PEABODY — Four days before she died, Stephanie Moulton noticed Deshawn Chappell staring at her and following her around the Revere group home where she worked and he lived.
He had been refusing his medications for weeks.
Moulton, a 25-year-old Peabody resident who had recently been promoted to senior residential counselor, felt “uncomfortable” because of Chappell’s conduct. She made a note in his records and emailed the program director, who was on maternity leave.
Four days later, on Jan. 20, 2011, Moulton was alone in the North Suffolk Mental Health group home with Chappell when he murdered her, a jury found on Monday.
Like other lower-level employees of the private company contracted by the Department of Mental Health to run the group home, Moulton had no idea of Chappell’s extensive history of violence.
A Department of Mental Health investigation, released Monday by Barry Feinstein, an attorney representing Moulton’s parents, found that administrators and others “created or contributed” to a situation that was “dangerous, illegal and/or inhumane,” in violation of state regulations.
Moulton’s parents, Kim Flynn and Bob Moulton, are pursuing a wrongful-death suit against the board of North Suffolk Mental Health, whom they hold as much responsible for their daughter’s death as they do Chappell, a man who had a diagnosis of schizophrenia.
The investigation found that while the agency started out by following proper procedures, conducting an assessment and treatment plan, it failed to monitor that treatment or respond to the changes that resulted from his refusal of medication.
And the staff “lacked full awareness” of Chappell’s “violent, psychiatric, and criminal history,” the report said.
That history included numerous arrests for violent behavior, starting in his teenage years, as well as incidents in which he was the victim of violence, including being struck in the head with a bat in one incident, a pipe in another, and being shot in the ankle.
The records make note of gang activity, drug use and larceny.
He served just 90 days of a one-year jail term for a violent attack on his stepfather in 2006.
That year, he was hospitalized at Massachusetts General Hospital and diagnosed with nonspecified psychosis, traumatic brain injury and marijuana abuse.
Chappell was hospitalized again the following year at Bridgewater State Hospital, following his conviction in the assault on his stepfather. At Bridgewater, he engaged in “hypersexualized” and disorganized behavior and attacked another inmate.
After his release from custody, Chappell stopped taking the Risperdal he was prescribed at Bridgewater.
A few months later, he was back at Massachusetts General, after making threats to kill his ex-girlfriend and assaulting a stranger on the street. That is when he was referred to the DMH for services.
However, the report found, he continued to resist treatment, refusing to attend counseling, as his behavior continued to worsen.
In February 2009, Chappell called a female case worker “four or five times” and made “sexually inappropriate and harassing comments” and inappropriate gestures during some meetings with female staff, the report said.
The absence of the program manager from Seagull House contributed to a lack of communication about Chappell’s deteriorating behavior, the report concluded. No one was there to follow up on reports about Chappell’s worsening behavior.
On Dec. 6, 2010, he punched another resident of the Perkins House group home four or five times, and police were called, the report said. After an evaluation, he was returned to the program. Two days later, he began staring in a “sexualized manner” at a female staffer.
After the resident who had been assaulted obtained a restraining order, Chappell was moved to the Chelsea Respite Program, but after more troubling behavior, he was moved to the Seagull House on Jan. 3, 2011.
Less than three weeks later, he murdered Moulton, who had been left alone with him.
“In the report, it states the biggest situation was the lack of communication and that my daughter wasn’t aware of what she was dealing with at the time,” Flynn said.
While there is no evidence that any of the staff’s actions were intentional, the report said, “there were gaps in staffing, supervision and communication that appear to have hindered the transmission of relevant information about the client, both to the line staff who had day-to-day responsibility for service provision, and from the line staff to supervisors and senior clinical and administrative staff who might have been able to initiate additional assessments or different interventions.”
Courts reporter Julie Manganis can be reached at 978-338-2521, via email at email@example.com or on Twitter @SNJulieManganis.