In interviews, one anguished rail worker after another said they have no place to report their concerns and that their clashes with management have triggered panic attacks, elevated blood pressure and thoughts of suicide. In 2011, a Norfolk Southern car inspector, under mounting pressure to stop reporting car defects, drove to work, clocked in and shot himself. His death shook the industry but didn’t change it. Norfolk Southern did not comment.

Karl Alexy, chief safety officer for the FRA, disagrees with the industry assertion that it is the safest it’s ever been, noting that grievous worker injuries and deaths haven’t changed in over a decade. “We’re not seeing an improvement in what’s really important: the lives of the workers,” he said. He also said worker fear is real and keeps critical information from regulators. “It definitely influences safety,” he said, “definitely for the worse.”

Haynes, the Union Pacific inspector, said he was tempted to overlook hazards after Letcher’s threat but came across a problem three weeks later that he couldn’t ignore: a car with faulty brakes, on its way out of the yard. Hayes flagged it for repair, but his manager again overrode him, so Haynes reported what happened to the FRA that morning. Though the agency has the capacity to inspect only about 1% of the rail system annually, its regulators can compel companies to make repairs, giving them deadlines and levying fines when they fail to meet them. The regulator issued a violation, Haynes said.

Haynes carried a digital recorder and captured a maintenance director, Andrew Letcher, threatening to dole out punishment to inspectors if they hurt productivity by finding defects Letcher deemed unnecessary. (Elise Kirk for ProPublica)

About two weeks after Haynes’ report, Union Pacific closed the yard’s car shop, furloughing Haynes and a number of his colleagues indefinitely. The workers filed a complaint to OSHA, sharing the recorded threat and alleging retaliation. They asked for an expedited ruling so they could move the case to the Labor Department’s Office of Administrative Law Judges, the next step. OSHA administratively dismissed the case, and the one in the new venue is pending, according to Haynes’ attorney.

Letcher, who is still at Union Pacific, did not respond to attempts to reach him. The company did not address any of the statements on the recording, but it told ProPublica any claim that the car shop was closed in retaliation is false. “The shop was closed in 2019 as part of our efforts to streamline the railroad,” the company said, which means “removing how many times the car is ‘touched.’ Every time that happens, it adds about 24 hours to a car’s journey, and our goal is to move them as quickly and safely as possible for our customers.”

In reports to investors, Union Pacific touts these efforts as a key part of its strategy to maximize profits. Jim Vena, who is now chief executive officer, even mentioned the Kansas City closure as one of the moves that contributed to record efficiency in 2019. “We’ve made a number of changes to our operations in the last year and the results have been outstanding,” he told shareholders in an earnings call. “As we move forward, look for us to continue pushing the envelope.”

Matt Sweeney, Chris Johnson, Roman Berndt, Corey Schanz and Haynes. The five were present during the conversation Haynes recorded with management, and they were furloughed. (Elise Kirk for ProPublica) Time Is Money

Much like the veins and arteries that transport blood through our bodies, America’s vast freight rail network quietly powers the national economy, moving 1.6 billion tons of product a year over 140,000 miles of track in trains that can each weigh as much as a fleet of jumbo jets. As they trundle through communities carrying cars packed with explosive or hazardous materials, the companies that run them insist safety is their top priority.

But the Association of American Railroads, in its online marketing, describes a powerful undercurrent that pulses through every mile of those tracks: “In the digital age, speed and efficiency are everything.” Customers who make one-click purchases expect their products delivered the very next day. And demand is only growing — the Federal Highway Administration projects that freight shipments will see a 30% increase by 2040. Governments can’t afford to build roads quickly enough, the industry group argues, but freight trains are already adapting: “Trains have been improved to carry more cargo in a single journey.”

ProPublica previously delved into the dangers of precision scheduled railroading, in which companies are running longer trains with smaller crews, adhering to tight schedules. Anything that slows trains can have job-ending repercussions.

On the busy rail corridor running through northwest Atlanta, there was a notorious stretch of track known for tripping up engineers. Larry Coston didn’t feel like he could navigate the large number of signal lights safely going the speed limit of 60 mph, so he radioed the dispatcher that he’d be driving at a slower speed, a 6 to 8 mph crawl, in an effort to avoid an accident.

Norfolk Southern fired him for “intentionally” delaying his assignment. The company declined to comment on specific cases. But his boss, and his boss’ boss, testified in his ongoing lawsuit that his judgment didn’t matter; engineers should travel at maximum authorized speeds regardless of their safety concerns. “Run your train,” his direct supervisor, Travis Bailey, a senior road manager of engines, said in a deposition. “Do your job.”

Supervisors have strong incentives to push their workers like this. Court records show that several freight rail companies rate and rank their managers using metrics that reward them for trains staying on schedule and penalize them for disruptions — even when the delays are caused by safety precautions. “Slow order delays,” for example, calculate the amount of time lost from slowing trains because of unsafe track conditions.

Lewis Ware, a senior general foreman in Norfolk Southern’s Savannah, Georgia, yard, had a reputation for keeping a close eye on bad orders. In 2019, car inspectors Kelvin Taylor and Shane Fowler filed a federal complaint alleging that Ware had repeatedly removed their repair order tags, allowing dangerous cars to leave the yard. They said Ware told them he had a quota — no more than 10 a week — regardless of the actual number of defects the inspectors found. (Ware disputed that figure, arguing that his goal was actually 20 bad orders at the time.)

Numbers like “bad order counts” can be used on scorecards to rank a manager. For example, Ware’s supervisor said in a deposition that metrics related to bad orders made up 15% of her final score.

The supervisor said that Norfolk Southern discourages managers from unilaterally removing repair tags and that Ware had been advised to stop.

The federal lawsuit filed by the workers was settled in October under confidential terms, and Ware, who still works for the company, declined to comment for this story. A Norfolk Southern spokesperson noted that OSHA sided with the company before the car inspectors filed their lawsuit, and said in a statement that it “does not tolerate retaliation of any kind” and has “partnered with our unions and their leaders to improve safety and collaboration.”

To assess the internal pressure on rail supervisors, ProPublica interviewed former managers who worked at CSX, Norfolk Southern and Union Pacific between 2011 and 2021. They confirmed that fewer safety reports made their jobs easier: less time spent driving miles up and down territory to eyeball a “complainer’s” claims, less time trying to fix the issue and less time doing paperwork.

For people in their jobs, they said, time literally is money. Across the industry, managers receive year-end bonuses tied to performance, often defined by how efficiently they move trains through yards. The managers estimated that on a $100,000 base salary, someone with a good evaluation can earn a $20,000 to $25,000 cash bonus. These payouts can drop dramatically if managers fail to meet certain metrics.

In Minnesota, a BNSF track inspector named Don Sanders recorded his manager, Keith Jones, berating him for writing up defects that reflected poorly on Jones. “I’m about to lose my job, my family’s welfare,” Jones, a division engineer, said in one recording. He would later testify that his annual bonus was tied to his year-end evaluation, which factored in the sort of defects flagged by Sanders. But Jones’ supervisors heaped on praise after he helped fire Sanders. His review: “Your team is injury-free, slow orders are at an all time low, relationships are good. Don Sanders is no longer working for BNSF.”

“Why in the World Would We Ever Call FRA?”

A BNSF track inspector, Don Sanders, recorded his manager, Keith Jones, berating him for calling the Federal Railroad Administration.

Jones declined to comment other than to emphasize that Sanders was fired for time theft, not in retaliation for safety reporting. Sanders claimed the time theft investigation against him was retaliatory. A federal jury sided with Sanders and awarded him over $9.4 million in 2021 for his wrongful termination; because of a cap on damages, the award was later reduced to $2.3 million. BNSF, which did not comment on the case, is appealing.

Sanders lost more than money from the entire episode. His estranged wife testified that he sank into a deep depression after he got fired, slept all day and was no longer the attentive partner and father he’d once been. “I lost my husband, basically.”

Accountability Is Elusive

Track inspector Brandon Fresquez had an odd sense of deja vu in 2015 as he performed his duties in a BNSF hub in Denver. He was seeing the same defects in the same spots he’d previously flagged for repair. Sometimes the company’s computer system said they’d been fixed; sometimes the entry was missing entirely.

Fresquez and some co-workers suspected their manager, roadmaster Michael Paz, was falsifying repairs at the direction of his boss. They viewed Paz as a bully who they said spoke openly about badgering inspectors into changing their safety reports and firing those who did not fall in line.

BNSF maintained an anonymous hotline for employees who wanted to report unsafe conditions. According to trial testimony in a lawsuit Fresquez later filed, nearly a dozen calls had come in about Paz. The inspectors would later testify that they believed the company told local managers, including Paz, which of them had called. “They were trying to nitpick every little thing we did and trying to get us in a disciplinary action,” testified Jacob Yancey, a worker responsible for making track repairs. “There was a list of people they wanted to meet with afterwards, and everybody who had made that phone call was on that list.”

Fresquez, who questioned the confidentiality of the hotline, took his concerns straight to the FRA after Paz asked him to change information about a defect so a track would stay in service. An official told him that would be a violation of safety standards, Fresquez said, but the FRA didn’t do anything more to intervene.

Fresquez said he came back to Paz relaying what the FRA official had told him and saying he would not lie about track defects. Paz declined to comment when reached by ProPublica, but he denied falsifying records when he was later called to the stand to testify. Paz gave inconsistent answers in his deposition and trial testimony about whether he knew Fresquez called the FRA. What is clear is that by the end of that day, Fresquez was on leave for insubordination. The railroad later fired him.

And so, Fresquez began his slog down the well-worn track of trying to seek justice for his perceived retribution — one that, for many railroaders, is a yearslong grind.

Brandon Fresquez, a former track inspector for BNSF, with gear from his time at the railroad. He took on BNSF in court, saying the company retaliated against him after raising safety concerns. (Eli Imadali, special to ProPublica)

Workers who contend that a railroad company violated their whistleblower rights must first file a claim to OSHA. The agency can accept complaints about harassment and threats before a worker is punished, but those can be more difficult to prove. More commonly, the agency becomes involved only after the employee is disciplined or is sitting at home without a paycheck.

It can take a year or longer for OSHA to complete an investigation. A spokesperson for the Department of Labor told ProPublica that while the optimal caseload for a whistleblower investigator is six to eight cases, the current average caseload is 17.

If 210 days have passed without an OSHA finding, workers can remove their cases and file a lawsuit in federal court. This can win them a big check, but it essentially allows the company to dodge any government ruling of retaliation. Take the case of Johnny Taylor, fired from Union Pacific under circumstances similar to Fresquez. After waiting seven months for OSHA to weigh in, he withdrew his whistleblower complaint and sued his former employer. Taylor was awarded $1.3 million after a jury found the company wrongfully terminated him. But because the OSHA case dead-ended, Union Pacific was never subjected to a ruling about whether it violated federal whistleblower law, which could have added to its public record about how it treats its employees.

In Fresquez’s case, OSHA quickly returned a finding that BNSF had retaliated against him. But knowing the company would likely appeal, his attorney, Nick Thompson, wanted to get the case in front of a jury sooner; he said most of his clients are often “destitute” within a year or two of losing their jobs. So began a gantlet of questions and cross-examinations, a trial and an appeal. “You’re a little guy trying to battle a million-dollar company,” Fresquez said. “I was in court basically for seven years. I lost sleep. I gained weight.” Some days, he wished he could disappear.

In 2019, a jury found that he was wrongfully terminated; he was awarded $1.7 million. An appellate court upheld the verdict late last year. BNSF declined to comment on this or any other case, but it wrote in a statement that “at BNSF, the safety of our employees always has been and always will be the most important thing we do. We believe that’s reflected in our record over the last decade, which produced the lowest number of injuries in our railroad’s history.” Paz is still a supervisor at the company.

Fresquez’s attorney got a sizable chunk of the payout, and what is left for Fresquez, he said, can never restore what he lost. “I’m fucked up, honestly,” Fresquez said. “My anxiety is so, so, so bad now.”

The change is palpable, Thompson said, serving as a cautionary tale to Fresquez’s former colleagues about what happens when you go up against a railroad company.

“Make no mistake about it,” Thompson said. “The winner of Brandon’s case was BNSF.”

BNSF train cars at a Denver facility (Eli Imadali, special to ProPublica) Reaching for a Lifeline

This June in Hernando, Mississippi, a train pulling 47 tanker cars filled with highly flammable propane somehow escaped from its crew. The workers had parked their train to remove a section of cars. When they returned, they discovered that the remaining 90 cars, including the tankers filled with propane, had begun rolling down the tracks on their own.

The crewless bomb train traveled for 3 miles through two public crossings until it gradually came to a stop.

“Oh my God. That’s terrifying,” U.S. Rep. Melanie Stansbury, D-N.M. said after ProPublica informed her of the incident. “Unbelievable that in the year 2023 this is happening.”

Because it didn’t crash or derail, neither Grenada Railroad, the small company that ran it, nor its parent company, Gulf & Atlantic Railways, needed to tell the FRA. Laws and rules don’t require companies to tell regulators when they lose control of a train, even one carrying explosive cargo.

But word got around. Alarmed railroaders encouraged the workers to report the close call to regulators; someone needed to investigate what happened to prevent it from happening again, they argued.

The workers were too afraid, said Randy Fannon, a national vice president of the Brotherhood of Locomotive Engineers and Trainmen. “Evidently the employees felt that they couldn’t acknowledge it or report it for fear of retribution,” he said.

A week after the incident, an FRA official got a text message from someone other than a Grenada employee, which prompted a government investigation. Gulf & Atlantic declined to comment on the incident. The FRA told ProPublica penalties are forthcoming.

“That Grenada personnel were concerned for their personal well-being [and didn’t] report the incident is unfortunate and diminishes safety on that railroad and the industry in general,” Alexy wrote in an email to ProPublica.

There is an alternative: the Confidential Close Call Reporting System, which the FRA piloted in 2007 and fully implemented in 2014. It allows railroaders to anonymously disclose safety concerns or close calls to a third party, NASA. Officials at the space agency screen them, and, after 30 days, forward them to a team of railroad and FRA officials. But the program is voluntary; just 25 of the nation’s roughly 800 railroads participate; none of the six largest freight companies, the so-called Class 1s, do.

This year, after the East Palestine derailment, lawmakers and Transportation Secretary Pete Buttigieg pushed for them to join the system. They all originally agreed to, but months later, progress has stalled. Rail companies and their industry representatives say that they don’t want employees to have blanket immunity from discipline and that NASA takes too long to communicate information on hazardous situations. They say their internal hotlines are more effective. Discussions are ongoing, and a spokesperson for the Association of American Railroads said the companies are "working in good faith to get an agreement."

Stansbury, the New Mexico lawmaker, along with U.S. Rep. Jamaal Bowman, D-N.Y., introduced the Rail Worker and Community Safety Act in September, which would create a close call reporting system, prohibit retaliation for use of sick leave, increase funding for FRA inspectors and expand the U.S. transportation secretary’s power to create rules.

Alexy said his agency is exploring revisions to federal law that could expand the kind of incidents that must be reported to the government, including runaway trains like the one in Mississippi, and is conducting safety audits on all of the large railroad companies — including interviews that will give employees opportunities to say how they are treated when they report safety concerns. He said the work will be done by the end of 2024 and shared with the public.

Deidre Agan, a BNSF conductor in Forsyth, Montana, hopes those kinds of changes will help. “I don’t want to see anybody else have to struggle and suffer through the stuff that I had to put up with,” she said.

In the gloom of a late summer evening in 2016, she was in a locomotive going over 50 miles per hour when the engineer, Scott Weber, rounded a curve and saw an object on the tracks that seemed to loom as big as a house. She heard him yell, “Duck!” and the train slammed into what turned out to be a 6-ton cottonwood tree that had fallen across the tracks.

The two workers were thrown from their seats as glass from the windshield sprayed the cabin. The locomotive dragged huge chunks of the tree down the tracks for nearly a mile before it finally stopped.

Deidre Agan was a BNSF conductor in 2016 when her train slammed into a 6-ton cottonwood tree, some of the remnants of which are pictured. (Erin Trieb, special to ProPublica)

In a flurry of emails between BNSF managers in the direct aftermath of the crash, one thing became clear: They’d been warned. According to conductor Don Purdon, everyone in the yard had noticed the tree at some point — its precarious lean, its dead bark. Five months before the collision, he’d reported it to an internal BNSF hotline. His managers promised to look into it but ultimately did not cut the tree down.

Just before the crash, Purdon’s managers forbade him from using the hotline because he was calling it too often, Purdon said. Then, they shut down the hotline altogether. “They tried to sweep it under the rug and say it wasn’t reported,” Purdon said.

BNSF declined to comment on the case. In depositions, Purdon’s manager claimed that decisions about the anonymous hotline had nothing to do with the accident. The best way to report hazards, he said, was to tell an immediate supervisor. That’s the very reporting method workers told ProPublica they feared most.

