Rose Landino has an easy time imagining the happy routine she should have been following last Oct. 26.
As evening approached, she and her husband would have climbed into a car for the drive to Stratford to pick up Rose's twin brother, Douglas, who would be wearing a clean button-down shirt and a huge smile.
Off they would go to Dougie's favorite spot in the universe — a Red Lobster restaurant — where he would be told to order anything he wanted. At the end of the laughter-filled meal, waitresses would sing a spirited round of "Happy Birthday to You" and deliver slices of cake — maybe extra-large slices for the twins' 50th birthday.
Then, well after dark, they would return to the car to drive Dougie back to Stratford, turning the car onto the winding access road to the Ella Grasso Center, where he lived with about 45 other men and women with developmental disabilities.
That's how Rose Landino imagines the day. Instead, she spent most of her birthday in her compact New Haven home, somber and teary against an incongruous background of birthday decorations on the wall and dangling from the ceilings.
"Dougie's death — it is so senseless," she says, wiping a tear as she sits on a couch a few feet from a small memorial she has built for her brother.
"It hurts. You don't know how much it hurts," she says. "The doctors that did this to him, how do you sleep at night, knowing that us — a loving family to Dougie — that we have to hurt for the rest of our lives?"
A Life-Changing Loss
Rose and Douglas were born just before the advent of ultrasound in obstetrics, and their fetal position allowed doctors to hear only one heartbeat, so the multiple pregnancy was a surprise. Douglas was born first, a difficult breech delivery in which he came out blue, with the umbilical cord wrapped around his neck. Rose was born two minutes later, without complications.
Starved for oxygen, Douglas's brain suffered a serious developmental injury. As he grew, his mental capacity stopped at that of about a 6-year-old's.
But he had an endearing innocence and a longing for interaction. He would stand at the sidewalk and ask passersby the spelling of their names, then write them down on his ever-present pad of paper.
"And if he didn't see you, say, for a year and you showed up, he would have still remembered you and would still know how to write your name and your last name," Landino said. "He was a very smart boy. He may have been mentally retarded, but let me tell you: this kid was so smart. So smart."
When he wasn't writing names on his pad of paper, he'd write on shopping bags his mother would save. He wrote on his sisters' album covers, and on the labels in the center of records.
"We had a pencil sharpener in our kitchen growing up — for Dougie," Landino said.
Their mother, also named Rose, built her life around caring for her son, dressing him and feeding him every day for decades.
And then came Oct. 3, 1994.
A few weeks shy of Douglas's 32nd birthday, Rose Davis suffered a heart attack and died. She was 56. Landino said her father wasn't equipped to care for Douglas, and his three sisters were all married and working. She said there was no viable option other than placing him at the Ella Grasso Center.
Douglas built a life there, listening to his bags full of cassette tapes, keeping active and losing weight on a healthier diet than he received at home, where his mother would spoil him with food.
He did well for years; there was even talk of having him move to a supervised apartment in the community with other developmentally disabled men. But it never happened, and after September 2003, it never would.
Cited For Neglect
Douglas had a history of becoming agitated when he didn't get his way, and doctors controlled the behavior with Haldol, a drug that decreases abnormal excitement in the brain and that is often prescribed to children with aggressive behavior.
But in September 2003, Douglas' psychiatrist switched the prescription to Seroquel, a newer anti-psychotic that usually had a lower risk of serious side effects.
Douglas' medical records show that almost immediately after Douglas' medication was changed, he experienced strange and dangerous changes in behavior. Within days of the switch, records show, Douglas was unsteady on his feet, and staff at the Ella Grasso Center began chronicling episodes of "dropping" – when Douglas would simply slump over or collapse to the floor. Twice, he was injured seriously enough in falls that he was taken to the hospital, and once required stitches over his eye to close a wound.
"He dropped one day 60 times," Landino said, recounting notes from Douglas' medical records, which she obtained years after his death. Once, during dinner, his muscles gave out and he slumped face down into his food.
