Inhospitable and in Denial

The parents of two little girls placed them in the Broward Children's Center hoping their daughters would be cured. Something went wrong.

The Frisbee soared over Eric Rebenkoff's head in the crowded park, landing some 30 yards behind him, in the shallow outfield of a nearby softball diamond. Frank McDonough Park in Lighthouse Point was teeming with children and adults on that Tuesday evening in May 1995. The plastic platter happened to land next to a little girl named Jenna Bernardo, who scooped it up happily.

Jenna, seven years old and standing little more than three feet tall, was wearing a baseball glove and waiting for softballs to come her way. The balls hit to her were few and far between. It was a little boring for Jenna, a natural athlete who always seemed to be doing something -- swimming, playing tennis, doing cartwheels, just about anything so long as she was in motion.

Looming beyond home plate, a storm was brewing in the northwest sky. Clouds black like an industrial fire hovered there, but play wasn't affected. The dark clouds, by contrast, only seemed to make brighter the sun shining on the park. When the Frisbee landed, Jenna smiled broadly and leapt at the chance to hurl it back. She made it fly some 30 yards right into Rebenkoff's hands. He was amazed by the strength and accuracy of the throw coming from a girl he judged to be only four or five.

"Whoa!" he said, as he turned back to his friends. "Did you just see that?"
Then came a white flash of light and a tremendous, crackling boom of thunder. People heard the thunder's report and felt its percussion more than a mile away. Rebenkoff saw everyone fall -- or jump, he's not sure which -- to the ground. He's still not sure why he was left standing but suspects it was because the lightning's flash was to his back, near where the little girl had just thrown the Frisbee.

Rebenkoff turned and, in the pandemonium of panicking people screaming and running every which way, saw a little girl facedown on the charred ground. Jenna was burned, the soles of her sneakers scorched. The lightning struck her in the shoulder, went through her body, and came out her ankles. The electrical surge short-circuited her heart and her lungs stopped instantly. She was in cardiac arrest.

"She looked like a rag doll that got tossed out of the window of a car," recalls Rebenkoff, who was 30 at the time. "It's the only way I can explain it. She was all twisted up."

The storm front now blocked the sun and rain drizzled on the darkening field. Jenna's mom, Michelle Bernardo, ran to her daughter, screaming, "My baby! My baby!" Rebenkoff ran to his car to call 911 on his cell phone and then ran back to Jenna. He and a friend, who was medically trained, performed CPR on Jenna until medics and police arrived.

"It felt like an eternity," Rebenkoff says.
His precipitous actions helped save Jenna from death, but the lightning had already done irreversible damage. From that point forward, she never smiled again, let alone did another cartwheel, hit another softball, or astonished anyone with a Frisbee throw.

Doctors were able to heal her seared internal organs, but the lightning gave a near-fatal shock to her nervous system and caused extreme damage to her brain. She was left catatonic, in a comalike trance. She could still cry, though, and sometimes she'd cry for days at a time, rhythmically and nonstop. It horrified family members, who wondered if anything was going on behind her inscrutable, chestnut-colored eyes.

After nearly three years caring for her at home, her parents, devastated by the strain, separated, making it all but impossible for Jenna to remain at home. This past April they placed Jenna in a group home for developmentally disabled children run by Broward Children's Center in Pompano Beach, a nonprofit agency funded primarily with government dollars. At the group home, Jenna would be surrounded by other children, and, her parents thought, cared for by well-trained professionals.

Jenna died there on a Friday morning, June 5, seven weeks after she was admitted and six days after her 11th birthday. The cause of death was listed as a lack of oxygen to the brain caused by the lightning strike. Nobody had any reason to think otherwise.

Except her mother. Michelle Bernardo contacted the Broward County Medical Examiner's Office and dropped a bombshell: "She thought they may have overdosed [Jenna]," an assistant medical examiner wrote in a report.

The mother told an assistant medical examiner that a drug called thioridazine -- a prescription antipsychotic -- was disappearing from the group home at an alarming rate. A subsequent toxicology test revealed what the medical examiner's office considered dangerously high levels of thioridazine in Jenna's blood. A criminal investigation ensued. The group home's staffers, two students and several nursing assistants, couldn't explain the disappearance of the drug or the high levels of it found in Jenna's bloodstream.

