On May 31, 2003, a Saturday, a staff member became worried that residents on Jerry's unit were "rowdy," and that the staff assigned there were "weak," according to a confidential report from an Oklahoma child-welfare agency obtained by The Inquirer.

Just a week before, the Oklahoma Commission on Children and Youth had told High Pointe it needed to better supervise the children.

As the staff member talked to nurses about his worries, a resident slammed Jerry to the ground.

It was an easy maneuver. Jerry stood just 4 feet tall and weighed 90 pounds. He landed on his sternum with a loud thump.

He said he was having trouble breathing, and asked to go to a hospital. "Not today, maybe tomorrow," was the response. The staff did call in a nurse, but he only examined Jerry's attacker.

That night, Jerry was in and out of sleep, except when he sat up to try to breathe. He vomited blood and was handed a rag and a bottle of disinfectant to clean it up. He asked repeatedly to go to the hospital, at one point enlisting friends to plead on his behalf.

On Sunday, Jerry's lips and ears turned blue. His breathing turned to a pant.

He asked two friends to hold his hands.

They screamed for a nurse. Staff put Jerry in a wheelchair and slipped his shoes on his feet.

How far away is the hospital? he asked.

Just down the street, they said.

Jerry said he didn't think he could make it.

He began to convulse. The staff called an ambulance.

At 7:43, Jerry was pronounced dead at Children's Hospital at the Oklahoma University Medical Center.

The report found that High Pointe staff incorrectly told the hospital he suffered from asthma.

A doctor who reviewed the file said the staff "administered oxygen blindly as he gradually smothered to death over the course of a day and a half."

"I find that the treatment Jerry received at High Pointe was grossly inadequate," said Jonathan Finder, chief of pulmonology at Children's Hospital in Pittsburgh.

"He had a life threatening condition, and they ignored it."

Because of Jerry's complex medical condition, the state did not hold High Pointe responsible for his death.

The Oklahoma state nursing board disciplined five nurses for failing to provide adequate care.