Julian Carter was Baker Acted 44 times. Without proper care, he died at 11.

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Editor’s note: This story includes discussion of suicide. If you or someone you know is considering suicide, reach out to the resources at the bottom of this story.

On the first day of fifth grade, Julian Carter earned a sticker from his teacher.

The 11-year-old placed it on his nose, drawing laughter from classmates.

But Julian thought they were laughing at him, and his mood darkened. He cursed them and his teacher and was sent to the principal’s office.

Julian had been battling mental illness since he was 8 and wasn’t getting the help he needed. His outbursts, many at the St. Petersburg schools he attended, were serious enough that he had been involuntarily committed under the state’s Baker Act 44 times.

Julian sat in the office until his grandmother could pick him up. He had been staying with her in Polk County and attending school there after his mother, fearing she’d lose her job, sent him away for a while. Caring for him required so much time. Julian apologized to the principal and to his grandmother, and she drove him home.

The two made dinner together. While he was eating, Julian complained of an upset stomach. In the next few hours, he grew sick enough that his grandmother called 911. A lethargic Julian told a sheriff’s deputy who responded that he had taken pills because he wanted to kill himself. He said he had been having thoughts about shooting his classmates.

Julian died on the way to the hospital. His death was ruled a suicide.

What went wrong

An investigation produced for the state by a public-private group of child welfare experts spelled out how agencies responsible for Julian’s mental health care failed him in the months and years before his death on Aug. 12, 2019. Among the findings:

• Julian had tried to take his own life before, once by running into traffic at school. His illness was so severe, mental health professionals recommended him for long-term residential treatment at least 20 times. He never got it.

• Julian’s treatment was fragmented, spanning six health care systems. Between 2016 and 2019, he received at least 11 diagnoses, including depression, impulse control disorder and bipolar disorders. Doctors prescribed medications that at times may have counteracted one another.

• Julian’s problems were complex, at one point the focus of three interventions at the same time. Yet no one conducted a full assessment of his needs or of his mother’s ability to care for him. What’s more, procedures put in place by the state eight months before his death to ensure coordination of care in cases like his were not followed.

• During the six months before Julian’s death, the agency in charge of his day-to-day care transferred him among three case managers and four supervisors. His last case manager described her workload as overwhelming.

The investigation, released eight months after Julian’s death, was one of 15 triggered by the deaths of children receiving welfare services from the state in 2019. No one was blamed for Julian’s death, no punishment was meted out. But the investigation found failures by the state Department of Children and Families and its regional contractor, Eckerd Connects Community Alternatives.

The state has sweeping responsibility for the welfare of children who come under its care, expanded through the years by legislative action and court rulings. Among these is to prevent child abuse and neglect and ensure proper placement and care for children.

The state outsources many responsibilities to 17 private lead agencies. The nonprofit Eckerd Connects handles the Pinellas-Pasco region under a contract worth $81 million this year. Eckerd, in turn, hired the nonprofit Directions for Living to provide day-to-day supervision for families like Julian’s through the case managers it employs.

With children’s mental health, this care can include a variety of treatments — counseling, psychotherapy, behavioral therapy, art therapy, equine therapy, substance abuse treatment and parenting classes.

The investigation into Julian’s death faults the state for failing to provide the framework and training to carry out needed improvements in coordinating Baker Act cases involving children. It also faults Eckerd Connects for failing to help Directions for Living when a growing caseload placed the subcontractor “in a state of crisis.”

In a response letter made part of the final report, Eckerd Connects disputed the investigation’s findings, saying it did act to help Directions for Living — paying more than $100,000 toward daily transportation for children, contributing $214,000 to hire personnel, and providing the names of Eckerd staff willing to work part-time for Directions for Living.

All told, Directions for Living received $13.1 million for its work in 2019, the year Julian died, according to a federal tax report filed by Eckerd Connects.

