by Julie K. Brown, Miami Herald

Patrick Quercioli was big and burly, and with pumped muscles and an elaborate Indian tattoo on his arm, he looked more like a bodybuilder than a corrections officer.

Though he’d been arrested twice — once for allegedly dealing steroids and again, on charges of beating a motorist in a fit of road rage — Quercioli managed to persuade the Florida Department of Corrections to hire him in 2004.

Prisoners say Sgt. Q, as he was known, was among the most menacing officers at Lowell Correctional Institution for women, a man whose patience was not to be tested. But on Sept. 21, 2014, one inmate dared to do just that, after seeing something she wasn’t supposed to see: Quercioli allegedly having sex with an inmate in C Dorm, in a rear bathroom behind the officers’ station.

Disgusted, the inmate — Latandra Ellington — vowed to report it, even though, according to her, Quercioli threatened to kill her if she didn’t keep her mouth shut.

Ten days later, after telling her family and prison authorities about the threat, Ellington was found dead in a confinement cell at Lowell.

The death of Ellington, a mother of four with only seven months left to serve at the nation’s largest women’s prison, is a case study in how the state of Florida often fails to fully investigate suspicious inmate deaths. The story includes an inmate who was seemingly too young to die, a controversial autopsy, unchecked leads, uncollected evidence, unresolved contradictions and, finally, a finding that she died of natural causes, even though she had an elevated — and possibly toxic — level of medication in her system.

Her death also unearthed a history of violence and abuse at Lowell, including allegations of corruption and of an almost unbridled physical, sexual and mental persecution of inmates by corrections officers and staff at the prison.

The Florida Department of Law Enforcement closed the Ellington case on Jan. 21, 2015, with no findings of foul play. Ellington, 36, died of heart disease, the medical examiner said.

During the investigation, Quercioli, 51, and other officers were linked to possible sexual misconduct — a third-degree felony in Florida.

One Lowell sergeant was so disturbed by Ellington’s sudden death on Oct. 1 and the events that happened afterward that he took a leave of absence and secretly met with an FDLE investigator at a police department close to his home because he was too nervous about meeting at the prison. He told FDLE and the Herald that he suspected his commanders had been covering up prostitution, sexual abuse and corruption at Lowell.

The officer, Sgt. Berend Bergner, said that after he took Ellington’s complaint on Sept. 21, 2014, Quercioli and another officer, Dustin Thrasher, 31, threatened to beat him up. Bergner also told FDLE that the report he took from Ellington then suspiciously vanished from the sergeants’ office that evening.

Bergner, 32, told FDLE agent John Carlisle he suspected that Quercioli, Thrasher and other officers were giving inmates cigarettes in exchange for sexual favors, according to the FDLE report.

The Herald reached out to Quercioli’s and Thrasher’s attorney, H. Richard Bisbee, for this story, but there was no response to a request for comment. In a prior letter to the Herald, Bisbee noted that Quercioli wasn’t working the day that Ellington died, and FDC confirmed that he had taken comp leave from Sept. 24 to Sept. 30, returning to work on Oct. 3. Thrasher was on duty during that time, FDC records show.

Both officers were terminated from the department this August because, FDC said, they were unable to perform their duties. In a letter to the Herald, Bisbee said Quercioli had suffered severe emotional distress as a result of past media coverage on Ellington’s death and he threatened to sue the Herald if previous stories weren’t retracted and an apology issued.

Ellington’s family, who filed a civil lawsuit against the state in September, blames the Department of Corrections for failing to recognize that “employees, including [Lowell’s] assistant warden and/or corrections officers, were using excessive force, being sexually inappropriate with female inmates, and/or making threats of physical violence towards the inmates.”

The family alleges that Ellington was beaten and was subjected to inhumane treatment and medical neglect.

Barbara Wolf, the medical examiner who performed Ellington’s autopsy, said she found no evidence of trauma indicative of a beating.

