INSANITY," WROTE L. Ron Hubbard in 1970, "is the overt or covert but always complex and continuous determination to harm or destroy. Possibly the only frightening thing about it," he added, "is the cleverness with which it can be hidden." This condition, Hubbard believed, afflicted 15 to 20 percent of the human race, though he maintained that the vast majority of the insane had no "reality" on how irrational they might be, nor did anyone else.
The last, and most obvious, stage of insanity, the "psychotic break," according to Hubbard, was present only in someone who has become what Hubbard called a "PTS Type III," or simply Type Three.* This would be an individual who "sometimes has ghosts about him or demons," a person whom even the Founder believed was most often found in mental institutions. That such a person might be found in Scientology was, by the church's own doctrine, taboo. The purpose of Scientology, as Hubbard wrote, was to "make the able more able," not to treat the mentally ill. He did not consider psychosis to be a field of practice in Scientology, he wrote, "and Scientology was not researched or designed as a cure for psychosis or 'substitute for psychiatry.'"
And yet, from as far back as 1950, when Dr. Joseph Winter first noticed that clients at the Elizabeth Foundation were suffering breakdowns as a result of their auditing, the phenomenon of Scientologists "going Type Three" was far from uncommon. So much was this the case, in fact, that in June 1971, Hubbard wrote a confidential memo to his senior officials advising them how to handle the prospect of a member becoming emotionally unstable. "Policy is that we assign any case or upset in Scientology to past damage and interference with the person by medicine or psychiatry," he wrote. "They were sent to us after medicine or psychiatry had already destroyed them. We cannot be blamed for psychiatric or medical failures."
Three years later, the church unveiled the Introspection Rundown, which Hubbard, with typical brio, announced as a "cure" for what he called the last "unsolvable" mental condition, the psychotic break. "I have made a technical breakthrough which possibly ranks with the major discoveries of the Twentieth Century," he proclaimed in a bulletin dated November 24, 1973. "THIS MEANS THE LAST REASON TO HAVE PSYCHIATRY AROUND IS GONE."
The Introspection Rundown began with providing a patient with a regimen of peace and quiet. This, Hubbard was clear to point out, was not a cure itself, but a temporary measure aimed at calming an individual to a point where he or she could receive the rundown—which, Hubbard believed, would then deliver the cure. To this end, he instructed his followers to "isolate the person wholly with all attendants completely muzzled (no speech)," which would, he said, "destimulate and ... protect them and others from possible damage." Vitamins and minerals, such as B complex and calcium magnesium compound (known as "Cal Mag"), were to be administered "to build the person up." If needed, medical care "of a very unbrutal nature," such as intravenous feedings or tranquilizers, might also be administered. Then, once the initial upset had subsided, a person could begin auditing in short sessions, though between the sessions the muzzling would still be in effect. The Founder was very proud of his creation. "You have in your hands the tool to take over mental therapy in full," he said. "Do it flawlessly and we all win."
Over the next twenty years, numerous Scientologists suffered psychotic breaks and were handled in accordance with Hubbard's policies. "I'd heard about people going Type Three for years," recalled Jeff Hawkins, who said that in the Sea Org, these people were usually sent away, "presumably to family," though not always. "I remember there was one lady who was sent to a ranch Scientology owned near Santa Clarita, and spent probably a year in isolation with one or two other people. Other people who went crazy were sent to a ranch near the Int Base." Hawkins didn't know what happened to these people. "All you knew was they flipped out somehow."
Scientologists knew better than to ask what happened to a member who went Type Three, which was not to say that church insiders were unaware of how psychotic breaks were handled. "Without question, most seasoned Sea Org members are aware of what is done to a person when someone is declared PTS Type Three," said Nancy Many, who was based in Clearwater in the late 1970s and early 1980s. Though she never took part in an Introspection Rundown, she was well aware when they were occurring, as she often saw guards posted outside various hotel rooms at the Fort Harrison. "I'd ask them why they were there and they'd tell me that a member had just gone Type Three and needed to be watched," she said. As a church official in charge of external relations, "I'd see Telexes come in from other organizations all the time, reporting that someone had gone Type Three and needed to be 'fixed.'"