In the letter, Brian Bostick, executive director of Eckerd Connects, acknowledged that the added support supplied to Directions for Living didn’t help solve the problem of high caseloads immediately. But Bostick cast some blame on the state, saying his agency “being one of the lowest funded Lead Agencies in Florida for years has exasperated the problem over time.”

Faulting Eckerd Connects for a lack of support to its subcontractor amounts to “personal opinion and is not supported by any other information,” he wrote.

Both agencies declined to comment for this story. The state Department of Children and Families initially indicated it would speak with the Tampa Bay Times, but then declined to do so.

In August, two years after Julian’s death, attorneys representing his estate filed a lawsuit in Hillsborough County against Eckerd Connects, alleging it showed disregard for the boy’s life and safety.

As the lead agency, Eckerd was obligated by the state to ensure Julian’s mental and physical health needs were met, the lawsuit said.

“They just abdicated their own responsibility to the mother,” Stacie Schmerling of Fort Lauderdale, one of the attorneys who filed the suit, told the Times. “But this is the lead agency responsible for the child welfare system. It’s their job to take protective action.”

The lawsuit comes as the state is investigating whether Eckerd Connects violated a state law prohibiting excessive executive compensation paid with government dollars. Eckerd Connects and another private child welfare organization are accused of exceeding an annual salary cap of $213,819 for individual executives.

A family in need

A small photo of Julian is embedded in his gravestone at Royal Palm Cemetery South in St. Petersburg. He’s smiling, his cheeks chubby and his hair curly and free.

When Chera Nyerick, 36, his mother, paid a visit to the grave one afternoon in September, this month, a yellow butterfly flew around her. She’s convinced it was Julian. She has seen yellow butterflies everywhere since he died — at the cemetery, in her yard.

She and her three other children, twin daughters and an older son, always say hello to the boy they called “Bubba” when they drive past the cemetery.

Julian was close to his younger sisters. He would set up concerts for them and Nyerick in the living room, singing or rapping with the music, a microphone in hand.

“He would sit in his room listening to music,” Nyerick said. “I think that was one thing that really calmed his mind.”

Another was the outdoors. The family enjoyed going on hikes, sometimes to Weedon Island or Sawgrass Lake Park. Julian also liked spending time at the skate park with his father.

Julian started showing signs of mental illness around 6 or 7, Nyerick said. He became more defiant and would have outbursts at school. His first commitment under the Baker Act, as a danger to himself or others, was at 8.

Julian appeared on the state’s radar March 2, 2016, after he was Baker Acted a second time, the lawsuit said. Nyerick called the Florida Abuse Hotline. The call was referred to Eckerd Connects.

“I was told on the phone that he wasn’t an emergency situation ... and that it could be dealt with outpatient,” Nyerick said. “I would bring him to the psychiatrist, and he would run away.”

Julian threatened to kill himself, harm other kids and “bash his teacher’s face in,” the lawsuit said.

Eckerd Connects is required by Florida law to contact the hotline reporter, in this case Nyerick, but it closed the case without speaking to her or connecting her to family services, the lawsuit said.

A year later, in April 2017, Julian received his first referral to a residential center for emotionally troubled children. But after another year passed, he was still living with his family and had been Baker Acted at least 10 times.

He was 9.

Missed chance

In June 2018, the Department of Children and Families sent a new set of rules to a host of agencies involved in child welfare. They elevated the urgency of cases where children are committed under the Baker Act while they’re also receiving services from the state.

Under these rules, department staff, private contractors, sheriff’s offices and others must meet to address treatment. These meetings serve as a step toward residential placement.

The rules also mandate that a caseworker contact the hospital where any child receiving state services is being held under the Baker Act and notify any court involved in the case.

Still, Julian remained in his family’s care.

After his death, the state investigation concluded that high-level agency employees had been notified about the state’s new policies in a memo but that those policies didn’t reach lower-level staff responsible for carrying them out.

By December 2018, Julian had been Baker Acted 29 times, and medical professionals had suggested residential placement 15 times, the lawsuit said.