Police and medical examiner's investigators tried to check Jenna's dosage records but that, too, proved to be a dead end. The records, which are required by law to be kept, were somehow lost at the group home.

Broward Children's Center President Bill Beggs claims center staff did nothing wrong in medicating Jenna.

"We certainly are cooperating fully with the investigation, and if the investigation shows culpability on our part and we find culpability on our part, we will address that," says Beggs. "But frankly, I don't anticipate there will be."

With missing records and no explanation, Broward County Medical Examiner Joshua Perper says the case is a frustrating puzzle with missing pieces.

Jenna's case in some ways mirrors another case at the center, involving a two-year-old named Cristal McBean. It wasn't a flash from the sky that caused Cristal to become permanently brain-damaged in 1994; it was, according to a medical malpractice attorney, a series of indefensible decisions made by Broward Children's Center staffers. Key issues raised in that case included the violation of doctor's orders and questionable training of staff.

The center continues to deny any wrongdoing in that case, too, even after damaging information surfaced that prompted the center's insurance company to pay a $4 million settlement to Cristal's family before the case ever got to court.

The cases of Jenna and Cristal both remain, to some extent, mysteries, due in no small part to the center's habit of substituting explanations with denials of blame.

Broward Children's Center's main facility is officially licensed as a nursing home but is much like, and often referred to, as a pediatric intensive care unit. It is the only residential nursing facility in the state designed solely for medically dependent children.

It's a place full of heartbreaking stories -- birth defects, chronic disorders, abused children, catastrophic injury. It's also an expensive place to stay. The children in the 36-bed facility are attached to tens of thousands of dollars' worth of state-of-the-art machinery that keeps them alive. The state has given the center, which is regulated by the Agency For Health Care Administration, some $3.6 million in Medicaid money this year as of November 11. The center, which has been much honored and enjoys an all-but-unblemished reputation for helping children, also raises cash with grants and fundraisers.

In addition to the main facility, the center also runs three group homes, one for young adults and the other two for severely retarded children, most of whom suffer from cerebral palsy and rely on wheelchairs and feeding tubes. The kids in the group homes, say staffers, aren't as medically fragile as those in the main facility.

Because Jenna could breathe on her own, she was put in one of the group homes, a remodeled, white stucco house in a working-class neighborhood in Pompano Beach, about a mile away from the main facility. The white-tiled group home's main room -- complete with a television, sofa, and chairs -- opens to a kitchen on one side and a hallway on the other. The hall is lined with rooms where the 12 children sleep, usually two in each. The hallway empties into another little room in back where the medication is kept in locked cabinets and a padlocked refrigerator.

When Jenna was moved in, Broward Children's Center staffers remarked on her condition in notes: "No ability to make decisions and no memory or understanding... unable to communicate to make needs known... unable to take oral feeding... totally dependent for dressing, bathing, toiletry, locomotion, transfers and eating."

All of the children in the group home went to a center-run preschool, according to staffers, except Jenna, who was taken to another group home or to the main facility to spend her days. School would do her no good. She spent most of her time in bed. But both her mother and father noticed something different about her while she was in the center: She didn't seem as agitated as she was at home. Instead she was always calm or, as her mother would later put it to an assistant medical examiner, "knocked out."

For about a year, Jenna had been on Mellaril, which is the trade name for thioridazine. Thioridazine (pronounced "THIGH-a-RID-a-zeen") is a powerful neuroleptic, the name given to drugs that act directly on the central nervous system and are used primarily for psychiatric patients. Thioridazine's basic function is to block production of dopamine, a chemical that transmits nerve impulses deep in the brain. While it isn't fully understood, dopamine is known to be crucial in making us who we are; it has a profound impact on movement and emotion. As if it were fuel for the central nervous system, those who lack it can literally lose the ability to move. Parkinson's disease, the most famous victim of which is Muhammad Ali, is caused by a natural deficiency of dopamine.

Thioridazine was developed in the 1950s to treat schizophrenics, who are believed to have a natural overproduction of dopamine. In addition to mental disease, the drug is also used in nursing homes as a tranquilizer. In blocking the production of dopamine, it also depresses the entire central nervous system, which reduces agitation and, according to critics of the drug, can lead to a kind of "zombification" of the user. Studies have shown that nursing homes, in general, often overprescribe thioridazine as a "chemical restraint" for residents or, as some critics call it, a chemical straitjacket.

