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.