What neither the autopsy nor the FDLE report noted, however, was that toxicology tests showed Ellington had a potentially toxic level of a blood pressure medication, called Amlodipine, in her system. Wolf, in a recent interview with the Herald, attributed the elevated Amlodipine to a process called “post-mortem redistribution,’’ in which levels of certain medications can increase in a person’s bloodstream after death.

Ellington’s level, however, was seven or eight times normal — an amount that should have been suspicious enough to investigate, particularly given the circumstances surrounding her death, according to two forensic pathologists consulted by the Herald, as well as a third hired by Ellington’s family.

Normal protocol would be for a medical examiner to note in the autopsy any drug levels that were out of the ordinary.

That was just one of many potential breaches in the wake of Ellington’s death. Among other issues:

The FDLE report shows that Ellington’s two-bunk, 10-by 12 “administrative confinement” cell — where she was isolated after clashing with Quercioli — was never processed as a crime scene. No fingerprints were taken, no DNA was collected. Trash wasn’t examined. Virtually nothing in the cell, from the drain in the sink to her toilet, was processed. No crime scene experts were called; no tests were conducted for trace blood, hairs or fibers.

The inmates and officers who served Ellington her meals weren’t interviewed. No inmate orderlies who worked in confinement that morning were questioned; many of the corrections officers and nurses who were seen on surveillance video coming in and out of her cell in the hours before she died weren’t named in the FDLE report. There’s no indication that FDLE investigators tracked them down, identified or interviewed them.

There were widely divergent accounts, unresolved in the FDLE report, about what medication, if any, was found in Ellington’s cell at the time of her death. The doctor who was first on the scene told FDLE there were empty packets of medication by her body, but the nurses and FDLE agents who checked her belongings said all of her prescriptions “were accounted for’’ and that only one pill was missing from one packet.

FDLE investigators questioned Ellington’s confinement bunkmate, Jaime Shepherd, who told them that when Ellington was placed in confinement, corrections officers took several packets of “KOP’’ (keep on person) medication from her because they were outdated. Shepherd said nurses came the following morning to give Ellington her medication, and recalled that Ellington told the nurse who delivered her medication: “I don’t really take these like that.”

It’s not clear what she meant, and FDLE did not address it in its investigation. The Herald contacted FDLE numerous times to ask for an explanation. Initially, the agency — designated to investigate all state prison deaths — declined to comment, saying the medical examiner’s finding of “natural causes” made further inquiry unnecessary. Weeks later, after more prompting by the Herald, FDLE sent the following statement:

“FDLE Agents conducted 38 interviews and reviewed 30 hours of video tape. Agents interviewed correctional officers and medical staff. Two FDLE agents and a field inspector from the medical examiner’s office searched Ms. Ellington’s cell. There was no trash to be examined and there was no indication of foul play.

“Despite that, FDLE investigated by conducting interviews and reviewing the video tape showing the outside of Ms. Ellington’s cell. The question of medication is not unresolved by investigators although that information cannot be released to anyone other than the next of kin. Upon review, FDLE stands behind its investigation.”

According to one veteran homicide detective, FDLE’s actions violated a basic principle of police work.

“You don’t wait for the autopsy to come back to treat a prison death as suspicious,’’ said retired detective Joe Matthews, formerly with the Miami Beach Police Department. “You must treat it as a potential crime from the very beginning because if you wait for the autopsy, if you wait for the toxicology, and you don’t do due diligence in asking the right questions, and collecting all the evidence, then it’s too late by the time the tests come back to retrace the trail.”

The Ellington family lawsuit also blames Corizon, the private healthcare company that provides medical care to inmates at Lowell. Corizon has declined to comment on the pending litigation.

“She did not have heart disease, at least not at the time she died,” said Dr. John Marraccini, a forensic pathologist who reviewed the record — including slides of blood samples taken during the autopsy — at the request of the Herald.