Long-term use of thioridazine can have other terrible side effects, including tardive dyskinesia, a disorder marked by a total loss of control over bodily movements. Symptoms similar to those of Parkinson's also occur.

An overdose of thioridazine, which isn't considered a highly toxic drug, can cause an irregular heartbeat or, at worst, full cardiac arrest, which has led to hundreds of deaths -- though a statistically minute number in relation to the number of people who have been prescribed the drug.

In Florida, thioridazine made news in 1984 when it contributed to the overdose death in West Palm Beach of 28-year-old David Kennedy, the son of Robert F. Kennedy. Kennedy also had cocaine and Demerol in his system. In another highly publicized case, a nurse in Tampa was convicted of killing three nursing home residents with massive doses of thioridazine in the early '90s. The nurse, Brian Rosenfeld, confessed to overdosing 23 other patients.

Even in dosages considered safe, patients in rare cases have died from a condition known as "neuroleptic syndrome," which toxicologist Lee Hearn, of the Miami-Dade Medical Examiner's Office, says is marked by an elevation of body temperature followed by the body going rigid and cardiac arrest.

In Jenna's case, records show that thioridazine was being used as a tranquilizer. Jenna's central nervous system had already taken a near-fatal shock from the lightning, so no one could know what effect thioridazine -- especially in large amounts -- might have on her. Her prescription, according to the medical examiner's records, called for 20 milligrams of the drug a day, ten in the morning and ten at night, or "as needed." The prescription, so long as the "as needed" stipulation wasn't abused, was well within safe limits. According to the manufacturer's guidelines, a girl of Jenna's weight and age should never be given a daily dose of more than 76 milligrams a day.

"Anything over that is dangerous," says Michelle Bernardo's pharmacist, David Andrews, who handled Jenna's prescriptions. "You just don't exceed that."

Michelle Bernardo administered the thioridazine -- which came in a liquid that was simply dropped into Jenna's feeding tube -- when her daughter was at home. When Jenna was moved to the group home, the mother used her private insurance to buy the thioridazine and delivered it there.

She delivered a 3600-milligram bottle on May 6. On May 28, 22 days later, the bottle was empty.

According to the prescribed dosage of 20 milligrams a day, a bottle should have lasted 180 days. A bottle emptied in 22 days comes out to an average of 164 milligrams a day -- well over twice the maximum-allowed dosage for children her age, according to the drug manufacturer's guidelines.

Andrews says that when Bernardo came into his pharmacy to get a refill after barely three weeks, he was alarmed. She told him the center was completely out of it. The mother, when she cared for Jenna, went through bottles of thioridazine relatively quickly, but she "never used it anywhere close to this fast," says Andrews, who owns David's Pharmacy on Atlantic Boulevard in Pompano Beach.

"I said, 'Wow, why are you getting this filled now?'" recalls Andrews. "I said, 'There's something wrong here. They're using too much.' I asked her to please check with [the group home] to see if they spilled this, or dropped this, or if there was somebody else using this."

Andrews never heard back. The next news he heard about Jenna was that she had died on June 5, eight days after that last refill.

Jenna's mother would later tell an assistant medical examiner that the last full bottle she'd bought was already half-empty at the group home when Jenna died. If that's correct, then the average use of the drug climbed to 225 milligrams a day, which is just shy of three times the maximum-allowed dosage.

Assistant Medical Examiner Eroston Price had no knowledge of this when she ruled that Jenna died of anoxic encephalopathy, or a lack of oxygen to the brain, due to the lightning strike three years earlier.

The ruling went unquestioned until Michelle Bernardo called Price and asked her if any drugs were found in Jenna's system. Price told her there were no tests done, because there was no suspicion. That's when, according to the medical examiner's records, the mother told about the missing thioridazine and about Jenna's chronic drowsiness -- which happens to be the most common sign of thioridazine overdose.

Price did tests on a reserve sample of Jenna's blood and found that the level of thioridazine in it was equivalent to .76 milliliters of the drug per liter of Jenna's blood. That level, says toxicologist Hearn, is equivalent to an actual daily dose of 130 milligrams, or nearly twice the maximum dosage.

The Pompano Beach Police Department was called, and a homicide investigation was begun.

"Thioridazine affects the brain, and one of the functions of the brain is to control respiration and circulation," says Perper, describing the reason the investigation was started. "It is not surprising that an overdose of these types of drugs can result in severe damage or death."