Don Purdon, a now-retired conductor, had voiced concerns about the tree that Agan’s train hit. He said his managers forbade from using an internal hotline because he was calling it too often. (Erin Trieb, special to ProPublica)

Weber had surgery to implant a metal plate and eight screws in his neck; the injuries pushed him into an early retirement.

And Agan, nursing a herniated spinal disc and a torn rotator cuff, was fired two days after the crash; she’d recently been written up for missing a deadline to renew one of her certifications. With no job or health insurance, there were days she remained in bed and cried. She self-medicated with alcohol and developed a severe drinking problem.

After more than two years in arbitration and in pain, BNSF reinstated Agan and she finally had spinal surgery. She’s been sober for a year and a half.

She said she hopes that speaking out will reveal the atmosphere of fear that she and her colleagues operate in every day, but her expectations are low.

“I honestly don’t think anything will help because, you know, money talks,” she said. As long as the companies continue to profit, “they really don’t care.”

Railroad tracks about an hour and a half outside of Billings, Montana (Erin Trieb, special to ProPublica)

Help ProPublica Report on Railroad Worker Safety

Jeff Kao, Carolyn Edds, Mollie Simon, Mariam Elba, Miriam Pensack and Ruth Baron contributed research.

by Maya Miller and Robin Fields

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This story is part of a partnership with Scripps News.

Forrest VanPatten was 50 and strong after years as a molten-iron pourer when he learned in July 2019 that a hyperaggressive form of lymphoma had invaded his body. Chemotherapy failed. Because he was not in remission, a stem cell transplant wasn’t an option. But his oncologist offered a lifeline: Don’t worry, there’s still CAR-T.

The cutting-edge therapy could weaponize VanPatten’s own cells to beat back his disease. It had extended the lives of hundreds of patients who otherwise had no chance. And VanPatten was a good candidate for treatment, with a fierce drive to stay alive for his wife of 25 years and their grown kids.

VanPatten didn’t know it, but he also had the law on his side. His home state of Michigan had long required health insurers to cover clinically proven cancer drugs.

He and his family gripped tight to the hope that the treatment promised.

Then, his insurance company refused to approve it.

Across the country, health insurers are flouting state laws like the one in Michigan, created to guarantee access to critical medical care, ProPublica found. Fed up with insurers saying no too often, state legislators thought they’d solved the problem by passing hundreds of laws spelling out exactly what had to be covered. But companies have continued to dodge bills for pricey treatments, even as industry profits have risen. ProPublica identified dozens of cases in which plans refused to pay for high-stakes treatments or procedures — from emergency surgeries to mammograms — even though laws require insurers to cover them.

Companies can get away with this because the thinly staffed state agencies that oversee many insurers typically don’t open investigations unless patients file complaints. Regulators acknowledge they catch only a fraction of violations. “We are missing things,” said Sebastian Arduengo, an assistant general counsel for Vermont’s insurance department.

In the 34 years since Michigan began to require cancer coverage, regulators there have never cited a company for violating the law.

Like most policyholders, VanPatten had no insight into the decision made by his insurer, a nonprofit called Priority Health that covers about a million Michigan residents.

He didn’t know that around the time the therapy won the Food and Drug Administration’s approval, executives at Priority Health had figured out a way to weasel out of paying for it.

Forrest celebrates his birthday in 2012. (Courtesy of the VanPatten family)

Through interviews with former employees and a review of company emails and VanPatten’s medical records, ProPublica was able to crack through the usual secrecy and expose the health insurer’s calculations.

Former employees said the decision not to cover this treatment and a related one was driven almost entirely by their high price tags — up to $475,000. Side effects that could land a patient in the hospital can push the bill over $1 million. Priority Health number crunchers calculated to the penny the monthly cost per policyholder if the company shifted the expense to them: 17 cents. But executives didn’t raise premiums or absorb the extra cost. They decided to save that money.

Patients’ needs weren’t part of the equation, recalled Dr. John Fox, then Priority Health’s associate chief medical officer. “It was, ‘This is really expensive, how do we stop payment?’”

Over Fox’s objections, fellow executives came up with a semantic workaround: These cancer drugs aren’t technically drugs, they argued, they’re gene therapies. All Priority Health had to do was to exclude gene therapies from its policies, and it could say no every time.

Priority Health said in a written statement to ProPublica that it provides compassionate, high-quality, affordable coverage and spends 90 cents of every premium dollar on member care.

“We are committed to making medical innovations available to members as quickly as possible, regardless of cost, as soon as they have been proven to be safe and effective,” Mark Geary, a spokesperson, wrote. The company said it initially didn’t cover CAR T-cell therapy because there was a “lack of consensus” about the treatment’s effectiveness.

“Major life-threatening complications and side effects were common, with a high rate of relapse,” the statement said.

At the time of VanPatten’s denial there was, in fact, already substantial consensus about the medication. In December 2017, the National Comprehensive Cancer Network, then an alliance of 27 leading U.S. cancer treatment centers, spelled out in its guidelines for B-cell lymphomas which patients should receive the therapy and when. VanPatten’s doctor said he met the criteria.

“It was, ‘This is really expensive, how do we stop payment?’”

—Dr. John Fox, Priority Health’s former associate chief medical officer

VanPatten’s family signed a privacy waiver giving Priority Health permission to discuss his case with ProPublica. Nevertheless, Priority Health did not respond to questions about his case or whether the company had violated Michigan’s mandate to cover cancer drugs when it refused to pay for his therapy.

VanPatten was disappointed but tried to remain optimistic after the first denial in January 2020. He and his wife, Betty, who worked in medical billing, knew it often took an appeal to coax the insurer to approve care.

In early February, Dr. Stephanie Williams, then the head of the blood and marrow transplant program for Spectrum Health, came to see VanPatten in his hospital room on Grand Rapids’ Medical Mile. It had been more than six months since his diagnosis.

He was sitting up in bed hooked up to an IV. His face, once framed by reddish eyebrows and a signature goatee, was hairless and drained of color. Betty pasted on a tight smile.

Priority Health had denied the treatment again, Williams told them, though she vowed to keep fighting.

When she left the room, VanPatten swung his legs over the side of the hospital bed. He had remained resilient and good-humored through his illness. But at that moment, he felt like Priority Health was treating him like an expense, not a person. It got to him, the idea that the insurer he dutifully paid each month knew this was his only chance and was holding it just out of reach.

He grabbed a tissue box from a tray and hurled it against the wall.

Fox, whom Willams described as the “conscience of the company,” had long been the point person for oncology in Priority Health’s medical department. In his earlier life as a practicing physician, he had trained at the Centers for Disease Control and Prevention as a chronic disease epidemiologist. When he joined Priority Health in 2000, he admired the company’s focus on preventive care and the fact that his bosses encouraged him to build deep relationships with local hospitals and doctors.

Dr. John Fox (Kristen Norman for ProPublica)

CAR T-cell therapy was a breakthrough more than 20 years in the making, and Fox had tracked clinical trials and talked to oncologists about it. By genetically reengineering patients’ own white blood cells, then infusing them back into the body to fight cancer, the treatment helped most participants in clinical trials get into remission within three months.

He knew this would be a game changer for patients. He also knew the law. So when news of the FDA’s approval of the first CAR-T medication, Kymriah, hit his inbox in August 2017, he recalled, “I said, ‘You know, we’re required to cover this. This is a treatment for cancer.’”

But the culture at Priority Health had shifted over the previous year under new leadership to focus on cost savings, Fox and four other former employees said in interviews. The company brought in a new chief medical officer, Dr. James Forshee, in late 2016 from Molina Healthcare, an insurer known for wringing profits out of Medicaid managed care plans.

In conversations about the new treatment, several former Priority Health employees recall, Forshee pointed out that the law required covering cancer “drugs,” and he argued that the new treatment actually wasn’t a drug; it was a gene therapy. (Through a company spokesperson, Forshee declined to comment for this article.)

Fox thought this was ridiculous. He pressed company lawyers for an opinion. Priority Health’s filings with the state “indicate that we have to cover FDA approved cancer drugs,” Fox wrote to two members of the legal department in a September 2017 email.

Senior counsel John Samalik responded, bolstering Forshee’s position that Priority Health didn’t have to cover Kymriah: “I believe legally we have a defensible argument that Kymriah is a gene therapy and not a drug.” (Samalik declined to comment through a company spokesperson.)

A September 2017 email written by John Samalik, a Priority Health senior counsel (Obtained by ProPublica. Highlighting by ProPublica.)

Fox pointed out that the company already covered another gene therapy. He told ProPublica that he suggested asking state regulators whether the cancer-drug mandate applied to Kymriah, but Forshee and at least one other executive refused.

“My inference being that, if we ask the state, they would say yes, so let’s not ask,” Fox said. Two other former Priority Health employees involved in the discussions confirmed Fox’s recollections.

The FDA approved a second CAR T-cell medication, Yescarta, seven weeks after the first approval.

When ProPublica asked if the FDA considered CAR T-cell therapies drugs, an agency spokesperson said yes. She wrote in an email that they have been regulated as gene therapies, and that they “are biological products and drugs under the Public Health Service Act (PHS Act) and the Federal Food, Drug and Cosmetic Act.”

Fox continued to push Priority Health to cover them; Forshee didn’t budge.

As they often did for new therapies, Priority Health’s actuaries calculated the price tag. They estimated that each year, one patient would need Yescarta and one Kymriah. If spread across the company’s members, the therapies would cost an extra 17 cents per member per month — 8 cents for Yescarta and 9 cents for Kymriah, emails show.

If the company had chosen to absorb the cost rather than raise premiums, the extra expense — potentially more than $1 million for each patient receiving the therapy — could have hurt its bottom line. Other insurers had also balked at the cost of CAR-T and were slow to cover it.

Priority Health made a slight tweak to its 2018 filings to state regulators, one with life-changing implications for patients like VanPatten. As it had in the past, the company said it covered drugs for cancer therapy “as required by state law.” But the insurer slipped in a new sentence more than a dozen pages later: Gene therapy was “not a Covered Service.”

Watch the Scripps News Report “Hope Denied”

Meanwhile, regional and national health plans began approving the drugs. Kaiser Permanente started covering them within months of the FDA’s approvals. Blue Cross Blue Shield of Michigan — the state’s biggest health plan and Priority Health’s main competitor — paid for a cancer patient to receive CAR T-cell therapy in December 2017. (A spokesperson said in an email that the plan added coverage based on the treatments’ efficacy, without considering whether Michigan’s mandate applied. “We would have covered these drugs irrespective of the law,” she said.)

When the national Blue Cross Blue Shield Association made an announcement about CAR-T coverage later in 2018, employees at Priority Health forwarded it to one another. It was an I-told-you-so moment for Fox.

At a meeting that December, Fox made the case again that Priority Health should ask the state whether Michigan’s law required covering the new cancer treatments. 

Forshee bristled. “You don’t trust our legal counsel?” he responded, according to Fox and another executive who attended.

His own temper rising, Fox considered what would happen if the company maintained its position. Patients who needed these therapies would likely die. Fox and his team would have to sign the denial letters, knowing the despair and anger they would sow.

After working at Priority Health for more than 18 years, Fox had once thought he’d retire there. He left that meeting certain he had to move on.

“Health plans have a right to make money; we’re providing a service,” Fox said. “But we have to do that honestly and fairly, putting patients first, not profits or premiums first. To me, that’s where we crossed the line.”

Priority Health’s headquarters in Grand Rapids, Michigan (Kristen Norman for ProPublica)

About seven months later, on a sticky night in July 2019, Forrest and Betty VanPatten were sipping beers with friends at the local club of the Fraternal Order of Eagles.

When they’d moved to Sparta, a small Michigan town known for its apple orchards, this was where they’d found community. The club had hosted countless charity raffles and fundraisers, including a “pink night” for the American Cancer Society for which Forrest squeezed into a hot-pink minidress Betty sewed for him. (There wasn’t much off-the-rack that could fit his almost 6-foot-8-inch frame.)

They were expecting biopsy results at any moment. Forrest had gone to the emergency room the previous weekend with intense pain. He’d made it through two previous bouts of lymphoma and suspected he was about to face another.

Forrest’s phone rang. It was the office of his primary oncologist, Dr. Brett Brinker. Oncologists meet hundreds of patients and their families, but Brinker had grown deeply fond of the VanPattens. Forrest was the guy who could talk to anyone, who made the party worth attending. Betty was his perfect foil. Their laughter and candor left a lasting impression.

The news was bad. Forrest had something called Richter’s transformation. It made his lymphoma significantly more aggressive and less likely to respond to conventional chemotherapy. After hanging up, Forrest typed Richter’s into his phone. Almost immediately, he proclaimed, “This is a death sentence.”

Betty needed to clear her head. She walked around the block, passing a restaurant where Forrest’s name was on the wall for completing a taco-eating challenge. When she got back, she urged Forrest to snap out of his defeatism.

He had just celebrated his 50th birthday and was determined to be around for his 51st. His kids, Donovan, 23, and Madison, 22, were in serious relationships, and he wanted to be there for their weddings.

“So we went in and got a game plan,” Betty said. Forrest would begin with chemotherapy, and, if the cancer went into remission, they would try for a stem cell transplant. If the cancer didn’t go into remission, Brinker made it clear they weren’t out of options. He told them about CAR-T.

It felt reassuring at the time.

By January 2020, CAR-T was all they had left. Brinker said he thought the treatment could at least bring Forrest’s disease under control for a few years. “It’s hard to use the word ‘cure’ when it’s acting like that,” he said of Forrest’s cancer. But if they won some extra time, he said, “there’s always something in the wings you can hope for.”

On Jan. 28, Williams, the doctor who ran the transplant program, worked with her team to submit a request for coverage to Priority Health. Williams knew the company’s policy on CAR-T but thought the insurer might relent when faced with an actual patient who was certain to die without the treatment. Plus, by that point, the federal government was covering the therapies for Medicare patients, and insurers often follow its lead.

Knowing it could take weeks to grow the cells used in the treatment, his doctors prepared to extract his white blood cells. “These are diseases where we don’t have a lot of time to waste,” Williams said.

Then Williams’ office found out that Priority Health had denied the request. Forrest’s doctors appealed but were turned down again, prompting Forrest to throw the tissue box at the wall.

Williams felt it, too. “I was deflated. I was angry,” she recalled. “We kept trying to work it out, and we kept hitting roadblocks.”

The VanPattens didn’t have the money to pay out of pocket, and Forrest didn’t want to saddle his family with medical debt. His medical team filed a third and final appeal, this one to an independent reviewer.

As that went forward, the VanPattens received a letter from Priority Health explaining its reasons for denying Forrest’s treatment. CAR-T cell therapy “is not a covered benefit,” and “therefore, we are unable to approve this request,” the letter stated. Somehow, seeing the words in writing conveyed a different finality, sending Forrest into a downward spiral.

“Everybody deserves the chance of fighting,” Betty said. “Once you take somebody’s hope away, you kill them — you really, really do. It was evident with him. He was defeated, and he had never been defeated in his life, and that was hard to watch.”

“He was defeated, and he had never been defeated in his life, and that was hard to watch.”

—Betty VanPatten

Their son, Donovan, took to social media to blast Priority Health for its decision, hoping to shame the company into a last-minute about-face. He included a screenshot of a text message from Forrest, who knew his insurer was an outlier. “It should be noted that Blue Cross and Blue Shield of MI pays for Car T Cell!” it read.

A reporter for Scripps News Grand Rapids, WXMI, a local TV news station, interviewed Forrest on Feb. 13 in the suede recliner he’d long claimed as his chair in the family’s living room.

“I feel like I’m being ignored,” he said, tears streaming down his face. “Left out to die, basically.”

Days later, Forrest was back in Butterworth Hospital with shortness of breath. “He is in acute distress,” an emergency room doctor noted when he was admitted.

The following night, his heart stopped beating. Betty retreated to the back of the room as doctors and nurses swarmed in. Donovan sat in a chair outside, his head in his hands.

Madison raced through Grand Rapids’ snow-covered streets to join them. When she reached her father’s room, a member of the medical team was still pushing down on his chest. But, she recalled, “it was clear he wasn’t there anymore.” The family told his doctors to end the resuscitation effort.

Forrest died on Feb. 17, before the independent medical reviewer had a chance to weigh in. Three weeks had passed since Williams and her team had asked Priority Health to cover the therapy.

Williams said that if Priority Health had approved the first request, Forrest could have received the infusion. It’s unknowable whether the treatment would have given him more time, she said, but if he’d had that chance, “anything is possible.”

Not long after Forrest died, his family received a handwritten card from a clinical coordinator who cared for him.

“I am so so so sad that we didn’t get the chance to put the rest of our plan into motion,” she wrote. “In honor of your kind (+very funny) husband, dad, friend, I promise to continue to push for Priority Health to cover CAR-T and to bring hope to all who need it.”

