Matt Driscoll

He jumped in front of train after being turned away by Tacoma’s new psychiatric hospital

Kevan Carter Sr. was searching for his only son, and the search had grown frantic.

Hours later, he’d be faced with a parent’s worst fear: the death of a child, by suicide.

It’s a continuing nightmare that began in the middle of the night, when Carter and his wife, Bedez, received a call at their home in Puyallup from a provider at the newly opened Wellfound Behavioral Health Hospital in Tacoma.

The voice on the other line, they said, calmed them, striking spiritual themes that resonated with a family of deep Christian faith. It was reassuring, making them feel like things were going to be OK.

Toward the end of the conversation, though, the voice delivered news they didn’t want to hear.

Their son — 29-year-old Kevan Carter Jr. — was being sent home from Wellfound for the second time in 12 hours.

Carter Jr. “didn’t fit the profile” to be admitted, his parents remember the provider telling them, despite his repeated and increasingly desperate attempts to seek help at the tax-payer supported $41 million hospital, which opened earlier this year.

In the months and years leading up to its ribbon cutting in May, Wellfound — a joint venture between MultiCare and CHI Franciscan —promised 120 new behavioral health beds to help alleviate Tacoma and Pierce County’s known shortage.

In 2017, Pierce County had roughly 2.8 psychiatric beds per 100,000 residents, while King County had 27.1 beds per 100,000 residents.

It was this crisis-level deficiency in Pierce County that compelled cities throughout the region, the county and the state to contribute millions of dollars toward its construction. Pierce County budgeted $1 million in 2017 to help build the new facility, while Tacoma contributed $1.5 million. Altogether, the state’s contribution was $8 million.

Wellfound is designed to “provide voluntary and involuntary admissions with a focus on general adult psychiatric care for ages 18 and older,” according to its website.

Despite opening in May of this year, still only 14 of the facility’s 120 beds are currently being utilized, the hospital confirmed this week.

In a statement emailed to The News Tribune, Wellfound described its opening earlier this year as an “introductory process.”

The full 120 beds aren’t yet available because Wellfound has yet to achieve accreditation from an independent, nonprofit organization known as the Joint Commission, the hospital acknowledges.

The accreditation process, Wellfound says, “occurs after the hospital is open and has demonstrated it can comply with applicable regulatory requirements.”

According to a Joint Commission spokeswoman, the private accreditor accesses “policies, procedures and practice that organizations should have in place to sustain high quality of care and patient safety.”

The spokeswoman confirmed that Wellfound currently lacks Joint Commission accreditation.

While Joint Commission accreditation is voluntary, and just one accrediting agency a behavioral health hospital can choose to be accredited by, it’s also extremely important in this case.

Among other things, many insurance providers, including Medicaid and Medicare, require such accreditation for hospitals to bill for services.

That means that currently Wellfound is operating just eight inpatient beds and six crisis stabilization beds.

According to an emailed statement from the hospital, the Joint Commission is expected to visit “as soon as October to conduct our accreditation survey.”

Steve O’Ban, a state senator and the acting senior council for behavioral health with Pierce County, tells The News Tribune that he now expects the hospital to be fully operational by June of 2020, noting that he’s surprised that the hospital hasn’t achieved accreditation yet.

“I‘m sure to some extent so was Wellfound,” O’Ban says.

‘My heart just stopped’

On the morning of Tuesday, July 23, the Carter family didn’t know any of this.

All they knew as Kevan Carter Jr. — a Wilson High School graduate who grew up in Tacoma and made a local name for himself as a rapper and R&B artist — never returned home after what would be his final trip to Wellfound.

In the weeks leading up to his death, Carter Jr. — who his family says had battled depression since shortly after graduating high school and had been diagnosed with borderline personality disorder on multiple occasions — had visited the facility three times.

Each time, he was sent away.

On one occasion, after arriving at Wellfound by ambulance from Good Samaritan Hospital in Puyallup, he arrived back at home hours later by Uber, the family says.

