By: Anita Wadhwani, The Tennessean
Kendall Oates spent most of his short life as a typical upper-middle-class Brentwood kid, playing hockey and his Xbox, treated to expensive birthday parties and attending the best public schools Williamson County has to offer.
But a scuffle with his father landed him in the juvenile justice system, where the 17-year-old - who had never been in serious trouble before - was placed with some of the state's most violent juvenile offenders.
His mother spent more than a year trying to persuade the Department of Children's Services to release him. Five days before his homecoming, he died in a place where family, friends and even a judge said he did not belong.
Kendall suffered a seizure at Nashville's Woodland Hills Youth Development Center, where DCS records show he may have lain sick or dead for hours, undetected by a security guard who was supposed to check on him every 15 minutes but did not.
DCS was required to administer anti-seizure medication to Kendall, but an autopsy performed the day he died, May 25, 2012, found no trace of the medicine in his bloodstream.
Kendall also did not have his lifesaving anti-seizure wristband, which he was required to wear at all times. Kendall had used the device to stop previous seizures, swiping the band over his chest at the onset of symptoms to activate an implanted seizure-regulating device, similar to a pacemaker. Kendall's wristband was discovered after his death in a guard's booth, out of reach.
In the months before his death, a Williamson County judge issued two separate court orders urging DCS to place the teenager in a 24-hour residential medical care facility that could better monitor his seizures.
After his death, one Woodland Hills staff member noted in DCS records that Kendall "should have been in a different facility because of his medical condition."
Kendall's mother, Diane Oates, is devastated. A former IBM executive, Oates had dedicated herself full time for more than a year trying to get Kendall out of DCS custody.
"I've been thinking that if that was Kendall's day to die, why did it have to be there?" she said. "Kendall should have been with me."
When a child dies in DCS custody, the agency conducts its own investigation and authorities outside the agency review the evidence DCS provides for possible prosecution.
DCS closed its internal investigation, finding the teenager died of natural causes.
Kendall was weeks away from turning 18 when he was taken into DCS custody in 2011. The teen had been moody and angry, frustrated that his friends were getting their driver's licenses and new cars.
Kendall couldn't drive until he had been seizure-free for six months, but that hadn't happened since the eighth grade, when Kendall experienced his first seizure after suffering a blow to the head playing field hockey in the school gym.
His parents divorced just after Kendall started high school, entering into what would become a years-long dispute over custody and finances. His mother moved out of the family's home into a nearby apartment. Then Diane Oates got laid off from her job as an IBM project manager, moved to live with her parents in Alabama and began visiting Kendall and his younger sister on alternating weekends.
Those family hardships - a divorce, a job loss - affected everyone in the family, but they hit Kendall especially hard, his parents said.
Kendall couldn't stop thinking about brain surgery to stop the seizures. But his father, Gary Oates, said brain surgery was not an option.
In March 2011, Gary Oates called police to report an outburst at his home. It followed several fights Kendall had gotten into at school. Oates reported that Kendall had slammed doors and smashed his father's cellphone. Oates, a courier for FedEx in Nashville, later amended his complaint to say that Kendall also had lunged at him.
Had Kendall's blowup happened just a few weeks later, he would have turned 18 and been subject to the adult court system, where consequences for a first-time offender are typically light - ranging from court-ordered community service to counseling or probation, and an expunged record.
But for minors, such offenses bring DCS involvement. With Oates' consent, DCS asked a Williamson County juvenile judge to remand Kendall into state custody, where he would spend more than a year.
It was a decision Diane Oates said she didn't learn about for weeks. DCS records noted her address as "unknown" at the time Kendall was placed into custody. Diane Oates said someone could have reached her. State child support records, divorce records and her ex-husband had her home address.
She disagreed with the decision to place her son in state care and began petitioning juvenile court and contacting DCS to release Kendall to her.
Meanwhile, Kendall grew frustrated at having been removed from his home, dis-enrolled from his Brentwood high school and placed in a group home for wayward boys at a time when his friends were going on dates and taking family trips to visit colleges, according to juvenile court records.
Kendall began hitting his head against the wall until he bled. Later, he pulled out the staples used to stitch his wounds. He threatened suicide. He got into fights. He suffered a series of seizures and had to be rushed to the hospital.