What that meant, she understood, was very specific, not only for the person suffering the breakdown but also for the organization. "The worst thing that could happen would be that someone would lose it and cause a lot of work for staffers, which would cause the organization to lose money," she said. "You wanted to get these people isolated and away from the org and its income lines as fast as you could."
In October 1989, one Scientologist, thirty-one-year-old Marianne Coenan, suffered a breakdown and was confined in a ranch house in a well-do-to section of Pomona, California, by her husband and family, who were all church members. Two months later, the police received a tip and went to the house, where they found Coenan locked in a sparsely furnished room, behind a bolted door "into which a small, square opening was cut and steel bars had been inserted" as an observation grate, according to one report in the Los Angeles Times. Authorities described her as "incoherent," with "bruises and scratches on her legs, wrists, and neck." Scientology material was found in the house, including information about the Introspection Rundown. A church spokesman insisted that Coenan's treatment "was not a church matter ... nor did the church take any stand with relationship to her treatment."
With Lisa McPherson it would be different. That a newly minted Clear, someone "in control of their own mind" by Scientology's own definition, could suffer what by all appearances seemed like a total mental breakdown on a public street in Clearwater, the heart of Scientology's spiritual empire, was not only a situation that needed "fixing" but also a potential public relations nightmare for the church, and particularly for the Flag Land Base, the highest-grossing organization in Scientology. "This is not what the members pay $100,000 or more to get," said Many. "There are many, many Scientologists who have moved to Clearwater to advance on the Bridge and are regularly paying big money to Flag. You would never want them knowing that one of these high-ranking people just went crazy."
But there was also another reason McPherson's breakdown caused such a fuss: according to several former church officials, it had been Scientology's leader, David Miscavige, who'd declared Lisa McPherson Clear to begin with.
For the better part of 1995, Miscavige was in Clearwater, where he was working on his project to "remake the face of Flag," as one former official put it, through the Golden Age of Tech. To do this, he involved himself in every facet of the base's daily operations, issuing streams of orders that staff were expected to follow exactly, and right away. "In the Sea Org, if you get an order from Dave Miscavige, everything else in your entire life stops until that order is complied with and he accepts it as done," Marc Headley, a former Sea Org member, told me in an interview. Headley was based at Scientology's Golden Era Productions studio on the Int Base but was sent to Flag in 1995 to oversee the installation of new audiovisual systems. As he recalled, Miscavige put "relentless pressure on the Florida staff to crank as many people through Flag as possible." The ultimate result was that the Clearwater organization grossed more than $1 million per week.
By the summer and fall of 1995, when Lisa McPherson was struggling most profoundly, Miscavige, though not a highly trained auditor (by all accounts, the leader's experience with auditing others stopped after his teenage forays at Saint Hill in the early 1970s), began to take control of the auditing delivered at the base. One summer evening, Headley was in the Flag auditorium when Miscavige held a briefing. In attendance were all of Flag's top auditors, men and women who were revered throughout the church for their years of expertise in counseling and understanding the intricacies of Hubbard's processes.* The leader was infuriated, as Headley recalled, by the slowness and, as he viewed it, the arbitrariness of auditing at Flag: some clients advanced very quickly, while others floundered for years. As an example, Miscavige cited the case of Lisa McPherson, who, he told his staff, had paid for a large number of services and should be treated with the best of care.
The leader began to leaf through Lisa's auditing folder, pointing out things that had been done wrong concerning her case. As Headley recalled it, "He told the staff that he was going to review her folders and make sure that she was being handled correctly."