Perper also said that because of Jenna's already precarious state of health, the drug given in too-high doses might be more dangerous to her than to healthy individuals but tempered the statement with the fact that he couldn't be sure of it.

"We know that this drug can slow the heart, which would slow down the breathing," which could cause reduced oxygen to the brain, says Andrews. "It could at least contribute to her death -- if not cause it."

The first thing for investigators to do was to get Jenna's dosage records, which would tell them how much thioridazine Jenna was given, by whom, and when.

"The center has not been able to locate the records," Perper says. "It obviously makes the investigation more difficult and the conclusion more difficult to reach."

Beggs, the center's president, wouldn't comment on the missing records, except to say they weren't crucial, as they would only "show what drugs she was getting." He also said one of Jenna's thioridazine bottles had either been broken or was spilled at the center, though he said he didn't know by whom or exactly when this occurred. There is no record of any spillage, however, and the pharmacist was never informed of it. Michelle Bernardo refused to discuss the case with New Times.

Beggs says a record of a prescription drug being spilled wouldn't necessarily be kept.

"It's conceivable that if a bottle broke, it would be, 'Whoops,' and then we'd call the mom and get another one," Beggs says. "That wouldn't necessarily have to be recorded."

Such records are supposed to be kept at the group home, however. State guidelines dictate that all medication used must be recorded in the group home, which is regulated not by the agency that oversees the main facility but instead by the Department of Children and Families. The director of the center's group homes, LeShawn McCray, said every time Jenna was medicated, all pertinent information -- time, amount, who gave it, et cetera -- was marked on her dosage records. McCray wouldn't comment on why, in Jenna's case, those records are missing.

Kurt Hoppe, the chief local regulator over the group homes for the Department of Children and Families, says he hadn't heard anything about the missing records or the investigation itself. He says that under normal circumstances, his agency would investigate such a matter.

"We would have to review the clients' medications, when they were seen by a doctor; we'd count pills -- there would be a full investigation," Hoppe says.

McCray is in charge of all three of the center's group homes. She is "on call" at the group home where Jenna was staying but doesn't normally work there. The group home is staffed by students and nursing assistants, who make between $7.50 and $10 an hour, McCray says. They generally handle all facets of care at the home, including giving out prescription medications, like the powerful sedative phenobarbital, and, in Jenna's case, thioridazine.

The drugs are kept in the locked cabinets in the home's back room. McCray says that, in addition to herself, only two other staffers -- one of them a nursing student, the other learning to become a respiratory therapist -- have the keys to the cabinets. It's the two students' job to measure out the proper amounts and place them in small cups on a tray, which is stored in the padlocked refrigerator. Every staffer administers medicine, so each has a key to the refrigerator. (Staffers contacted at the group home had no comment about Jenna's case.)

McCray says she's trained all the staffers in how to give medicine. None of the group home staffers, however, would be allowed to handle a bottle of thioridazine, or for that matter any other prescription drug, in a hospital. Only McCray, the registered nurse, would. Group homes in the state of Florida don't fall under the same stringent regulations as other medical facilities.

"Anybody can give it," McCray says. "They do not have to be a licensed professional, unlike a hospital. The guidelines are totally different.... Even my position is not required as an overview. But our board of directors felt that it was important."

Jenna was given a proper amount of the drug, McCray says, once in the morning and once at night. Is it possible that one of the staffers gave Jenna more to keep her from crying?

"She cried all the time, even when we gave her [thioridazine]," McCray says. "We're used to that. We have kids who don't sleep at night and scream and cry for hours. That doesn't bother us. All of our staff is trained to deal with that."

When confronted with the high rate that thioridazine was going through the center and the toxic levels in Jenna's bloodstream, McCray says she is "absolutely, 100 percent positive that Jenna was not overmedicated" at the group home.

Beggs says he's also confident that Jenna wasn't given too much thioridazine at the group home. When asked about the level of training of staff at the group home, he said that he's evaluating the situation and may add licensed staff if it's deemed necessary.

"It's really a matter of economics," he says.
As center staffers learned in the case of Cristal McBean, economics can also play a role -- a $4 million role -- when a relatively inexperienced employee performs a task meant for experienced professionals.