In June 2011, Williamson County Judge Sharon Guffee ordered DCS to take Kendall for a medical evaluation regarding his seizures. She noted, "The Court recommends a ... residential treatment facility to address the child's mental and physical illness and for the protection of the child and others." One month later, she issued another order, again telling DCS that Kendall belonged in a medical facility that could keep round-the-clock watch. Also, she urged DCS to communicate with his mother, juvenile records provided to The Tennessean by Diane Oates showed.
But by December 2011, DCS had transferred Kendall from a group home to Woodland Hills, a high-security facility surrounded by barbed wire and reserved for teenage boys who have committed multiple or violent felonies ranging from drug offenses to armed robbery to rape.
Guffee said confidentiality rules barred her from commenting on Kendall's case. But, she noted, there has been an "ongoing conflict" between DCS and judges over where kids are placed, because state law gives the agency full authority over such decisions.
"Juvenile courts have virtually no say over where these children get placed," said Guffee, noting that part of the problem was DCS funding.
DCS data obtained by The Tennessean show waiting lists for children in DCS' juvenile justice system needing beds in medical facilities or other treatment centers have doubled in the past two years. Four successive years of budget cuts have eliminated 38 percent of DCS' juvenile program budget.
Other teens inside Woodland Hills said Kendall was different from the other teens at the facility.
John Foster, a former Woodland Hills inmate who estimated he had more than 30 convictions ranging from drugs to assault by the time he was 18, remembers seeing how Kendall interacted with his mother during a visit.
"A few days before he died, I saw him kissing his mom," Foster said.
"Sometimes you see a guy hug his mom, but you never see any of the guys kiss them," he said. "He was cool and all, but he wasn't that tough. He just seemed different, like he shouldn't have been there."
DeCari Cradle, 19, who was in Woodland Hills for drug-related offenses, said he and others tried to protect Kendall.
"A lot of us watched out for him because we knew he had seizures and sometimes he was feeling so bad about wanting to get out, he'd bang his head into the wall," Cradle said.
A DCS caseworker noted in Kendall's records that she once found Kendall in the gym banging his head against the wall repeatedly.
"He reported he is just sad and he wants to go home," the caseworker noted, saying he seemed to feel better after a phone call from his mother.
'God, please don't let the child die'
DCS records, police reports, 911 audio files and personnel records obtained by The Tennessean detail witnesses' accounts of what happened at Woodland Hills on the day Kendall died.
On the morning of May 25, after breakfast and a routine anger management training for kids at the facility, most of the other youths in Kendall's dorm went outside to a party rewarding good behavior. But between 7:45 and 8 a.m., Kendall told friends he was tired and returned to his room. The Read Dormitory, where Kendall lived, was quiet and mostly empty.
Shortly before 11 a.m., when the party was over and the teens were heading to lunch, one of them noticed that Kendall was missing. He told Calvin Gooch, the guard on duty. Two teens then went to check on Kendall through the rectangular window in his locked door. Kendall was lying on his bed and didn't appear to be moving, they reported.
The guard followed them to Kendall's room and unlocked the door. Kendall "looked like he had already been gone for a while, his eyes were glistening like they had glue on them and his lips were ashy, his body seemed real stiff," one of the teens later reported. Gooch sounded a "Code Blue" and a senior security guard rushed to the room, followed soon after by two nurses.
The senior security guard performed CPR, repeating, "God, please don't let the child die" between chest compressions. Nurses took over CPR, then paramedics. But Kendall never revived. He was taken by ambulance to Vanderbilt University Medical Center, where he was declared dead a short while later.
Gooch first told internal DCS investigators that he had checked on Kendall regularly as he was trained to do, by doing a "visual check" through the window of their locked rooms. Gooch said he "has never been trained to see a child sleep a certain way, if the student is in the cell they just write that the student appears to be sleep." DCS investigators noted the guard "appeared to be very remorseful and tearful during the interview." The records noted that Gooch should have checked on Kendall every 15 minutes.
After examining video monitoring tapes inside the facility, checking logs, and in interviews with teenagers at the facility, DCS investigators concluded that Gooch made no checks on Kendall for 2½ hours between 8:15 a.m and 10:56, when he sounded the Code Blue, according to a termination memo addressed to Gooch in his personnel file.
Instead, Gooch sat at a guard station about 20 feet away from Kendall's room, left for a 24-minute break, returned and at one point read the Bible at his desk with other youths.