“Her heart showed only slight damage. She may very well have developed heart disease [in the future], but she didn’t have enough to die from it at 36.’’ said Marraccini, who previously served as Palm Beach County’s medical examiner.

Mounting scrutiny

At the time of Ellington’s death, the Department of Corrections was facing mounting scrutiny over troubling reports suggesting that prisoners had, for years, been subjected to mental and physical cruelty. Overall Florida inmate deaths were climbing to a record high that year, and human rights activists were demanding federal intervention.

Gov. Rick Scott, on the verge of a close election in November 2014, had said little up to then about the controversy, although his chief inspector general, Melinda Miguel, was facing a lawsuit. The court action was filed by a handful of seasoned FDC investigators who claimed that the prison system’s top watchdog, Inspector General Jeffery Beasley, was sandbagging their efforts to investigate cases involving inmate abuse, death and medical neglect 

At the same time, another scandal was unfolding at Lowell. The assistant warden, Marty Martinez, was accused of having inappropriate relations with inmates and giving special privileges to young and pretty prisoners who were so cozy with him that they called him “daddy’’ or “Marty.” His behavior so disrupted the prison routine that officers began to fear it was causing a security risk. Martinez often moved inmates around and delayed critical head counts, an FDC investigation showed.

In July 2014, Lowell Sgt. John Meekins was so disturbed by the assistant warden’s actions that he filed a complaint with the Marion County Sheriff’s Department. He claimed that Martinez had threatened to have him beaten up after he tried to root out the source of contraband being smuggled into the prison.

It was amid this controversy that Ellington claimed that Quercioli and other officers were flagrantly trading sex for tobacco, drugs and other contraband, fueling a black market of corruption within the walls of Lowell. FDLE, in its report on her death, recommended that the department investigate some of the allegations it had received during the probe.

When the Herald asked the FDC over the summer whether there were any pending investigations in connection with the Ellington case, spokesman McKinley Lewis said there were none.

Loss of privileges

The Herald has reviewed hundreds of complaints filed by inmates over the past four years that show clear patterns. The same officers are named over and over; the same kinds of abuse is detailed, right down to similar terminology the officers use when they allegedly threaten inmates. The reports, as well as interviews with former and current inmates and corrections officers, indicate that the prison continues to have a thriving sex trade in which inmates receive privileges and other forms of payment in exchange for giving officers sexual favors.

In nearly every case, the inmate who brought the complaint was promptly isolated in some form of confinement, a restrictive type of incarceration away from the general population. FDC says confinement in these cases is not a punishment, but a precaution to protect the inmate from the person she has accused of wrongdoing.

That’s not the way many of the women see it. When they go into confinement, they often lose basic comforts such as books and MP3 players, get less frequent showers and lose some access to recreation, inmates past and present told the Herald. They say their property sometimes isn’t returned to them when they get out. And, despite the fact that confinement is one of the few areas in the prison with video surveillance cameras, inmates can still be harmed, they say.

Meninea Culick, a former inmate, said officers gave special privileges and even money to inmates who were willing to beat up women in confinement.

She claims an officer once offered her a deal: If she would beat up a certain inmate known for being “mouthy and loud,” the staff would leave her alone for the remaining months of her sentence — which meant that she would not get any discipline, and would be the officer’s “pet.”

“All you have to do is put a lock in a sock and hit that bitch over the head,” Culick recalled the officer saying. She agreed to do it.

Ultimately she didn’t have to because the officer took care of it himself, she said. “He threw her down before she even got in the dorm, then stripped her and patted her down,’’ Culick, who was serving a one-year, 11-month stretch for check forgery, recalled.

2012 Arrest

Latandra Tynese Ellington was born June 9, 1978, in Bartow, east of Tampa Bay, and raised in Lake Wales, part of a region where bright orange citrus groves still dot dusty back roads like an old Florida postcard. Ellington was raised by her aunt, Algarene Jennings, and her grandmother, Jeanette Jones, along with an extended family of cousins, nieces and nephews.