Unlike Jenna, Cristal was born in dire straits. Fourteen weeks premature, she weighed only a couple pounds at birth. Her early months, spent in an intensive care unit, were marked by numerous medical emergencies. She suffered from a lung disease and other complications of her birth but survived them. She was transferred from Miami Children's Hospital to Broward Children's Center on January 17, 1994, a few months before her second birthday.

While Jenna was the worst off of all the children at the group home, Cristal was one of the most promising kids in the main facility. According to records kept by Broward Children's Center, Cristal could sit up on her own, pull herself up to a stand, and crawl. She liked to play with toys and watch people go by her crib. When she got agitated, center staffers knew what to get her: "She loved her chocolate milk," said Broward Children's Center staffer Robin Sargent in a deposition.

According to a reputable pediatric doctor from San Diego who was hired as an expert witness by Cristal's attorney, she had a good chance at a relatively normal, happy life, free from life-support machines. By June, in fact, she was being weaned off the ventilator. She breathed on her own through a tracheostomy tube in her neck during the day but still needed a ventilator at night to ensure that she wouldn't stop breathing while sleeping in the center's nursery, where 14 other babies connected to life-support machines slept, too.

On the morning of June 19, 1994, something tragic happened in the nursery that stripped Cristal of all of her hard-won physical advancements.

According to civil court depositions, the nursery was being supervised that morning by a respiratory therapist and a licensed practical nurse. Also on duty was a "floating" respiratory therapist, Chackocan Vadakkel, who helped in the nursery as well as in other wings.

Vadakkel, an Indian immigrant with limited English and a heavy accent, in a sworn deposition told Gary Cohen, a medical malpractice attorney hired by Cristal's family, that employees were concerned that staffing levels were too low:

Cohen: Were you ever concerned that there wasn't enough help in the nursery? Fifteen babies is a lot of babies.

Vadakkel: Lot of babies.
C: For two people to handle.
V: So, that is why floating therapist -- for helping them.

C: Was there ever any talk at the center that you know of about getting more help?

V: They were asking for more help. Everybody asking for more help.
C: Everybody thought they were in need of more help?
V: Yes.

Shortly after 5 a.m. on June 19, Cristal remained connected to the ventilator, which literally breathed for her, though she was also able to take spontaneous breaths on her own. The ventilator was set on 12 compressions -- or breaths -- a minute. The oxygen went through a ventilator tube, which connected directly to her tracheostomy tube.

Dawn Jackson, the nurse in charge of the babies, instructed Vadakkel to take Cristal off her ventilator. That was the first mistake.

To become a respiratory therapist, Vadakkel had to complete a 15-month course and pass a state test, which he did six months prior to the incident. When he was hired by the center in March 1995, however, he had had no training or experience working with children. More important, he'd never before in his life unhooked a ventilator from a patient when Jackson asked him to unhook Cristal's.

The respiratory therapist on duty in the nursery, Robbie Harris, said under oath that he didn't know Vadakkel had never performed such a basic task, which consists of snapping the ventilator tube off the tracheostomy tube and making sure the latter is still in place afterward.

Cohen questioned Vadakkel about his lack of experience:

C: Were you worried that you may not be able to [take off a ventilator] just right?

V: No.
C: How did you know how?
V: Because I -- teach in the school.
C: But they didn't teach you with babies?
V: No.
C: You never touched a baby before you went to Broward Children's Center?
V: No.

C: How did you study it without doing it? Anyone who is giving health care has to work on patients, don't they?

V: Book saying what to do.

Vadakkel's deposition also showed that, even if he would have had experience with ventilators, he never should have been ordered to take off Cristal's in the first place. Cristal was asleep at the time, and doctor's orders forbade her sleeping without a ventilator. Nurse Jackson would later say in a deposition that she thought Cristal was awake when she told Vadakkel to take off the ventilator. Vadakkel said Cristal never woke up.

Cohen believes that when Vadakkel took off the ventilator he also inadvertently dislodged the tracheostomy tube in Cristal's neck. In depositions staffers agreed that it was likely. Since Cristal was, by Vadakkel's own admission, asleep and couldn't have knocked it out herself, there is no other sufficient explanation.

When a tracheostomy tube comes out, skin often folds over the airway, obstructing it. According to depositions and other court records, it appears that almost everyone agrees that it was the dislodging of the tracheostomy tube that led to Cristal's brain damage.