In Priority Health’s statement, Geary, the spokesperson, wrote that the company began covering the therapy “after extensive clinical work improved the treatment.” The company would not say when it began paying for the treatment or whether Forrest’s death influenced its decision.

“It is devastating when a disease takes a member’s life,” the statement said. “We recognize the deep pain of losing someone you love.”

First image: The VanPatten family gets together on Sundays for dinner and has continued the tradition after Forrest’s death. Second image: Family photos line a shelf in the VanPattens’ home. Forrest didn’t live to see his children’s weddings. (Kristen Norman for ProPublica)

To former state Sen. Joe Schwarz, now 86 and retired, the story of Priority Health and Forrest VanPatten is a painful echo of a problem he thought he’d fixed.

More than 30 years ago, Schwarz helped write the Michigan law requiring insurers to pay for cancer drugs. Schwarz, a physician, still recalls what drove him to action: Insurance companies were refusing to pay for drugs given to make chemotherapy more effective, arguing they weren’t themselves chemotherapy. An op-ed in the Wall Street Journal by the head of the Association of Community Cancer Centers confirmed that insurers nationwide were denying coverage for cancer patients.

At a Senate hearing, Schwarz accused health plans of abandoning their policyholders based on a “play on words.” When ProPublica told Schwarz about Priority Health’s gene-therapy argument, he let out a mirthless “hah,” scoffing at the wordplay.

“You shouldn’t split hairs between the term gene therapy and the term chemotherapy or the term radiation therapy or the term surgical therapy,” he said. “They’re all cancer therapies and they should all be covered.”

“You shouldn’t split hairs between the term gene therapy and the term chemotherapy or the term radiation therapy or the term surgical therapy. They’re all cancer therapies and they should all be covered.”

—Former state Sen. Joe Schwarz

ProPublica gave Michigan’s Department of Insurance and Financial Services a detailed description of VanPatten’s case, as well as Priority Health’s contention that it didn’t have to cover CAR T-cell cancer therapies. We asked if Priority Health broke the state law on cancer treatments. Laura Hall, the department’s communications director, wouldn’t say. The agency can investigate if it spots a pattern of improper denials, but “in general,” she said, it only acts if a patient or their representative files a complaint.

The VanPattens didn’t do that. And they didn’t know about the Michigan law until ProPublica told them about it.

In the months after her husband died, Betty VanPatten was too weighed down by grief and anger to tangle with Priority Health through state insurance regulators. The days were a blur. Donovan and his partner, McKenzie, moved in with Betty, who threw herself into her job.

“I’d get up at 4, and I’d have my laptop and I just worked until about 9 or 10 o’clock,” Betty said. “And a lot of times I’d just sit there and the tears are just running down my face.”

The VanPattens still struggle with the sense that Forrest suffered an injustice and that Priority Health got away with it.

“They lost sight of the patient,” Betty said at a family dinner this July. Madison agreed.

“Insurance is meant to protect people,” she said, “not to make them fight through the last day to get what they should.”

Do You Have Insights Into Dental and Health Insurance Denials? Help Us Report on the System.

Kirsten Berg contributed research.

by ProPublica

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A New York state appeals court has handed freelance journalist William D. Cohan a legal victory, affirming the dismissal of a defamation lawsuit filed against him by the subject of an article published by ProPublica. Ruling with unusual dispatch — the court issued its opinion on Oct. 31, only three weeks after oral arguments — it declared that the article “flatly contradicts the existence of actual malice,” the standard of proof that a public figure must meet to win a libel suit. “The plaintiff failed to show,” the opinion stated, “that his claims had a substantial basis in law.”

The plaintiff, Jide Zeitlin, sued Cohan in 2021, claiming that he was defamed by the article, “The Bizarre Fall of the CEO of Coach and Kate Spade’s Parent Company.” The article examined Zeitlin’s rise from being the son of a Nigerian maid to a Goldman Sachs partner and Fortune 500 CEO, and then his downfall, as allegations of an extramarital affair with a woman he photographed contributed to his resignation from Tapestry, the corporation that owns Coach and other brands.

In its four-page opinion, the appeals court credited the fact that Cohan cited Zeitlin’s denials in the article, provided links to original documents so that readers could judge for themselves and relied on a “host of other sources whose reliability plaintiff does not challenge.” As the opinion put it, “plaintiff’s allegations of actual malice rest largely on his own statements.”

“We are extremely gratified by this victory,” said Jeremy Kutner, ProPublica’s general counsel. “The court immediately recognized that the article was balanced and deeply reported, rejecting Zeitlin’s claims just three weeks after it heard the case.”

ProPublica was represented by Jay Ward Brown and Emmy Parsons of Ballard Spahr LLP.

by Robin Urevich, Capital & Main, and Gabriel Sandoval, ProPublica

This article was produced for ProPublica’s Local Reporting Network in partnership with Capital & Main. Sign up for Dispatches to get stories like this one as soon as they are published.

As part of Mayor Karen Bass’ signature homelessness initiative called Inside Safe, the city of Los Angeles awarded Las Palmas Hotel a contract potentially worth about $2 million to temporarily shelter people living on the streets.

But the 62-unit hotel in Hollywood was already supposed to be providing housing for people who couldn’t afford to live anywhere else under a 2008 city law meant to ease a “housing emergency” that has grown more severe in the past 15 years.

Inside Safe participants now fill most of Las Palmas’ rooms at nightly rates of up to $140, according to the hotel’s contract with the city — more than double the amount Las Palmas would likely earn if long-term residents rented the rooms as that law requires.

Las Palmas is one of eight residential hotels that have received contracts over the past year to house homeless people through the new Inside Safe program, a Capital & Main and ProPublica investigation found. Of those, five hotels including Las Palmas have collected city funding despite seemingly violating the housing ordinance by offering rooms to tourists.

LA’s struggle to preserve low-income housing while simultaneously trying to shelter the growing number of people living on the streets represents an increasingly common national problem as city leaders wrestle with the competing needs of different populations amid a limited housing supply.

Residential hotels, which offer basic single rooms sometimes with shared bathrooms, have long been a kind of last-resort housing for low-income, older and disabled people. The 2008 law bars landlords from turning their buildings into condos or tourist hotels unless they build new units or pay an equivalent fee to the city’s Affordable Housing Trust Fund.

Altogether, at least 18 residential hotels have turned into interim shelters through various homeless services programs since 2016, according to a review of the LA Housing Department’s residential hotel list, Inside Safe contracts, state awards for housing construction and a Los Angeles Homeless Services Authority database of interim housing sites.

Now, that number is set to grow as dozens more residential hotels could become temporary shelters. On Nov. 1, citing a “desperate need for interim housing,” Bass issued an executive order that allows Inside Safe or similar programs to use the city’s 16,000 residential hotel rooms in 300 buildings during the city’s declared homelessness emergency as long as the rooms are unoccupied.

Turning such permanent housing into temporary shelters only makes the city’s housing problems worse, said Barbara Schultz, director of housing justice at the Legal Aid Foundation of Los Angeles.

“It is inconceivable to me that the city would reduce the number of permanent units affordable to low-income people when we are in the middle of this ginormous housing crisis,” Schultz said.

Bass' press secretary Clara Karger said in an email that the mayor’s office decided that temporary housing is a better use of the rooms given LA’s housing crisis.

“It is troubling that residential hotels were being misused for daily rates and short-term vacation rentals,” she wrote. “Now, many of those rooms are being used to urgently bring people inside and save lives, and the mayor has directed the Housing Department to address enforcement and to conduct a comprehensive review of all residential hotels.”

This summer, Capital & Main and ProPublica reported that the Housing Department had done little to enforce the residential hotel law as 21 properties openly offered rooms to tourists on travel websites. Following a request by the mayor’s office, Housing Department managers investigated and issued citations to the owners of 17 hotels, including Las Palmas.

Pankaj Naik, CEO of Shivay Hospitality, which operates the hotel, declined to comment or answer questions. Las Palmas has appealed its citation and joined other hotels in a federal lawsuit against the city, alleging that residential hotel enforcement violates their constitutional protection against unreasonable searches. The owners also argue the city has given them tacit approval for short-term rentals by accepting nightly hotel tax payments. The lawsuit is ongoing.

The Housing Department told the mayor that with additional resources, the agency could “stop rogue property owners from violating the Residential Hotel Ordinance and undermining the availability of affordable housing stock.”

But now Bass’ office has removed hundreds of those same residential hotel rooms from the permanent housing market. And the Housing Department’s enforcement hasn’t stopped the city from giving the hotels hundreds of thousands of dollars in taxpayer money. Las Palmas’ Inside Safe contract expires in mid-November, but it provides for a six-month extension.

Patricia Harrold, an 80-year-old pianist at Miceli's, a landmark Hollywood restaurant, has lived at Las Palmas for 29 years. (Barbara Davidson for ProPublica)

Under Inside Safe, which Bass launched shortly after taking office in December, city staffers target tent cities under bridges or on sidewalks. Outreach workers offer motel rooms while buses stand by to ferry those who accept the offers to their temporary dwellings. Once the encampment residents are gone, sanitation workers break up the camps, toss trash and hose down sidewalks.  

The pressure on city leaders to bring people inside from street encampments is “immense,” said Gregg Colburn, a University of Washington real estate professor who studies homelessness. On any given night, an estimated 32,700 Angelenos live in cars, tents and makeshift shelters, and Bass promised to find housing for 17,000 of them in her first year.

“The problem with that strategy,” Colburn said, “is it doesn’t end homelessness. It recharacterizes it from unsheltered into sheltered, which is why I and many others argue we need a lot more permanent housing.”

Housing Enforcement, Then Lucrative Contracts

The Housing Department is supposed to approve any conversion of residential hotel buildings from permanent housing, but department records for 10 of the hotels obtained by Capital & Main and ProPublica didn’t show that permission was obtained to turn the hotels into temporary shelters.

The Housing Department did not provide all the hotel files that the newsrooms requested. It also didn’t respond to an interview request or answer emailed questions about whether it had cleared the hotels and what procedures they have for Inside Safe. Instead, the agency said it would handle the queries as a public records request.

Housing Department records revealed that inspectors had cited two of the Inside Safe properties for residential hotel violations in recent years. Hotel booking websites showed three others were openly renting rooms to tourists against Housing Department rules shortly before signing contracts with the city.

Las Palmas is a prime example. The hotel for years advertised its central location for travelers visiting Hollywood, capitalizing on its fame as the site of the final scene in the movie “Pretty Woman.”

The final scene in the movie “Pretty Woman” was filmed on Las Palmas’ fire escape. (Barbara Davidson for ProPublica)

The Housing Department had designated Las Palmas as a residential hotel in 2011. It based its decision, in the Las Palmas case and others, on the state’s legal definition of a residential hotel: a building of six or more units that are the primary residences of their guests. During the period analyzed in 2005, hotel tax records showed that 93% of its occupants were permanent residents.

But as tenants moved away or died, the struggling actors, writers and celebrity impersonators who called Las Palmas home watched as their landlord turned more and more of the units into tourist rooms. The hotel’s website features a photo of the lobby with a mural of “Pretty Woman” stars Richard Gere and Julia Roberts reuniting on the building’s fire escape. The website promises visitors a “wonderful holiday” and a “blissful stay.”

Today, only about a dozen permanent residents remain, according to residents and the latest rent registry filed with the Housing Department.

As rents have soared, Las Palmas is the only housing most can afford, said writer John Bucher, 72. He got his third-floor room at the hotel 12 years ago “when there was still a payphone in the lobby.” Bucher has driven for Uber and DoorDash to supplement his income and can count on his adult kids to help him in an emergency. But for his neighbors, the hotel “is their safety net,” he said. “They’ll die here.”

John Bucher, a 72-year-old writer, has lived at Las Palmas for 12 years. Over time, more and more rooms have been rented to tourists as residents have moved away or died. (Barbara Davidson for ProPublica)

As Las Palmas turned into a tourist hotel, it did little to hide its marketing efforts. Outside was a large sign offering “DAILY” and “WEEKLY” rentals. A housing inspector even snapped a photo of it in 2019, potential evidence that the hotel was violating the residential hotel law. But there’s no indication the inspector asked about the sign or followed up to ensure the hotel wasn’t being rented to tourists. And Las Palmas wasn’t cited under the ordinance until this summer, a few months after receiving the Inside Safe contract.

That wasn’t the case for two other hotels that similarly landed Inside Safe agreements: the Top Hat Motel and the Central Inn in South Los Angeles. The Housing Department cited both hotels in recent years for advertising to tourists in violation of the residential hotel law.

But in both cases, the hotels’ attorney wouldn’t allow inspectors to reenter without administrative warrants. Housing Department enforcement records show no evidence that inspectors obtained warrants, and no further enforcement action was taken.

Yet even that knowledge of violations didn’t prevent the city from awarding them Inside Safe contracts.

Neither of the owners of the Top Hat or the Central Inn returned phone calls seeking comment, and the Top Hat’s owners didn’t respond to an email. One of the Top Hat’s owners, Dipakkumar Patel, said at an appeal hearing that he would lose “everything” if he were unable to continue short-term rentals at the hotel. The hotel also joined the civil rights lawsuit against the city.

The Top Hat brought in nearly a half million dollars between late March and the beginning of October through Inside Safe, while the Central Inn earned more than $200,000 from May to September, according to invoices the motels submitted to the city’s administrative officer.

Stealing Permanent Housing

By turning residential hotels into temporary shelters, Bass may be working against her ultimate goal of transitioning people to permanent homes, housing experts said.

While Bass reported in late October that nearly 19,000 people had moved to motels, traditional shelters or tiny home villages since she took office, only about 3,300 had found permanent homes. For Inside Safe, just 190 of the nearly 1,700 participants had landed a permanent place to live. The city’s administrative officer, Matt Szabo, has told the City Council that there is not enough staff to help people find housing and also a shortage of affordable housing.

Inside Safe isn’t the first time the city has allowed residential hotels to be turned into temporary shelters. It’s unclear whether prioritizing getting people off the streets over preserving permanent housing was a deliberate policy choice or simple bureaucratic oversight: the result of well-intentioned housing policies from different eras colliding.

Eight other residential buildings have been pressed into service as temporary housing since 2016 through Los Angeles County or U.S. Veterans Affairs programs for emergency shelter or mental health and drug and alcohol treatment, or as part of the COVID-19 public health response.

Additionally, the state Housing and Community Development agency granted Los Angeles County and two nonprofit groups $19.3 million in Project Homekey funds to acquire and remodel two other residential hotel buildings to use as interim housing.

Schultz, the legal aid attorney, said it is a “mind-bogglingly terrible strategy” to use residential hotels as temporary housing because the ordinance provides such strong legal protection for their preservation — at least on paper. Residential hotels are the city’s only housing that can’t legally be demolished or converted to another use unless the housing is replaced, Schultz said.

The 72-room Highland Gardens, a midcentury modern hotel in Hollywood, highlights the tension between the city’s need for temporary shelter and its equally pressing need for permanent housing. Formerly known as the Landmark Motor Hotel, it is best known as the place where singer Janis Joplin died of a heroin overdose more than 50 years ago.

Highland Gardens had been designated as a residential hotel in 2009 but for years had also advertised its rooms to tourists. Then when local officials needed temporary housing to stop the spread of COVID-19 in homeless shelters, the hotel received a contract under Project Roomkey, paid for with federal pandemic relief funds.

Highland Gardens’ owner didn’t return phone messages left at the hotel.

By the time the program ended in December 2022, few participants had found permanent homes, and City Councilmember Nithya Raman pushed to keep Highland Gardens open as an interim housing site. She said she didn’t know it was a residential hotel.

“That’s part of the problem with the city is that we have such an ad hoc process for finding interim housing,” Raman said. Before Bass took office, Raman said, council offices took the lead in finding sites. “I personally would speak to the owner of this facility to tell them about the program and convince them that there would be benefits for them,” she said.

Raman’s colleagues backed her request, and now a $6 million contract, in effect until mid-2025, includes nearly $4 million to rent the hotel’s rooms and about $2 million for social services for people who had been living on the street. At just $50 per room per night, it’s a more favorable deal for the city than the Inside Safe hotels have negotiated.

Raman said she doesn’t think using the Highland Gardens for temporary housing is a mistake, given the urgent need for shelter. “It has saved lives,” she said.

Tommy Lachenmyer, 36, who moved into Las Palmas through Inside Safe after a fire ripped through a Hollywood encampment near where he slept this year, said the temporary housing has been “a blessing.” But while he’s found a job at Pizza Hut and is studying at a local film school for a career in music production, his quest for stable housing may be harder.

Lachenmyer revisits the location where he once lived in a tent on Vista Del Mar Avenue in Los Angeles. (Barbara Davidson for ProPublica)

Lachenmyer said he filled out an application for permanent housing when he moved in about six months ago. He’s still waiting for approval before he can begin his housing search and said he holds out hope that his stay at the hotel will lead to permanent housing. As for the long wait, Lachenmyer said, “I’m OK with it. People have waited for years.”

