By Spencer Hunt and Debra Jasper
The Cincinnati Enquirer

A stuffed toy is left behind at the Dayton home where Denise Tavner lived and died. (Photo by Michael E. Keating)

In the months before her death, Denise Tavner's skin was covered with urine burns because no one bothered to change her sheets.

She didn't drink for days because no one bothered to give her water.

She was infested with lice because no one bothered to give her a bath.

Finally, on a blustery April day, her tortured existence ended.

The 44-year-old Dayton woman, who was severely mentally retarded and had cerebral palsy, curled up on a broken-down couch and died of thirst.

"She was found to be cradled in a fetal position, lying in urine," says an Ohio Legal Rights Service report.

Confidential records from the service, which represents the rights of the mentally retarded, provide a rare look at what can go wrong inside a mental retardation system that's supposed to quickly identify and act on suspected cases of abuse and neglect.

The documents, obtained by the Enquirer, show that Ms. Tavner lived with her sister, Dorothy, in a run-down house on Dayton's east side during the winter of 1999.

She attended a Montgomery County workshop for the mentally retarded, and often showed up dirty, hungry and covered with lice. After her sister died in January 2000, Ms. Tavner stayed in the house with her brother-in-law and other relatives.

Her condition quickly got worse.

Lice kept her home from the workshop for days. When she returned, she was so filthy, hungry and thirsty she drank seven glasses of water.

County officials called the police, and together on Feb. 3 they took Ms. Tavner from the workshop to Franciscan Hospital for a medical exam. They also visited her home, where they discovered she slept on an old pull-out couch in a room with dog feces on the floor.

"She couldn't walk or talk. She crawled on her knees," says Doris Tavner, a sister-in-law in Dayton. Ohio law allows police to remove adults from their homes to protect them from further injury or abuse. County officials also can remove an adult who is incapacitated or has been found incompetent.

But no one took action to move Ms. Tavner.

Instead, she was released from the hospital, returned home, and her relatives took her out of the county workshop.

While the county spent the next two months debating what to do, Ms. Tavner died on April 2, 2000.

She weighed 85 pounds, down from 140 just four months earlier.

The coroner ruled her death a homicide, saying an emaciated Ms. Tavner died of severe dehydration due to neglect. Despite such horrific conditions, her case attracted little attention. Nearly two years after the coroner ruled her death a homicide, no one has been charged.

Jim Knight, a spokesman for the Montgomery County Prosecutor's Office, says the case could be difficult to prove. "There apparently is a question of whether or not she refused food and liquid nourishment," he says.

Ms. Tavner's brother-in-law, Gene Bailey, told Dayton police right after Ms. Tavner's death that he would sometimes cut up a hot dog for Ms. Tavner, but she stopped eating and drinking after her sister died.

"However, he did state that she would walk on her knees and try to pull soft drinks or coffee off of the counter in an effort to obviously get something to drink," the police report said.

It said Mr. Bailey and Elizabeth Boone, Ms. Tavner's niece, decided to take her out of the county workshop because they wanted to teach her to take care of herself. Mr. Bailey and Ms. Boone told police, "They babied her too much, because they would feed her."

Tamera Sue Perkins, a woman who lived with the family for a brief time, told police that Ms. Tavner was given a hot dog or TV dinner only now and then and wasn't allowed to drink anything after 5 p.m.

She said Ms. Tavner was routinely beaten, and "the lice on Denise was so bad she would have cuts on her head."

Ms. Perkins said she asked Mr. Bailey to bathe her, but he didn't want to handle her urine-soaked sheets.

"It was almost unbearable to smell the room where she stayed," Luke Boone, Ms. Tavner's nephew, told police.

The family has since vacated the house where Ms. Tavner lived and died. Efforts to locate them for comment were unsuccessful.

An ombudsman for the Ohio Legal Rights Service reviewed the case after a complaint was filed by a confidential source. Legal Rights issued a report last November saying county workers and police needed more training, and recommended police more aggressively pursue criminal prosecution.

Lack of public safeguards for Ms. Tavner, the report said, was "a failure of the system and is a shared responsibility among many agencies."

Dayton Police Lt. John Barnes acknowledges that police could have removed Ms. Tavner, but he says the officer at the time didn't see her situation as life-threatening. He said police relied on the Montgomery County Mental Retardation Board to watch over Ms. Tavner and make sure she was safe.

"They were her advocate, we were just assisting," he says.

Judy La Musga, superintendent of the county mental retardation board, says the case spurred the agency to train staff in how to work with police and courts to intervene in abuse or neglect cases.

Such moves, she recognizes, come too late for Ms. Tavner.

"The death of Denise," she says, "was absolutely tragic."

Ms. Tavner's other sister, Claudia Hill, says she is still shocked by the death.

She says her relatives collected more than $500 a month from Ms. Tavner's Social Security checks and should have given her sister water and food.

"She was my sister," Ms. Hill says. "It's not right she should have starved to death."

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