Randall Jordan-Aparo died weeping and gasping for breath on the concrete floor of his prison isolation cell, naked except for his white boxer shorts.
Incensed that he had cursed at a nurse, guards at Franklin Correctional Institution in the Panhandle fired nine blasts of noxious gas into his 13-by-8 cell through a slot in the door and, ultimately, left him there, sobbing.
"I can't breathe, I can't take it no more, please help me,'' he pleaded.
Five hours later, the 27-year-old was found lifeless, face-down on the bare slab. His mouth and nose were pressed to the bottom of the door, as if trying to gulp fresh air through the thin crack. His hair, legs, toes, torso and mouth were dusted with a faint orange residue, a byproduct of the gas.
A paperback Bible was under his shoulder.
The Florida Department of Law Enforcement sent two investigators, Michael Kennedy and Michael DeVaney, to look into what had occurred. Their conclusion, summarized in one paragraph: The "disciplinary actions" taken by guards had no bearing on the death.
"They just said he got sick,'' Jordan-Aparo's father, Thomas Aparo, recalled being told by corrections officials.
Four years after the September 2010 incident, Jordan-Aparo's death, and the Florida Department of Corrections' and FDLE's highly questionable account of how and why it occurred have spawned a federal investigation, a new probe by FDLE and an uprising by staff in the prison system's inspector general's office. Four inspectors say their boss, Inspector General Jeffery Beasley, threatened them at last year's Christmas Party, saying he'd "have their asses" if they didn't quit poking their noses into the case, court papers say.
Meanwhile, at least three Franklin guards involved in the gassing or its aftermath have been suspended with pay, one since March 2012, the others since summer of 2013. According to documents obtained by the Miami Herald, many others who were involved remain gainfully employed, and some have been promoted.
An investigative detour
The Jordan-Aparo case is one of a growing number of deaths being scrutinized by criminal investigators, part of a scandal that has embarrassed the head of the Department of Corrections, Secretary Michael Crews, and begun to tar those closer to Gov. Rick Scott.
The current investigations grew out of a 2013 probe of "garden variety" corruption at Franklin, including allegations that a female corrections officer was brazenly engaging in sex with multiple inmates inside the compound. Inmates who were not part of these alleged romps became jealous and complained. Corrections department inspectors Aubrey Land, David Clark, Doug Glisson and John Ulm went to the prison to investigate.
Inmates at Franklin were incredulous, saying the dalliances were a trifling matter compared to the brutal circumstances surrounding Jordan-Aparo's death.
Intrigued, the inspectors began digging. They interviewed inmates, studied the use-of-force report, the video captured by surveillance cameras, audio of the incident and photographs of Jordan-Aparo's body. Among their findings:
• A claim by prison staffers that Jordan-Aparo was being "disorderly" before his death was false.
• Initial reports downplayed the fact that Jordan-Aparo was complaining about experiencing extreme pain and simply wanted medical attention, preferably in a hospital.
• Contrary to claims that his cell had been decontaminated after the gassing, photos clearly showed residue everywhere — orange smears on the floor, in the sink and in the toilet bowl. There was a dense orange cloud above the bunk where Jordan-Aparo would have sat.
• Although reports said Jordan-Aparo was issued a fresh set of clothing after the gassing, he was dressed only in dirty, orange-stained boxers.
• Nobody assigned to investigate the matter administratively from the Department of Corrections watched the "use of force" video showing Jordan-Aparo being gassed.
Their conclusion: Jordan-Aparo died as a result of medical negligence and the "sadistic, retaliatory" use of chemical agents on a sick and helpless inmate who did nothing wrong. And that staff reports following the death contained inconsistencies, errors, omissions and outright lies.
According to the four inspectors who went to Franklin, these findings received a frosty reception from Beasley, who soon informed them that they were now under investigation. The reason had to do with their handling of the probe into the sexual escapades at Franklin. One inmate, challenged to provide proof of his relationship with the guard, described in detail and diagrammed the tattoos on her buttocks. To verify the inmate's statement, Land obtained a search warrant. A female inspector and lieutenant executed it, located the tattoos and photographed them.
The photos were taken as evidence. A lawyer for the corrections officer later complained.
For that, they were told, they were now being targeted.
Relations between the inspectors and their boss deteriorated further, culminating in the alleged encounter during the 2013 Christmas party. The inspectors went above Beasley's head, approaching Secretary Crews and, ultimately, the governor's chief inspector general, Melinda Miguel. They sought whistle-blower status, essentially a guarantee that they would not face retaliation for bucking the chain of command.