“I called her Tangerine. She was the most beautiful baby I had ever seen,” Jennings said.

Ellington’s mother was in and out of jail, records show, mostly on drug charges. Jennings took custody of Ellington straight from the hospital and raised her like her own daughter. She also raised Ellington’s brother, Gerald.

Growing up in the Central Florida community wasn’t easy, Jennings said. African Americans who once held steady jobs harvesting oranges in the surrounding orchards were displaced by migrants and labor-saving technology. It remains tough to earn a living in Lake Wales, she said.

Ellington dropped out of school and worked a number of low-paying jobs, but soon began filing fraudulent tax returns. She married, had four children, then divorced. In 2012, her then-fiancé, Tracy Thompson, was arrested on charges of grand theft in connection with a tax-fraud scheme. Ellington turned herself in shortly thereafter to face similar charges. She was sentenced to 22 months, and set foot in prison for the first time just before Christmas of 2013.

She was housed in “Charlie” — or C Dorm — in Lowell’s main unit, an open-bay dorm with more than 80 other women, all of them assigned to bunks. Crystal Harper, an inmate who was released in August 2015, recalls that Ellington, known by the nickname “Tan,’’ was trying not to make waves because she was hoping to get time off for good behavior — known as gain time — and return to her children. Her inmate history shows Ellington filed few complaints and didn’t get into trouble.

She did file a grievance against officers who forced her to sleep on a top bunk even though she had injured her back and had a pass for the bottom bunk, records show. Jennings said Sgt. Quercioli had been harassing her niece, calling her trash and racial names. It’s not clear from the file how the complaint was resolved.

Ellington also suffered from hypertension and complained that she wasn’t getting her medication, Jennings said.

“The only way she could get her blood pressure medication is she had to ask for it,” Jennings said. “Then someone would give her a smart comment and tell her to put in a medical slip for it. On a regular basis she was not getting her medicine.

“Sometimes her head would hurt so bad she didn’t know what to do,” Jennings said.

The last time Jennings visited Ellington at the prison, on Sept. 14, 2014, Jennings said Ellington was distraught about something but seemed afraid to talk in front of the officers and other inmates. She was menstruating so profusely that the blood leaked through her uniform.

“She said ‘I’m bleeding real bad. If they run out of pads, they say to use your socks,’ ” Jennings said. Ellington told her she had two pairs of socks in her underwear to absorb the blood, but it wasn’t enough.

Jennings kept pressing Ellington because she could see she was upset. Ellington kept hinting that the officers were doing something “nasty,” but she wouldn’t go into detail because she was afraid, Jennings said.

On Sept. 21, 2014, Ellington wrote Jennings two letters, which were enclosed in an envelope with a return address from another inmate. Jennings later told authorities that Ellington suspected the officers were intercepting her outgoing mail because of what she had seen, so she asked another inmate to mail the letters. Both letters told the same story, alleging she had seen something that she wasn’t supposed to have seen. “Q” and Thrasher engaged in abuse of inmates, she said in the letters, which were given to FDLE as evidence. Ellington didn’t explain exactly what she had seen — but it was clear she was frightened of Quercioli, Jennings said.

“He was gone [sic] beat me to death and mess me like a dog,” Ellington wrote of Quercioli. “He was all in my face. Sqt. Q then he grab his radio and said he was gone bust me in my head with it. . . .”

FDLE said in its report that an inmate named Brandy Coulliette claimed that Ellington told her that she had seen Quercioli having sex with an inmate named Stephanie Cook.

“Sgt. Quercioli went to Ellington and told her she was not going to cause problems in his life, and that if she said anything, he would get rid of her,” Coulliette told FDLE, according to the report.

FDLE could not find an inmate by the name of Stephanie Cook. An inmate, however, did reach out to Carlisle, the FDLE investigator, earlier this year, claiming to be the woman who had been involved with Quercioli in the week before Ellington’s death, records show. The inmate, who is not named Stephanie Cook, agreed to an interview with the Herald, but did not want her name used for fear of retaliation by staff.

