CLEARWATER -- More than two hours had passed since emergency room doctor David Minkoff had spoken with staffers at the Church of Scientology. As a favor, he had agreed to treat the young woman who had spent more than two weeks in the church's Clearwater hotel. She had an infection, they said, but was not seriously ill.
It was an hour's drive to the Pasco County hospital where Minkoff worked.
They said they'd bring her right up.
Now he assumed they weren't coming.
At 9:30 p.m. he heard the cries of an ER technician.
"Help! Help! Help!"
The patient was splayed across a wheelchair -- limp, gaunt and unkempt. Minkoff went to work but there were no vital signs, just the faint wiggling of her heart, signifying death.
Only then did it hit him. This was Lisa McPherson, the woman from the church.
"Oh my God!"
"The whole thing was just such a fiasco," Minkoff said three years later in a 1998 sworn statement to prosecutors, who charged the church's Clearwater operation with two felonies.
His account is contained in nearly 1,000 pages of sworn statements from five Scientologists with first-hand knowledge of McPherson's final days at the Fort Harrison Hotel, where church staffers tried to nurse her through a severe mental breakdown. Prosecutors released the statements in December to buttress their case that the church abused McPherson and illegally practiced medicine on her. Now, the statements loom large after a judge's ruling Wednesday that delayed the release of the 10,000-page investigative file on McPherson's death. In the absence of that file, the five Scientologists provide the most complete telling thus far of Lisa McPherson's death and of the investigation that followed. Among the disclosures:
Alain Kartuzinski, a church counseling supervisor, admitted lying to police in 1996, telling them he had little to do with McPherson. Speaking with prosecutors two years later, he said he arranged to have McPherson, 36, confined in a special "isolation watch" and authorized her to be medicated.
Kartuzinski lied, he said, because Clearwater police detectives were "sneeringly antagonistic" and he was scared. Janis Johnson, a church medical officer, also misled police, telling them her office gave only "basic first aid" and considered McPherson a regular hotel guest. In fact, fellow Scientologists revealed that Johnson oversaw an unusual regimen of care for McPherson at Kartuzinski's direction. An unlicensed doctor, she also authorized medication and gave McPherson injections of a prescription muscle relaxant. David Houghton told how he filled a large syringe with ground aspirin, liquid Benadryl and orange juice, then worked it along the outside of McPherson's teeth and squirted the mixture behind her tongue. He had help from his fellow Scientologists, who held McPherson's arms and legs. A veteran dentist from Iowa and Ohio, he was not yet licensed in Florida and had no doctor's authorization and no medical history on McPherson. Judy Goldsberry-Weber, once a licensed practical nurse, heard of Houghton's procedure and was outraged. "What doctor's order did you have to do this?" she demanded to know, almost coming to blows with Johnson. She later reported her fellow staffers to the church legal office. Minkoff, a longtime Scientologist who is not on the church staff, told prosecutors he violated standard medical procedure by prescribing sleep aids for McPherson without ever examining her. "It was foolish to do what I did," the doctor admitted.
Three of the five Scientologists admitted to prosecutors the effort to help McPherson was hurt by poor decisions and miscommunication. Also, some of those caring for McPherson missed or minimized the signs of her physical decline. But they were motivated, they told prosecutors, by a sincere desire to help McPherson. They tried to be gentle, and many suffered bruises and scrapes from violent encounters with McPherson.
"I wasn't trying to let her die," Kartuzinski said, adding: "There was no doubt in my mind that I had to do what I was doing, right or wrong." Houghton said he performed the oral injection "because I felt it was something that would help her."
"These people were actually trying to do something right," said Minkoff, who is not a church staffer. But they "got in over their heads and didn't know it."
Once a senior Scientology executive, Kartuzinski was demoted to a file clerk in a church warehouse after McPherson's death became public. He told prosecutors he made three big mistakes. He violated a church policy that states that Scientology counseling at the Fort Harrison Hotel is of no use to "psychotics" such as McPherson, lest they "leave the organization open to failures." He did not delegate his heavy workload to others, which might have left him more time to deal with McPherson. He also designated himself as her "case supervisor," which meant that under church policy he could have no direct contact with her.