Carter Jr. “didn’t feel good,” he kept telling his parents and medical providers, which given his two previous suicide attempts was cause for serious concern for the family.

After receiving the call from Wellfound shortly after midnight, Bedez Carter remembers getting up and unlocking the front door, expecting to see her son when morning broke.

Then she went back to bed.

When the family woke up and Carter Jr. was nowhere to be found, the search began.

After visiting his son’s workplace and scouring the Wellfound parking lot, Carter Sr. headed to Titlow Beach in Tacoma on the advice of his daughter, Nicole, Kevan Jr.’s “best friend.”

Titlow was a meaningful place for the family. They had lived in the area during Carter Jr.’s youth, and the family’s old address number — 8518 — still served as the passcode on his cell phone.

When Carter Sr. arrived, the first thing he saw was his son’s car.

Next, he saw the train — stopped on the tracks.

Then, he saw the police SUV, lights flashing.

“My heart just stopped, because I knew what happened at that point,” Carter Sr. recalls.

According to the Pierce County Medical Examiner’s office, Kevan Carter Jr.’s death was the result of multiple traumatic injuries.

The manner of death was determined to be suicide.

Tacoma police spokeswoman Loretta Cool says at least one person witnessed Carter Jr.’s death.

“It appeared to be intentional,” Cool says. “He saw the train and jumped in front of it.”

While privacy laws prevent medical providers from discussing individual patient care, a statement from Wellfound sent via email to The News Tribune says the hospital was “heartbroken by the passing of this man, and we extend our sympathies to his family.”

While noting that it didn’t represent “an all-inclusive list and are intended as guidelines,” the statement says that the criteria for inpatient psychiatric hospitalization includes determining whether a patient is a threat to self or others requiring 24-hour observation.

Other determining factors include various psychiatric symptoms, including hallucinations, delusions, panic reaction, anxiety, agitation and depression, or behaviors like mania or incoherence.

“Our physicians and certified professional staff provide the safest care to everyone who needs it,” the statement continues. “Assessing, diagnosing and treating mental health patients poses unique challenges since symptoms aren’t always visible. We are constantly evaluating the care we provide based on the best standard of care.”

Meanwhile, Carter Jr.’s family is left with more questions than answers.

Medical records obtained by the family and shared with The News Tribune document Carter Jr.’s visit to Wellfound before his death. The records note that Carter Jr. described being “unable to feel anything” and “only feels numbness around him.”

The records indicate that Carter Jr. had a “history of personality disorder,” arriving at Wellfound voluntarily “due to anxiety and depression which has/have been worsening for 12 hours in the context of untreated borderline personality disorder.”

“Patient was discharged earlier today and presents back with complaint of anhedonia. He states that when he is talking with others he feels better, but that when he is alone he feels worse,” the discharge paperwork continues. Anhedonia is an inability to experience pleasure from activities usually found enjoyable.

“A general theme has started to emerge from my interactions with Kevan,” the records continue. “He has the expectation that he must be perfect at his work, at his faith, in his relationships and when he is disappointed in all of these pursuits he tends to think that all is lost and he must give up.”

There’s no way of knowing whether things would have turned out differently if all of Wellfound’s 120 beds had been available when Carter Jr. walked into the behavioral health hospital looking for help, but his family believes something is very wrong at the facility.

Their son and brother was discharged from Wellfound for the final time at approximately 4 a.m. on July 23.

In less than four hours, he was dead.

“You would think they would be able to look at his medical history and take him seriously,” Carter Jr.’s sister, Nicole Enera, says. “I think in his heart he just thought he needed to be somewhere where he was safe and that could help him get his meds right, and he could talk to somebody.”

“My main thing is they sent him away twice, within 12 hours, twice in one day, for a man walking in and saying I need help,” Bedez Carter adds.

“I am not convinced that Wellfound is ready to handle this.”