She said she was placed in confinement after talking to both FDC and FDLE.

The inmate acknowledged that she was having sex with Quercioli in the bathroom in C Dorm when they were suddenly interrupted. Thrasher, she said, was acting as a lookout when someone — she could not see who — walked in.

“Q was hollering. . . . They were describing this tall, black girl and how they were going to pack her out for running her f---ing mouth,’’ said the inmate.

The inmate, in a report separate from the Ellington case file, gave a statement to FDLE about her sexual encounter with Quercioli, records show. In an interview with the Herald, she said she told Carlisle that she had sex with Quercioli about four times, that the sex was consensual and that he never used protection.

Her father, who visited her at Lowell prior to her being transferred to another prison, said his daughter is frightened that something bad may happen to her.

“She is scared for her life. She said, ‘Daddy you don’t understand what it’s like in here. If you open your mouth here to the wrong person,’ she says, ‘at the least you’ll go down to lockdown for a long time, and [at worst] you can wake up dead.’ ’’

Alleged bender of rules

Before he was hired at Lowell Correctional Institution in 2004, Quercioli already had a history of problems with the law, records show. While employed as a corrections officer in training with the Martin County Sheriff’s Office in 1994, he was arrested for selling steroids. At the time of his arrest, he was working at a new boot camp for juvenile felons. He admitted to sheriff’s deputies that he had used steroids, the arrest report said. He was placed on leave and subsequently resigned from the sheriff’s office, public records show.

His Martin County employment record includes a letter from one of Quercioli’s superiors saying that he had been repeatedly counseled and reprimanded.

“He continues to ignore department policy and acts as he pleases,’’ wrote Sgt. David Sansone. “He consistently manipulates and ‘bends’ department policies to benefit himself and shows no regard for supervisors or other officers, and he shows no respect for authority.”

The criminal charges were dropped when he agreed to undergo an 18-month drug prevention program, according to his FDC file. His law enforcement certification was suspended for two years, from 1994-1996, after which he was put on probation for another year, according to FDLE.

Quercioli became a personal trainer during his hiatus from law enforcement. Then in 2000, before having his certification reinstated, he was arrested again, accused of beating a motorist in a fit of road rage. According to the incident report, witnesses told Coral Gables police that Quercioli beat the driver so hard that Quercioli’s feet left the ground as he was leaning into the driver’s car. The driver had “swollen welts’’ above his eyes and on his forehead, the police report said.

Quercioli was charged with simple battery and received six months probation, court records show.

At the time he was hired by the FDC, he wrote a letter to his prospective employer to explain his arrests. He said that the steroids were really oil and water that were planted in his home by a disgruntled former girlfriend. He claimed that the road-rage incident was self-defense, and that witnesses apparently didn’t see how the motorist — the one sitting in the car — had threatened him first.

Death timeline

In its summary report on Ellington’s death, the FDLE offers a timeline from surveillance footage of officers and others coming and going in the second-floor quad, a grouping of confinement cells where Ellington was housed.

At 5:06 a.m., on Oct. 1, 2014, a female corrections officer who is unidentified in the report, along with a nurse, Donna W. Weeks, are seen at her door, the report notes. Weeks, an LPN, told investigators that after reviewing Ellington’s medical chart, she completed a Medication and Treatment Record and supplied her with three pills. But upon reviewing the form after Ellington’s death, FDLE investigators said the names of the pills were illegible.

After Ellington questioned what she was being given, Weeks told her they were “two of this and something else,’’ Shepherd, the cellmate, said.

The video shows that at 6:05 a.m. an unidentified female corrections officer and an unidentified inmate passed out food trays to Ellington’s cell, and another corrections officer picked up the trays at 6:16.

Danielle Canovan, one of the inmate orderlies who helped serve food that day, told the Herald in an interview that orderlies picked up the carts in the kitchen with the breakfast already packaged, then rolled them down to confinement. There, they were separated for each of the quads.

