* This story is truly disgusting on all levels…
A multimillion-dollar operation under state contract was supposed to be taking care of people with special needs. Instead, its employees are accused of fatally beating two residents and several incidents of abuse. […]
Forty-two-year-old Paul McCann suffered a brutal beating in January. The man called a gentle giant, who functioned at the level of a 6-year-old, was punched, kicked, and struck with a frying pan inside his group home for reportedly taking a cookie.
McCann’s death was ruled a homicide and two men were arrested. The family has filed a lawsuit…
The lawsuit claims that the group home employees would pile heavy books on McCann’s outstretched arms, then beat him when he dropped them.
And…
Also, the lawsuit will allege that McCann had been abused before the Jan. 19 beating. Kathleen Slovick, McCann’s sister, noticed McCann had broken his nose in April 2010. In response to McCann’s broken nose, the Illinois Department of Human Services sent Lois McCann, Paul McCann’s mother, a four-word letter response that stated, “The findings were unfounded.”
Oy.
* McCann was not the only victim of this monstrous facility…
State records obtained by CBS 2, which date back to 2003, reveal 33 cases of Graywood staff abusing residents. Those cases included sexual abuse, physical battery and alleged coercion of residents to attack each other.
Even worse, in 2008, a resident named Dustin Higgins was murdered by staff. That death prompted an internal memo from the Illinois Department of Human Services Inspector General. The memo warned that Graywood residents were at risk amid an increase of serious allegations of abuse and neglect.
A resident is murdered by facility staff three years ago and it prompted an internal DHS memo, but apparently not much else because human beings were still being sent there, even though it had a “substantiated abuse rate” which was double the state average. Great job, DHS. Raises for everybody!
More on that other death…
In 2008, Dustin Higgins, another resident of Graywood died after two employees allegedly beat him.
Three years later, the mother of Paul McCann recalls seeing her son’s body just days before his death.
“From his ankles all the way up his leg, big gash marks, blue, blue gash marks like he’d been kicked with a boot or shoe,” said Lois McCann.
Idiots.
* More…
They found caregivers dumping water on people when they wouldn’t do their chores or get out of bed.
Other cases involved employees biting, punching, and threatening the developmentally disabled clients they were taking care of.
Many only have the capacity of a child.
And, yet, this facility has received $30 million in taxpayer money since 2001? The mind reels. Thankfully, DHS is finally moving residents out of there next week. Too late for McCann and the rest, however. I do not understand how the people at DHS who knew about this place could possibly sleep at night.
One of the government’s prime jobs is to help care for people who cannot care for themselves. The abominable treatment of residents alleged at that facility and the unconscionably slow pace of state action makes me ill.
My great aunt is severely mentally disabled and lives in a facility in Iroquois County. I can’t imagine what would happen if my family found out something like that had happened to her. It wouldn’t be pretty, I guarantee it.
I can feel my blood boiling right now, so I better stop writing.
- Anonymous - Tuesday, Mar 22, 11 @ 1:24 pm:
This is a terrible tragedy. I hope that no politics get in the way of punishing those responsible to the fullest extent of the law, including DHS staff who knowingly allowed these abuses to continue. Taxpayer funded abuses and murder. How pathetic and sad.
- Patrick - Tuesday, Mar 22, 11 @ 1:24 pm:
My blood is boiling too much to comment. Except to say: where was Lisa Madigan’s office?
- Cassiopeia - Tuesday, Mar 22, 11 @ 1:25 pm:
The director of DHS will soon issue a carefully worded explanation as to why DHS did not take action sooner. A staffer is now putting together the blah blah blah bureaucratic response.
The culprit is really probably a government lawyer in DHS.
Anybody who has worked in government knows how the guilt denial thing works.
Its disgusting.
- bored on1 - Tuesday, Mar 22, 11 @ 1:27 pm:
A memo covers a murder. We were over in Charleston just the other month and drove right by the facility. I made the comment that it looked like a modern church. Too bad it was hell instead. Everyone associated with this, from our Governor on down, should be ashamed of themselves. There are good people out there that would be more than willing to take care of people in need, and some do it for very little pay. There are people out of work around the State, so what is the answer. I know people will get on and say the State should have done more, but the hard reality is: learn a lesson from it and start doing more RIGHT NOW. Don’t wait, don’t attempt to make a press statement out of what happened, don’t create task forces or special committees, but instead go into DHS and find somebody willing to take the lead and start keeping these places accountable.
