Ja’Ceon Terry was 7 years old when he suffocated to death in the care of people who were supposed to look after him when his parents could not.
The boy was a ward of the state and had been staying at Brooklawn, a foster care facility in Louisville, Kentucky, for children with mental and behavioral needs, when he died July 17 of “positional asphyxia,” according to the Jefferson County Coroner’s Office.
On the day Ja'Ceon died, a program manager recalled being told that the child had been held in a chokehold by two employees and that he began to vomit, according to a source with knowledge of the encounter.
But there had been allegations of wrongdoing at the facility and its sister campus for several years before Ja’Ceon’s death, according to an NBC News review of incident reports filed with the Kentucky Cabinet for Health and Family Services from 2014 to 2022, a lawsuit against the facility and a former employee who says she was intimidated into quitting after she reported abuse. Among the violations “confirmed” by state investigators from the Kentucky Cabinet were improper use of restraints and aggression by staff members.
The facility said that since Ja’Ceon’s death, which the Jefferson County Coroner’s Office ruled a homicide, it has “dismissed” two employees who it says were involved, and the Kentucky Cabinet of Health and Family Services, the state agency that oversees youth centers, has suspended new foster care placements at Brooklawn. But Brooklawn has remained in operation, and its license is in good standing with the state agency. As of Oct. 20, 32 children who are in state custody remained in Brooklawn’s care, according to the facility.
Police and state officials say they are still investigating Ja’Ceon’s death, and no charges have been filed.
Dominique Terry, Ja’Ceon’s birth mother, said Brooklawn should have been shut down after her son died.
“I just don’t see how they’re still open,” she said. “I just need closure and justice for what happened. The people who did this need to be charged.”
Some social work experts, who do not have direct knowledge of Brooklawn’s internal operations, said the facility may still be in operation because the state deemed it a minimal risk of harm to the remaining children and because of a shortage of other placement options.
Ja’Ceon’s death exposed critical cracks in Kentucky’s foster care system, including dwindling staffing, according to child advocacy groups that hope the tragedy will bolster a push to have a body outside state government oversee foster facilities.
Uspiritus, the nonprofit organization that owns and operates Brooklawn, and its sister facility, Bellewood, said in a statement to NBC News that it is “still searching for answers to the many questions about what happened on that Sunday afternoon.”
“He should not have died on our watch. As protectors of Kentucky’s most vulnerable children, we are dedicated to making sure it never happens again. The health and safety of the Brooklawn family is always our top priority,” the company said. “The leadership of Brooklawn will continue cooperating with state and local officials investigating this tragedy.”
‘Nothing came’ of reported abuse allegations, former employee says
Uspiritus contracts with the state to care for children who have been removed from their homes, describing itself as “providing residential treatment, therapeutic foster care and adoption, and several community-based services” for children ages 6 to 18.
From 2018 to 2021, Uspiritus received almost $43 million in payments from the Kentucky Cabinet of Health and Family Services, according to state records obtained by NBC News.
The state agency conducted at least 35 internal investigations into complaints filed against employees of the Brooklawn and Bellewood facilities from 2014 to 2022, according to nearly 200 pages of records NBC News obtained from the agency. The agency did not respond to a question about how the complaints compared with those about other facilities.
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The agency found most of the reports to be unconfirmed, sometimes because there were no witnesses or video evidence or because children had been placed elsewhere.
The complaints, while not confirmed, included reports that children had been slammed to the floor or pushed down by staffers, that a child had a broken leg and that an employee held a child down using a knee in the back. Others included reports of verbal and sexual abuse.
In one unconfirmed report, an investigator writes to the state agency about being concerned “because of a pattern at Uspiritus of broken bones” during restraints.
It is unclear whether police were called for a separate investigation into any of the complaints.
A former employee of the facilities said investigators should have been keeping a more watchful eye over them before Ja’Ceon died. Rebekah Frank was hired in 2018 as a youth care worker at Brooklawn, a position that was advertised as requiring an “extensive two week training.”
Frank said that staff members received training in Safe Crisis Management, a program often taught to adults who work with children, which emphasizes techniques to de-escalate high-stress or unruly situations, and that they were required to continue training regularly as a part of the job.
