Posted at: 07/30/2014 2:38 PM
Updated at: 07/30/2014 11:28 PM
On a rainy spring afternoon, the small memorials are a splash of color alongside a busy road in rural Duluth. They are purple, blue, and rainbow-colored.
"Purple is my favorite, and rainbow also. Jeremy's favorite color was blue," said Gail Radinzel.
Jeremy is her son. The 28-year-old lost his life here, back on February 16th. He was living off of Midway Road in a group home run by Stepping Stones for Living, LLC. He was dealing with a variety of emotional, physical, and behavioral issues.
That February night, the passenger in the car that hit Jeremy reported the crash to 9-1-1. When police arrived, a staff member reported that Jeremy had jumped in front of an oncoming car. He died from his injuries.
A few months later, Radinzel came up from southern Minnesota to hold a small service for him.
"He might have had mental illness and issues. But we also deserve to celebrate his life, and what a wonderful person he was. Jeremy had so much love, he loved everybody," she said.
And this mother still had questions.
Why didn't caregivers stop Jeremy that night?
"I just feel more could have been done to prevent what happened," she told us.
She said she and her attorney are considering filing a wrongful death lawsuit against the facilit.
The Minnesota Department of Human Services says it opened up an investigation because of the circumstances surrounding Jeremy's death. Their report came out June 30th.
The report says that the incident started earlier that day when Jeremy and another resident had a conflict regarding the radio station. A staff member told investigators Jeremy was "very agitated."
The report says he asked a staff member, "Can you call crisis because I'm going to elope and jump in front of a car on the highway?"
Crisis is someone who responds during an emergency, and elope means to leave or run away from the facility.
The report says Jeremy walked out, and went 30 yards down the driveway, but then went back inside to call his father. During the phone call, the report said Jeremy was speaking in appropriately about other residents, and was told by staff he couldn't do that. The document said he again said, "He was going to elope and kill himself."
This account of what happened was also recorded in police interviews of staff members the night of the crash.
The police report said staff then unplugged the phone, after Jeremy refused to get off after several warnings.
The Human Services report said that one staffer saw Jeremy punch and kick another staff member. Around this time, a crisis team member arrived. According to the witnesses, Jeremy was screaming and swearing. He then walked to the garage and out the back door. The crisis team member and another staffer followed him, about 20-30 feet behind. Then, as Jeremy walked down the driveway, investigators said another crisis worker arrived.
According to interviews done by Human Services, this crisis team member had responded to similar situations with Jeremy in the past, and that usually, staff were able to calm him down. The other crisis person who responded, recalled that Jeremy used to threaten to hurt himself at least once a month.
When we asked Stepping Stones to comment about this case, they declined an on-camera interview through their attorney. They did issue a statement:
"Because of the vulnerable adult's history of self-harm and suicidal statements, the facility had detailed procedures for handling situations of self-harm, suicidality, and elopement."
The state report said that Crisis Intervention Plan included having the staff person call for more help, follow him at a distance of about 1/4 block, and to leave him alone unless he became threatening, or displayed self-injurious behaviors.
Last summer, his behavior had triggered more action from staff. The Human Services Report said Jeremy went too close to the road, and staff had to use manual restraint.
The Minnesota Legislature passed a law during the 2013 session, adding more language for the use of manual restraint. Representative Tom Huntley was the co-author of the bill, and said proper use is a fine line.
"We're trying to draw balance, protect our employees, and also give as much freedom to the people who are in these facilities," he explained.
The law sets standards for emergency use of manual restraint. It must meet the following condition: Immediate intervention must be needed to protect the person or others from imminent risk of physical harm.
The report from Human Services said that people who were interviewed had differing opinions on what could or should have been done.
One Stepping Stones employee said, if Jeremy had been "taken down" before getting so close to the road, the incident could have been prevented.
A mental health professional interviewed for this report said, "I was not there. I could speculate. But you know if someone knew something, if he had made suicidal statements I would think that he should have been placed in a restraint or something of that sort."
However, Jeremy's guardian told investigators, if staff had tackled Jeremy, somebody would have been hurt, and if 911 had been called, they would not have been there in time. The guardian also said, "I will never believe that he jumped in front of a car with the intent of killing himself. He has very poor impulse control, and did things without thinking."
In its conclusion, the state said the facility had detailed procedures for handling this situation, and followed those procedures. While two people said there could have been manual restraint, the report says Jeremy made similar statement in the past but never acted on them. The report says staff made several attempts to intervene, but were unsuccessful.
The department said, "Although Jeremy's death was tragic, there was not a preponderance of the evidence that there was a failure to supply him with care or services that were reasonable and necessary."
Also, they said, "it was not determined whether neglect occurred." The disposition is listed as "inconclusive."
Stepping Stones said in their statement: "This death is an unfortunate incident. Stepping Stones for Living, LLC shares in the grief and sadness of this death of our resident."
Radinzel's attorney told us on Friday last week that he continued to work on the investigation, and that litigation is likely to begin soon. In the meantime, Radinzel is taking it, one day at a time.
"I'll always be his mom. He'll always be my son. Although he's gone, taken tragically, the pain will always be there."
The driver and passenger in the car that night were not hurt. They declined to comment for this story. The State Patrol report said they driver did not have time to react.