A tragic death. A system in crisis. For Missourians with developmental disabilities, the state’s care system is proving to be anything but safe. In the past six years, thousands have died under state supervision—many in preventable circumstances. Families, advocates, and even former employees are raising alarms about a system that seems to be crumbling under the weight of neglect and bureaucratic dysfunction.
A Death That Should Never Have Happened
Ronald Scheer’s life ended in a way no one should have to endure. The 62-year-old, who had developmental disabilities and used a wheelchair, was found dead in June 2020 at the St. Louis Developmental Disabilities Treatment Center in St. Charles. His cause of death? Strangulation by his own wheelchair straps.
According to a lawsuit filed by his legal guardian, one of Scheer’s caretakers failed to properly secure the safety belts that were meant to keep him in place. The caretaker then allegedly left him unattended, despite his care plan requiring frequent check-ins. At some point, he slipped down, his neck caught in a strap, and he suffocated.
Even more disturbing, no one was held accountable. The court ruled that because the caretakers were public employees, they were immune from civil lawsuits regarding negligence on the job. For Scheer’s family, there was no justice—only grief and unanswered questions.
Staggering Death Toll in State Care
Scheer’s case is not isolated. A deeper look into Missouri’s developmental disability care system reveals a pattern of deaths, injuries, and abuse that has continued unchecked for years.
State records show that between 2017 and 2023:
- 74 people with developmental disabilities died in accidental circumstances while in state care.
- 9 homicides and 7 suicides occurred within this population.
- 2,200 individuals died of natural causes.
- 392 deaths were classified as “undetermined.”
That brings the total number of deaths under state supervision to 2,682 over six years—an average of one per day.
Abuse, Neglect, and a System on the Brink
Frontline workers describe an environment plagued by understaffing, poor training, and administrative failures that put the lives of vulnerable individuals at risk every day.
Dina Lester, a registered nurse who previously worked in Missouri’s disability care system, eventually quit her job over the inadequate level of care. “I couldn’t watch it happen anymore,” she said. “People were suffering, and there was nothing we could do because the system just doesn’t work.”
Cases of neglect are widespread. Employees report situations where individuals were left in soiled clothing for hours, went without meals, or suffered from untreated medical conditions. In some cases, people with disabilities were physically or verbally abused by staff members. The state’s oversight mechanisms, many argue, are failing to catch these violations before they lead to catastrophic consequences.
Legal Immunity Shields Negligence
One of the biggest barriers to accountability is the legal immunity afforded to state employees. Under Missouri law, public employees are protected from civil lawsuits related to negligence on the job. That means families like Scheer’s have little recourse when their loved ones suffer due to neglect or misconduct.
Legal experts argue that this protection creates an environment where there are no real consequences for failure. “There’s no incentive to improve when no one is being held responsible,” said St. Louis attorney Mark Feldman, who has worked on multiple cases involving state care facilities.
The Human Cost of a Broken System
For families, these statistics are not just numbers—they are loved ones lost too soon. Each death represents a person who depended on the state for care, only to be failed in the worst way possible.
Rachel Simmons, whose brother lived in a state-run facility before passing away in 2022, says she constantly worried about his safety. “Every time I visited, I saw something that scared me,” she said. “Bruises, bedsores, weight loss—things that should never happen if someone is being properly cared for.”
Despite reporting concerns multiple times, Simmons says she was met with excuses and bureaucratic red tape. Her brother eventually died from what the state called “natural causes,” but she remains unconvinced. “I don’t know if he would still be here today if he had been somewhere else,” she said. “But I do know he deserved better.”
What Comes Next?
Missouri lawmakers have faced mounting pressure to reform the state’s disability care system, but change has been slow. Advocates are calling for:
- Better staffing levels to ensure individuals receive the attention they need.
- More oversight and accountability to prevent cases of abuse and neglect.
- Legal reforms to allow families to seek justice when negligence leads to harm or death.
So far, however, meaningful legislative action has been limited. In the meantime, thousands of developmentally disabled Missourians remain in a system that has already failed so many before them.
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