Inside Room 420 at Florida State Hospital, two roommates clashed in the dark.
Anyone who paid attention to their recent behavior, who compared their size and age, could see they should not have been together in the same bedroom.
Ruben J. Quinones, a 60-year-old who weighed less than the average woman, had spent most of his life in a mental hospital. He was severely schizophrenic, sometimes ate from the trash and walked with a limp. Within the span of a few months, he had been the victim of two documented incidents of aggression.
Jeremiah Heywood, a 19-year-old who weighed 20 pounds more, was bipolar, developmentally delayed and occasionally violent — the aggressor in three reported incidents, including one in which he and another patient held Quinones in the bedroom against his will.
The Department of Children and Families, which oversees the state's mental hospitals, should have known what could go wrong. In January 2015, a pair of young men at the hospital stomped to death a 57-year-old, jumping on his head, crushing his skull, sending a shard of nasal bone into his lung.
The Tampa Bay Times had exposed this death, and more than a dozen others, in a joint 2015 investigation with the Sarasota Herald-Tribune that yielded promises of reform.
But now in April, five months after the investigation, more than a year after the stomping death, Quinones was on the ground, helpless, as his roommate loomed above.
Heywood raised his bare foot and stomped on the older man's head. He did it again and again, five times in all.
Quinones stopped moving.
Heywood pounded the wall with his fists.
• • •
Inside Florida's mental hospitals, patients and staff continue to fall victim to preventable violence.
Earlier this year, Florida State Hospital, which has 984 patient beds, reported the following during a six-month period alone: four patients suffered serious hip, femur and rib fractures in beatings; a patient threw bleach on a nurse who had to be rushed to the hospital; five staff members struck patients; and one ward attendant stood at a bedroom entrance, watched and did nothing while a patient punched another in the head.
In addition, an employee admitted to having an "inappropriate" relationship with a patient, and another patient escaped and robbed a credit union when he was supposed to be in fitness class.
It was this kind of chaos that prompted the newspapers to spend more than a year chronicling life in the state's six largest mental hospitals, showing how $100 million in budget cuts had doubled violent incidents and contributed to the deaths of at least 15 people.
After the investigation, Gov. Rick Scott made the hospitals purchase new security cameras and body alarms for workers. Lawmakers added at least $55 million to the budget for new mental health programs. The state hired a top-level administrator who is supposed to find ways to curb violence and improve medical care.
Every Monday morning, DCF staff meets with Secretary Mike Carroll to brief him on "significant events" at the state's mental hospitals. Carroll promises his administrators are conducting an "extensive analysis" to identify ways to ensure safety, and that DCF "remains committed to providing the highest quality of care possible" to patients.
It is perhaps premature to measure the state's efforts. The Legislature gave DCF money for 159 new full-time workers to start at the state's mental hospitals in July, including 64 at Florida State Hospital.
But those reforms would come too late for Ruben Quinones.
• • •
It is 11:33 p.m. on April 23, at Florida State Hospital in Chattahoochee, the state's largest mental institution located on the Georgia border, just northwest of Tallahassee. The surveillance cameras are rolling.
Dianne Blanks, a ward attendant, hears thumping coming from Room 420. She opens the door and sees Heywood pounding the walls. Two of his roommates appear to be asleep. One bed is empty, the covers gone. She asks him about that. He tells her to look in the corner: Quinones on the floor, blood pooling beneath his head and in his ear.
Eighteen minutes later, emergency workers arrive with a gurney. Staff members rush in and out, yelling to each other. The stretcher leaves with Quinones, who will not wake up from these injuries, and will die in 11 days.
Down the hall in the common room, Heywood is sitting on the floor in the dark, barefoot. He had arrived 18 months earlier, a teenager with a history of putting himself and others in danger.
He was 17, living with his family in Lakeland, when he argued with his mother, elbowed her out of the way, headed for the closest road and tried to jump in front of cars. Police picked him up and held him for the 15th time under the Baker Act.
Now Heywood gets up and finds a ward attendant.
He tells him, and it is the story he will later tell police, that he walked into the room and turned to look at a poster of a car. Then, from out of nowhere, Quinones took a swing at him, saying: "You wanna box? Wanna fight?" He mimics it all for the employee: Quinones pushing him. Him pushing Quinones. Tussling. Quinones on the ground. Heywood stomping on his head.
He gives one final stomp and points to an 8-inch scratch on his forearm. Quinones put it there, he says. Self defense.
The staff member nods.
A janitor sops up the blood.
No one calls the Chattahoochee Police Department for two days.
• • •
Florida State Hospital's Specialty Care Unit, otherwise known as Dorm F, houses 161 patients with special needs. On the top floor, 32 men and women who are both mentally ill and intellectually disabled live three or four to a room.
Marcy Owens, Heywood's social worker, said patients were often separated one to a room until 2011, when budget cuts forced them to bunk together.