Whether Miscavige took an interest in Lisa's case purely by chance, or because of his budding friendship with Bennetta Slaughter—several ex-officials suggest the latter not long after this meeting, Tom De Vocht, who headed the Commodore's Messenger Organization at Flag, recalled Miscavige personally supervising several of Lisa McPherson's auditing sessions.
Standing in a control room, with video feeds from several different counseling rooms, Miscavige could see everything that went on during Lisa's counseling. As De Vocht recalled, "He's watching live with the video cameras every session that she's in and [supervising], saying 'Do this next, do that next' and so forth." He watched Miscavige make notations on Lisa's auditing folder, which De Vocht also saw being taken in and out of Miscavige's office in Clearwater, which was next to his own.
Another former top Flag official, Don Jason, said he witnessed Miscavige watching one of Lisa's sessions; Miscavige then took off his headphones and announced that she had achieved the state of Clear. According to Jason, Miscavige wrote a note to Lisa's auditor, declaring her new status. "He wrote out a very lengthy four-page communication to her ... by hand, I watched him do it," Jason told me. "Then it was typed up and she went into session and was told she was Clear." It was notable, he said, because Scientology staffers are required to take a special course to help them identify a person who's become Clear. He wasn't aware that Miscavige had completed that course.
Marty Rathbun was also at the Fort Harrison on the day that Lisa became Clear. He'd been walking down a corridor of the closed-off floor where auditing sessions were held, when a door to one of the auditing rooms suddenly kicked open and a woman's voice could be heard whooping with joy. Rathbun was shocked—noise of any sort is strictly prohibited near auditing rooms—but there was something more than that, a strange quality to Lisa's voice. When he returned to the RTC office later that day, he mentioned Lisa to Angie Trent, the RTC official in charge of supervising Flag's technical training. "You've got somebody up [at the Fort Harrison] who just attested to Clear who looks to me to be on the verge of psychosis," Rathbun said.
Trent told him to mind his own business. "That's Lisa McPherson. David Miscavige is programming her case," she said. In other words, as Rathbun interpreted it, he ought to "buzz off."
Six weeks later, Rathbun and other top-level staff were informed that Lisa McPherson had suffered a psychotic break and that Miscavige, who was now in Los Angeles, would be directing the staff on how to treat her. De Vocht and Jason said they were aware of this as well. "People at Flag knew that DM had case-supervised her, but no one said anything," De Vocht told me. "You're talking about the pope of Scientology."
Though it has long been policy that when a member suffers a breakdown, the church's international management, specifically the RTC, must be informed,* says De Vocht, "for Miscavige to be personally handling Lisa's Type Three situation was astounding." And it was because of Miscavige's personal investment, he and others believe, that officials who intervened at the hospital on Lisa's behalf did not make arrangements to have her brought to her apartment or to stay with friends or family. Instead, Lisa was driven to the Fort Harrison Hotel, where she would to undergo the Introspection Rundown for the second time, under the supervision of Scientology's international management.
Assuming command of Lisa's welfare was Flag's senior case supervisor, Alain Kartuzinski. Though he lacked medical training, Kartuzinski, the "minister" in charge of the spiritual welfare of the entire congregation, served as the point person for Lisa's treatment. Kartuzinski was a Class 12 auditor, an elite counselor in Scientology whose rank in the spiritual hierarchy is comparable to a church bishop's. It was he who had been in charge during the summer of 1995 when Lisa had suffered her first breakdown, recovered, and attested to Clear. Now Kartuzinski would review Lisa's confessional folders, direct the base's medical officers, and supervise her isolation. Behind the scenes, according to Rathbun and De Vocht, RTC officials in Clearwater, and ultimately David Miscavige in Los Angeles, were kept informed of Lisa's condition and had the final say over the details of her care.
Understanding how a woman suffering psychosis would be taken to the equivalent of corporate headquarters is crucial to understanding what happened to Lisa and why. Many said, "I have asked many, many former Sea Org members whether they would call 911 if they saw someone fall from a balcony at the church. The answer is always no, never. And that's because on that org board you've been chanting, chanting, chanting, as demanded by Hubbard's 'Chinese School,' only the security guard can call 911. So you would run to the security guard and tell him to do it."