“I can’t even specifically remember that morning — that’s how normal it was,’’ Canovan said.

Canovan recalled that Ellington’s cell was in an area where there were no orderly helpers, which is why officers served them their trays. She said it would be very difficult, but not impossible, for someone to taint Ellington’s food.

“There are covers on every tray. The food is not sitting there in the open,’’ she said. She said she was not interviewed by FDLE.

At 7 a.m., another unidentified female corrections officer made a round of checks, and she is seen looking through the window of Ellington’s cell.

From 8 to 11 a.m. there is no record on video of anyone doing checks on Ellington’s cell, although checks are supposed to occur every 30 minutes, the FDLE report said. The corrections officer assigned to monitor the quad that morning, identified in the FDLE report by the last name “Eidson,” admitted that she missed her checks between 8:52 and 10:01 a.m. The video, however shows a three-hour window with no checks.

Shepherd, the bunkmate, told FDLE that she and Ellington both fell asleep after breakfast, then woke up about 9 a.m. She said Ellington seemed fine. Later in the morning, they went back to sleep and Shepherd told FDLE that she was roused by Ellington’s snoring.

In addition to her “really loud” snoring, both of Ellington’s fists were clenched. She was lying on her left side, facing the wall of the cell.

When Eidson finally returned to the cell at 11 a.m., it was lunchtime, the FDLE report said. Shepherd said she tried to shake Ellington to wake her up. Her eyes were partially open, but she didn’t respond. Shepherd summoned Eidson, who kicked the door to try to get Ellington’s attention.

Another officer then arrived with the keys, and Shepherd was relocated to another cell. Eidson and officer Joni Moore shook Ellington and got no response, the FDLE report said. Medical assistance was called, but it was too late.

“Eidson, she was very upset and barely spoke for days after that,’’ Canovan recalled.

The doctor on duty, Jose Rodriguez, arrived to find officers doing CPR. He touched Ellington and she was cold. Paramedics arrived about 11:15, and she was pronounced dead at 11:20, the FDLE report said.

Rodriguez reviewed Ellington’s chart, noting that she was taking three different medications, the FDLE report said. The names of the medications are redacted from the FDLE report. Rodriguez told FDLE investigators that he noticed medication in her cell, and that one of the prescriptions — one that was filled on Sept. 20 — was missing more than would be expected.

“This indicated to Dr. Rodriguez that the particular medication was misused or taken inappropriately by the inmate,’’ FDLE’s report said.

Rodriguez’s statement contradicted those of the nurses who responded to Ellington’s cell that morning.

A nurse who came in after Ellington’s death, Angela Hanlon, reported recovering a large blister pack of medication in a drawer under Ellington’s bunk. The pills were blood pressure medication. She said there was only one pill missing — and she could find no other medication or empty packets in the cell, the FDLE report said.

There’s no indication in the FDLE report whether agents ever tracked through the chain of personnel how Ellington was supplied her medications.

The FDLE report mentions that Ellington’s family told investigators they received “multiple” tips from inmates, alleging that Sgt. William Weiss and his wife — a nurse at the prison, according to these tips — forcibly injected Ellington with drugs before she died.

In December — two months after Ellington’s death — her sister, Kawana Robinson, told FDLE agents a bizarre story that she hadn’t mentioned previously: that inmates — she did not say who — claimed that Weiss and a nurse “Jackson’’ ordered Ellington to hold out her arm for an injection.

“Ellington told her she was not ill and wanted to know what the injection was,’’ the FDLE report said. “Jackson again ordered her to hold out her arm and Ellington refused, and that is when Weiss assisted nurse Jackson in forcing the injection into Ellington. . . .’’

Carlisle noted that he would follow up, but there’s no indication in the report whether he did.