I am with you Rich, I need to stop writing also.
- OneMan - Tuesday, Mar 22, 11 @ 1:29 pm:
There needs to be answers, there needs to be people who lose their jobs, there needs to be folks who spend time in jail.
- bored on1 - Tuesday, Mar 22, 11 @ 1:29 pm:
And there we go…Lisa Madigan, a government lawyer in DHS, the Director of DHS…stop blaming and start coming up with answers. It is not always political.
- Patrick - Tuesday, Mar 22, 11 @ 1:34 pm:
Bored on1: You don’t think we have a right to blame Madigan and DHS when this man had a history of abuse that was ignored. And, another resident was murdered by staff 3 years ago? And there were dozens of other cases of abuse?
Apparently you don’t believe in oversight or accountability.
- Rich Miller - Tuesday, Mar 22, 11 @ 1:37 pm:
Patrick, in the stories I’ve read about this case I didn’t see any mention of the AG’s office ever being notified of anything. DHS, however, knew everything.
- Cincinnatus - Tuesday, Mar 22, 11 @ 1:38 pm:
- Patrick - Tuesday, Mar 22, 11 @ 1:24 pm:
“My blood is boiling too much to comment. Except to say: where was Lisa Madigan’s office?”
- Cassiopeia - Tuesday, Mar 22, 11 @ 1:25 pm:
“The culprit is really probably a government lawyer in DHS.”
Here’s an even more novel thought,
“Where is the legislative oversight?”
Once a program, any program, is authorized, there should be a sunset provision and strict legislative oversight of the program and the behavior of its head. Instead, legislators would rather spend their time dreaming up new fiascos and then refusing to accept responsibility for these new programs or those from past legislatures.
Each awful story such as this, and stories documenting government waste, fraud and abuse erodes the confidence in the government by the citizens in purports to represent. Is it any wonder voter participation is down and citizen temperature is up?
- bartelby - Tuesday, Mar 22, 11 @ 1:41 pm:
“The lawsuit claims that the group home employees would pile heavy books on McCann’s outstretched arms, then beat him when he dropped them.” — It has taken far too long, but at least we have closed this particular Abu Ghraib in Illinois. But others remain. In the State’s prisons, longterm lockdowns and solitary confinement (for example as at Tamms supermax) create conditions of such cruelty that they cry out for change. In fact, people with special needs, (14% of the prison population have serious mental illnesses), ARE housed in solitary confinement, often for years (even decades) at a time. So while we are at it, lets stop torture everywhere in Illinois!
- Ahoy - Tuesday, Mar 22, 11 @ 1:53 pm:
Some heads need to role at DHS. I can’t believe that people would not be fired and/or go to jail for allowing this to occur at DHS.
- Patrick - Tuesday, Mar 22, 11 @ 1:57 pm:
Okay, Rich, Cincinnatus, boredon1:
Thank you for your thoughts. I accept that DHS is squarely to blame and that maybe Lisa Madigan’s office didn’t know about this, or hear word that there was a murder at this facility. Her name sprang to mind because she campaigns so heavily on protecting the residents of nursing homes from all kinds of “predatory” sorts, but she never mentions the danger that comes from staff which is statistically a greater source of abuse. I’m also more than outraged about the worker’s comp scandal, so I am already feeling more than a little frustrated with the lack of state oversight. Anyway, I am too angry to be commenting at all on this subject and will stop right now.
- Quinn T. Sential - Tuesday, Mar 22, 11 @ 2:02 pm:
Patrick, in the stories I’ve read about this case {I didn’t see any mention of the AG’s office ever being notified of anything. DHS, however, knew everything.}
This is a reactive rather than a proactive approach. There are a whole host of advocacy issues for which the AG’s office is regularly issuing Press Releases patting themselves on the back, for which they did not likely receive contact from victims or complaints of infractions before acting.
Time and time again they have chosen their battles from a selection of low hanging fruit, and they don’t seem to want to get their hands dirty unless there is an easy headline to grab.
They’ll be all over this now however because any prior action will be dismissed as “not our primary responsibility” and any future (re)eaction on their part will be lauded by the editorial boards as somehow being “vigilant”.