It is this doctrinal principle—the principle of the org board— that determined the treatment of Lisa McPherson; its tragic outcome was determined by another precept, which reduced individual Scientologists to mere cogs by making autonomous thought, or speech, a crime. "There is a policy letter in Scientology that says that you are your job title," said Many. "I could not send a Telex or a report without citing L. Ron Hubbard. And it did not come from me; it came from 'LRH Staff Aide for Division Six,' which was my job title."
All of this, as Many pointed out, sprung from the mind of L. Ron Hubbard. But starting in the 1990s, these policies were meted out by David Miscavige, who, in his typical style, enforced them to an extreme. According to former Scientology officials, for David Miscavige, "keeping Scientology working" meant doing whatever it took to consistently generate profit, particularly at Flag.
A multitude of reasons—the dogmatism of Hubbard's technology, the exacting nature of Scientology ethics, the church doctrine governing public relations and self-preservation—explain why the next two weeks unfolded as they did. Above all was the fundamental tragedy that from the moment she left Morton Plant Hospital on November 18, 1995, Lisa McPherson put herself in the hands of the Sea Org rather than family or friends. By doing this, she ceded control to a group who, in their inexorable commitment to Hubbard's doctrine, believed they were doing the right thing. Instead, this commitment would lead to her death.
That night, Lisa arrived at the Fort Harrison from the hospital just before midnight. By all accounts she was calm, quiet, and physically healthy. According to Emma Schammerhorn, a Flag medical liaison officer who accompanied her, she had even told Kartuzinski that she was glad he'd come to retrieve her. She was given a room at the back of the hotel, next to the housekeeping office and far from most hotel guests.
To manage Lisa's physical care, Kartuzinski pulled Dr. Janice Johnson, a senior medical officer at Flag, from her regular duties. Susan Schnurrenberger, the medical officer who had cared for Lisa over the summer, initially supervised Lisa's day-to-day management. An aide named Gabriella Sanchez was tasked by Kartuzinski to staff the watch around the clock. About twenty women were ultimately assembled, generally low-level or interim employees with little or no medical experience, nor much background with the Introspection Rundown or isolation watches. "This wasn't supposed to go on very long," said Sanchez. "The whole purpose of it ... was just so that she starts to calm down, she can get some rest, start to eat and start to ... chill out."
The instructions for the watch were simple. The caretakers were to provide Lisa with water and whatever food was available from the cafeteria, plus daily doses of Cal Mag and various other vitamin and mineral supplements. The caretakers were to keep a log of Lisa's food and fluid intake and also note her behavior. If she needed to talk, they should let her, but, per Hubbard's guidelines, they could communicate with her only by writing notes. Every day they were to submit their log to the senior case supervisor, who would determine when Lisa was well enough to be audited. "This is what I was told," said Heather Petzold, then a seventeen-year-old who was one of the caretakers. "We need to get her enough food and enough sleep so we can get her in session."
By mid-afternoon on Sunday, November 19, her first day in room 174, Lisa McPherson was talking incessantly. By the second day of isolation, Lisa was refusing to eat, had barely slept, and was restlessly jumping in and out of bed. Her caretakers found it impossible to get her to drink any fluids.
Lisa's friend Susanne Reich, who'd help watch her that Sunday night, was horrified. "I would not stay with Lisa alone for one second," she later told the police. "The way she was, in my eyes, I thought she would kill me." That afternoon Reich wrote a report, marked the word rush on the document, and sent it to Kartuzinski. She never returned to Lisa's room. Not long after, Susan Schnurrenberger followed suit.