In a meeting with Miguel that was tape recorded, with permission, by Land, he detailed what he called the Jordan-Aparo cover-up, other corruption within the department and the retaliation he and others were subjected to by Beasley. Miguel denied whistle-blower status to Land and to the others, who had similarly requested protection.
The four filed suit in federal court in July of this year. In the lawsuit, which names Miguel, her deputy, Beasley and his deputy as defendants, the four say they faced retaliation for trying to investigate alleged departmental wrongdoing, which is their job.
Recently, two more inspector general staffers came forward, claiming that they, too, were subjected to threats and intimidation after telling their bosses and Miguel about possible criminal misconduct by prison staff. One of them, inspector James Padgett, claimed that Beasley and deputy Kenneth Sumpter committed perjury and obstruction of justice while trying to squelch other investigations.
In a written statement Friday, Miguel said she and corrections staff are cooperating with the investigation into Jordan-Aparo's death, adding she has "zero tolerance for unethical or abusive behavior'' in the department.
Crews, in a written statement, said that he is cooperating as well, and working hard to make it clear that "fabrication, lies, deception, retaliation or other unethical behavior'' will not be tolerated in the system.
Neither Miguel nor Crews would talk about the case with a Miami Herald reporter.
Culture of 'impunity'
In May, the Herald began a series of articles about prison deaths with the story of Darren Rainey, a 50-year-old mentally-ill inmate at Dade Correctional Institution south of Homestead.
After he defecated in his cell and refused to clean up the mess, Rainey was herded by corrections officers into a locked, closet-like shower and left there, subjected to a stream of unbearably hot water for as long as two hours until he collapsed and died. His pleas for mercy went unheeded, according to inmate witnesses.
Unlike the Jordan-Aparo case, where the recent allegations have been made by highly regarded staffers, the complaints about Rainey's treatment came from fellow inmates, who witnessed what went on or heard his screams and sent a string of letters and grievances to prison department leaders. They were ignored. The June 2012 death went uninvestigated for nearly two years, until the Herald began interviewing inmates in May.
In the wake of the Herald's reporting, Crews fired Dade Correctional Warden Jerry Cummings and his deputy, Royce Dyke. The guard suspected of being primarily responsible for forcing Rainey into the shower, a beefy former college lineman, resigned in July. To date, no one has been criminally charged. At a pair of news conferences, Crews vowed reforms, not only at Dade Correctional, but across the prison system.
When they filed suit, the prison system inspectors attached copies of the Herald stories on the questionable deaths of Rainey and other inmates to support their claim that the department isn't exercising due diligence in investigating suspicious inmate deaths.
Howard Simon, executive director of the ACLU of Florida, said despite Crews' promises of reform, the state's prison system isn't likely to change until people are held accountable and prosecuted.
The problem, he said, is not one incident but "a culture within the (Department of Corrections) in which guards feel they can kill inmates with impunity.''
Life was not easy for Jordan-Aparo even before he landed in the bleak confines of Franklin Correctional. Shawn Jordan-Aparo, his younger brother, said their birth father was a drug dealer who sexually abused him and his older brother from the time they were little. Their mother, he said, was a drug addict who was in and out of prison and was never able to take care of them.
At the ages of 5 and 7, the boys began a nomadic life that Shawn says took them to 28 different foster homes over the next five years,
"We got to the point that we didn't even unpack our stuff. We just skipped from home to home,'' he said.
Both boys suffered from a genetic blood disorder, Osler-Weber-Rendu (HHT) syndrome, a treatable but little-known disease that causes abnormal blood vessel formation in the lungs, liver, skin and brain that often leads to chronic nose-bleeding and lesions on the skin and around the mouth.
Shawn said he and Randall ended up in an orphanage in Tampa, where they were mentored by the recreation director, who though single, eventually decided to adopt them.
"I just knew it would be hard for them to be adopted at their age," Thomas Aparo said. "I wanted to give them a second chance."
But by then, the boys were teenagers, and after spending most of their young lives tethered to foster care, the lure of new-found freedom was too tempting. They struck out on their own and began getting into trouble.
"Neither one of us knew anything about drugs, sex, school, friends that get you trouble, having a work ethic. No one really taught us all those things.
"We were always kind of on our own. We weren't bad people. We did what we had to do to survive. We stole food from Walmart — no gang-banging or violent things,'' Shawn said.
He said Randall was like a father figure, taking care of him and sometimes taking the fall when they got into trouble.
While both served time in prison on and off, they remained in touch.
In 2010, with Randall doing a stretch at Franklin and Shawn on the outside, the brothers started planning a new life. They spoke on the phone three months before Randall's death.
"He was talking like he was happy. He was saying 'I'm almost out and maybe we can get together and change.' And three months after that — bam — he is dead.''