"We all knew it was a bad idea," said Owens, who left her job at Florida State Hospital last April. "The problem is overcrowding in that dorm. It was just awful and it was hard to keep everybody separated when they got upset with one another. Staff were having to move people all the time and eventually, you just run out of room to move people. It was hard to keep the right people together so they wouldn't be taken advantage of."
Owens said she and other staff members tried to work around the chaos. DCF records from inside the Specialty Care Unit reveal that in one six-month period, at least four patients in the 32-patient unit were seriously injured.
Workers inflicted most of the injuries, according to reports citing verified abuse. One punched a patient in the temple and shoved the patient's wheelchair into a wall, tipping it over. Another punched a patient in the face, causing stitches beneath the eye. Yet another lost his temper with an unruly patient who wanted a blanket, pushing the patient to the floor so hard that the patient lost consciousness.
Then there was Quinones, whose cause of death was listed as "delayed complications from blunt-force head trauma."
"We had a lot of fighting, but I never dreamed anything this bad would happen," Owens said.
Jessica K. Sims, DCF's communications director, said "following the incident," the hospital developed guidelines for bed assignments. The fixes, which went into effect in June, call for a review of patient backgrounds and temperaments before assigning them to a room. Factors considered include level of aggression, age difference, vulnerability and change in behavior.
Reports show that after Quinones' death, the administration "reinstituted its screening process" for Dorm F and ordered the psychology department to evaluate each resident for "appropriateness of placement."
Joel Dvoskin, a psychologist on the faculty of the University of Arizona College of Medicine and an architectural design consultant for mental hospitals around the country, says today's mental patients typically get their own rooms or, at the most, double occupancy rooms.
"There are still a lot of hospitals with four-person rooms," he said, "but in a brand new hospital, that would be rare."
Dvoskin, who was once acting commissioner of mental health overseeing 31 psychiatric hospitals in New York, wanted to know what the selection methods were for placing Quinones and Heywood in the same bedroom.
One was 19, the other 60. One had been an aggressor several times, the other a victim. They were both clearly agitated and had nothing in common but a room with two other bunk mates and a car poster on the wall.
Dvoskin knows no psychiatric hospital can guarantee zero violence, but added that hospitals have a responsibility to use common sense when making bedroom assignments.
"If you put two people in a small bedroom who don't want to room together," Dvoskin said, "you are asking for friction."
• • •
There were signs of trouble.
Heywood's parents, Eric and Elaina Gratton, said even they knew about the rising tension. He complained often that his roommate was always shadow boxing him. They said Owens, the hospital counselor, told them Ruben was harmless. In an interview, Owens also used the word "harmless" to describe Quinones.
"The problem is that I don't think Jeremiah, with his mental problems, knew he was harmless," said Elaina Gratton. "I think he perceived him as a threat."
DCF says there is no record of the Grattons or Heywood complaining. Heywood's family says that's because staff members did not understand their son or choose to listen.
Heywood had been born premature with two lesions on his frontal lobe, which controls cognitive skills, including behavior. His lifelong problems are documented in police and psychological reports.
He had poor impulse control. He threw furniture. He punched a teacher. He threatened suicide. He also managed to go months without acting out.
At Florida State Hospital, Heywood was the aggressor in four incidents between January and April. DCF refused to turn over reports detailing those incidents, saying they were confidential because they were not serious enough to send someone to the hospital. The only one they disclosed involved an incident, a month before the attack, in which Heywood and another patient held Quinones in his room against his will.
"My nephew was complaining to staff at the hospital for weeks," said Heywood's aunt Jessica Catlin, a social worker in Tennessee. "He was trying his best to keep it under control. He was saying please do something. He was not confident in his ability to handle it the right way."
"We knew Jeremiah was getting to a crisis point," said his stepfather Eric Gratton, "but nobody was listening to us."
• • •
Quinones died on May 4, more than a week after the beating.
His 80-year-old mother, Gloria Esther Dominguez, had no idea he had been the victim of any previous incidents.
"There's no security," she said. "They are supposed to be watching people. How could someone get that beat up in a state hospital without someone interfering? It doesn't make sense."
She said her son was first institutionalized in California when he was 14. After the family moved to Florida, he spent the next 31 years in a mental hospital near Jacksonville. In 2012, the state released him to a group home, but Quinones did not like it there and asked to be moved. He was sent to Florida State Hospital.
Treatment cannot take place in a less restrictive setting because of the patient's social isolation, withdrawn, acting out, hallucinations, aggression, and poor insight and judgment, noted one order in his case file.
"My son had schizophrenia," Dominguez said, "but he was not abusive or anything like that."
Florida State Hospital neglected to protect her son, she said. She has contacted a lawyer.
Heywood has pleaded not guilty to second-degree murder. But he won't stand trial any time soon. He has been deemed incompetent to proceed.
So he now resides in Gainesville — at another state mental hospital.
Times staff writer Anthony Cormier and researcher Caryn Baird contributed to this report. Leonora LaPeter Anton can be reached at 727-893-8640 or @WriterLeonora on Twitter.