The training prohibits chokeholds or any kind of holds that interfere with respiration, said Joe Mullen Sr., the president of JKM Training Inc., which created the Safe Crisis Management method, which he said has been taught to instructors at Brooklawn for 30 years. The program does teach physical restraint, but it is “taught to be used as a last resort only when there’s harm to self or others,” he said.
But Frank said she often saw the techniques they were taught being used improperly.
Over her five months at Brooklawn, Frank said, she witnessed dozens of interactions in which children as young as 8 screamed that they were in pain as staffers pinned their faces against the wall.
“You’re not supposed to put them up against anything, because you’re not supposed to restrict breathing at all. It’s just about containing the chaos. It’s not about restraint so much as it is securing them,” Frank said, referring to her training. “These kids had experienced so much trauma already, so if you’re putting a child against a wall to teach them a lesson, that’s abuse.”
NBC News reached out to other former Brooklawn employees who Frank said observed similar interactions, but none responded to requests for comment.
Mullen said employees are not taught to use a wall or other objects to hold children, calling it “not appropriate” and “not legitimate under professional standards.”
Frank said she reported her concerns to at least three people in the organization — a trainer, an internal investigator and a director — who were above her direct manager in the organization.
Frank said she told them that staff members were “improperly using physical interventions and would use walls to get leverage on children” and that it was a “toxic environment where the kids were not being respected or treated in a way that I felt was conducive to their healing, and they were receiving dismissive, antagonistic, passive-aggressive sorts of interactions.”
But she believes “nothing came of it,” she said, because the people she reported continued to work and behave the same way. Instead, her complaints contributed to other staff members’ isolating her, she said.
In a statement to NBC News responding to Frank’s allegations, Uspiritus said, “Many of the details provided by Ms. Frank’s account of events do not align with our records, which includes videotapes, emails, interviews with staff, and investigatory reports.” Uspiritus did not specify which details it disputed.
The organization added: “We take very seriously any allegations made by a child in our care or by an employee of our organization. To protect our children and employees, we thoroughly review every allegation and take timely and appropriate actions — to include termination of employees — if necessary. We self-report allegations to Child Protective Services and guardians that have been brought to our attention. Self-reporting includes a child or staff member calling or electronically reporting to the Department for Community Based Services (DCBS) and their relevant guardian, including DCBS, when appropriate.”
Frank quit in January 2019 after, she said, she felt embarrassed when her manager asked her to go off-site to take a drug test in the middle of her shift. Frank said she was drug-free.
“It came out of nowhere,” she said. “So I just handed her my keys and I was done. I couldn’t do it anymore.
“I felt alienated from an operation that was very much reliant on teamwork,” she said.
In a statement, Uspiritus said, “If an employee is suspected of being under the influence of drugs or alcohol, which is validated by the member(s) of management and consulted with HR, the concerns would be explained to the employee, and arrangements made to transport the employee to a testing facility.
“We are committed to following all employment policies and procedures, and we did so with respect to the separation of Mr. Frank’s employment.”
Days after Frank left, another employee, Nicole Richardson, alleged in a wrongful termination lawsuit filed in a Kentucky court in 2020 that she was fired on Jan. 30, 2019, for having reported abuse.
According to an affidavit filed with the court, Richardson said she witnessed staff members “waterboard” children with a cooler, drag a “naked juvenile on the floor” and threaten to “hit a child with a book.”
“I have heard so much emotional abuse from the staff I worked with toward the juveniles,” Richardson said, according to the affidavit.
She also alleged that a manager allowed a child to “lay his head on her breast,” “play with her hair” and give her “front hugs not side hugs.”
Richardson also alleged that she witnessed a colleague tell “residents to go ahead and call the child protective services, saying to the residents, they are not going to believe you and will not do anything to me.”
An attorney for Richardson did not respond to requests for comment.
Uspiritus said it was “unable to comment” on the wrongful termination lawsuit, which continues. In legal documents filed in response to the lawsuit, Uspiritus has denied that Richardson was fired in retaliation for reporting wrongdoing but did not address the allegations of abuse.