But longtime resident Bucher said he is not as optimistic that his new Inside Safe neighbors will find permanent housing.

“All they’re doing is warehousing people,” he said. “Nobody thinks about anything but getting them off the streets.

Correction

Nov. 17, 2023: This story originally misstated the number of people living on the streets. There are 46,000 homeless people in the city of Los Angeles, but 32,700 live on the streets, as opposed to shelters or temporary housing, according to this year’s count by the Los Angeles Homeless Services Authority.

by Bianca Fortis

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

In a stunning shift, Columbia University announced on Monday a sweeping series of changes to address the school’s failures to protect patients who were sexually assaulted by a Columbia doctor.

A ProPublica investigation, published in collaboration with New York Magazine, found that Columbia had failed to act on years of warnings as Robert Hadden, an OB-GYN, abused at least hundreds of patients during his 25-year career at the university. In 2012, administrators allowed Hadden to continue seeing patients even after he was arrested for assaulting a patient.

The story prompted waves of criticism toward Columbia. State Assembly members held a press conference on campus. A unanimous resolution by the university senate said that the Hadden revelations have “shaken our community to the core.”

In Monday’s announcement, the university said it would commit to an external investigation to examine systemic failures that allowed Hadden’s abuse to continue. It also said it would notify nearly 6,500 former Hadden patients about his crimes. Columbia will also open a $100 million survivors’ settlement fund for those who don’t want to go through the court system.

The university had long sought to distance itself from the scandal, placing blame solely on Hadden. Columbia had refused demands from survivors that the school notify all of Hadden’s patients. It hadn’t commissioned an external investigation and had aggressively fought lawsuits filed by survivors.

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Hadden was convicted in federal court of sex crimes in January, and he is now serving a 20-year prison sentence. More than 600 patients have so far come forward to allege abuse.

“Columbia failed these survivors, and for that we are deeply sorry,” President Minouche Shafik and Columbia University Irving Medical Center CEO Katrina Armstrong said in a statement on Monday.

Columbia’s announcement comes just ahead of a looming deadline for survivors to file suit against the university. The Adult Survivors Act, put into law in New York last year, opened a one-year lookback window, during which survivors can file civil suits against perpetrators of sexual abuse, or institutions that protected them, even if they are past the statute of limitations. The deadline closes on Nov. 23.

The university has previously settled civil suits with 226 patients for $236.5 million.

Marissa Hoechstetter, a former Hadden patient who pushed for the Adult Survivors Act, said she was glad Columbia finally acted.

“This is what we’ve been asking them to do,” Hoechstetter said. “This is good. But we need to continue to hold them accountable and see what comes of this and continue to support survivors.”

Still, Hoechstetter said, the $100 million figure will likely be too low. “We don’t yet know the full extent of his crimes,” she said.

by Joshua Kaplan, Justin Elliott, Brett Murphy and Alex Mierjeski

Update, Nov. 13, 2023: This story has been updated throughout.

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The Supreme Court on Monday released a code of conduct governing the behavior of the country’s most powerful judges for the first time in its history. But experts said it was unclear if the new rules, which do not include any enforcement mechanism, would address the issues raised by recent revelations about justices’ ethics and conduct.

The nine-page code, with an accompanying five pages of commentary, was signed by all the sitting justices and covers everything from the acceptance of gifts, to recusal standards, to avoiding improper outside influence on the justices. The step followed months of reporting by ProPublica detailing undisclosed gifts to Supreme Court justices from wealthy political donors.

The code does not specify who, if anyone, could determine whether the rules had been violated.

The new Supreme Court code’s lack of any apparent enforcement process is “the elephant in the room,” said Stephen Vladeck, a law professor at the University of Texas who studies the court. “Even the most stringent and aggressive ethics rules don’t mean all that much if there’s no mechanism for enforcing them. And the justices’ unwillingness to even nod toward that difficulty kicks the ball squarely back into Congress’ court.”

Nevertheless, some leading observers of the court described the creation of an explicit, written code as a landmark in the court’s 234-year history.

“The Supreme Court’s promulgation of a code of conduct today is of surpassing historic significance,” former federal appellate judge J. Michael Luttig told ProPublica. “The court must lead by the example that only it can set for the federal judiciary, as it does today.”

A statement released by the court on Monday accompanying the code said it was formulated to dispel “the misunderstanding that the Justices of this Court, unlike all other jurists in this country, regard themselves as unrestricted by any ethics rules.” It said the code “largely represents a codification of principles that we have long regarded as governing our conduct.”

A series of ProPublica stories this year detailed a pattern of behavior by Supreme Court justices that legal ethics experts said was far outside the norms of conduct for other federal judges. ProPublica disclosed that Justice Clarence Thomas has accepted undisclosed luxury travel from Dallas billionaire Harlan Crow and a coterie of other ultrawealthy men for decades. Crow purchased Thomas’ mother’s home and paid private school tuition for a relative Thomas was raising as his son. Thomas also spoke at donor events for the Koch network, the powerful conservative activist group. Separately, ProPublica revealed that Justice Samuel Alito accepted a private jet trip to Alaska from a hedge fund billionaire and did not recuse himself when that billionaire later had a case before the court.

Reporting from other outlets, including The Washington Post and The Associated Press, has added to the picture. The New York Times revealed that Thomas received a loan from a wealthy friend to purchase an expensive RV. A Senate investigation later found Thomas did not repay the loan in full.

Federal judges below the Supreme Court have long been subject to a written code of conduct, the foundations of which were set down a century ago following a major ethics scandal in the judiciary. Lower court judges are subject to oversight by panels of other judges, who review allegations of misconduct.

The high court’s new code of conduct is separate from an existing federal law that requires all federal judges including the justices on the Supreme Court to annually report income, assets and most gifts on a publicly available disclosure form. The law, which passed after the Watergate scandal, has been at the center of the controversies involving Thomas’ undisclosed gifts. Thomas and Alito have argued they were not required to disclose the luxury travel, and Thomas’ lawyer has said that “any prior reporting errors were strictly inadvertent.”

The new document largely echoes the code that applies to lower court judges. Many of its prescriptions are lofty but vague. It requires the justices to “act at all times in a manner that promotes public confidence in the integrity and impartiality of the judiciary.” It prohibits justices from soliciting gifts, practicing law or sitting on cases where their “impartiality might reasonably be questioned.” It states that the justices should not engage in “political activity,” but it does not define what that means.

Court observers are likely to spend weeks parsing the differences between the new code and that of the lower courts. Small changes were made without explanation. For instance, lower court judges are prohibited from lending “the prestige of the judicial office to advance” their own private interests. The justices are merely prohibited from “knowingly” doing so.

Whether any of the conduct that sparked the push for a formal ethics code would now be prohibited seems to remain open for interpretation. Take Thomas’ appearances at Koch network events. A federal judge told ProPublica that if he’d done the same as a lower court judge, it would’ve violated prohibitions against fundraising and political activity and he would’ve been subject to a disciplinary proceeding. It’s unclear if the high court’s new code would bar such activities or if each justice would answer such questions for him or herself.

Sen. Sheldon Whitehouse, D-R.I., who has introduced a bill that would require the Supreme Court to adopt an enforceable code of conduct, said in a statement that the new code fell short of what is needed.

“The honor system has not worked for members of the Roberts Court,” he said. “This is a long-overdue step by the justices, but a code of ethics is not binding unless there is a mechanism to investigate possible violations and enforce the rules.”

Whitehouse’s bill advanced out of the Senate Judiciary Committee in July, but it has since stalled in the face of GOP opposition. It would create an enforcement mechanism for the court’s code of conduct and set up a process where panels of appellate judges would investigate potential ethics violations.

It’s unclear whether the court’s release of the code will affect the ongoing Senate investigations into justices’ relationships with businessmen and others involved in undisclosed travel and gifts. For months, the Senate Judiciary Committee has been seeking information from Crow and others about undisclosed gifts to Thomas.

Last week, Senate Judiciary Democrats deferred an effort to subpoena Crow in the face of intense Republican opposition on the committee. Sen. Dick Durbin, D-Ill., the panel’s chair, said last week the committee would continue its efforts to authorize subpoenas in the near future.

The court’s new ethics standards are in many ways more lenient than those governing employees of the executive and legislative branches. There are still few restrictions on what gifts the justices can accept. Members of Congress are generally prohibited from taking gifts worth $50 or more and would need preapproval from an ethics committee to take many of the gifts Thomas and Alito have accepted.

Jeremy Fogel, a retired federal judge in California who had publicly called for the Supreme Court to adopt an ethics code, said Monday that he was “heartened to see that the justices unanimously have recognized the need for an explicit code of conduct.”

“Whether it will make a difference in the justices’ day-to-day actions or in public perceptions of the court remains to be seen,” Fogel said.

by Melissa Sanchez and Maryam Jameel

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When dairy workers die on farms across the country, the circumstances are often similar: They drown in manure lagoons, get crushed by skid steers, are trampled by cows.

But whether the government investigates their deaths depends on factors that advocates for worker safety say seem arbitrary: the state where they died, the size of the farm where they worked or whether they lived in employer-provided housing.

For decades, Congress has banned the federal Occupational Safety and Health Administration from investigating worker deaths, injuries and complaints on farms with fewer than 11 workers unless those farms have employer-provided housing known as a temporary labor camp. How this exemption for small farms plays out looks different in the country’s dairy states.

In New York and Vermont, for instance, worker advocates say they don’t bother calling OSHA when workers die or get hurt on small farms because they’re so used to the agency saying it can’t investigate.

In Wisconsin, OSHA has sometimes investigated dairy worker deaths on small farms when those farms provide housing to immigrant workers. In such cases, the agency has called that housing a temporary labor camp that gives it jurisdiction to inspect.

And in California, which has a more robust occupational safety and health plan than the federal program, inspectors look into dairy workers’ deaths and injuries no matter how many workers a farm employs. The question of whether there’s worker housing is irrelevant.

This patchwork of enforcement, in which some deaths are investigated and others are ignored, is fundamentally unfair, advocates say.

“It’s unjust and it’s inhumane,” said Crispin Hernández, a former dairy worker and a member of the Workers’ Center of Central New York, a nonprofit focused on workplace and economic justice. “It is on small farms that workers get injured the most.”

Last month, ProPublica reported on how OSHA has inconsistently labeled farm housing for immigrant dairy workers in Wisconsin as a temporary labor camp. Our reporting identified three worker deaths on small farms over the past decade, including the March drowning of an undocumented Mexican immigrant in a manure lagoon, that OSHA said it couldn’t investigate even though workers lived in farm housing.

OSHA officials declined interview requests but have said the agency has a consistent national policy on how it views temporary labor camps.

Since 2005, OSHA offices said they couldn’t investigate 44 safety incidents on dairy farms — including deaths, injuries, complaints and referrals from local agencies such as medical examiner’s offices — because of the small-farms exemption, records show. It’s unknown how many of those farms provided housing to immigrant workers, something common on dairy farms across the country.

None of this is as clear cut as many advocates and farmers would like, and the issue has received scant attention. More than a dozen farm safety advocates, farm worker attorneys and dairy worker researchers from a number of states — including Wisconsin — told us they had no idea it was even possible for OSHA to look into deaths and injuries on small dairy farms that provided housing to immigrant workers.

“We end up in these granular arguments over what counts as temporary or seasonal or what’s a labor camp,” said Hannah Gordon, an attorney with the Farmworker Law Project of the Legal Aid Society of Mid-New York.

One of the key factors in OSHA’s approach to deciding if a dairy farm has a temporary labor camp is whether it considers the workers themselves to be temporary or permanent. The answer is not immediately obvious because cows are milked year-round. Agricultural jobs such as picking apples or blueberries are more clearly seasonal.

In addition, dairy farms can’t use a federal guest worker program to bring in immigrants on temporary visas. Instead, the industry by and large relies on undocumented immigrant workers whose ability to stay permanently in this country — and, by that logic, stay permanently on a job — is precarious.

“Being undocumented and constantly facing the risk of deportation” is one reason these workers could be considered temporary, said Maggie Gray, an associate professor of political science at Adelphi University who studies New York farm workers. “They have permanent homes in their home country where they intend to return.”

OSHA doesn’t ask workers whether they’re in the U.S. legally. But in Wisconsin, OSHA inspectors have described some immigrant workers who live on dairy farms as temporary workers because they are hired with the understanding that they may go back and forth to their home countries to visit their families.

The prospect of OSHA taking a similar view of dairy workers in New York — where an estimated 80% live and work on small farms — led to pushback from a group of seven members of Congress from that state in late 2013.

At the time, OSHA was preparing to launch a program to improve safety on New York’s dairy farms. The program would allow the agency to conduct random inspections, something it typically doesn’t do.

But the representatives wrote to OSHA’s top official, asking for it to be delayed and to discourage the agency from considering immigrant dairy workers as temporary when deciding whether a small farm was eligible for inspections.

“A dairy farmer hires an employee with the understanding and intent that the employee will be here long term,” the lawmakers wrote. “A dairy farm employer does not embrace the cultural assumption that an employee of a foreign ethnicity or whose primary language is not English is seeking work as a temporary or seasonal worker when they accept a permanent position on a farm.”

OSHA conceded the point. David Michaels, then the assistant secretary of labor for OSHA, wrote back to the lawmakers and said the agency had decided to limit the scope of the program to “dairy farms with eleven or more employees, so the definition of temporary labor camp is no longer relevant.”

Outside of the New York effort, Michaels wrote, the agency would not inspect small farms that provided housing to their workers if the employers had offered them permanent jobs.

In a recent interview, Michaels said he did not recall the controversy around temporary labor camps. He also said he wasn’t aware that OSHA officials in Wisconsin had concluded that housing for immigrant workers on dairy farms was a temporary labor camp so they could investigate deaths on small farms.

But he said he was “glad to hear that” and thought that the agency’s work in Wisconsin should be more widely known. That way, he said, perhaps more advocates would call OSHA when workers die or get injured “in situations where OSHA could actually answer.”

Erica Sweitzer-Beckman, an attorney and the legal director of the Farmworker Project at the nonprofit Legal Action of Wisconsin, said that when a farm “asserts an exemption, OSHA could thoroughly investigate to determine if the exemption actually applies.”

Not every state relies on federal OSHA; more than 20 states have their own safety and health workplace programs. At least three of those states, California, Oregon and Washington, use state funds to inspect farms of all sizes, regardless of whether there’s housing for workers.

“There is no small-employer exception,” said Garrett Brown, a retired field compliance officer and senior official with the California Division of Occupational Safety and Health. “If you have one employee, that’s it; you’re an employer and you fall under Cal/OSHA’s jurisdiction the same as United Airlines or Coca-Cola.”

Some research has shown that the fatality rate for farm workers is significantly lower in California, Oregon and Washington than in states where the small-farms exemption is observed. Dairy farms on the West Coast tend to be larger operations than those in the Midwest and East Coast, and there are far fewer of them, which may also contribute to the difference in fatality rates. California is the nation’s biggest dairy producer. Wisconsin ranks second; New York is fifth.

Matthew Keifer, an occupational medicine physician and researcher who lives in Washington state and previously ran the National Farm Medicine Center in Wisconsin, said small farms in states that rely on federal OSHA don’t always put a priority on safety issues because they know “they’re not likely to be investigated, fined or found culpable if someone is seriously injured.”

He added that in Washington, by contrast, “there is a healthy preoccupation about the possibility of being inspected.”

Other states, including Vermont, have state OSHA plans that mirror the federal OSHA when it comes to the small-farms exemption. Vermont hasn’t considered employer-provided housing for dairy workers a temporary labor camp.

In December 2009, a worker named José Obeth Santiz Cruz died on a small Vermont dairy farm after he was pulled into a piece of machinery and strangled by his own clothing. The state OSHA sent two inspectors to the farm. Santiz, an immigrant from Mexico, lived in farm housing, according to interviews and records.

But the agency determined it couldn’t investigate because the farm employed too few workers.

In an email to ProPublica, Dirk Anderson, the director of the Vermont OSHA, said his general understanding was that dairy work was not “of a seasonal or temporary nature.” However, he said, “it is certainly something I will discuss with both our legal counsel and my commissioner in the near future.”

Santiz’s death helped lead to the creation of Migrant Justice, a dairy worker-led human rights organization in Vermont. Marita Canedo, the group’s program coordinator, said nearly all of the 1,000 or so immigrant dairy workers in the state live on the farms where they work.

Canedo and her colleagues routinely hear about workers who get hurt on the job. But they rarely call the state agency for a number of reasons, including its hands-off approach to small farms. Recently, when a worker lost several toes after the heavy metal bucket of a skid steer crushed them, Canedo said she didn’t bother to contact OSHA.

“We don’t even think about OSHA,” she said.