At first, Shawn said, the family was told that Randall had suffocated in his cell. Then they were told he died of internal bleeding. But nothing seemed to make sense because, Shawn said, Randall was in good health the last time he spoke to him.
After the memorial service, Shawn heard from an inmate's mother. She said her son had written her from Franklin that Randall's death didn't happen the way the department was claiming.
Anguish and anger
A week before Jordan-Aparo's death on Sept. 19, 2010, he began experiencing bleeding problems, Department of Corrections records indicate. On Sept. 15, senior registered nurse Pamela Housholder noted that Jordan-Aparo had complained of back pain after falling while playing basketball on the prison grounds.
Over subsequent days, Jordan-Aparo collapsed several times and was taken at least three times to the infirmary, where nurses did little to help him, records show. He had a fever of 102, told the medical staff his lungs and his heart were hurting and that he was having trouble breathing.
At one point, nurse Martha Greene performed an electrocardiogram, but admitted she wasn't good at reading the results. She said his heart was working fine.
Greene contacted the prison doctor, who instructed her to start an intravenous application and keep the inmate in the infirmary. After several unsuccessful attempts at inserting the IV, they gave up and left Jordan-Aparo in the infirmary overnight, records said.
The next morning, at 4 a.m. Sept. 18, Greene and LPN Lucy Franklin examined Jordan-Aparo, who complained he was in pain and needed to go to the hospital.
Jordan-Aparo, becoming agitated, at one point blurted: "I am going to sue your f- - - - - - ass. I need to go to the hospital!''
Greene summoned Capt. Mitchell Brown, who without consulting a doctor, decided to remove Jordan-Aparo from the infirmary and place him in an isolation cell — No. 1104 — for causing a "disturbance," prison records said.
"Ain't nobody comin' to help you,'' a guard known as Big Jit told Jordan-Aparo, according to witnesses. He then ordered the inmate to "man up'' and shut up.
Jordan-Aparo's file was then reviewed. Although his disease could cause respiratory difficulties and the department was aware of his affliction, the file indicated that he "had no known medical condition that would be exacerbated by the use of chemical agents."
At 11:25 a.m., after receiving approval of Col. Timothy Copeland, the duty warden, Lt. Roland Austin gave the order to gas Jordan-Aparo.
First he was given a "final statement," telling him why he was being gassed. Then, with video surveillance cameras rolling, Officer James Hamm sprayed three one-second bursts of OC, a concentrated form of pepper spray, striking Jordan-Aparo in the upper torso, Hamm's report said. Three bursts equaled one application.
At 11:59, Hamm sprayed another three bursts. Approximately six minutes later, after contacting Copeland, Austin gave the order for a third application, this time using tear gas, an agent that causes severe burning in the lungs, particularly in confined spaces.
In all, Jordan-Aparo was subjected to 600 grams of chemical agents in a confined space.
Sven-Eric Jordt, a professor of pharmacology at Duke University who studies the effects of pepper spray and tear gas, said that after just 10 minutes of exposure to the tear gas alone in such a confined space, the concentrations would have been near lethal.
"Obviously, the agent was sprayed directly onto the inmate and may have deposited on his skin, clothing, eyes and mouth at much higher concentrations, with less of it airborne, making the concentrations that much higher,'' he said.
The guards said they "escorted'' Jordan-Aparo to a decontamination cell, although inmates would later say that Jordan-Aparo was dragged. Photographs and other evidence raise questions about whether he was decontaminated at all.
"He was orange,'' one inmate told investigators two years later.
"I can't take it, I can't take the gas, I can't breathe,'' Jordan-Aparo said, according to another inmate interviewed by prison system inspectors in 2013.
Jordan-Aparo was so weak after a shower that guards had to put him in a wheelchair to take him back to his cell. Photographs of his body reviewed by the four inspectors in 2013 show that, despite visiting the shower, he was clearly still coated with residue.
If he and his cell were not properly decontaminated, Jordt and other experts said, Jordan-Aparo would have continued to be exposed to the chemicals, breathing in the toxins — until breathing would become almost impossible.
At about 12:30 p.m. he was taken to the infirmary and examined. Nurse Ola Riley couldn't get a blood pressure reading because the inmate was uncooperative, prison records said. But she did record wheezing in the lower right lobe of his lung. She and nurse Franklin then contacted the on-call physician, Dr. Mohammad Choudhary, who instructed them to try again to take his blood pressure. Instead, they allowed the guards to take Jordan-Aparo back to his isolation cell.
Nearly two hours later, reports say, Riley and Franklin went to the inmate's cell in a repeat attempt to take his blood pressure. Jordan-Aparo was unable to move, refused to cooperate and wouldn't sign a release form, so the nurses left, records said.