True vigilance however requires someone to check to see if the barn door is open before the horse gets out, rather than just trying to round up the horse afterwards.
- wordslinger - Tuesday, Mar 22, 11 @ 2:13 pm:
–Once a program, any program, is authorized, there should be a sunset provision and strict legislative oversight of the program and the behavior of its head.–
You’re going to have a sunset provision on what, the need to provide for the mentally disabled?
I’ll say this though, in addition to DHS, the GA members whose districts this facility was in should have been more personally involved in their work.
Party politics is fun and games, but every GA member should be a constant presence in facilities for the helpless in their districts that are pulling down that kind of state coin. Represent your district first, your party somewhere down the line.
- Because I say so - Tuesday, Mar 22, 11 @ 2:13 pm:
It would be another crime if the people responsible for these heinous acts are not brought to justice. I also think, and hope there is a special hell for those to prey on the disabled.
I am not an expert in this area but the State of Illinois pays a lot of people to oversee the health and well-being of the disabled. Swift measures need to be put in place to make sure things like this do not happen again.
- OneMan - Tuesday, Mar 22, 11 @ 2:14 pm:
I love to bash the AG as much as the next Republican sometimes but I am not seeing it here.
If for no other reason she (and by extension her office) strikes me as smart enough to have realized if they had gotten one whiff of this how it would blow up in their face. No elected with a small sense of self preservation would ignore something like this if it came before them.
Addressing this stuff is how you make your name, ignoring is how you destroy it.
That being said, since this falls ultimately under the governors office, there are questions that need to be answered.
- Rich Miller - Tuesday, Mar 22, 11 @ 2:20 pm:
===I’ll say this though, in addition to DHS, the GA members whose districts this facility was in should have been more personally involved in their work.===
They both got relatively small but significant contributions.
- soccermom - Tuesday, Mar 22, 11 @ 2:37 pm:
the formatting on this is odd, at least on my computer. I am running Safari on a Mac, if it makes any difference.
- soccermom - Tuesday, Mar 22, 11 @ 2:39 pm:
A quick Google search shows all kinds of serious problems at this facility. Whose job is it to oversee these facilities? Does that person have internet access?
- Rich Miller - Tuesday, Mar 22, 11 @ 2:39 pm:
Better now, soccermom?
- John A Logan - Tuesday, Mar 22, 11 @ 2:39 pm:
This is awful. It saddens me to read stories of what people are capable of doing to one another. The cowardice is of particular depravity when the abuse is inflicted upon those who have little mental capacity to defend themselves. I did some googling around to see if Illinois law set stricter penalties for abuse of the mentally disabled, much like the laws for elder abuse. Came up empty so far. I did not read the full text of the story yet, so perhaps it addresses that question.
- OneMan - Tuesday, Mar 22, 11 @ 2:40 pm:
Try this version
http://tinyurl.com/62bojkq
- soccermom - Tuesday, Mar 22, 11 @ 2:44 pm:
thanks, rich.
- x ace - Tuesday, Mar 22, 11 @ 2:49 pm:
Unfortunately, abuse is such homes in not uncommon.
Multiple agencies taking path of least resistance and greed by the home operators comes into play.
Child molesters paroled to non secure homes poorly staffed with minimum wage workers in small easy to walk around towns. Offender leaves home. Home does not immediately report the parolee child molester missing. Offender loose in community for days.
Local Officials , Sheriff , State’s Attorney all up in arms demanding answers. IL DOC and DHS
stonewall with bottom line being ” Where we supposed to put them? “. Shots fired , meetings held , promises made , promises forgot , same old crap goes on .
Abuse by one impaired person to another impaired person a big problem. Death due to lack of supervision.
If a full scale investigation gets going , please print the contact information . Thank you for bringing out this tragic incident and calling for action.
- Aldyth - Tuesday, Mar 22, 11 @ 2:54 pm:
Because I say so: “I am not an expert in this area but the State of Illinois pays a lot of people to oversee the health and well-being of the disabled”
No, actually Illinois pays less per capita than any other state in the union for services or care for people with disabilities. Congratulation to Mississippi on outranking us in your financial commitment to the decent treatment of people with intellectual disabilities.
- wordslinger - Tuesday, Mar 22, 11 @ 3:00 pm:
–They both got relatively small but significant contributions.–
Sen. Righter and Rep. Rose have been cashing those $500 and $1,000 checks over the years from Graywood, so they’re obviously aware of this snakepit in their districts.