Mariam Elba contributed research.

by Isabelle Taft, Mississippi Today

This article was produced for ProPublica’s Local Reporting Network in partnership with Mississippi Today. Sign up for Dispatches to get stories like this one as soon as they are published.

Fourteen years ago, Mississippi legislators passed a law requiring county jails to be certified by the state if they held people awaiting court-ordered psychiatric treatment.

Today, just one jail in the state is certified.

And yet, from July 2022 to June 2023, more than 800 people awaiting treatment were jailed throughout the state, almost all in uncertified facilities, according to state data.

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Mississippi Today and ProPublica have been reporting on county officials’ practice of jailing people with mental illness, most of whom haven’t been charged with a crime, as they await treatment under the state’s civil commitment law. After the news organizations started asking about the 2009 law earlier this year, the state attorney general’s office concluded that it is a “mandatory requirement” that the Mississippi Department of Mental Health certify the facilities where people are held after judges have ordered them into treatment.

The Department of Mental Health, which oversees the state’s behavioral health system and has no other responsibility for jails, responded by sending letters to county officials across the state encouraging them to stop holding people in uncertified jails. But the law provides no funding to help counties comply and no penalties if they don’t.

Caption: Wendy Bailey, executive director of the Mississippi Department of Mental Health, sent a letter in October to officials in all 82 counties encouraging them to stop holding people awaiting mental health treatment in uncertified jails. According to the department’s data, more than 800 people were held in jail before being admitted to a state hospital through the civil commitment process in the 12 months ending in June. (Obtained by Mississippi Today and ProPublica, highlighting by ProPublica)

Under state law, counties are responsible for housing people going through the commitment process until they are admitted to a state hospital. Counties are allowed to put them in jail before their court hearings if there’s “no reasonable alternative.”

The last time the Department of Mental Health tried to ensure those jails met state standards, more than a decade ago, it had little success. After the law passed, the agency got to work to inform counties about the new rules. Some didn’t respond. Others expressed interest but didn’t follow through. By 2013, just two jails had been certified. (One of them no longer is.) After that, the effort apparently petered out, according to a review of state documents.

To be certified, a jail must offer on-call crisis care by a physician or psychiatric nurse practitioner and must have a supply of medications. Staff must be trained in crisis intervention and suicide prevention. People detained during the commitment process must be housed separately from people charged with crimes, in rooms free of fixtures or structures that could be used for self-harm, according to Department of Mental Health standards that took effect in 2011.

“If they’re going to be held in jail, they have to receive some kind of treatment in a semi-safe environment,” a department attorney told The Clarion-Ledger at the time.

Until recently, many county officials weren’t even aware of those requirements, according to interviews across the state — even though they were routinely jailing people solely because they might need mental health treatment. Mississippi appears to be the only state in the country where people awaiting treatment are commonly jailed without charges for days or weeks at a time.

Mississippi jails are subject to no statewide health and safety standards. Many jails treat people going through the civil commitment process virtually the same as those who have been charged with crimes, Mississippi Today and ProPublica found. They’re shackled and given jail uniforms. They’re often held in the same cells as criminal defendants. They receive minimal medical care. Some said they couldn’t access prescribed psychiatric medications. Since 1987, at least 18 people going through the commitment process for mental illness and substance abuse have died after being jailed, most of them by suicide.

Colett Boston, left, and Everlean Boston hold a photograph of their mother, Mae Evelyn Boston, in Oxford, Mississippi. In 1987, when Colett was a newborn and Everlean was 12 years old, their mother died in the Lafayette County jail as she waited for a mental health evaluation. (Eric J. Shelton/Mississippi Today)

Some local officials say getting certified could be expensive. Sheriffs worry it could codify their role as their county’s de facto mental health care provider.

“It looks like the state wants the sheriff to be the chief mental health officer,” said Will Allen, attorney for the Mississippi Sheriffs’ Association. “This is coming down to the state stuffing the cost of this down to the counties, and frankly I just think that’s wrong.”

“Are You Going to Shut the Jail Down? No.”

The genesis of the 2009 law was a conversation state Sen. Joey Fillingane had with his girlfriend at the time, a social worker who worked with troubled youth. She told him that Mississippians going through the commitment process in some counties were locked in jail cells like criminals, while in other counties they were held in hospitals like patients, according to a 2011 news story in The Clarion-Ledger.

Fillingane’s bill addressed that. “Shouldn’t there be some kind of minimum standard where you’re holding people who haven’t committed a crime?” the Republican from Sumrall, near Hattiesburg, said in that story about his legislation.

His bill passed with little fanfare. It made it “illegal for individuals committed to a DMH behavioral health program to be held in jail unless it had been certified” as a holding facility, an agency staffer wrote in a timeline of the law’s implementation obtained by Mississippi Today and ProPublica.

The board overseeing the Department of Mental Health set detailed standards for those facilities. Department staff surveyed counties to see whether they could meet them.

Ed LeGrand was head of the department when the law passed. He said he viewed it as a progressive effort that could spur counties to stop holding mentally ill people in jail. And even if that didn’t happen, the law would improve jail conditions — at least somewhat.

“I didn’t think that everybody would be able to meet those standards. I thought they would give it a try,” he said in a recent interview. “A lot of them did, but some of them didn’t.”

Department staff met with county officials and toured jails to offer assistance. Those visits, which records show mostly took place in 2011 and 2012, were the first time the Department of Mental Health had tried to get a comprehensive look at the local facilities where Mississippians awaited psychiatric treatment in state hospitals, LeGrand said.

Many jails were poorly equipped to care for these people, according to notes by agency staff.

“Toured the current jail (scary),” reads a status update written after staff visited Tishomingo County, in the northeast corner of the state, shortly before the county opened a new jail. In Jones County in south Mississippi, where the jail had 180 inmates and only four staff: “The holding cells are not safe for violent behavior. Too much cement.”

Jones County Sheriff Joe Berlin said the cells have not changed since then, though now detainees are monitored with cameras.

In early 2011, LeGrand told county officials who hadn’t already begun the certification process that they had six months to find a certified provider to house people awaiting treatment.

Sheriffs were frustrated. Some objected to being told they had to upgrade their jails and train guards so they could care for mentally ill people they didn’t think they should be responsible for in the first place.

“What do they expect of me?” one sheriff was quoted as saying in the 2011 news story. “What they need to do is turn around and certify some places that are under Mental Health’s control so they can be responsible for it, not me.”

In 2011, The Clarion-Ledger reported that sheriffs were frustrated by a law requiring the Department of Mental Health to certify their jails if people were detained there as they awaited admission to a state psychiatric hospital. Sheriffs worried that the law would force them to spend time and resources on a job they didn’t sign up for. (Hattiesburg American via newspapers.com. Blurred by ProPublica for emphasis.)

Some county officials concluded there was little the state could do if they didn’t comply. Mike Harlin, the jail administrator in Lamar County, discussed the standards with a Department of Mental Health staffer in 2012, according to an agency memo. In an interview this year, Harlin said he remembered thinking, “What are you going to do? Are you going to shut the jail down? No.”

By June 2013, jails in just two of the state’s 82 counties had been certified, according to the department’s tally. (A hospital was certified in another county, and a different type of facility was certified in a fourth.)

Six counties said they couldn’t meet the standards. Another 23 had received guidance from the department on how to meet them. Thirty, including a few of the counties that had received advice, eventually said they didn't jail people, some because they had contracts with providers. Twenty-one never responded.

Mississippi Today and ProPublica requested all Department of Mental Health records since 2010 related to enforcement of the certification law and correspondence with counties. Documents through 2013 included standards, correspondence, memos describing visits to county facilities and a log summarizing contact with each county. After that, the records released show no statewide outreach.

The final entry in the department’s timeline of the law’s implementation reads: “June 2013 was the last attempt to update the information about DMH Designated Mental Health Holding Facilities due to lack of additional responses from the counties.” That timeline is undated, but a department spokesperson said data in the file shows that it was created in January 2015 by a staffer who held positions in the certification and behavioral health divisions.

LeGrand, who served until 2014, said he doesn’t recall any decision to stop contacting counties about the law.

Katie Storr, the current chief of staff at the Department of Mental Health, told Mississippi Today and ProPublica it’s possible staff did communicate with counties beyond what the records indicate. “After more than a decade, a lack of correspondence, email, or other documentation is not indicative that communication and follow-ups did not take place,” she wrote in an email. However, she said the department had no additional records that would show this.

During this time, Storr wrote, the department was focused on trying to get counties to hold people going through the commitment process in short-term crisis stabilization units rather than jail.

Department Can’t “Boss Counties Around”

The recent effort to implement the certification law stems from inquiries by Mississippi Today and ProPublica.

In January, the news organizations asked the head of the Department of Mental Health, Wendy Bailey, if the department certifies jails where people are held as they await admission to a state hospital. Bailey, who handled communications for the department when the certification law passed, initially said it didn’t apply to jails. In March, after reviewing documents showing prior efforts to certify jails, she said she didn’t believe the law was intended to apply to them.

After our inquiries, Bailey sought an opinion from the attorney general. (Such opinions are not binding, but officials who request and abide by them are protected from liability.)

Around the same time, the Department of Mental Health contacted the four facilities it had previously certified to schedule inspections. The department’s standards say such inspections will happen annually, but this was the first year in which staff had sought to visit all of them since 2017. (Storr said the inspection effort was planned before inquiries by Mississippi Today and ProPublica.)

In March, staffers inspecting the Chickasaw County jail in rural northeastern Mississippi found serious violations. Inmates and people awaiting mental health treatment were housed together in the same cells, where beds were anchored with long bolts that “could be used by a person to harm themselves,” the reviewers recorded.

The department suspended the jail’s certification in August, but reinstated it after the county submitted a compliance plan that included shortening the bolts and providing mental health training for staff.

Lafayette County told the state it didn’t want its jail to be certified anymore. The certification for a holding facility in Warren County, home to Vicksburg, was suspended. A hospital in Alcorn County in northeast Mississippi maintained its certification.

In 2021 and again early this year, Lafayette County Sheriff’s Department staff told the state Department of Mental Health that they no longer wanted their jail to be certified. In an interview conducted before the department notified counties about the certification law this fall, Sheriff Joey East, pictured here, said he believes people in his jail waited longer to be admitted to a state hospital because the state prioritizes those waiting in uncertified jails. “There was not a lot of benefit” to being certified, he said. DMH director Wendy Bailey said people held in any jail get priority for psychiatric treatment. (Eric J. Shelton/Mississippi Today)

In August, the attorney general’s office confirmed that the department must “ensure that each county holding facility, including but not limited to county jails,” meets its standards. If they don’t, an assistant attorney general wrote, the law allows the department to require counties to contract with a county that does have a certified facility.

When Bailey informed county officials about the opinion in her October letter, she instructed that if a county holds someone in an uncertified facility, including a jail, officials should contact the department to seek certification or work with local community mental health centers. These are publicly funded, independent providers set up to ensure that poor, uninsured people can access mental health care.

Several counties, including Lamar, have taken up the matter in public meetings or have contacted the department to begin the certification process.

Storr told Mississippi Today and ProPublica that the department asked counties to initiate the certification process because the law says it’s up to counties to determine which facility they use.

But the Department of Mental Health already knows which counties have held people in uncertified jails. Starting in July 2021, in response to a federal lawsuit over the state’s mental health system, department staff have tracked how many people come to state hospitals directly from jails for psychiatric treatment.

The tally for the year ending in June breaks down all 71 jails, only one of which is certified, where a total of 812 people who had been civilly committed were held before being admitted to a state hospital. (The tally doesn’t include anyone who was jailed and released without being admitted to a state hospital.)

For the past two years, the Mississippi Department of Mental Health has gathered data on how many people are admitted to a state hospital directly from jail and how long they wait in jail after commitment hearings. (Obtained by Mississippi Today and ProPublica)

In Lauderdale County, on the Alabama line: 83. Across the state in DeSoto County: 76. A couple hundred miles down the Mississippi River in Adams County: 33.

Storr and Bailey have emphasized that they have limited authority over counties and no way to force them to do anything. The department’s only means of enforcement, Storr wrote, is to put a jail on probation, then revoke certification — if the jail in question even was certified in the first place — and require the county to contract with another provider.

LeGrand said a law without teeth is effectively optional. "The department’s not really in a good position to boss counties around,” he said.

James Tucker, an attorney and the director of the Alabama Disabilities Advocacy Program, which has sued that state over its civil commitment process, said the agency has a responsibility to make sure counties are treating people properly. “You don’t discharge that duty by sitting on your hands and waiting for every local sheriff to report in,” he said.

Bailey’s department encourages counties to connect families with outpatient services in order to avoid the commitment process. If someone does need to be committed, the department said, counties should hold people in crisis stabilization units operated by community mental health centers.

“I do not believe jails are an appropriate location to hold someone who is not charged with a crime and is awaiting admission to a treatment bed,” Bailey told Mississippi Today and ProPublica in an email. “The person should be in a safe location, receiving treatment.”

Adams County Sheriff Travis Patten said he doesn’t think the county jail, pictured here, could meet state standards. Due to deteriorating conditions, most people facing charges — but not those awaiting court-ordered mental health treatment — are now sent to another jail. Lacey Robinette Handjis died in another part of the jail in August while she was awaiting mental health treatment. (Eric J. Shelton/Mississippi Today)

But there are only 180 crisis beds in the state, and crisis stabilization units frequently turn people away because they are full, can’t provide the needed care, or deem a patient too violent. Storr said the agency is working to reduce denials and plans to use one-time federal pandemic funding to expand capacity.

Allen, the sheriffs’ association attorney, said the state will need more crisis beds if officials want to keep people out of jail as they await mental health care. He said he’s been meeting with sheriffs and county officials since the guidance was issued.

“This has catalyzed the county governments and law enforcement to do something,” he said. Sheriffs agree on the need for “certified centers, just not in the county jail.”

Mollie Simon contributed research.

by Rose Lundy, The Maine Monitor

This article was produced for ProPublica’s Local Reporting Network in partnership with The Maine Monitor. Sign up for Dispatches to get stories like this one as soon as they are published.

One lunchtime in 2021, a longtime resident at Woodlands Memory Care of Rockland started throwing up. His fingernails turned purple, and his skin became red all over. He was lethargic and fidgety, and his breathing grew shallow, according to the facility’s daily care notes.

The resident was well known at this residential care facility in Maine’s Midcoast region. Former facility employees told The Maine Monitor and ProPublica that he was a nationally renowned concert pianist who continued to play a portable keyboard in his room even as his Alzheimer’s disease advanced.

It wasn’t until a family member arrived and asked if the resident had eaten peanuts that employees realized that he was having an allergic reaction to the peanut butter sandwich that he had been served for lunch, according to the facility care notes. Staff used an EpiPen to treat his anaphylactic shock and took him to the hospital. He died days later, though no official records were made available that show the cause of his death.

The employee who gave the sandwich to the resident wrote in the facility care notes the day after the incident that they “didn’t know” that the resident “was allergic to peanuts.”

In interviews with the Monitor and ProPublica, however, four former employees said the resident’s severe peanut allergy had been documented throughout the facility: in his resident profile, in his room and posted in the kitchen.

“It said it everywhere you looked around him that he was allergic to peanut butter,” said Stacy Peterson, who served as the human resources coordinator at Woodlands of Rockland from 2018 to 2020.

So it was a mystery to the former employees how the resident had been served a peanut butter sandwich that day for lunch.

After receiving an anonymous complaint, the Maine Department of Health and Human Services investigated the incident and cited Woodlands of Rockland for two resident rights violations — first by failing to protect the resident from a severe allergic reaction and the second time by not reporting the case to the state. (The citations do not identify the resident.)

Under state regulations, the health department had the power to impose a fine of up to $10,000 or issue a conditional license that would bar Woodlands of Rockland from accepting new residents for up to 12 months. But it did neither. Instead, it simply required the facility to submit a report, called a plan of correction, stating how it intended to address the deficiencies.

In that plan, Woodlands of Rockland acknowledged that the resident’s allergy had been documented but disputed the health department’s characterization that the facility violated the resident’s rights in the incident. Still, it promised to discipline the employee who served the sandwich and to retrain others on how to handle allergies and to report incidents.

The Maine Department of Health and Human Services found that Woodlands Memory Care of Rockland violated a resident’s right to be free “from abuse, neglect or exploitations” by serving him a peanut butter sandwich despite his documented peanut allergy. (Obtained by The Maine Monitor and ProPublica. Highlighted by ProPublica.)

The health department’s modest response to the peanut allergy incident exemplifies its approach to oversight, an investigation by the Monitor and ProPublica found. The health department rarely imposes fines or issues conditional licenses against the state’s roughly 190 largest residential care facilities, classified as Level IV, which provide less medical care than nursing homes but offer more homelike assisted living alternatives for older Mainers.