Weiss is married to a nurse, Donna Jackson Weiss. Corizon, the private company that provides healthcare at Lowell, confirmed that Jackson worked as a nurse at Lowell but said she had left the prison’s employ before Ellington’s death. She is friends on Facebook with Weeks, the nurse who gave Ellington her medication that morning. The Herald was unsuccessful in reaching William and Donna Weiss, as well as Weeks.

Unauthorized relocation

Bergner, the corrections officer who took Ellington’s complaint on Sept. 21, said he believed that Ellington was truly frightened when he first encountered her, as she was being moved into his dorm that Sunday evening.

In a recent interview, Bergner said everything about that day was odd. For one thing, he explained, Ellington was being moved on a Sunday, when moves are never made. Another staffer named in the report, Maj. Gary Patterson, also told FDLE investigators that Ellington’s move was done without permission and had not been authorized through the proper channels, the report said.

Ellington told Patterson and Bergner that Quercioli and Thrasher ordered her to move from C Dorm to A Dorm that Sunday, the FDLE report said.

“Not only was it a Sunday, and inmates aren’t moved on Sunday, but it was 7 a.m., before count time,’’ said Bergner, who resigned from the department this past summer because he said he couldn’t deal with the corruption.

“She was crying and told me she was being harassed and she was going to be killed. I knew at that point that it was very dangerous — the tone of voice that she had, her crying, you can tell especially after working 10 years with the department — you can tell when an inmate is sincere or not.”

He told her to fill out a witness statement.

“I didn’t have a chance to read it. It was a very busy day and the statement was front and back and it was a lot to read,’’ he recalls.

He put the report into a binder where he kept other records for safekeeping. He told FDLE he didn’t turn in Ellington’s statement right away because he didn’t trust his shift commander, an individual he claimed had blown off similar complaints involving sex and inmates.

About two hours later, Quercioli and Thrasher confronted him about the report. According to the FDLE report, Sgt. Weiss witnessed the confrontation, telling agents that the two officers had “hunted down” and “barked’’ at Bergner.

“They were saying we could pretty much take care of it in the parking lot, which means they would do harm to me,’’ Bergner told the Herald. “It basically means a beat-down off prison grounds. I was very stressed out.’’

Later that same day, Bergner had to write up another report involving Quercioli. An inmate, Stephanie Bell, claimed that Quercioli had beaten her up when she tried to declare a mental health emergency, according to FDC records. Bergner, who also had to use force to subdue the inmate that day, said she was unruly. But the video showed Quercioli used unnecessary force, Bergner told the Herald. She was dragged in the mud and covered with dirt, according to the FDLE — and the FDC incident report.

When he got home that evening, Bergner realized he had left his binder at work, in the sergeants’ office. He called the prison, and was told it was gone. He panicked, and drove back to the prison, a 45-minute trip, to look for it. It wasn’t there.

“I ended up taking a stress leave the next day,’’ he said.

About a week later, while still on leave, Bergner saw Ellington’s photograph on the TV news and learned she had died.

“Then I got really scared,’’ Bergner said. “Not for me, but for my family, because if they were able to get to her, they would be able to get to me. I just felt, personally, that something wasn’t right.’’

He arranged to meet FDLE investigators, insisting that they rendezvous far from the prison. They met on Oct. 14, 2014, at the police station in Williston, 31 miles from Lowell. Bergner gave a detailed statement to Carlisle, the investigator, the FDLE report said.

Bergner told Carlisle that Ellington reported that Quercioli and Thrasher were having sex with inmates, and that she had caught Quercioli with one inmate that day. Ellington did not complain she had been physically harmed, but was clearly afraid.

He talked not only about the conversation with Ellington, and the threat by Quercioli, but also about an incident two weeks before Ellington’s death when another officer observed Quercioli in a compromising position with an inmate, the FDLE report said. Bergner told that officer to write up the incident, but said he was overruled by a captain, the FDLE report said.