An ‘absolutely preventable’ death
Ja’Ceon had arrived at Brooklawn sometime earlier this year after having bounced among therapeutic care and foster families after his birth parents lost parental rights in August 2021. The state has not disclosed the circumstances or the timeline surrounding the placement because the records are “confidential” under Kentucky law, said Susan Dunlap, a spokesperson for the Kentucky Cabinet for Health and Family Services.
Dunlap said the agency is investigating Ja’Ceon’s death.
Brooklawn said the facility has implemented new safety measures and increased training for staffers who provide direct care to children. The training includes de-escalation and relationship-building strategies “which have been shown to reduce and prevent the need for holds.”
The facility also said it has increased consultation with staff members about intervention strategies, leadership presence and oversight in children’s cottages, as well as screening and assessments of all youths before they are admitted.
A lawsuit alleging wrongful death, negligence and negligent hiring, training, supervision and retention was filed on behalf of Ja’Ceon’s estate last month.
“His death was no freak accident and absolutely preventable,” Paul Croley, a lawyer who filed the suit, said in a written statement. “Uspiritus and the employees involved should be held accountable for this senseless and tragic loss. This type of incident should never be allowed to happen again.”
Some child advocates say Ja’Ceon’s death should prompt systemic change.
“In many ways, this tragedy should make leadership in Kentucky think systemically on ‘how did this happen?’” said Terry Brooks, the executive director of Kentucky Youth Advocates, an independent nonprofit advocacy group for youths, adding that officials should examine how restraints are used.
Moreover, Brooks said, both the number and the quality of available staff members have reached “crisis levels” in Kentucky, leading to an “unacceptable and extraordinarily high turnover rate” and less experienced staff members.
“If we had enough staff and if we had enough highly qualified staff, then de-escalation techniques, they would know those,” he said, referring to Kentucky’s child care system. “They would know effective and safe and responsive de-escalation techniques.”
Stephanie Saulnier, a professor of social work at Eastern Kentucky University, said that while it is still unclear how experienced or educated the staff members allegedly involved in Ja’Ceon’s death were, “we are struggling in Kentucky with the sheer number of children that need support and services and getting qualified people that are providing the direct service to them," she said. "You can have the very best intentions and not have the education or the training behind that in order to work in high-stress situations.”
The state is also reckoning with waiting lists for residential facilities that leave few options for kids, especially if one facility shuts down, she said.
“One of the problems that we run into is if we shut down a problematic facility, where do those kids go? That leaves kiddos that are in need of residential treatment with no place to go,” Saulnier said. “There aren’t enough beds for little guys that need this level of care, and the child welfare system has to kind of figure out ‘how can we do the best with what we have?’”
Brooks believes some issues within the foster care system could be remedied if complaints were reported to a body other than the state’s Department of Community Based Services, which sends out investigators to follow up.
Brooks is pushing for an external ombudsman and an external review process for complaints at youth centers.
“The more independence, transparency and sense of security that we can give folks on the ground that have concerns at these facilities, that’s a safeguard,” he said. “It’s common sense to give folks more freedom or comfort to call in those complaints.”
Brooks concedes that while Brooklawn and facilities like it are not owned by the state, the state heavily depends on them to fulfill its function. Cabinet-level decisions about placement and assessment are strongly linked to residential facilities, enmeshing them, he said.
Only when there is a death or a near-death incident does another body, the state’s Child Fatality and Near Fatality External Review Panel, become involved. The 20-member team reviews the case “to become aware of systemic deficits and to make recommendations for improvements to help prevent child fatalities and near fatalities due to abuse or neglect,” according to its website.
“We believe that Kentucky needs an external ombudsman and an external review process, and the idea that we have been pushing is let’s establish a quasi-governmental agency that is outside the Cabinet,” Brooks said. “If I were the Cabinet, I would want that, because whatever the findings are, if the concern is legitimate or the concern is not accurate, in either case having that external lens gives the finding credibility.”
In the meantime, Ja’Ceon’s maternal grandfather wants someone to be held accountable for his death.
“I’m patiently waiting for justice for my grandson,” George Terry said. “This shouldn’t have happened, and that place should have closed down when he died.”