From 2020 to 2022, the health department issued “statements of deficiencies” against these facilities for 59 resident rights violations and about 650 additional violations — involving anything from medication and record-keeping errors to unsanitary conditions and missed mandatory trainings. Despite these violations, however, it imposed a fine only once: a $265 penalty against a facility for failing to comply with background check rules for hiring employees. And it issued four conditional licenses: three in response to administrative or technical violations and one in response to a variety of issues, including a violation of a resident’s privacy rights.

By contrast, Massachusetts, which has 269 assisted living facilities, doesn’t shy away from imposing stiff sanctions. From 2020 to 2022, the state suspended eight facilities’ operations for regulatory violations.

The paucity of sanctions in Maine comes at a time when Level IV facilities like Woodlands of Rockland — which are similar to what are known generally as assisted living facilities in other states — are expanding their presence in the state. The share of Maine’s population that is 65 or older, 21.7%, is the highest percentage in the country.

As the Monitor and ProPublica have reported, the state’s decision in the mid-1990s to tighten the requirement to qualify for nursing home placement helped spur thousands of older Mainers, many with significant medical needs, to move to these nonmedical facilities — which are subject only to state regulations that hold them to much lower minimum staffing, nursing and physician requirements than nursing homes, which face both state and federal scrutiny.

In stark contrast to how rarely Level IV facilities face sanctions, nursing homes in Maine are often hit with considerable fines for regulatory violations.

Health department spokesperson Jackie Farwell said that plans of correction are often sufficient for improving conditions at facilities. She added that as part of an effort to improve the long-term care system in Maine, the state has been considering rules changes to “establish fines and sanctions as more meaningful deterrents.” But she declined to elaborate on the specifics.

Dan Cashman, spokesperson for Woodlands Senior Living, which runs 14 Maine facilities including the one in Rockland, said the company has “a zero-tolerance policy” and has taken disciplinary actions against any employees who were found to have violated residents’ rights.

Cashman added that the company is in favor of stronger state action against individuals found to have violated residents’ rights to prevent them from working in residential care settings again.

But long-term care advocates say the health department is not doing enough to crack down on facilities, as opposed to individuals, and is allowing poor conditions to persist for vulnerable residents.

Richard Mollot, executive director of the Long Term Care Community Coalition, a national advocacy group focused on improving nursing homes and assisted living facilities, said stiff sanctions should be imposed more, so that there’s a “meaningful ladder of sufficient penalties to ensure that facilities are properly motivated to take steps to ensure resident safety.”

Otherwise, Mollot said, facilities have no incentive to change their behavior. “To pussyfoot around resident neglect or abuse,” he said, “is essentially encouraging. It’s allowing it to happen.”

A review by the Monitor and ProPublica of state inspection records from 2020 to 2022 shows that the health department employed the lowest intervention possible, even for some of the most serious abuse and neglect incidents.

In the summer of 2021, for instance, a resident at Crawford Commons in midcoast Maine was found to have sexually abused another resident multiple times, according to the state’s investigation. The health department cited the facility for two resident rights violations but only required it to submit a plan of correction.

A year later, a resident in Jed Prouty Residential Care Home in the Penobscot Bay region was found around 6:30 a.m., naked and asleep on the floor, “soaking wet with urine,” after falling sometime after 10 p.m. Witnesses said the resident had been crying for help and complaining of thirst until medics responded. No efforts had been made by staff to move the resident from the floor or provide clothing, according to the state’s investigation. Again, the health department cited the facility for a resident rights violation but only required it to submit a plan of correction.

Similarly, in 2021 and 2022, the health department also investigated Woodlands of Rockland for two other serious incidents. In one, a certified nursing assistant at the facility slapped a resident who had spit at and attempted to bite her, according to the state’s investigation. In the other, a resident wandered out to the facility’s locked courtyard, but employees didn’t notice that she was missing until they went to give her medications nearly two hours later, according to the state’s investigation. When the resident was found outside in the snow at around 8:40 p.m., employees wrapped her in blankets and called for emergency medical care. The resident died in hospice days later, and the state investigation cited the cause as “complications of hypothermia.” In the end, both incidents also led to plans of correction.

The Maine Department of Health and Human Services cited Woodlands Memory Care of Rockland for not protecting “a resident’s health and welfare” after the resident wandered out unsupervised into the facility’s locked courtyard. (Obtained by The Maine Monitor and ProPublica. Highlighted by ProPublica.)

Woodlands of Rockland has been disputing the health department’s characterization that the facility violated the resident’s rights in the courtyard incident. But Cashman declined to elaborate on the specifics.

Edward Sedacca, CEO of Magnolia Assisted Living, which runs Jed Prouty, said his company took over the operation of the facility in August 2022, a month before the incident, and has since made it a priority to enhance its staffing and training. “The staff we inherited was lacking in overall general knowledge,“ he said. “Magnolia has built an infrastructure well beyond that required under regulation to enable us to provide a higher level of care to all of our residents.”

Crawford Commons did not respond to requests for comment.

For Maine’s nursing homes, however, the response to similar incidents has been very different.

From 2020 to 2022, more than half of nursing homes in Maine received fines — 98 penalties in all, totaling nearly $700,000 — according to U.S. Centers for Medicare and Medicaid Services reports. These fines were imposed in response to a range of violations, including not following COVID-19 infection prevention protocol, making medication errors, not reporting unexpected deaths and failing to protect residents from harm.

In 2020, for instance, an employee at Pinnacle Health & Rehab, a nursing home in Canton in western Maine, “lost it” when a resident became combative, according to CMS investigation records. The employee punched the resident, who ended up with a black eye and bruising around the eyebrow. CMS fined the facility $41,650.

A year later, a resident at Heritage Rehab and Living Center, a nursing home in central Maine, wandered off the premises at night using a walker and was found later by police by the side of a road in the rain. No one at the facility had noticed that the resident was missing, according to CMS investigation records. CMS fined the facility $71,243.

Ken Huhn, administrator of Pinnacle, said the employee was fired, and he made it clear that “that type of behavior would not be tolerated” at his facility.

Heritage did not respond to requests for comment.

Even without the involvement of CMS, which does not regulate assisted living facilities around the country, the health department has the power to adopt a tougher approach toward Level IV facilities. Under state regulations, for instance, it can impose a fine when an incident poses “a substantial probability of serious mental or physical harm to a resident.”

Long-term care advocates told the Monitor and ProPublica that under this standard, some of the egregious abuse and neglect incidents in recent years at Level IV facilities should have resulted in stiff sanctions.

“Because the incidents are so egregious and show such disregard for the well-being of residents, they would have warranted some significant penalty and not just a pro forma requirement that the facility submit a plan of correction,” said Eric Carlson, director of long-term services and support advocacy at Justice in Aging, a national legal advocacy nonprofit focused on ending poverty among seniors.

Paula Banks, who has served as the executive director of another Woodlands facility in Cape Elizabeth and as an assistant administrator of a Maine nursing home, said the fear of such sanctions would be effective. If she were still helping run a residential care facility, she said, it would spur her to take immediate action to address any problems.

“What’s the impetus to change if there’s no consequence?” said Banks, who now runs a geriatric consulting and care management firm.

But Dr. Jabbar Fazeli, who has served as medical director at multiple residential care facilities and nursing homes in Maine, said that rather than imposing sanctions, the state should require more medical attention by increasing nursing hours and requiring a medical director to be on the premises.

“If they had more medical care, I would say 50% of these issues will self-resolve,” Fazeli said.

The health department metes out sanctions in only a small percent of the incidents it hears about each year. Most of the time, it hardly does anything.

To better understand the health department’s process for looking into potential issues, the Monitor and ProPublica analyzed a database of incidents reported to the state by Level IV facilities themselves. Unlike the state inspection records, the database of facility-reported incidents gives a window into what happens earlier in the health department’s enforcement process.

Level IV facilities are required to report an incident to the state when a regulatory violation may have occurred or when a resident’s safety was put at risk. We focused particularly on reports of incidents with the potential for direct harm: the cases of abuse and neglect.

From 2020 to 2022, the state received more than 550 reports of abuse and neglect incidents from Level IV facilities, according to the Monitor and ProPublica analysis. Of those, 342 cases involved residents abusing other residents, 102 cases involved “elopement,” in which residents wandered away unsupervised, and 61 cases involved a staff member abusing a resident.

The analysis shows that in nearly 85% of these incidents, state investigators took “no action” — which, according to Farwell, means that the health department decided not to investigate. She said this could have been for a range of reasons, such as when a facility has already taken corrective action, when state investigators do not expect to find a regulatory violation, or when an incident is being investigated as part of another case or is expected to be reviewed later.

The analysis also shows that the health department did not step up its enforcement even when individual facilities repeatedly reported similar issues.

From 2020 to 2022, 13 Level IV facilities, including Woodlands of Rockland, each had at least 10 abuse and neglect incidents, collectively reporting 348 cases to the state. Even after these facilities had reported multiple cases, the health department still took no action in 91% of them, the analysis shows.

Farwell said state investigators do pay attention to repeated incidents. “If patterns are observed, specific issues may be flagged for follow-up at the next scheduled survey,” she said.

But such follow-ups might not happen for many months, depending on the timing of the next inspection required for license renewal, which takes place only once every two years.

Dionne Mills, who served as the program coordinator at Woodlands of Rockland from 2019 to 2021 and also worked at two other Level IV facilities, said she became aware of the lack of state oversight during her time at the Rockland facility. She said she reported multiple incidents to the state until eventually a state investigator told her that they were too overwhelmed with complaints and that she would have more success taking her concerns to the media.

“The state is so super busy that they only have time to look into the absolute worst-case scenario,” Mills said.

Dionne Mills outside her home in Northport, Maine (Tara Rice for ProPublica)

Farwell disputed Mills’ account, noting that state investigators made seven visits to Woodlands of Rockland from 2020 to 2022, the time period when the facility was under investigation for the courtyard, peanut allergy and slapping incidents. Mills’ account “is inconsistent with the number of onsite visits that were conducted at this facility,” she said.

According to Farwell, the health department has 13 investigators — and is in the process of hiring two more — to inspect more than 1,100 assisted housing facilities in the state for license renewals and to investigate any incidents.

Mollot, of the Long Term Care Community Coalition, said the health department needs to do more against facilities with a history of repeated incidents, such as requiring independent monitoring and, possibly, revoking licenses.

“Faced with the fact that these facilities have reported over and over and over and over and over again incidents of abuse and neglect, why have there been a paucity of enforcement acts?” Mollot said.

Several former employees told the Monitor and ProPublica that the history of repeated incidents at Woodlands of Rockland illustrates what can happen to a facility’s standards when the health department takes little enforcement action.

Stacy Peterson, a former human resources coordinator at Woodlands Memory Care of Rockland, said facility managers made little effort to address recurring problems when she worked there. (Tara Rice for ProPublica)

From 2020 to 2022, Woodlands of Rockland had the highest number of abuse incidents reported by a Level IV facility — 48 cases in all, including 38 in which a resident abused another resident, according to the health department database.

But the health department investigated only five of the incidents that Woodlands of Rockland reported, took no action on the rest and imposed no sanctions other than requiring the facility to submit one plan of correction.

With little pressure from the health department, efforts to address recurring problems “were nonexistent when I worked there,” Mills, the former program coordinator, said.

Joshua Benner, who served as a residential care aide at Woodlands of Rockland from 2018 to 2020, said he found it concerning that when the facility was cited by the health department, none of the managers at the facility shared with employees what problems had been found.

“Every other health care place that I’ve ever worked, you have interventions, usually after the state comes in, to go over what you’re dinged on and what can be improved,” said Benner, who has worked at a nursing home and two other residential care facilities.

Cashman, the Woodlands spokesperson, denied that Woodlands of Rockland had “an ongoing or systemic problem” with abuse incidents, noting that the bulk of the cases involved a small number of residents “whose progressively worsening dementia-related behaviors became more and more challenging.”

In response to these residents’ behaviors, Cashman said Woodlands of Rockland has been proactive and taken “multiple interventions,” including resident care plan updates, medication modifications, referrals for hospital treatment and discharge planning.

Cashman said Woodlands of Rockland and its employees have been doing “their best to manage what can be extremely difficult behaviors by individuals living with significant cognitive impairments.”

But Banks said something is amiss if any facility has repeated incidents, noting that she would have been alarmed to see more than one or two incidents of abuse in three years, let alone 30 or more as Woodlands of Rockland did.

“When you have people in your building and you took them in and you told their families you would take care of them and you took their money,” Banks said, “I don’t care what’s going on. I don’t care if you have a staff of three. You’ve got to take care of your people.”

Mariam Elba contributed research.

by Kyle Hopkins, Anchorage Daily News

This story details allegations of violence against Indigenous women and girls.

This article was produced for ProPublica’s Local Reporting Network in partnership with the Anchorage Daily News. Sign up for Dispatches to get stories like this one as soon as they are published.

KOTZEBUE, Alaska — On a subzero Monday morning in March 2020, police found another woman dead at the ex-mayor’s property.

Two years earlier, the body of 25-year-old Jennifer Kirk lay curled at the foot of a bed, a rifle on the floor, strangulation marks on her neck and a bullet hole beneath her chin. City police swiftly closed the case, declaring it a suicide.

Now police were back at the property, where the lifeless body of Susanna “Sue Sue” Norton, 30, was discovered in an adjacent house, beaten and strangled. An autopsy determined the cause of death to be homicide.

Kirk and Norton, both Inupiaq, had each dated sons of the former borough mayor, and the sons had previously been convicted of beating each of them. One of the sons had admitted to strangling Kirk twice before. Another pleaded guilty to kicking Norton in the stomach when she was six months pregnant.

No one has ever been charged with a crime in connection to the deaths.

In a state where women are 2.5 times more likely than the national average to be killed by a man and Alaska Native women are especially at risk, elected leaders here have repeatedly pledged action. The Department of Justice declared a rural law enforcement emergency in Alaska following a 2019 report by the Anchorage Daily News and ProPublica on glaring lapses in local policing. Two years later, the governor created a state council on Missing and Murdered Indigenous Persons, and in 2022, new investigators were hired to solve cases like Norton’s.

Unexplained holes in the investigations into the deaths of Kirk and Norton call into question this commitment, a review by the Anchorage Daily News and ProPublica found. More than that, the events leading up to the women’s deaths illustrate how police, prosecutors and judges here have regularly given pass after pass to people accused of domestic violence and strangulation.

Police records obtained by the newsrooms show that Kirk’s body revealed signs of strangulation. Her boyfriend, Anthony Richards, son of then-Mayor Clement Richards Sr., admitted to police that he had caused the marks on the day she died. After reviewing the records, former Kotzebue Police Chief Ed Ward said the 10 red flags that the Training Institute on Strangulation Prevention instructs police to look for in cases of domestic violence killings all appeared to apply to the scene of Kirk’s death. (Ward did not work at the police department at the time of her death.)

Yet the Kotzebue Police Department closed the case after a single day of investigation, labeling it a suicide before receiving the final autopsy report.

In Norton’s case, police never told her family she had been strangled, family members said. Police didn’t ask the public to help catch the suspect, as they had the prior year when a fire department dog was killed in the same neighborhood. They never interviewed key witnesses and failed to obtain a search warrant, leaving evidence uncollected.

State troopers, who took over the investigation into Norton’s death in 2022, told her family they planned to travel to Kotzebue over the summer to investigate further. Norton’s family says that didn’t happen either. (A department spokesperson said on Oct. 27 that investigators had not yet visited Kotzebue for the case but planned to do so before the end of the year. He said the agency’s Missing and Murdered Indigenous Persons unit is “taking investigative steps with the goal of finding the person responsible for Sue Sue’s tragic death and holding that person responsible for their actions through the criminal justice system.”)

Both Kirk and Norton had been victims of domestic violence at the hands of two of the Richards brothers. The Daily News and ProPublica found that state prosecutors repeatedly allowed the men to avoid felony domestic violence convictions for strangling or beating women, including Kirk and Norton. In those cases, the state offered the sons deals, allowing them to plead guilty to reduced misdemeanor charges such as “harassment” and receive slaps on the wrist, not prison sentences.

In one sexual assault case involving a different woman, state Superior Court Judge Paul Roetman granted Anthony Richards, the mayor’s youngest son, uncommonly low bail. Roetman explained his decision by saying he had worked with Anthony’s mother and knew his father held elected office.

“Fine Third Parties” Listen to state Superior Court Judge Paul Roetman describe Annette Richards and Clement Richards Sr. as “fine third parties”in a 2015 bail hearing for their son Anthony Richards, who was facing sexual assault charges. (Obtained by Anchorage Daily News and ProPublica)

Roetman and two prosecutors, now a magistrate and judge, declined to comment through a court system spokesperson. “Judicial officers cannot and do not comment on their cases, in order to maintain the integrity of their decisions and to ensure that, for fairness reasons, their thinking is reflected solely in the official court record without extraneous commentary,” the spokesperson wrote.