Soon after, while he was staying with his father, Terrence Carter, Julian attempted suicide, the state investigation said. Carter didn’t lock up prescription medication and was arrested on a charge of child neglect. He pleaded guilty and received three years of probation.

Carter, who was not married to Nyerick and who hadn’t cared for Julian in years, didn’t understand the gravity of Julian’s condition, attorney Schmerling said. Carter declined to comment for this story.

The family had its struggles. A year after Julian was born in 2008, Nyerick filed the first of seven domestic violence complaints against Carter. The last was in 2016. The month after his child abuse arrest, Carter filed a domestic violence complaint against Nyerick, saying Julian threatened to kill himself if he had to live with his mother.

Later in December 2018, Julian reunited with his mother and the two received in-home services through Eckerd Connects, according to the investigation. But their situation didn’t get to a targeted case manager, which would have allowed for greater intervention, the investigation said.

There were other missed opportunities. Nyerick was supposed to submit documents seeking residential care for her son, the investigation said. But Nyerick said the packet was long and confusing.

She sought help from Eckerd Connects to fill it out, and later from Directions for Living. She pleaded for help from psychiatrists, therapists, welfare agencies, and mental health centers where Julian was sent under the Baker Act.

“This isn’t going to end well,” she told them.

She didn’t get the help, she said, and never submitted the paperwork. By this time, Julian had been committed under the Baker Act over 30 times and received 22 recommendations for residential placement.

“You’re basically playing doctor. You’re trying to figure out how to help your kid because you’re not getting help from the system,” Nyerick said. “There were times when I didn’t know what to tell him.”

Too many cases

At the time it was handling Julian’s care, Directions for Living was in trouble, according to the state investigation.

The last of three case managers assigned to Julian by Directions for Living told state investigators she had been working in the business just five months. Her cases had quadrupled from 10 children to 37 at the time of Julian’s death. The state’s rules limit new case workers to 10 children during their first month with a gradual increase after they prove they can handle more.

“They sent in maybe one or two different case managers each time we had a meeting, so it was not consistent … which is what I was wanting, consistency was the key for Julian,” Nyerick said.

In a letter to the state, Directions for Living said case workers had an average caseload in the 40s at the time of Julian’s death, well above the 25 children set as the standard in its contract with Eckerd. In addition, the letter said, 15 case managers had left because of salary caps imposed by Eckerd Connects.

The subcontractor also took a hit when Eckerd Connects ended a contract with another company to provide transportation for children and took on the task itself, according to the letter. Eckerd couldn’t keep transportation staff, and the job essentially shifted to Directions for Living.

A progress update was completed in Julian’s case in early April 2019, noting his many Baker Act commitments and the requests for residential placement, according to the lawsuit. Again, no placement came.

Nyerick made another call to the state hotline.

The following month, in May, Julian was denied an intensive, at-home care program meant to stabilize a child with mental health problems and provide team-based treatment at home. This was the second time Julian had been denied admission to the program, and the decisions were “inappropriate,” the investigation said.

The reason given both times: Julian had been identified as a candidate for residential care. But he never got that, either.

Then, on June 12, Julian was arrested for hitting his mother after he ran away from an outpatient care center. He was incarcerated at the Pinellas Juvenile Assessment Center, the lawsuit said.

A day later, a resource specialist from Eckerd Connects contacted Nyerick about her most recent calls to the hotline. Nyerick said she was almost finished with the required paperwork to apply for a residential treatment program and just needed to get Julian to complete physical and dental examinations.

She was having a hard time keeping appointments, according to a police report, because Julian was so often running away, getting arrested or being committed under the Baker Act.

Conflicting care

In early July 2019, Eckerd Connects closed Nyerick’s report to the hotline without action, the lawsuit said.

Julian was arrested that month after running away from home. Authorities recommended he remain in Department of Juvenile Justice custody until he could be placed in a residential center. Instead, he was released because no referral ever came and the department had no bed to put him in, according to the state investigation.