‘A master at masking it’

Performing onstage is where Kevan Carter Jr. was happiest, his family recalls. He learned to moonwalk like Michael Jackson by age 5, they say, and had his first drum set a few years later.

After high school, Carter Jr. began pursuing his passion for music. He wrote, recorded and produced several rap and R&B albums, and even moved to Los Angeles for a period of time to try to make it in the business.

Carter Jr.’s widest local success came in 2014 with the release of “Seahawks Time,” an ode to the former Wilson Ram’s favorite pro football team. The high-energy anthem quickly became a mainstay at tailgate parties near CenturyLink Field, and Carter Jr. began making frequent appearances with Delisa Lynch, the mother of Seahawks star running back Marshawn Lynch.

“Anything that Kev really set his mind to, he could do. He had such a drive, and his work ethic was like nothing I’ve ever seen,” says 29-year-old Cory Lien, who befriend Carter Jr. in elementary school and graduated from Wilson alongside him.

Lien describes Carter Jr. as “hilarious,” “ultra-talented” and possessing an innate ability to connect and inspire others around him.

“You have something you want to do, or that you’re passionate about, but you’re scared to do it,” Lien says. “It was like he didn’t have that. If he was passionate and he loved it, he was going to do it and probably succeed.”

Away from the stage or his circle of friends, Carter Jr. often struggled with depression, his family recalls. They describe their son as a “master at masking it.”

In 2014 and 2015, Carter Jr. attempted suicide twice — the first time by drinking a bottle of vodka and swallowing a handful of over-the-counter medication, the second time by attempting to overdose on prescription medication.

Each time, Kevan Carter Sr. found his son before it was too late.

Carter Jr. subsequently spent time at two regional inpatient behavioral health hospitals.

More recently, Christina Jones — who hired Carter Jr. nearly five years ago at Car Pros in Tacoma and quickly became a confidant — witnessed her friend’s battle with mental illness.

“He confided in me with a lot of things,” Jones says. “He became like my second son.”

Jones learned of Carter Jr.’s previous suicide attempts and remembers discussing it with him.

“I told him that no matter how bad a situation would be or how bad a feeling was, that doing something like that is something that’s forever,” she recalls.

At work, where Carter Jr. quickly became a star on the Car Pros sales staff, his struggles with depression remained. Jones says she sometimes gave him the time he needed to “regroup,” encouraging him to take a walk around the car lot.

She spoke to Carter Jr. four or five days before his death.

“He didn’t want to die. He wanted help,” Jones says. “He was begging for it. I still can’t make sense of it.”

Attempting to make sense of what happened also has consumed Carter Jr.’s parents.

“I am absolutely blown away that my son did this. There’s a spiritual side to us, too, and that’s what’s confusing,” Bedez Carter says.

“I guess I just thought he would get better.”

‘A big deal’

In 2016, when representatives for the Alliance for South Sound Health approached the Tacoma City Council for help funding construction of a new behavioral health hospital, then City Councilwoman Victoria Woodards — now the city’s mayor — was receptive, as were her council colleagues.

“This is an opportunity for us to care about the least ... in our community and ensure that their needs are met,” Woodards said in May of that year, according to News Tribune archives.

At the time, the county’s lack of mental health resources was well-known and established. The 120 psychiatric beds Wellfound promised to the community was supposed to represent a big step toward addressing the problem.

Nearly three months after Wellfound celebrated its opening, those beds have yet to materialize.

In June, only a month after the facility opened, Maureen Womack, Wellfound’s original CEO was replaced by Matt Crockett, who’s now serving as acting CEO. According to a statement provided by the hospital, Crockett is “a seasoned behavioral health leader” with “a proven track record in opening psychiatric hospitals as well as advancing through initial Joint Commission surveys.”

“Obviously, it’s not an ideal situation. It’s not a good situation,” says Glenn Czerwinski, the chief operating officer at Greater Lakes Mental Health, when asked about the impact that Wellfound’s struggle to get Joint Commission accreditation and fully open its 120 psychiatric beds is having in Pierce County.