One member of the Flag medical staff who did want to look after Lisa was Judy Goldsberry-Weber. She had been one of the officials who'd gone to the hospital after Lisa's accident and had helped convince the doctors at Morton Plant to allow Lisa to be released into her care. They had not been easily won over, she recalled later. "I'm holding you personally responsible," an angry Dr. Flynn Lovett at the hospital had told Goldsberry-Weber before agreeing to the discharge. "And if anything happens, I'm gonna nail you."
Goldsberry-Weber promised Lovett that she'd personally take responsibility for Lisa. But no sooner had she made this promise than one of the OSA officials informed her that she should return to her job as the staff medical officer. "I was angry about that," said Goldsberry-Weber. "If I promise somebody I'm going to do something, I take that promise very, very seriously. And it upset me greatly that my promise was being trashed."
Nonetheless, Goldsberry-Weber returned to her post. She assumed that Lisa was being well taken care of at her apartment, under the watchful eye of Schnurrenberger, until she was asked to drive to a drugstore and pick up what she was told were "sedatives" for Lisa McPherson. She thought it was strange that the drugstore was located in Largo, almost half an hour away, rather than the usual Eckerd's pharmacy Flag used in Clearwater. Upon her return to the Fort Harrison, Goldsberry-Weber was told to give the prescription to a Flag security officer. Now realizing that Lisa was staying at the Fort Harrison, she once again offered to care for Lisa; again she was rebuffed.
Goldsberry-Weber was a nurse with experience in Hubbard's techniques, including the Introspection Rundown. But from what she could piece together, Hubbard's policies weren't being followed. There were no set caretakers, to begin with. Instead, Janis Johnson and others were apparently scouring the base to find people to take part. Goldsberry-Weber had even heard that some of the caretakers didn't speak English.
She was right: there were multiple caretakers looking after Lisa, including some who didn't speak English, and none of them stayed for very long. One of them, Lesley Woodcraft, the British-born personnel manager at Flag, was pulled onto the watch on November 22 and almost immediately passed the responsibility to her roommate, Alice Vangrondelle, the Flag librarian.
Vangrondelle complained that it wasn't her job but grudgingly got out of bed. She found Lisa talking gibberish, freezing cold, with blotches on her face that looked like those caused by measles. She'd run around the room in a frenzied manner; later, exhausted, she'd collapse on the bed. At one point she rested her head on the librarian's shoulder. "E.T., go home," Lisa cried. "E.T., go home."
When Vangrondelle returned to her room later that day, she wrote a "Knowledge Report" on Woodcraft, whom she felt had improperly posted her to the watch. The report contained a lengthy description of Lisa's mania and noted that Lisa's breath was "foul." This is a sign of a toxic condition called uremia, caused by poor function of the kidneys. She also wrote that Lisa looked feverish.
This report, dated November 22, 1995, is the last one detailing Lisa's condition for several days. There are no logs for November 23–25, a period that was marked by an upsurge of violent behavior, as Lisa's caretakers later testified. Lisa, they said, pulled things off shelves, destroyed furniture, broke lights, threw a ficus plant at one of her watchers, screamed, and banged her head on the wall, floor, and bed. One minder recalled her gouging at her own face with her fingernails. Another stated that she drenched the floor with water, stripped naked, and lashed out with her fists. Security personnel removed everything breakable or dangerous, including the lamps, leaving Lisa in total darkness.
At three in the morning on November 24, Sam Ghiora, a Flag security staffer, was seated on a small bench outside of Lisa's room when he heard the doorknob rattle. Slowly, the door to room 174 opened, and Lisa stood at the threshold, fully dressed.
"Hey," she said calmly, walking a few steps toward him. "You're not CMO."
"You're right," Ghiora said. He was not a member of the Commodore's Messenger Organization but a new Flag security trainee.
"You can't tell me what to do," Lisa said.
"You're right," Ghiora said again. He knew he'd broken protocol by speaking to her, but he was momentarily shocked: How had she just walked out of the room? Where were her minders? Ghiora gently put his hand on Lisa's shoulder and steered her back toward her room. She stopped at the threshold. "I just don't know what's happening," she said.