In the center of Kotzebue, Norton’s adoptive mother, Susanna “Mama Sue” Norton, is waiting for answers from Alaska’s criminal justice system. She lives three doors down from the house where her daughter was found strangled to death.

“My family is not going to have peace until they know that they found someone that did this to her,” she said in an interview in 2020. Three years later, as another winter begins, the case grows colder by the day.

Susanna “Mama Sue” Norton says police never talked to her about her daughter’s homicide. (Emily Mesner/Anchorage Daily News) In this overview of Kotzebue, the two green houses in the center belong to Clement Richards Sr., while Mama Sue Norton lives in the brown house in the bottom right. Kotzebue City Hall and the police station are to the left of the intersection. (Emily Mesner/Anchorage Daily News) A History of Criminal Charges

Kotzebue lies just above the Arctic Circle on a frying-pan-shaped peninsula, nearer to Russia than to Anchorage. Clement Richards Sr. was born here in 1961, two years after Alaska became a state. The city sold itself back then as the Polar Bear Capital of the World, where small planes carrying trophy hunters from across the globe parked on the sea ice. (One of the largest polar bears ever recorded was hunted here in 1963.)

In the 1970s, geologists confirmed what a local bush pilot long suspected: The red-stained creeks that veined the tundra hinted at a massive mineral deposit. In the ’80s, Kotzebue and surrounding villages voted to create a new Northwest Arctic Borough government, with the second-largest zinc mine in the world funding public services such as search and rescue.

Meantime, Clement Richards Sr. and Annette Richards were busy growing their family. The couple had two sons, Amos and Clement Jr., and another on the way in May 1989 when Clement Sr. kicked Annette in the stomach, according to charges filed in Kotzebue state Superior Court. Clement Sr. had previously struck her, Annette wrote in an earlier restraining order request. This time she was eight months pregnant.

The charges say Annette was “bleeding profusely from her genital area.” The couple’s third son, Anthony, was born the next day.

Clement Richards Sr. is sworn in to the office of mayor of Kotzebue. He also served as mayor of the Northwest Arctic Borough. (Arctic Sounder)

Clement Sr. pleaded no contest to felony domestic violence assault and received a six-month jail sentence. The conviction wasn’t mentioned by his opponents or the media a decade later when he won a seat on the city council in 1999 or still later when he became the city’s vice mayor, then mayor. Annette began working in a local office for the Alaska State Troopers where her duties involved assisting state prosecutors, including one who later served as the judge in domestic violence cases against her sons.

The sons wrestled in high school, competed in fishing derbies and sometimes worked at the nearby zinc mine. Now 34, 37 and 39, all three have listed the former mayor’s property as their home address for most of their adult lives.

All three sons have been charged with assaulting women at the mayor’s property but dodged serious punishment.

The Daily News and ProPublica reviewed 31 criminal court cases involving the three sons, including more than 800 pages of charging documents, testimony, sentencing orders and protective order requests. In 12 of those cases, one of the sons was charged with committing domestic violence. The victims — six different women — included the sons’ relatives and current and ex-girlfriends, including Kirk and Norton. (The other criminal cases involved driving while intoxicated, indecent exposure and trespassing.)

Seven of these domestic violence cases were filed while Clement Sr. held political office, from 1999 to 2018. All told, the three sons have been charged with a combined 16 counts of domestic violence, including five felonies. Yet none of the charges against them resulted in a felony domestic violence conviction.

While the details in each case differ, seven of the domestic violence cases unfolded in familiar ways:

First, one of the girlfriends or a worried neighbor called the Kotzebue police. Officers arrived to find the victim with visible wounds such as bruises, markings on her neck or a bloody nose. The girlfriend told police one of the sons punched, kicked or strangled her.

She told police the attacks began when she tried to stop the son from drinking, attempted to leave the house or refused sex. In two cases, police noted the mayor or his wife refused to cooperate with the active investigation. The Kotzebue Police Department then arrested the son but usually labeled the attack as a low-level misdemeanor rather than felony assault.

Next, the son appeared before a local judge or magistrate who was sometimes a former state prosecutor who had worked alongside the ex-mayor’s wife. The judge or magistrate agreed to set bail for the son — once even acknowledging on the record that the bail was unusually low and telling the victim that the mayor and his wife would help keep the son out of trouble until the trial.

But the cases never made it to trial. They were settled at a change-of-plea hearing where prosecutors dropped any felony charges and the son promised to do better. Within a few months, maybe a year, the cycle would begin again.

In one 2013 case, a woman said Clement Richards Jr. punched her in the face and police filed a charge of domestic violence assault. Clement Jr. eventually pleaded guilty to harassment and received a suspended sentence, scrubbing his conviction from the public record. In a sexual assault case filed the following year against Anthony Richards, Roetman reduced Anthony’s bail from $7,500 to $2,500 over the protests of the victim, who said in a quaking voice that she feared running into Anthony in the town of 2,900.

“You Dodged a Bullet” Listen to Roetman, a judge, speak to Anthony Richards, who was facing sexual assault charges. “To say that you dodged a bullet is probably an understatement on this one,” Roetman said. (Obtained by Anchorage Daily News and ProPublica)

“I know Mrs. Richards from when she used to work for the troopers,” Roetman said at Anthony’s bail hearing. “She has a lot of experience with these types of cases and knows what these are like.”

The Alaska Judicial Code of Conduct states that a judge “shall not allow family, social, political, or other relationships to influence the judge’s judicial conduct or judgment.” Roetman did not respond to questions about his remarks in court, his work relationship with Annette Richards or the cases he presided over involving her sons. A court system spokesperson provided the newsrooms with a statement saying “judicial officers cannot and do not comment on their cases.”

Although a Kotzebue grand jury indicted him on felony charges of sexual assault and attempted sexual assault, Anthony Richards eventually pleaded guilty to a single misdemeanor count of indecent exposure in the 2014 case. The deal allowed him to avoid registering as a sex offender. (The prosecutor, Rachel Ahrens, is now a state superior court judge and declined to comment through a court system spokesperson.)

“To say that you dodged a bullet is probably an understatement on this one,” Roetman told him at the change-of-plea hearing.

Increasingly Dangerous Attacks

Clement Richards Sr. won election as Northwest Arctic Borough mayor in November 2015, campaigning on his experience leading the city and his bona fides as a born-and-raised son of Kotzebue. He became chief executive of a region the size of Indiana with a population of about 7,500. As climate change threatened the nearby village of Kivalina, the Northwest Arctic moved into the national spotlight.

“What’s happening here is America’s wake-up call,” then-President Barack Obama said after flying over the village and touring Kotzebue just before Richards was elected in 2015.

Clement Sr. had been in office just a month when Kirk showed up at the local hospital. She told police that Anthony had punched her five times.

Kirk grew up in the village of Buckland, 75 miles outside of Kotzebue. She and Anthony sometimes lived in one of two teal homes that Clement Sr. and Annette Richards own on a grassy lot, one block from the police department and City Hall. Officer Nate Lecours came to the property to investigate the beating.

Former Kotzebue mayor Clement Richards Sr. lives on this multi-home lot that his sons have also listed as their home address for much of their adult lives. (Emily Mesner/Anchorage Daily News)

“Upon arrival the Borough Mayor, Clement Richards, who appeared extremely intoxicated, answered the door and stated how can I help you a total of three times speaking over me then slammed the door in my face,” Lecours wrote in a Dec. 6, 2015, affidavit. (In a brief phone interview, Lecours said he remembered that encounter but no longer works for Kotzebue police and referred all questions to the department.)

A few days later, Magistrate Judge Stephan Brady reduced Anthony’s bail in this new assault case to just $100. (Brady no longer works for the state. He did not respond to phone messages or emails.)

As the years passed, the attacks grew more dangerous. On March 14, 2017, Kirk told police Anthony strangled her until her field of vision began to shrink and she nearly passed out.

That would have been enough, under a 2005 Alaska law, to charge him with a felony for nonfatal strangulation. Alaska was one of the first states to recognize that strangulation is often a precursor to homicide and increases suicide risk, according to the Training Institute on Strangulation Prevention.

The prosecutor, Ahrens, allowed Anthony to plead guilty to a single count of misdemeanor assault.

Despite the light punishment, Magistrate Judge Aaron Michels warned Anthony he could have killed Kirk that day.

“Strangulation is a very serious thing and it’s recognized that way by the Legislature, that’s why these types of cases can be charged as felonies,” Michels said at an October 2017 change-of-plea hearing. (He declined to comment through a court system spokesperson.)

“The result of strangulation — if it’s not stopped, if a person can’t breathe — is death,” the magistrate told Anthony Richards.

“You Are Getting Away From a Felony Conviction” In a hearing where Anthony Richards pleaded guilty to misdemeanor assault as part of a deal to avoid felony charges, Magistrate Aaron Michels tells Richards that “the natural result of a punch or a kick or kind of your typical misdemeanor assault is a bruise or an injury, that sort of thing. The result of strangulation — if it’s not stopped, if a person can’t breathe — is death.” (Obtained by Anchorage Daily News and ProPublica)

On May 23, 2018, Kirk and Anthony’s final argument began on the mayor’s property.

Alerted by a neighbor, two officers came to the house around 6 p.m. They found Anthony in the bedroom holding Jennifer Kirk’s body, according to police records, his hands and clothes coated in blood.

Anthony told police he had been watching TV with two children in the living room when he heard the pop of a gunshot and discovered Kirk dying on the floor. A .22-caliber rifle lay across her feet and a gunshot wound pierced the underside of her chin.

The police department’s investigator at the time, Thomas Milliette, measured the weapon.

“I noted the length of the rifle from the tip of the barrel to the tip of the trigger as being 27 1/8 inches long,” Milliette wrote in his report. Next he measured the length of Kirk’s arm: 26 3/18 inches. In interviews, members of Kirk’s family wondered how Kirk, who was 5 feet, 5 inches tall, could have shot herself with a long gun.

Robert Shem, a retired firearm expert for the state crime laboratory, said in an interview that such measurements can be useful in determining whether a death is indeed a suicide, but in this case, more information would be needed. (Shem was the forensic scientist who first established a link among the shooting victims of Alaska serial killer James Dale Ritchie in 2016.)

“Before I would write it off as a suicide myself,” he said, “I would probably try to locate somebody of the same size and build and use that rifle, or one similar to it, with the same length barrel and configuration, demonstrate that it’s completely unloaded and see if the person can lean over and potentially get their thumb in position to pull the trigger.”

Kirk’s father, Timothy Gavin, said Kirk gave no hints she might kill herself.

“We never seen that in her. No signs, nothing,” Gavin said. “So it’s hard to believe she did that to herself.”

Tim Gavin, Jennifer Kirk’s father, has questions about whether his daughter’s death was really suicide. (Emily Mesner/Anchorage Daily News)

Gavin knows something about policing and public service. A Buckland city councilmember and the former mayor, he served 11 years as a village police officer. He’s also no stranger to gunshot deaths. His stepfather shot and killed his mother, Kirk’s grandmother. (The stepfather was convicted of manslaughter and sentenced to prison.)

Kirk’s mother, Dora Stalker, chatted with her daughter hours before the shooting and recalls that nothing seemed amiss. They even made plans. “She was trying to ask me to send diapers for her daughter,” Stalker said.

“We kind of had a plan to send each other some Native foods,” Stalker said. Kirk would trade her mother beluga muktuk in exchange for springtime smelt from Buckland.

Two days after Kirk’s death, the state medical examiner’s office phoned Kotzebue police and said her body “showed signs of strangulation,” according to the death investigation report compiled by police and obtained through a public records request.

In his first interviews with police, Anthony had not revealed that he and Kirk violently fought before she died. Once Milliette knew about the strangulation marks, Anthony admitted to causing the injuries to her neck. He said he acted in self-defense.

Anthony said Kirk slapped him and he “held her away by the neck and didn’t know how hard he was squeezing,” according to the police report. Anthony said Kirk continued to slap him so he pushed her to the ground, twice. He said he didn’t know if he knocked her unconscious.

Milliette closed the case after one day of investigation. He concluded his report with a note that the medical examiner’s office had called again and said Kirk’s death would be ruled a suicide, with the final autopsy findings to be sent to Kotzebue police when finished. Kirk’s mother, Stalker, said police never interviewed her or asked her what her daughter had said to her the day she died.

“They should have investigated a lot better, a lot more thorough before they said it was a suicide,” Stalker said. “It’s like they just rush and do whatever to get it over with.”

The Kotzebue Police Department did not answer certain questions about the death investigation, including any about what conclusions Milliette drew from the rifle measurements, referring questions to the former police chief. Milliette did not respond to interview requests. The Alaska Department of Law, which oversees state prosecutors, did not answer questions about why no charges were filed in the case.

“I would have prosecuted him for the strangulation before she died,” said Casey Gwinn, a former prosecutor and president of the Training Institute on Strangulation Prevention.

A Missing 10-Year-Old Girl

Kirk’s death never made the news. Three months passed and the city of Kotzebue, along with the rest of Alaska, became absorbed with the case of a missing child. In this time of crisis, everyone turned to Mayor Clement Richards Sr.

Hundreds of volunteers hunted for 10-year-old Ashley Johnson-Barr, who disappeared in September 2018 from a playground at the center of town. The Northwest Arctic Borough Assembly chambers, adorned with antlers and a scrimshaw walrus tusk, served as the nerve center for the search with Clement Sr. acting as spokesperson.

“We’re a small community where everyone knows everyone, so we’re trying as hard as we can to find her,” Clement Sr. told the Daily News at the time.

“I’m deeply concerned she hasn’t been found yet,” he said, explaining that as many as 50 people were looking for the child at any one time. Norton joined in, her family said, cooking her best-loved food, caribou stew with pilot bread crackers, to feed fellow searchers.

After eight days, a volunteer spotted Johnson-Barr’s body in a brushy hollow outside the city. Federal investigators and state troopers raced to Kotzebue to aid local police and soon arrested a 41-year-old man for her death by strangulation. To solve the case, law enforcement used cellphone location data, DNA evidence, search warrants, surveillance video and the advantage of the FBI, who first arrested the suspect on grounds of lying to a federal officer. The killer, Peter Wilson, pleaded guilty to first-degree murder and first-degree sexual abuse of a minor and is serving life in prison.

The response shows how cases involving missing and murdered Indigenous people can be solved when they are immediately prioritized by local authorities and when state and federal agencies give assistance. The state declared an annual Ashley Johnson-Barr Day and hired a retired Kotzebue-area trooper, Alaska Native Anne Sears, as Alaska’s first full-time Missing and Murdered Indigenous People investigator.

Ashley Johnson-Barr’s aunt holds a photo of the murdered girl at a Missing and Murdered Indigenous People event in Kotzebue this year. (Marc Lester/Anchorage Daily News)

The message: Alaska would no longer tolerate the rape and killing of Indigenous women and girls.

But as the mayor prepared to leave office, nothing appeared to change for his sons. On Nov. 17, 2018, two months after Johnson-Barr was found dead, Kotzebue police received yet another report of domestic violence.

This time the victim was Norton, who by then was six months pregnant. Police found her crying, her right eye swollen shut. She said she had tried to stop her boyfriend, Amos Richards, from drinking by pouring out his beer.

City police Sgt. Norman Hughes described the attack in a report: “Susanna said the defendant became angry and grabbed her by the hair and drug her around the house. Susanna said the defendant kicked her repeatedly in the head, face, stomach and back. Susanna showed me her forearms which were swollen and told me she was holding her arms up to protect her head when the defendant was kicking her.”

Hughes categorized the beating in a criminal complaint filed in state court as misdemeanor, fourth-degree assault, the least serious form of assault spelled out by state law. (Hughes did not respond to interview requests or written questions.)

According to medical records, Norton flew to Anchorage, where her baby was born two weeks later at the Providence Alaska Medical Center. Doctors noted she had suffered “premature rupture of membranes.” Her family said the trip to Anchorage was medically necessary and believe the premature birth was brought on by the attack.

The baby weighed 3.1 pounds. Norton named her Eden.

“She is a tough baby girl,” Norton posted that day to friends and family. “Please remember us in your prayers.”

Sue Sue Norton’s Facebook post announcing the birth of her daughter (Screenshot courtesy of Lesley Sundberg)

Doctors recommended the baby stay in Anchorage, even after leaving the hospital, because Eden had health problems unrelated to the premature birth and needed surgery to survive. Mama Sue Norton said the Office of Children’s Services became involved and planned to temporarily place Eden with a foster family so she could be closer to medical care.

Sue Sue sang to the baby in Inupiaq over FaceTime, said Lesley and Joel Sundberg, a foster family who housed Eden after she left the hospital and have since adopted her. Amos, for a time, frequently texted the foster parents to ask how Eden was feeling and discuss the upcoming adoption.

Up in Kotzebue, a new strangulation case captured the attention of City Hall and local police. Authorities did not hesitate to seek the public’s help.