Gooch was fired from DCS in February. His termination memo notes he "failed to conduct a physical count of the students upon your return from break at 10:23 a.m. You further stated you did not hear any noises or sounds coming from K.O.'s room. You were aware that K.O. had a history of seizures because you were present on another occasion when K.O. had a seizure."
DCS declined to take specific questions about the death of Kendall Oates, instead issuing a statement on July 25 that addressed only the security guard's role.
"We were aware that this young man was having medical issues, and we were working hard to address them," the statement said. "This is not how we regularly do business. We have policies, procedures and protocols in place that we use every single day to ensure the safety of the youth in our care. ... Once we learned the officer had not followed policy and procedure, we terminated his employment at DCS. He was marked for no-hire at DCS."
Gooch appears to be the only DCS staffer disciplined in connection with Kendall's death. But others inside the agency raised questions about whether any Woodland Hills security guard should have been responsible for monitoring a child with a serious medical condition.
After Kendall died, DCS records show an unnamed Woodland Hills staff member told internal investigators that the teen "should have been in a different facility because of his medical condition because it is hard to focus on one child and keep an eye on him all the time."
Police records also show that the DCS nurse on duty reported that Kendall had been given his anti-seizure medication at 6 a.m. that day. Another unnamed nurse told DCS internal investigators later that Kendall had gotten the medication at 6:30 a.m.
An autopsy found no trace of Clonazepam, the anti-seizure drug, in his system.
"I would expect had he taken the drug it would be there," said Deputy Chief Medical Examiner Adele Lewis, who performed Kendall's autopsy. "Clonazepam has a pretty long half-life - it hangs out in the blood anywhere from 20 to 50 hours. There was no evidence of him having taken his Clonazepam in his blood."
DCS records also show that a medical wristband Kendall was required to wear at all times to regulate his seizures was instead in a booth out of reach.
DCS emails obtained by The Tennessean show that DCS has ongoing challenges in keeping its juvenile facilities adequately staffed with medical personnel.
A week after Kendall's death, DCS nurse Patricia Slade sent an email to several DCS officials about nursing shortages at Woodland Hills and the New Visions facility for girls. Slade noted nurses had to cover double shifts each week.
"We just don't have enough bodies to staff the clinics," she wrote. "This has been a problem for several weeks and I'm afraid will continue to be a problem. ... Any suggestions are welcome."
Father sues DCS
For months after Kendall died, DCS attorneys denied separate requests from Kendall's parents to review their son's records and medical information.
DCS' top lawyer, Doug Dimond, noted in a February email to Diane Oates that he could turn over Kendall's records only with Kendall's consent - because Kendall had turned 18 in DCS custody and was no longer a minor. "I've got to follow the law that governs record release," Dimond wrote.
With Kendall's death, the records would be kept permanently sealed from his parents.
Oates said she read Dimond's email, looked up at the photo of Kendall hanging on the wall above her computer and wept.
The parents got their first glimpse of DCS records when The Tennessean obtained copies of records of more than 200 children who died or nearly died in a 3½-year span after being brought to the agency's attention. Those files were released under court order beginning in May.
Gary Oates filed a wrongful death lawsuit against DCS. He told The Tennessean he believes the agency deliberately delayed its response to his records request to avert a lawsuit. Such wrongful death lawsuits must be filed within one year of a death. Oates' lawsuit came two days before the anniversary of Kendall's death on May 25, 2012.
"DCS has been giving me the runaround," Oates said. "Now I know why. Nobody checked on him like they were supposed to. Kendall should be alive right now if they had. And they stalled me. They stalled me, so I wouldn't know, so I couldn't sue them."
Diane Oates said it was agonizing for her not to know the details of her son's last hours.
"How long was he lying there by himself before they found him?" she asks herself.
A bitter divide
Losing their son has worsened the acrimony between his parents, who were married for nearly 20 years.
Diane Oates says she will never forgive her ex-husband for agreeing to place their son in DCS custody.
Today, Diane Oates sits in a minimum-security federal prison in Florida. Five months after Kendall's death she pleaded guilty to cashing in her children's Social Security checks when they did not live with her. Her children were entitled to the benefit when Diane Oates qualified for federal disability payments, said her attorney, Jesse Montagnino, who cited client confidentiality rules in declining to specify the disability. In May she began serving a 10-month sentence. Oates said in a telephone interview she did not trust anyone else with the money and had saved it for the children.
Gary Oates reported her to federal authorities.
Contact Anita Wadhwani at 615-259-8092 or firstname.lastname@example.org.