He told FDLE about other incidents, including a time he discovered a letter that an inmate was trying to shove in her mouth. It appeared that it had been written to a corrections officer, and that the two were engaged in a relationship. He turned the letter over to the FDC’s inspector general’s office, Bergner said, but a few days later, the IG’s office told his superior that there was insufficient evidence to investigate, the FDLE report said.

“The lack of pursuit in that investigation caused doubt for Sgt. Bergner that the department could be trusted to investigate the incidents involving Sgt. Quercioli and Ellington,” FDLE said in its summary report on Ellington’s death.

Bergner, who has been disciplined twice during his career — once for excessive absences and once for failing to conduct security checks — returned to work from his medical leave only to leave for good several months later. He said he was suspicious about some of the things in the FDLE report on Ellington’s death.

“I went back to [FDLE] several times. . . . There were some discrepancies. I wanted them to be aware that some of the names contained in it seemed almost like they were changed around on purpose so they couldn’t get to the truth,” Bergner said.

Coincidentally, the day Ellington died, a former Lowell inmate contacted the Pinellas County Sheriff’s Office to allege that Quercioli and other Lowell officers were trading sex for cigarettes and other contraband, according to an FDC report. Pinellas detectives wrote up a report and referred it to the FDC’s inspector general. Other than issue a one-page report saying the complaint had been received, there’s no indication it was investigated by FDC.

Pat Franklin, a former Miami Beach police detective who now works as a police internal affairs expert, said it’s clear that neither FDLE nor the prisons’ inspector general wanted to conduct a thorough probe of Ellington’s death. It’s telling, he said, that FDLE apparently didn’t investigate the threats that were allegedly made — in front of witnesses — against Bergner.

“These complaints were of a serious nature warranting investigation,’’ said Franklin, who reviewed FDLE’s report into Ellington’s death, as well as the autopsy. “The consistency of these complaints would tell a rookie out of the academy that something was amiss.”

Ellington’s family is calling for an independent investigation into her death, possibly by the FBI.

The forensic pathologists consulted by the Herald, Marraccini and Cyril Wecht, said the high level of blood pressure medication likely would have interfered with normal cardiac activity. Dr. William Anderson, hired by Ellington’s family to do a private autopsy, said he is shocked that the autopsy didn’t even mention the medication.

“Somebody should have seen it,” he said. “They had to see it. I just think they were trying to put it out of sight, figuring that nobody else would pick up on it.’’

Dr. Wolf, the doctor who did the autopsy, conferred with the Marion County State Attorney’s office after the Herald showed her the issues raised by Anderson, Marraccini and Wecht — all three of whom agreed that the level of Amlodipine in her system was high enough to cause her heart to fail.

The state attorney asked Dr. Bruce Goldberger, chief of forensic medicine at the University of Florida, to look at the toxicology findings.

Ric Ridgway, chief assistant state attorney, said Goldberger agreed that the level of Amlodipine in Ellington’s blood was high, but said that it was the result of post-mortem redistribution and that the concentrations increased after her death.

“He was confident that these drugs did not contribute to her death,” Ridgway said.

Both Marraccini and Wecht said they believe the level of Amlodipine in Ellington’s system was far too high to attribute it to post-mortem redistribution.

“In my opinion, this is a death due to drug toxicity,’’ said Wecht, a former president of the American Academy of Forensic Sciences who has reviewed a number of high-profile autopsies, including those of John F. Kennedy, JonBenet Ramsey and Elvis Presley.

“It’s not even a close call.”

After the FDLE closed its case into Ellington’s death, the corrections department’s inspector general opened an internal affairs review of possible officer/medical staff misconduct. Lewis, the FDC spokesman, said the administrative investigation — completed just recently — ended with a Corizon nurse being fired. Eidson, the officer who failed to conduct timely checks on Ellington, was disciplined.

The allegations made by Bergner as well as those made by the inmate who claimed to be sexually involved with Quercioli are still open criminal investigations by FDC’s inspector general’s office, Lewis said Tuesday.

This article was originally published by the Miami Herald on December 16, 2015; reprinted with permission from the author.