Julian was committed under the Baker Act for the 44th and final time on July 20, according to the lawsuit. The state investigation lists at least 34 Baker Act commitments for him. A psychiatrist said at the time that the boy would most likely end up in jail or a state hospital because of his severe antisocial personality traits, the lawsuit said.

Involuntary commitment under the Baker Act is like an emergency room for mental health patients, said Martha Lenderman, former director of the state’s Baker Act program.

A doctor diagnoses a patient over the course of a few days. Treatment doesn’t begin until afterward.

Lenderman has no knowledge of Julian’s case, but she said repeated commitments under the Baker Act are a sign that something isn’t right.

“The Baker Act, with all the controversy around it ... saves lives, every single day,” Lenderman said. “But it’s intended as a kind of emergency stabilization.”

Between 2016 and 2019, Julian received diagnoses for at least 11 mental health issues, the state investigation found. The lawsuit lists 17 diagnoses.

Julian was prescribed a number of medications, sometimes simultaneously. This can lead to a “prescribing cascade,” the investigation said, where a new medicine is prescribed in the mistaken belief that a new condition has arisen. In reality, the condition may be an adverse reaction to another drug.

Most of the drugs were prescribed during Julian’s Baker Act commitments.

Between Aug. 2 and Aug. 8, 2019, Eckerd Connects sent and received several emails about the need for more staffing to help Julian, but it wasn’t provided, the lawsuit said.

A new supervisor was assigned to Julian’s case at Directions for Living, the fourth since the agency took over his care, and she first came across his file Aug. 7. The boy died five days later.

Within two weeks, Eckerd Connects fired Directions for Living as its Pinellas-Pasco service provider. Two weeks after that, Directions for Living quit as the subcontractor in Hillsborough County — even though Eckerd Connects wanted the agency to continue providing services.

“Despite repeated requests for more funding, oversight, advocacy, and support, the child welfare system remains in crisis,” April Lott, president and chief executive of Directions for Living, said in a news release at the time.

Changes made

In a November 2019 letter to the team investigating Julian’s death, Lott said Eckerd Connects had taken over the work it once contracted out to Directions for Living and had made changes that her agency had been seeking — creating a dozen support positions, contracting with an outside provider for the highest-risk adolescents and reducing case management by one-third.

Lott said that if Eckerd Connects had provided these resources to her agency, “this death would have been prevented and the children and families of Pinellas County would have been far better served.”

Julian’s death brought about promises of change in the way the system deals with children receiving state services, according to the state investigation.

Eckerd Connects now requires that case managers identify “high-risk” children, make sure a staff member sees them at least once a month and tracks them on a spreadsheet for review by the executive director.

The Department of Children and Families pledged to revise documentation requirements and strengthen language around residential mental health treatment. It also has developed a strategy for interagency agreements when several agencies are involved in a case.

During this year’s session of the state Legislature, lawmakers recognized the need for more changes to help children receiving state services — expanding the use of interagency teams, tightening timeframes for planning care, and requiring assurances that contractors remain financially sound.

These measures are one step toward holding accountable those tasked with caring for children in need, said state Sen. Ileana Garcia, R-Miami, chairperson of the Children, Families and Elder Affairs Committee.

“We have to stop trying to fix things using the same components that made it inoperable to begin with,” Garcia told the Times.

Life has changed for Julian’s family, as well. But he remains a central part of it.

His name comes up in conversation every day for his sisters, now 6. They’re always looking through albums full of Julian’s photos.

And Nyerick said she aims to do more to advocate for children’s mental health.

“As a parent, you start to feel very alone,” she said. “They almost make you feel like it’s just another kid with some problems. That needs to change.”

Staff writer Christopher O’Donnell contributed to this report.

Need help?

If you or someone you know is contemplating suicide, reach out to the 24–hour National Suicide Prevention Lifeline at 1-800-273-8255; contact the Crisis Text Line by texting TALK to 741741; or chat with someone online at suicidepreventionlifeline.org. The Crisis Center of Tampa Bay can be reached by dialing 211 or by visiting crisiscenter.com.