Ghiora said nothing.
"Could you help me?"
Nothing.
"I need help," she said, and slowly entering her room, shut the door.
On November 29, about a week after she'd taken her turn on the watch, Alice Vangrondelle went to see Judy Goldsberry-Weber in the medical liaison's office. "I want to know how a person would act if they didn't get enough to eat or drink," she said. "What are the symptoms of dehydration?"
Goldsberry-Weber took out some medical books and gave Vangrondelle a list of symptoms, which include dry skin, loss of appetite, flushed complexion, dry mouth, weakness, chills, and in more serious cases, fever, increased heart rate and respiration, confusion, chest pain, and unconsciousness. "Have you ever taken care of anyone like that?" Vangrondelle asked. "How would they behave?"
Goldsberry-Weber told her that it would not be uncommon for a patient in this condition to behave "irrationally" for a short period, but given enough fluids, the condition could be turned around in a matter of hours. "If you have concerns, you need to let it be known what your concerns are to the proper people," she said. "And sooner, rather than later."
Vangrondelle told Goldsberry-Weber that she'd written a report. (No log from Vangrondelle was ever found, or included, in the official record.) Other caretakers also grew concerned. Lisa, several noted, had "lost a lot of weight," "looked thin," and her skin had become jaundiced and bruised.*
By the end of November, one caretaker, seventeen-year-old Heather Petzold, was "frantic," as she'd later say. Lisa had by now regressed to an infantile state. She was urinating and defecating on her bed. "I wouldn't say there was any day that she ate sufficiently," she noted; by the first of December, Lisa's caretakers were spoon-feeding her bites of mashed banana, sometimes forcibly opening her mouth.
Petzold had never spoken to any of the other caretakers about her concerns—remarkably, none of Lisa's minders spoke to one another about their experience, despite the fact that several felt so distraught, they cried in Lisa's room. Instead, Petzold sat down and wrote a letter to Alain Kartuzinski, explaining that Lisa was neither eating nor sleeping. "I said, hey, we need to change something," she recalled. Petzold herself didn't know how to handle the situation. "I was there, I was doing the watch [sixteen hours at a time], and I had eight hours to go home, sleep, and come back in. It wasn't like I had an extra hour to figure out what else could be done."
Petzold delivered her report to Kartuzinski's office, as she had been instructed to do. She never received a reply. Later she'd regret that she hadn't said enough. "If I had gone to higher terminals ... if I would have walked to the senior-most terminal there and said, 'Listen.'" But despite misgivings, neither Petzold nor any of the other caretakers took it upon themselves to call a doctor or go to a hospital—as several would later admit, taking that kind of initiative wasn't their job and would have broken with Sea Org protocol. "She had been seen by a doctor in the hospital," Rita Boykin, another minder, later said. "She signed herself out, and she didn't want to be there. She wanted to come back to the church."
In the early hours of Saturday, December 2, Boykin wrote in her log that she had given Lisa four valerian-root capsules, four other herbal sleeping tablets, and approximately six ounces of Cal Mag. At 3 A.M., Lisa was "still awake and talking," she wrote. "She has scratches and abrasions all over her body & on elbows & knees has pressure sores."
By late that night, Boykin wrote, Lisa, who'd tried to stand several times without success, was no longer moving herself, but being "moved" by her caretakers. She also accused her caretakers of being "psychs"—psychiatrists—"or other enemies who wanted to kill her," Boykin said. This psychosis extended into Sunday, December 3.
Boykin made another entry: "4:30 She had about 2½ hours of sound sleep—interspersed with restlessness. At one point it seemed she wanted a sweater on. I put it on her & she thanked me."
This is where the log ends. There are no other records for the remainder of December 3 or for December 4 or 5. However, the caretakers later testified that during those days, Lisa's condition declined dramatically. By the morning of December 5, she was lying in bed and barely moving. "There was one time when she rolled over ... and she fell on the floor," Petzold said. "So I picked her back up and put her back on the bed, of course."