But several minutes had passed before this crucial problem was recognized. Exactly how long will never be known, because everyone there has a different memory of the time frame. (The incident, in fact, prompted the center to install clocks in the nursery.) What is known is that by the time it was discovered, Cristal was already in cardiac arrest.

When a child stops breathing at the center, alarms are supposed to sound. An oxygen-saturation monitor to which Cristal was connected should have gone off when the oxygen level in her blood dropped to dangerous levels. Some employees said the monitor's alarm went off, others said it didn't. Vadakkel said it went off, prompting him to check Cristal, but he also said she was already in cardiac arrest -- her lips pale, her skin purple -- by the time he was alerted.

"These kids move in the night and the alarms go off and the nurses get annoyed by that. We believe the alarm was shut off," says Cohen. "That's the only way to explain it. The alarm should have gone off immediately. We know the alarm couldn't have gone off; the child was unresuscitable."

Upon discovering the problem, Vadakkel said he didn't know what was wrong. Center staffers later said in depositions that this was inexcusable: A respiratory therapist should immediately recognize when a tracheostomy tube is out of place.

Vadakkel called the other respiratory therapist, Harris, over to the crib. Harris quickly recognized the problem and put the tiny tracheostomy tube -- about five millimeters in diameter and an inch and a half long -- back in.

Harris estimated that up to eight minutes passed from the time he began CPR to the time 911 was called. Vadakkel guessed it was more like ten. In any case it was, according to depositions, way too long. Cristal was transported to Broward General Medical Center. At some point her heart started beating, but it was too late. She was already permanently brain-damaged. Today she is constantly on a ventilator, must be fed from a tube, and doesn't respond to the world. She remains in a vegetative state, says Cohen.

When it began an investigation into Cristal's death, the Florida Department of Health and Rehabilitative Services (now the Department of Children and Families), forbade Vadakkel from dealing directly with patients, Broward Children's Center chief executive officer Marjorie Evans said in a deposition. Vadakkel's boss at the time, Robin Sargent, said in a deposition that it was the center's decision to bar Vadakkel from looking after patients.

The center also took other action: Robbie Harris was demoted, and a new procedure was instituted to deal with cardiac arrests. The results of the state investigation are confidential, said Lynnette Beal, the spokesperson for the Department of Children and Families.

After learning that her daughter was suddenly brain-damaged and in critical condition, Tanganicka Edwards, Cristal's mother, drove from her Miramar home to the center, where she met with Evans. The meeting was a volatile one, with a mother furious about her daughter's sudden and unexpected turn for the worse and an administrator who didn't have a good explanation for it:

Cohen: That is not an inappropriate response is it, [for the mother] to be angry under these circumstances?

Evans: I think what was done for Cristal was appropriate.
C: Was she given an answer as to what happened?
E: Yes... by me she was. I explained what happened as I understood it.... I told her that Cristal was on a ventilator, and that her trache came out, and CPR was initiated. And I also said to her that, "You do understand that Cristal is a very sick child?" and she became absolutely outraged.... She wouldn't hear anything. We were getting nowhere. I said to her, "I told you everything I know, what do you want?"

Evans went on to say that Edwards was so furious that she refused to leave until Pompano Beach police came to the center and took a report.

Evans, who testified that she has no medical training, seemed unable to accept the fact that Cristal had been well on her way to a near-normal life. For instance, she insisted that Cristal was "respirator-dependent" rather than "respirator-assisted," apparently unaware that her own nurse, Jackson, had already testified to the fact that Cristal was technically "respirator-assisted."

Cohen, who sued for Tanganicka Edwards on the grounds of negligence by center staff, also questioned Evans about things the center's own social worker had noted in reports about Cristal -- before June 19.

Back to her deposition:

Evans: Everything Cristal was doing she was doing with assistance. She was not, you know, doing anything without physical assistance.

Cohen: OK. Were you aware that she was able to pull herself up?
E: No.
C: ... able to hold objects in her hand?
E: No.
C: ... able to play with toys?
E: No.
C: Were you aware that she was able to sit up?
E: I know she was not --
C: Unassisted?
E: -- able to sit up.

The day after the incident, the Miami Herald ran a news brief -- which didn't include Cristal's name and was marred by factual errors -- about the incident. The last line reads: "Center administrator Marjorie Evans said her staff was not to blame." The brief was the only article ever published about the case.