Czerwinski, like others, describes the “back-ups” that occur in the county’s behavioral health continuum of care. A lack of long-term psychiatric beds at Western State Hospital, Czerwinski says, means individuals who need extended inpatient care are often left waiting in the county’s 64 short-term beds, which are nearly always full.

Meanwhile, patients who need those 64-short term beds are often left waiting in emergency rooms or simply left to fend for themselves.

With the opening of Wellfound earlier this year, a handful of psychiatric beds at the CHI Franciscan hospital St. Joseph Medical Center were closed.

Today, Czerwinski describes the situation in Pierce County as “no different than what it was before” Wellfound’s opening.

“We’re eagerly awaiting these beds to go online to create additional capacity, which they are intended to do,” Czerwinski says. “It’s really that simple.”

It’s a sentiment shared by O’Ban in his capacity helping to oversee the county’s response to mental health.

Not having full capacity at Wellfound is a “big deal,” he acknowledges, while also assuring that he believes the hospital is doing everything in its power to obtain Joint Commission accreditation and fully open.

“We’ve been, of course, rather excited and looking forward to having those 120 beds. As you know, the state and our county in particular, have some of the fewest beds per population,” O’Ban says.

“To have 120 beds available to the continuum of care was pretty exciting, and we knew we would feel the positive impact. Without them, we just continue struggling along, trying to keep the system going as the population increases,” he continues.

O’Ban notes that the lack of operational beds at Wellfound is particularly felt by patients seeking voluntary care.

In defense of Wellfound, Multicare and CHI Franciscan, O’Ban says that the health care companies have invested heavily in getting the new behavioral health hospital up and running and believes that, together, they have the community’s best interest in mind.

“They must feel the pressure and need to get that up and running,” O’Ban says. “I don’t fear that they aren’t giving this the attention it deserves, and they’re very troubled by it. There’s a bit of egg on their face.”

In a statement emailed to The News Tribune, Crockett, Wellfound’s acting CEO, sought to reassure the community.

“Wellfound opened to the community this spring with a limited number of inpatient beds. Since then we’ve been hard at work ensuring our brand-new hospital adheres to the highest standards and best practices to become fully accredited, allowing us to open more beds and serve more patients,” Crockett said.

“We’re committed to delivering safe and quality behavioral health care in Pierce County and we greatly appreciate the community’s support as we work toward becoming fully operational.”

‘The system failed us’

Two weeks after laying their son to rest, Carter Jr.’s parents are still struggling.

Like everyone, Carter Jr.’s parents have no idea whether things would have played out differently if Wellfound had been fully operational when their son sought help there.

More than anything, they’re consumed by the grief and guilt that comes with losing a child.

What if they had taken their son to Wellfound instead of letting him drive himself?

What if the hospital had asked them to pick their son up?

They’re questions they’ll never know the answer to.

In their mind, what they’re certain of is that their son deserved better.

Now, they’re pledging to spend the rest of their lives trying to make sure other families don’t have to endure the same thing.

Nicole Enera holds out hope that her baby brother’s death will lead to change.

“I want to get Kevan’s story out there. My biggest wish is to change the stigma of what mental illness looks like, especially for men,” she says. “The more we can erase the stigma, the more support the field will receive. My hope is that more support will lead to more research, which will lead to more answers and better treatment, healing and solutions.”

As her daughter speaks, Bedez Carter clings to a hospital admittance bracelet.

It’s the only belonging recovered from what she describes as “the accident” that took her son’s life.

“There are two parts of the story here. One is about a brand new behavioral health hospital in Tacoma opening up and it failed us,” Bedez Carter says. “And the other one is that we will be advocates for more training and learning and listening, and acting upon people who are crying for help.”

Resources for those who need help

National Suicide Prevention Lifeline: 800-273-8255, available 24 hours. suicidepreventionlifeline.org

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