I hope for their sakes they can show some effort over the years to get to the bottom of what’s been going on there and set it right. Those people were their constituents and that place was pulling down major state money.
- Cincinnatus - Tuesday, Mar 22, 11 @ 3:04 pm:
Patrick,
The shot was not intended to be across your bow, it was aimed at the GA.
wordslinger,
I have no problem with even programs like this one needing specific reauthorization every few years. At that point, the effectiveness of the program would receive greater scrutiny than they are given when we just up the ante.
If all programs sunset, perhaps there is an eensy-weensy, teeny-tiny chance that some single program will be discovered to be unnecessary and eliminated.
- Cincinnatus - Tuesday, Mar 22, 11 @ 3:06 pm:
Hey, soccermom,
Wait until you get a load of the new Safari embedded in MacOS 10.7. Scroll bars are gone, get ready for trackpad finger swiping ala iPhone.
- OneMan - Tuesday, Mar 22, 11 @ 3:08 pm:
Aldyth, I suspect the managers at the top do ok.
- wordslinger - Tuesday, Mar 22, 11 @ 3:10 pm:
–I have no problem with even programs like this one needing specific reauthorization every few years–
What program are you talking about? Can you “sunset” the need to provide for wards of the state?
- Because I say so - Tuesday, Mar 22, 11 @ 3:11 pm:
- Aldyth -
I agree with you. Not being an expert, I don’t know what measures need to be implemented to prevent this but we as citizens cannot let this continue.
Unfortunately, I am well aware of Illinois’ terrible stats when it comes to caring for the mentally ill. I have several members of my extended family that suffer with mental/physical disabilities.
- Rich Miller - Tuesday, Mar 22, 11 @ 3:14 pm:
===Can you “sunset” the need to provide for wards of the state? ===
Yes, you can, and it might not be a bad idea because it would force the agencies involved to defend what they’ve done so far and allow stakeholders and others to propose new, more workable solutions.
- Lost Downstater - Tuesday, Mar 22, 11 @ 3:21 pm:
For as long as I can remember, going back to Gov. Jim Edgar’s days, I’ve been reading abuse horror stories at homes and institutions under the regulatory authority of DCFS or now Human Services. Situations in which state authorities had direct, repeated information about patterns of abuse or likely abuse, and in which nothing was done until the ultimate tragedy or tragedies came.
Why is there so little accountability for this agency for so long?
- Aldyth - Tuesday, Mar 22, 11 @ 3:25 pm:
I’m not going to get into a discussion about what executive directors make. I’m sure it isn’t in the same league as CEOs in the private sector.
The state of Illinois has been trying to run a dual system for decades, both state institutions (with lots of state employees)and community settings. When the state cut funding, it didn’t cut it in the state institutions (Quinn cut a deal with the unions, right?), it cut from the community settings.
Agencies haven’t been adequately funded for years and the rates haven’t gone up with inflation. Add increases in minimum wage and unfunded mandates and guess what you have?
Community service providers are left with competing with McDonalds for staff. Generally, when you work at McDonalds, you don’t have to wipe anyone’s rear end. If you treat a customer badly, they’ll complain. Not so in a group home for people with intellectual disabilities. So, you end up with people who take a job until something better comes along. Not a career commitment and in many cases, not really caring about the people you are supposed to serve.
This doesn’t excuse Graywood. It’s appalling that the state allowed them to skate along after violation piled on top of violation.
It’s just terribly frustrating to be continually dealing with the lack of commitment on the part of the politicians in Illinois to making sure that the least able and most vulnerable are taken care of. It takes money to hire people to do it. If you have to scrape the bottom of the barrel and hire whatever breathing body is willing to work for minimum wage while providing care for those who are the most helpless, you are setting up a system that is grossly inadequate.
I am the legal guardian for a relative with intellectual disabilities who lives out of state. I’d never bring him here. He’d never get the quality of services in Illinois that he is getting in Michigan.
Our system is disgraceful. Illinois can have state institutions - some of which are continually on the brink of being de-certified - or it can have a decent community-based system. It can’t have both. I’d much prefer to see that decent, tax dollar saving community support system in place. But, the politicians who count on union support don’t agree.