Lisa also wasn't talking much, which Petzold immediately noticed. "Prior [to this] it was like a broken record, just all of the time." Now Lisa was mumbling. "That's when I got pretty worried," Petzold said.
That afternoon, Petzold and Laura Arrunada, the other caretaker, decided to give Lisa a bath. She was too weak to walk to the tub, so the women carried her. As they were putting her in the tub, Lisa's sphincter muscle relaxed. "She shit herself," Laura Arrunada later said.
A relaxed anus is a sign that the body has begun to deteriorate. Petzold, a teenager with no medical experience, didn't know this. Arrunada, who had graduated from medical school in Mexico City but was not a licensed physician, might have been familiar with this warning sign. But as she told the police, Lisa "was not looking like she was [going] to die."
Arrunada was nonetheless concerned, and at six o'clock that evening, she called Johnson and told her that Lisa needed medical attention.
At approximately 7 P.M., Dr. David Minkoff received yet another call from Johnson about Lisa McPherson. The girl for whom he had written the prescription, she said, was suffering from acute diarrhea, had lost an extreme amount of weight, and also complained of a sore throat. Johnson thought Lisa had strep and requested penicillin. This time, Minkoff refused to call in a prescription.
"If she's sick enough to need an injection, then she needs to be seen by a doctor," he said. And if she were seriously ill, they shouldn't bring Lisa to him, but to a closer hospital like Morton Plant.
"No, she's not that sick," Johnson assured him. She told Minkoff they'd be there within the hour.
Soon after, Paul Greenwood, a Flag security officer, was dispatched to room 174. With Janis Johnson and Laura Arrunada assisting, Greenwood put Lisa in a van. Johnson got behind the wheel and drove north, past Morton Plant Hospital, where she and the others dared not stop, fearing the doctors might call the psychiatrists. They drove past several other hospitals as well, bound for Minkoff's facility, the Columbia HCA Hospital in New Port Richey, about forty-five minutes away. No one spoke. "When someone is sick or injured you don't talk around them because it puts impressions in the mind which create things ... later on," said Greenwood.
Johnson later said she heard Lisa's breath become labored, then grow faint. Sitting with her in the back of the van, Greenwood monitored Lisa's pulse. It slowly dwindled. Then Greenwood couldn't feel it anymore.
At approximately 9:30 that evening, Dr. David Minkoff was just finishing his shift when he heard the doors to the Columbia New Port Richey Hospital's emergency room swing open and an orderly cry out for help. A disheveled-looking woman, draped awkwardly over a wheelchair, was wheeled into the trauma room. She was drastically, almost skeletally thin; her skin was papery, had a grayish pallor, and was marked with small dark brown lesions. One emergency room nurse, shocked by the woman's emaciated state, concluded that she must have AIDS; another, noting the multiple bruises and lesions on her body, wondered if she might have an infectious disease such as Ebola. To Minkoff, it looked like a classic picture of "meningococcemia," a devastating bacterial infection that can cause inflammation of blood vessels, organ failure, and meningitis.
Lisa McPherson, the robust, five foot nine woman described as "voluptuous" by the paramedic Bonnie Portolano, was dead. Her arms and legs were covered with bruises, she had scrapes on her face, and her weight had dwindled to an emaciated 108 pounds. She was also dirty—a nurse later said she wondered if Lisa had been abused. "I was appalled," Minkoff later told police. After trying to revive Lisa to no avail, Minkoff confronted Janis Johnson in the waiting area. "What did you bring me?" he said. "What did you do?"
At least one other person at the Columbia HCA Hospital wondered the same thing. That night, the head ER nurse at the Columbia Hospital, Barbara Schmid, alarmed by the condition of Lisa's body, called the local authorities. By the next morning, a "suspicious death" investigation would be officially launched by the Clearwater Police Department on the matter of Lisa McPherson.