At 4:30 p.m. Sgt. Kevin Hampton tried to give Jordan-Aparo his dinner tray and found him sprawled on the floor. He refused to eat. Asked if he was okay, Jordan-Aparo purportedly gave a thumbs-up sign.
Even healthy inmates are supposed to be checked every 30 minutes, but it's not clear whether anyone looked in on Jordan-Aparo from 4:30 until the time his body was found at 6:08 p.m.
The Herald also reviewed hundreds of documents, including letters and emails, showing that the prison's then-warden, Diana Andrews, and Miguel had been told from at least 2011 that there were lingering questions about the way Jordan-Aparo had died.
On the night of his death and the following day, another Franklin inmate, Joseph Avram, called his sisters, Kimberly Donovan, and Christina Bullins, who is a probation supervisor with the Department of Corrections. He told them he had witnessed what the guards did to Jordan-Aparo and was worried about his own safety.
Bullins and Donovan began contacting prison officials, repeatedly writing letters. Bullins, who was also a member of the corrections officers' labor union, said she began receiving threats from her bosses that her job was in jeopardy.
In April 2011, two years before the four inspectors approached Miguel, she contacted the chief inspector general to request whistle-blower protection. The request was denied, the inspectors' lawsuit says. She was subsequently fired in a dispute over medical leave.
Dr. Lisa Flanagan, the medical examiner who did the autopsy on Jordan-Aparo, didn't attribute his death to the application of gas. She wrote that the cause was "complications of multiple cardiac and pulmonary abscesses'' and mentioned the gas only as an explanation for the staining of Jordan-Aparo's skin.
But in a post-autopsy meeting with FDLE investigators, Flanagan noted that had Jordan-Aparo received timely and proper medical care from the onset of his sickness, he may not have died.
Dr. John Balmes, an inhalation injury expert with the University of California's Berkeley School of Public Health, said the gassing almost certainly contributed to Jordan-Aparo's death.
"He had a fever. He passed out. He had a serious blood-born infection and they gave him an irritant gas that can cause fluid in his lungs," said Balmes, who reviewed records at the request of the Herald. "They gave him something that made him sicker and that gas contributed to his death.''
Cyril Wecht, a nationally known forensic pathologist who also reviewed the records at the Herald's request, called the case one of the worst he has ever seen in terms of how many people were involved.
"This prisoner's abscesses didn't develop overnight, and for him to have been in the (infirmary) and then to be gassed ... the people who have ignored this in some ways are even more ignorant than the horrible guards and nurses,'' said Wecht, who has been involved in various high-profile cases, including reviewing the deaths of John F. Kennedy, Robert Kennedy, Elvis Presley and Anna Nicole Smith.
Despite evidence of medical neglect and excessive force, no one was charged with a crime. The state attorney's office for Franklin County reviewed the findings and declined to prosecute.
The FDLE report said: "Though inmate Jordan-Aparo did complain numerous times of medical problems commencing four (4) days prior to this death, it is not the scope of this criminal investigation to address those issues."
That was based on the information available at that time, said FDLE spokeswoman Gretl Plessinger. When new information became available, the case was reopened and it remains active, she said Saturday.
Suspended with pay are Sgt. Hampton (aka, "Big Jit'') Lt. Austin and Randall Johnson. A fourth guard, Terry Whitlock, was fired in 2012, though it's not clear if that was connected to the Jordan-Aparo case, and prison system officials declined to explain.
The on-call doctor, Choudhary, held a temporary certificate to practice medicine in an area of critical need — in this case, the prisons. Five months after Jordan-Aparo's death, while on call at the Alachua County Jail in Gainesville, he was seen driving erratically, running over curbs, state records show.
He was later found passed out drunk behind the wheel of his car, according to state Department of Health records. A review by the state medical board resulted in a reprimand and a fine, but he kept his license. There is no criminal arrest on his record.
One of the nurses who examined Jordan-Aparo, Patricia Lemon, had her license put on probation for three years prior to coming to Franklin. According to the Florida state nursing board, she was found in 2003 to be forging prescriptions for painkillers. After she served her probation, her license was reinstated, state records show. There is no criminal charge in her name.
3 months too late
Jordan-Aparo, who was serving a 19-month stretch for credit card fraud and drug possession when the guards gassed him, would have been released three months later had he lived.
Instead he was cremated, with the remains sent home to Thomas Aparo in Palm Harbor.
Aparo, who had drifted apart from Shawn and Randall, declined to discuss Randall's death.
Randall Jordan-Aparo's brother, Shawn, had plenty to say. He is angry.
"There is no reason he should have passed away, no reason he shouldn't have been to the hospital," Shawn said. "I never got a chance to say goodbye.''