“The Kotzebue Police Department suspects foul play and is pursuing all investigative leads,” said Milliette, the investigator who had closed Kirk’s case without an arrest the year before. By this time, he had become chief of police. Volunteers raised thousands of dollars in reward money and the story made statewide news for days. After police released a surveillance photo of the suspect, a tipster came forward and identified the killer, who pleaded guilty to a felony in Roetman’s courtroom.

The victim was a dog: the city fire department’s pet husky.

A Second Death

On Jan. 19, 2020, Norton changed her Facebook profile photo to display a red handprint across her closed mouth, the symbol of the Missing and Murdered Indigenous Women movement.

Sue Sue Norton commemorated missing and murdered Indigenous women in her Facebook profile photo less than two months before she was killed. (Facebook)

A few days later, Amos Richards appeared in court to face charges for kicking Norton while she was six months pregnant. Once again the magistrate was Michels, who approved a deal that allowed Amos to plead guilty to a single count of “reckless endangerment.”

Despite the plea, Norton and Amos made plans to fly to Anchorage to finalize adoption paperwork.

“I cant tell if she has me or Amos’s eyes,” Norton wrote on Jan. 30, 2020, after seeing the latest picture of Eden at the hospital. She sent the Sundbergs a selfie of her and Amos, heads together, to show the baby.

Norton sent a photo of herself and Amos Richards to the couple who adopted their daughter, Eden. (Photo courtesy of Lesley Sundberg)

Like Kirk, Norton was a Leo. (Although born years apart, Kirk and Norton shared the same Aug. 21 birthday.) Norton had a habit of cracking her knuckles and dreamed of one day taking a Caribbean cruise. Her biggest fear, she once wrote, was losing her children.

Her mother remembers her, most of all, as a helper. The last time the whole Norton family gathered with Sue Sue, she sat on a square of cardboard on the tiled floor, separating the hide from the marbled meat of a freshly killed caribou.

Five days before Norton and Amos were to sign adoption papers, Amos stopped responding to texts from the adopting family.

The timeline of Norton’s last week alive is muddled by conflicting evidence. In a 2020 email to the Daily News and ProPublica, Kotzebue police estimated her date of death as March 5 or 6. But Norton’s sister, Vera Norton, said Sue Sue helped family prepare a caribou on March 7 or 8.

At 8:32 a.m. on March 9, police were called to the former mayor’s house, where they found Norton’s body, her head covered by a jacket.

Outside, the temperature fell to 13 below. Here above the Arctic Circle, graves must be carved into the icy soil and permafrost, and as Vera Norton was leaving home to look for a burial site, she saw police placing Amos into a patrol car.

Hughes later told Sundberg that police were unable to collect certain evidence. Asked to clarify by ProPublica and the Daily News, Kotzebue Police Chief Roger Rouse said in an email that Hughes had been referring to “the rejection of a search warrant from the judge in regard to some evidence.” The police chief would not say which judge he was referring to.

Amos skipped the funeral.

Mama Sue Norton said police never spoke to her about the case. She first learned the official cause of her daughter’s death was homicide when a death certificate arrived in the mail.

Norton is buried just outside Kotzebue. (Emily Mesner/Anchorage Daily News)

The certificate listed the cause of death as “asphyxiation due to obstruction of airways and compression of neck.” The autopsy also found that Norton had suffered “multiple blunt force injuries of head, neck and extremities.”

She’d been beaten. But it was the strangling that killed her.

“We’re Not Interested”

The homes on the Richards’ property are 440 feet from the Kotzebue Police Department lobby. City Hall is even closer. A dozen domed surveillance cameras circle the various government buildings, several within view of the former mayor’s house.

One day in June 2021, I knocked on the door of the main house, the first of three visits to the property where police found Kirk and Norton’s bodies. “What’s this about?” Clement Sr. asked.

Richards was no longer borough mayor at the time, having lost reelection in 2018. Norton’s family says the deaths on his property were common knowledge and gave voters pause. Other Kotzebue residents said the election was simply more competitive, with a new crop of respected candidates. When asked about the death of Norton, he said, “I have no comment,” and shut the door.

Clement Jr., the middle son, stood outside by a four-wheeler watching the exchange. He said he knew nothing about the case because he was in Anchorage with his father when Norton died. Asked how he thinks she died, Clement Jr. said he didn’t know, hasn’t thought about it and never asked.

Maybe she killed herself, he volunteered. “It’s a common thing in Alaska.”

In 2022, Sears, the state’s Murdered and Missing Indigenous People investigator, began looking into the case and met with Eden’s foster family to learn more. But Sears soon resigned, just five months into the new job. She declined an interview request.

The Daily News and ProPublica on June 14 of this year again attempted to interview Clement Sr. and his sons about the deaths. A man who answered the door at the back house refused to comment and closed the door.

“We’re not interested,” he said.

Last month, the newsrooms sent certified letters detailing the findings of this story to members of the Richards family; we didn’t hear back. The family also didn’t respond to letters, phone calls, texts and Facebook messages.

It’s all made for a long three years for Mama Sue, a devout Christian and a retired tribal doctor who practiced traditional medicine in Inupiaq villages. She suffered a stroke months after her daughter’s death and temporarily lost her ability to speak. On a recent weekday she sat in a formation of half-filled produce boxes, silently packing everything she owns as she prepared for her house to be demolished.

Her family built the home by hand decades earlier. Now a new house is arriving on a barge, and soon Mama Sue will have indoor plumbing and running water for the first time. Builders will place the new home on the same lot, 230 feet from the house where her daughter was found strangled.

As of September, Kotzebue police had never interviewed Mama Sue about the homicide. Nor had they talked to Norton’s other relatives and potential witnesses. Nor did they ever talk to neighbors who live between Mama Sue and the former mayor’s house, who regularly visit with Amos and Anthony Richards.

The new Kotzebue police chief, Rouse, said he could not comment on Norton’s death because it remains an open investigation, although the case is now in the hands of Alaska State Troopers.

In 2021, Lesley Sundberg, who adopted Amos and Sue Sue’s child, filed a formal complaint with the state regulators against the Kotzebue Police Department, accusing the department of “dishonesty and untruthfulness.”

“One must wonder,” Sundberg wrote to the Alaska Police Standards Council in November 2021. “If there are unethical reasons why a Native Alaskan woman, mother of 3, daughter, niece, sister, aunt, and well-known community member’s murder, has been swept under the rug.” (The executive director for the council said in an email to the newsrooms that the agency “does not investigate complaints of this nature until the involved criminal investigation is completed by the law enforcement agency working on it, so that we do not interfere with the criminal investigation.”)

She never received an answer.

Correction

Nov. 11, 2023: This story originally misidentified Rachel Ahrens’ current position. She is a superior court judge, not a magistrate.

by Melissa Sanchez and Maryam Jameel

Leer en español.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week. This story was co-published with the USA TODAY NETWORK-Wisconsin.

County officials in Wisconsin approved reforms this week meant to respond to a ProPublica report on the flawed investigation into the 2019 death of a Nicaraguan boy on a dairy farm. They include an $8 million fund for farmworker housing and measures to improve access to government services for people who don’t speak English.

Advocates said the housing initiative appears to be the first of its kind in Wisconsin, a state that calls itself “America’s Dairyland” but that offers few protections for the undocumented immigrants whose labor many farms depend on.

Separately, the sheriff’s office in Dane County — which investigated the boy’s death — has drafted its first-ever written policy on how to respond to residents with limited English proficiency.

The changes come in response to a February report by ProPublica that detailed the flawed law enforcement investigation into the death of Jefferson Rodríguez, an 8-year-old boy who had lived in a barn above a milking parlor on the farm where his father worked about a half-hour north of Madison.

ProPublica found that another worker had accidentally run Jefferson over with a skid steer, a piece of machinery used to clear manure off barn floors. But the deputy who interviewed the boy’s father, José María Rodríguez Uriarte, mistakenly concluded that he had been the one operating the machine. This failure, we found, was due in large part to a language barrier. Jefferson’s death was ruled an accident, but Rodríguez was publicly blamed.

In a recent interview, Rodríguez said he was glad to learn that the story of what happened to his son has led to changes that could help other immigrants. “Perhaps if all of this had happened five or six years ago, my situation would have been entirely different,” he said. “It would be much better to be able to communicate with police without the fear of calling and them not understanding.”

José María Rodríguez Uriarte and his son Jefferson in Wisconsin. (Courtesy of José María Rodríguez Uriarte)

The measures were approved Monday as part of the county budget. Joe Parisi, the county executive, can still veto the budget but is not expected to do so.

After our story was published, several members of the board and other elected officials began calling for measures to ensure that people who don’t speak English can communicate accurately with sheriff’s deputies.

When Jefferson died, the sheriff’s office had no written policy on what deputies should do when they encountered people who spoke limited English or when they should call for an interpreter. As a general practice, the department encouraged patrol deputies to ask for help from bilingual colleagues or to use a phone- or video-based interpreter, Elise Schaffer, a department spokesperson, said in a statement.

The department doesn’t test language skills of employees, who instead self-report proficiency.

The deputy who interviewed Rodríguez identified herself as a proficient Spanish speaker. When we interviewed her, however, we discovered that the words she used in Spanish to question Rodríguez didn’t mean what she thought. Rodríguez told us that he never understood the deputy was trying to ask if he was driving the machine that killed his son.

Sheriff Kalvin Barrett declined interview requests. But at a county board meeting in September, he acknowledged “shortfalls in the services that we have and we want to make sure that we’re continuing to provide individuals with the help and the services that they need, especially if they don’t speak English.”

Barrett said the department will test employees on their ability to speak a second language and that it was looking for ways to provide “additional financial support” to those who demonstrate proficiency. According to a draft policy, the department will provide training to staff on how to find qualified interpreters and ensure key documents and forms are translated.

Schaffer said she did not know when the draft policy would be adopted.

Law enforcement agencies that receive federal funding, like Dane County, are required by the Civil Rights Act to ensure that their services are accessible to people who speak limited English. ProPublica found that sheriff’s departments across Wisconsin routinely encountered language barriers when responding to 911 calls from dairy farms. Over and over, records showed, officers who couldn’t communicate with Spanish-speaking workers relied on farm supervisors, other workers, Google Translate and even children to interpret for them.

The Board of Supervisors on Monday separately approved the creation of three full-time positions and one part-time role to improve services for people who don’t speak English. Among them: a coordinator to help departments implement language access plans and engage community members with limited English proficiency.

Dana Pellebon, a member of the Board of Supervisors who chairs the county’s Equal Opportunity Commission, said the issue of language accessibility got more attention than ever this year.

“Your article started this investigation into what it is that needed to happen,” she said. “I am deeply sorry and ashamed that it had to take the death of a child for us to be aware, and we’re going to work proactively to make sure these situations never occur again.”

ProPublica’s reporting also put a spotlight on dairy worker housing, which goes largely unregulated and uninspected by state and federal authorities.

Dane County is home to more than 170 dairy farms, according to state records. It’s unknown how many provide housing to workers, but a recent statewide study on immigrant dairy workers by the University of Wisconsin-Madison’s School for Workers found that close to three-quarters of surveyed workers lived in employer-provided housing, typically on the farm.

Our reporting found that Jefferson and his father had lived in a room above a milking parlor — the place where cows are milked day and night with loud, heavy machinery. (In court filings, the farm’s owners disputed that they lived there. ProPublica spoke with more than a half-dozen people, including Jefferson’s bunkmate, who confirmed that they and other workers lived above the parlor.)

“The issue of safe housing for folks working on farms and in rural parts of the county I don’t think had been front of mind to me until hearing more about, honestly, the death of Jefferson Rodríguez,” said Heidi Wegleitner, a member of the Board of Supervisors who was the lead sponsor and author of the farm worker housing initiative. “This is a gap that existed, I think, before your important reporting, but it really gave me a sense of urgency about doing something about it.”

Wegleitner, who is also a housing attorney, said the first goal of the new initiative will be to assess the existing housing supply and needs of farm workers. The county could then purchase land and build new housing.

Advocates say there is a significant need for affordable housing for undocumented immigrant dairy workers who are excluded from existing programs due to restrictions in federal funding.

“This has always been a challenge for us,” said José Martínez, the chief operating officer of the nonprofit United Migrant Opportunity Services, which operates several affordable housing projects for agricultural workers across Wisconsin.

None of UMOS’ housing developments are accessible to people who are undocumented.

Neither is the 32-unit apartment complex for low-income agricultural workers that opened last year in Darlington, in southwest Wisconsin. Several people involved with the project said it was intended, in part, to serve immigrant dairy workers in the area, but instead the units have been mostly rented out to other kinds of agricultural and food-processing workers, including immigrants with work permits.

There are other challenges. For more than a decade, Wisconsin has barred undocumented immigrants from obtaining driver’s licenses, even though the state allows them to buy and register their vehicles. ProPublica reported earlier this year on how undocumented dairy workers are ticketed over and over for driving without a license. As a result, some workers prefer to live on the farms where they work so they can avoid having to drive.

Meanwhile, Rodríguez said he is glad somebody in Dane County is paying attention to the housing conditions immigrant workers encounter on dairy farms. It’s a subject he says comes up often when talking to friends who live and work in the area.

“The problem is you are just afraid that if you complain, there will be a negative reaction from the bosses,” he said. “That maybe they’ll tell you, ‘We don’t need you working here anymore.’ And so you just put up with the bad conditions.”

by Jessica Miller, The Salt Lake Tribune

Update, Nov. 14, 2023: Scott Owen was charged on Nov. 13 with multiple felonies related to the allegations of two men who say he touched them inappropriately during therapy. If convicted, he faces a five-years-to-life prison term on each charge. His defense attorney did not respond to a request for comment. The Salt Lake Tribune is publishing ongoing coverage of the case.

This story details allegations of sexual assault.

This article was produced for ProPublica’s Local Reporting Network in partnership with The Salt Lake Tribune. Sign up for Dispatches to get stories like this one as soon as they are published.

Former Utah therapist Scott Owen was arrested Wednesday in connection with accusations that he sexually abused patients during sessions.

The Salt Lake Tribune and ProPublica reported in August on a range of sex abuse allegations against Owen, who had built a reputation over his 20-year career as a specialist who could help gay men who were members of The Church of Jesus Christ of Latter-day Saints. He gave up his therapy license in 2018 after several patients complained to state licensers that he had touched them inappropriately. Some of the men who spoke to The Tribune said their bishop used church funds to pay for sessions where Owen allegedly also touched them inappropriately.

Owen, 64, was booked into the Utah County jail on suspicion of six counts of object rape and four counts of forcible sodomy. A Utah County judge has ordered that Owen remain in jail without the opportunity to post bail, finding that he could be a danger to the community and would likely flee if released.

Scott Owen (Obtained by The Salt Lake Tribune and ProPublica)

Owen had not been formally charged as of Friday morning. He has not responded to detailed lists of questions previously sent to him on two occasions regarding allegations that he touched his patients inappropriately. He co-founded Canyon Counseling in the late 1990s and continued to have an active role in the business until recently. The counseling center cut ties with him after sexual assault allegations became public before announcing in September that it was closing altogether.

In a probable cause statement released Wednesday, a Provo police officer wrote that the department had interviewed 12 former patients of Owen’s since August. Owen was arrested on allegations connected to two former patients, who both say Owen engaged in sexual contact with them during therapy sessions. That alleged touching included kissing, cuddling and Owen using his hand to touch their anuses. One man also alleges Owen performed oral sex on him.

Provo police allege in the statement that Owen used his position of trust as a therapist to coerce his patients into engaging in kissing, cuddling and sexual touching during therapy sessions. According to arrest records, many of the 12 former patients told officers that they began seeing Owen for treatment of “same-sex attraction.” The therapist told them their relationships with men were “broken” and that therapy could help them have “normal” relationships with men and eventually women, the men told police. From there, the patients allege, Owen would engage in touching that some say became increasingly sexual in nature.

Utah law says patients can’t consent to sexual acts with a health care professional if they believe the touching is part of a “medically or professionally appropriate diagnosis, counseling or treatment.”

Under a negotiated settlement with Utah’s licensing body, Owen was able to surrender his license without admitting to any inappropriate conduct, and the sexual nature of his patient’s allegations is not referenced in the documents he signed when he gave up his license.

Prior to the August publication of The Tribune and ProPublica article, Provo police said they had no record of anyone ever reporting Owen to law enforcement for alleged sexual misconduct.

Both state licensers and the local leaders in the LDS Church knew of inappropriate touching allegations against Owen as early as 2016, The Tribune and ProPublica reporting showed, but neither would say whether they ever reported Owen to the police. In Utah, with few exceptions, the state licensing division is not legally required to forward information to law enforcement.

The church said in response that it takes all matters of sexual misconduct seriously, and that in 2019 it confidentially annotated internal records to alert bishops that Owen’s conduct has threatened the well-being of other people or the church.