- wordslinger - Tuesday, Mar 22, 11 @ 3:29 pm:
Rich, I’m not understanding what you guys are talking about. The responsibility for providing for wards of the state can’t be subject to sunset. It’s been a function of all governments — in various degree of humanity and justice — since governments were formed.
You can eliminate DHS, at the extreme end, but the governmental responsibility will remain, regardless. These folks in need aren’t going to disappear.
- Rich Miller - Tuesday, Mar 22, 11 @ 3:36 pm:
===but the governmental responsibility will remain, regardless.===
True. It’s just the type of responsibility that we’re talking about. You can sunset just about any state program and then make the proponents justify renewing it and force them to improve it.
- Aldyth - Tuesday, Mar 22, 11 @ 3:37 pm:
When you talk about sunsetting, every agency in Illinois that receives state funding for providing services to individuals with developmental disabilities has to be licensed. There are procedures in place for pulling a license and closing down an agency. Depending on the program, there is a licensure inspection every year or three years. Violations of human rights are reported from the Office of Inspector General to the Bureau of Licensure.
A discussion about whether or not to pull Graywood’s license has probably been held a number of times at DHS. They made the wrong decision.
- Easily Entertained - Tuesday, Mar 22, 11 @ 3:39 pm:
I know a manager who rose near the top in a Graywood competitor’s CILA business. The profit margin in CILAs is obscene. They are businesses licensed by the State with inadequate State oversight. They choose to pay McDonalds wages, wilfully accepting the risk of this type of potential liability, because otherwise the investors’ returns will suffer. And the bottom line is that investors returns must never suffer. It is a crime. Before CILAs, people decried the horrible conditions of the state ops. Now the CILAs have become much worse than state ops ever were.
- Leroy - Tuesday, Mar 22, 11 @ 3:44 pm:
Easily Entertained, what is this profit margin you speak of?
- Aldyth - Tuesday, Mar 22, 11 @ 4:00 pm:
The vast majority of CILAs out there are run by not-for-profits. The money goes into providing services, not into the pockets of owners or shareholders.
- Easily Entertained - Tuesday, Mar 22, 11 @ 4:05 pm:
CILAs run a house of six adults for $35,000 per adult per year. That includes mortgage, utilities, food, staff, vehicle, and other costs. The typical resident is eligible for a minimum of $40,000 - $45,000 a year in state benefits, including social security disability, state assistance for developmentally disabled, assisted living, medical cards, etc. Far less than the State pays per resident for state ops. Staffing is the largest expense, which is why some CILAs refuse to invest in qualified people to run the homes.
- Easily Entertained - Tuesday, Mar 22, 11 @ 4:07 pm:
None of the CILAs in my area are run by not for profits. I’ve seen where the money goes when CILAs are run for profit.
- 3rd Generation Chicago - Tuesday, Mar 22, 11 @ 4:10 pm:
I know that DHS now is understaffed and too busy with investigating everything a teacher must report that a student says, many of these turn out unfounded.
But this they knew about problems here, and with the staff, it goes without saying that the staff was not qualified to work with special needs people, or any people.
Many parents take care of their special needs child until they are too elderly and can barely take care of themselves. It is a hard decision on an elderly parent, more worries they don’t need, but they feel that their child will be better cared for since they are too elderly. This is a horrendously awful and sad story, unfortunatley it won’t be the last.
- Easily Entertained - Tuesday, Mar 22, 11 @ 4:23 pm:
Oh and by the way, Graywood Foundation is just one of the corporate entities operating the CILA, the others include Graywood Enterprises, and Graywood Alternative Living. The Foundation identifier in the news articles suggests that the entire organization is not for profit. The foundation may be nothing more than a holding company for the properties, with the for profit side paying “rent”, equal to mortgage expenses.
- zatoichi - Tuesday, Mar 22, 11 @ 4:29 pm:
It pretty clear most people here have little knowledge about the community based systems in Illinois. The vast majority of CILAs are run by organizations that have been in business for 30-60 years, are often nationally accredited, have endless state surveyors coming through their programs, and have annual state licensure inspections not to the mention the OIG investigation about every complaint. Can’t speak for Graywood, but their rep has been well known as terrible for years.