Cohen says Evans was just following an obstructionist pattern set by the center's attorneys. Attorney Robert Cousins, who represented the center, wrote a letter to Cohen's law firm in 1995 that again blamed Cristal's health, rather than mistakes made at the center, for the incident.

"The defendant would affirmatively show that the injuries or damages alleged are the result of the natural consequences and course of [Cristal's] illness and not the result of the negligence or departure of care of any health care provider," Cousins wrote.

The center chose to refuse an early settlement offer of $1 million extended by Cohen's law firm. The following summer Cohen began deposing staffers and, as he puts it, "the truth started pouring out."

Cohen says the depositions not only proved that the center was negligent but that it was more negligent than even he suspected. Dr. Robert Spear, a veteran pediatric doctor who works at Children's Hospital in San Diego, was deposed on November 6, 1995. Spear, who was commissioned as a witness by Cohen, had reviewed the depositions and Cristal's available medical records. He testified that Cristal would have likely developed normally, independent of ventilators and tracheostomy tubes, had not staffers both been negligent and acted inappropriately.

He concluded that the reason Cristal went into cardiac arrest in the first place was almost certainly because Vadakkel accidentally pulled out the tracheostomy tube when he unhooked the ventilator. He testified that the ventilator never should have been unhooked while Cristal was asleep and that the untrained Vadakkel never should have been asked to unhook it under any circumstance. Spear also determined that it took way too long for staffers to call 911.

In short, Spear placed the blame for Cristal's catastrophe squarely on the center's shoulders.

On December 7, 1995, less than a month after that deposition was taken, the $4 million settlement was finalized.

Cohen says the way Broward Children's Center dealt with Cristal's case was reprehensible. "It was a screwup, and they tried to imply that they did nothing wrong," says the lawyer. "There was an attempt at trying to portray this in one way when it happened in another. It was frustrating."

The center is still denying any fault.
"That was our insurance company that made the settlement," Beggs says. "They did so without consulting us. We did nothing wrong."

Evans, who started the center 25 years ago, never returned messages left by New Times.

While Cohen and his lawsuit shed ample light on what happened the morning Cristal was brain-damaged, the truth about where all that thioridazine went and why Jenna died with dangerous levels of it in her bloodstream may forever be a mystery.

Medical Examiner Perper says that while the investigation is still officially open, he expects it will soon be wrapped up. Without records or a feasible explanation of where the medication went, few questions have sufficiently been answered.

"You cannot establish proof without evidence," Perper says. "We've been unable to produce an explanation."

As for the high levels of the drug in Jenna's system, Perper sent the results to toxicologist Hearn in Miami for a second opinion. Hearn determined that, though the level is in the toxic range, it wasn't high enough to be irrefutably lethal.

Hearn says another reason he decided not to rule thioridazine overdose as Jenna's cause of death was that Jenna easily might have died of complications of the lightning strike. Her central nervous system had suffered an extreme shock and could have stopped functioning properly at any time, leading to death, Perper says.

But Perper and Hearn both concede that thioridazine could have contributed to Jenna's death. If new information were to come to light, Hearn says, "it might be worth reconsidering. I can't say with absolute certainty that it didn't play a role."

The investigation has not yet been closed, but Perper says he expects it will be closed soon. Pompano Beach Police Det. Bill Wesolowski has also been investigating the case but won't discuss it while the investigation remains active.

Beggs, meanwhile, says Hearn's ruling vindicates Broward Children's Center, which he adds has helped many children have a better quality of life than they could have expected anywhere else. He's right about the center helping children. Everyone seems to agree that the center is often doing important work.

In fact, it still has among its supporters Greg Bernardo, Jenna's father. Despite the suspicious circumstances of his daughter's death, he says he only wants the center to flourish.

"The world needs places like Broward Children's Center," he says, adding that he has no plan to file a lawsuit in his daughter's death.

The father points out that Cristal's case was much worse than his daughter's. Jenna was lost to him, for all practical purposes, not when she died, but on the day that lightning struck. He believes death came mercifully for his daughter; it finally stopped her crying.

At the same time, he says he's concerned that his daughter died with toxic levels of a drug in her system and that the center lost her records. Bernardo wants to know the truth.

"If I said I wasn't concerned, I wouldn't be telling the truth," says the father. "If there were problems at a place where children are cared for and those problems affected my daughter, then other children may be at risk.

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