The Office of Protection and Advocacy for Persons With Disabilities, within what was then the Department of Mental Retardation, later cited the Ella Grasso Center for neglect in Douglas' care, finding that despite his obvious medical problem, staff at the center did too little to keep him safe or determine the cause of his condition.
"Though he was briefly examined at the hospital" for the second serious head injury in October 2003, the advocacy office wrote in a summary of the case, "there was no indication that the client ever received a full work up for the symptoms of unsteadiness he was experiencing and possible problems associated with his taking Seroquel."
The "droppings" continued nearly every day, month after month. But Landino said the center never notified her or her younger sister, who was Douglas' official guardian, of Douglas' frequent falls, and the state investigation concluded there was "no evidence that the guardians and family were fully apprised or informed of the client's condition during this time period."
Instead, records show, medical professionals continued to increase Douglas' Seroquel dosage, despite warnings that among its possible side effects are unsteadiness, dizziness, fainting and seizures.
Douglas was eventually taken to a neurologist, and records show the Center was instructed to track his standing blood pressure, as low pressure when standing can lead to fainting. But according to the state's investigation, those instructions weren't followed.
The Center's residential manager, who was not employed there at the time of Davis's death, said that health privacy laws prevented her from commenting on the case.
Although Douglas' sisters were unaware of his falls, they saw other strange behavior. During visits to their homes, he would scratch himself raw, as though he had a rash – a known side effect of Seroquel.
"There was a time when we took him over to my sister's house for a visit, and he just started growling like a wild animal in the house," Landino said. "Literally, it was like a wild animal, it was so deep from within."
Days before his death, Landino said, he was staring out the window, calling to their mother, who had died 10 years earlier.
By January 2004, Douglas was falling so frequently that staff at the Ella Grasso Center restrained him in a wheelchair, records show.
Landino says she knows that some of the workers at the Ella Grasso Center were committed and well-meaning.
"There were some people in there that did care about Dougie," she said. "And there were some people that my brother was a paycheck to."
Tears Turn To Anger
On Feb. 7, 2004, Landino was at the movies when she received word that Douglas had collapsed and was in the hospital. She rushed out of the theater and found him at St. Vincent's Medical Center in Bridgeport, disoriented but alive. He was discharged to the center that night.
Three days later, she received another call, saying Douglas had been found unresponsive at the Ella Grasso Center and was once again taken to the hospital. "When we got there, the chaplain met us, and he said, 'Are you the Davis family?'
"And I knew right then and there he was gone."
The chief state's medical examiner's office performed an autopsy but initially listed the cause of death as "pending further studies." Two months later, the cause of death was updated and listed as "sudden death associated with seizure disorder."
That did not answer Landino's questions, and she began a quest to understand why her brother died. More than a year later, she and her husband were permitted to read the state's 13-page investigation of Douglas's death.
"We cried reading that report," she said.
Those tears turned to anger, and in 2006, Landino filed a lawsuit against the state-run Ella Grasso Center. A settlement was reached four years later in which the state agreed to pay more than $2 million.
But what the state gave with one hand, it took away with the other.
The state, in keeping with standard practice when dealing with such windfalls, essentially billed Douglas' estate for the cost of his care — deducting nearly $1.7 million from the amount it ultimately paid.
"That was a slap in the face," Landino said. "That was a dagger in the heart — front, back and sideways."
After legal expenses, Landino, her two sisters and their father received a total of $190,000.
Landino pressed for legislation that would bar the state from seeking reimbursement when a family receives a settlement because of the state's negligence. She drove to Hartford and spoke before the legislature's joint committee on human services.
"Morally speaking, the state of Connecticut should not benefit and be rewarded for causing the death of another human being," she told the committee. "Where is the guilt and the shame? The state of Connecticut should be ashamed."
Landino assumed the legislation would pass easily. But a fiscal note estimated that the bill would have cost the state $9.1 million in lost reimbursements over the previous decade. After bouncing among committees for a couple months, the bill died.
As she turned 50 without her twin, Rose Landino fluctuated between grief and anger and effusive nostalgia for her other half. Most often, the grief won out.
"It hurts every day. Every single day," she said, "I wake up, I think about it. I go to bed, I think about it.