EE knows a guy who says “The profit margin in CILAs is obscene” and “They choose to pay McDonalds wages.” Please get some facts. Go run an 8 bed CILA and let one bed stay vacant for several months because the state will not/cannot authorize funding. Tell me what your bottom line looks like. When you go to sign up to start a CILA you are told up front you must have 6-8 months operating cash plus whatever you have to pay to purchase and remodel a building to meet life code requirements. You are looking in the $500,000 range. These are 24 hour 7 day week operations. Next go look at the rates being paid by the state for CILAs compared to the rates paid in a state facility. There was a campaign several years ago about Illinois being 51st in the country and failing because the support for these programs is so far below the national average. Has not changed much. Most CILAs are run by well managed organizations who work hard to provide quality services.
- sal-says - Tuesday, Mar 22, 11 @ 4:30 pm:
“The findings were unfounded.”
Oy.
Beyond an understatement. Not only the ‘people’ who personally did this, but also the management & owners need to be charged with premeditated murder. Sorry if this offends.
I understand that dealing with any folks with any deficient mentality is VERY difficult, but, this kind of treatment has to stop if we still want to be considered a ‘civilized’ society.
- Easily Entertained - Tuesday, Mar 22, 11 @ 4:46 pm:
Per DHS, the average annual assistance for assisted living last year was $52K. Add $1k per day for a day program.
Pay scale for workers: $9.76/hr.
- dupage dan - Tuesday, Mar 22, 11 @ 5:07 pm:
I have seen care provided in “public aid” nursing homes and “private pay” nursing homes vary quite a bit. It is amazing that a “cheap” NH can provide such good care while the private pay NH stinks of urine. Likewise with groups homes - so called CILAs (Community Integrated Living Arrangement). Some of the veteran providers have their problems as well as the newcomers. Some facilities take on clients no one else will due to behavior problems but provide little extra programs since the payout is the same. This can cause problems. With the advent of deinstitutionalization there were alot of subpar agencies that shot up like mushrooms after a rainfall. The thought of easy profits filled their heads. Even the veteran agencies saw the opportunity for building up their programs and added many group homes to the point of over-expanding which has caused many problems. Oversite is good but the group charged with that responsibility is, as you can guess, overworked and understaffed. And their recommendations are sometimes ignored. Essentially, you have things similar to any other company/industry that is being monitored/supervised/regulated by the government. The failures of the overseers can be quite dramatic and painful. IMO, the idea that numerous small, far flung, group homes can be monitired as effectively as fewer large centralized nursing homes has some inherent problems. The reality, tho, is that if the state is going to take on these tasks, the state outta be monitoring them better.
- Rufus - Tuesday, Mar 22, 11 @ 5:34 pm:
It is probably to late in the day to say this, but I work at DHS and am horrified, as is 99.95% of the other people that work here, as to what has happened at Graywood. We all have families and would never want this to happen to anyone.
Blago/Adams decimated this place, its probably going to take decades to recover.
If any one can make a significant difference, it will be Ms. Saddler, but it is an overwhelming mountain of a task.
- Ain't No Justice - Tuesday, Mar 22, 11 @ 6:05 pm:
Agree Rufus, but she needs to get rid of some SPSAs and PSAs (now union). Several of these were “promoted” to key positions under the Blago reign and kept their under Quinn. It has to start at the top. It is not the frontline social service employee but their managers. Clean house Sec. Saddler!!!!!!!!!!
- waitress practicing politics. . - Tuesday, Mar 22, 11 @ 6:23 pm:
Medicaid funds go to this facility, too. Where was HFS IG John Allen and his Fraud Exec who refers these cases to the Illinois State Police? Oh I forgot Mr. Allen was directing covert surveillance of employees in bars instead….
- 13th - Tuesday, Mar 22, 11 @ 7:51 pm:
there is profit in CILA, a lot of the CILA group homes are owned by the workshop executive directors ($100+ salaries on top) thru corporations, and run them in a manner to make as much money as they can of th DD clients…
It just a shame, community options are cheaper for tax payers, and give a better quality of life if ran right…
- Bemused - Tuesday, Mar 22, 11 @ 10:06 pm:
In my dealings with state agencies it sometimes seems they forget who it is they are there to serve. They become close to service providers and others they deal with. Someone in the agency takes a job with a company who deals with the state and vice versa. They attend the same insider seminars. Next thing you know it’s who can call up who and get a favor done. Finding out who did what for who and why can be very tough. Someone knew they should take action and did not. Why? Oh and if you call em out on it you be very bad.