On Nov. 18, 1995, McPherson took off her clothes at the scene of a minor auto accident and was taken to Morton Plant Hospital by paramedics. Kartuzinski was one of several Scientologists who arrived to secure her release, fearing she would be subjected to psychiatric care, which is shunned in Scientology. After failing to convince a friend of McPherson's to care for her at home, Kartuzinski said, he decided to take her to the Fort Harrison. There, he supervised the progress of hundreds of Scientologists as they underwent church counseling, called "auditing." It was Kartuzinski who determined McPherson was a "Potential Trouble Source, Type 3," a psychotic person who is not only a threat to herself and others, but to Scientology in general. He believed she was stuck in a disturbing "mental image picture" from her past, perhaps from a previous life. The antidote was a Scientology procedure called the "Introspection Rundown," which calls for a regimen of vitamins and forced, quiet isolation, followed by "auditing."
Once inside the Fort Harrison, McPherson became crazed, speaking nonsensically, spitting out food, staring at light bulbs, sticking her head in the toilet, attacking the staff and jumping around her hotel room. A counseling attempt went awry when the 13-year church member licked an e-meter, a small Scientology machine for measuring a person's reactions during auditing. Kartuzinski recruited Janis Johnson, the medical officer, to organize a "watch" over McPherson. They assembled female staffers "of a certain size" who could "gently put her back in the room if needed," he said. "Not meek little things that would be scared." He also authorized them to give McPherson a prescription sedative, chloral hydrate.
Talking with police in 1996, he minimized his role in McPherson's care and said she did not receive the Introspection Rundown. "Yes, I was lying to them," Kartuzinski told prosecutors in 1998. "I was scared. Scared for myself. Scared for the church, possibly." He said he thought the police were against Scientology and wouldn't understand. He began telling the truth after church attorneys reprimanded him, he said. In the days before McPherson died, staffers sent notes to Kartuzinski that she was weak and couldn't walk. He did not seek medical help, he said, attributing her symptoms to her mental condition. Had he known her problem was physical, he said, "I would have taken a completely different course."
On Dec. 5, 1995, 17 days after McPherson entered the Fort Harrison, Johnson came to Kartuzinski with the news that McPherson appeared sick with a raging infection. They decided to seek medical help, but Kartuzinski feared doctors at nearby Morton Plant Hospital would place her in a psychiatric ward. He asked Dr. David Minkoff to see her. He also said he was relying on the judgment of Johnson, who, he assumed, had been in good communication with Minkoff.
Kartuzinski assumed incorrectly. Before the day of McPherson's death, Minkoff remembered only two calls from the Scientology staff, who told him her problems were mental. He prescribed liquid Valium because they said she needed sleep, but he never examined her, got a medical history or found out if she was taking other medications.
"I'm not trying to justify it," Minkoff told prosecutors. "When I first saw the prescription for injectable Valium I thought, "Jeez, how could I have done that?"'
Meanwhile, Johnson, who did not have a medical license, was seen by fellow staffers giving McPherson injections of a prescription muscle relaxant that Minkoff never authorized. Houghton, the staff dentist, got involved when he overheard Johnson saying McPherson was refusing to sleep or swallow. He spoke up, saying he knew the anatomy of the human throat and could help. Kartuzinski vetoed the use of Valium, but he and Houghton devised their own treatment. They would give McPherson aspirin, which, according to Scientology founder L. Ron Hubbard, can block "mental image pictures" from surfacing in the mind. The Benadryl was to help McPherson get the rest required for "auditing." Houghton, who was still studying for a Florida dental license, performed his novel procedure three times with a large syringe that prosecutors now refer to as a turkey baster. At least one other staffer in the church medical office objected. Judy Goldsberry-Weber had promised the doctors at Morton Plant Hospital that the church would look after McPherson 24 hours a day. Days later, she overheard Johnson and Houghton discussing how McPherson had to be held down, and she heatedly confronted them.
"I says, "You can't do this,"' she told prosecutors. "You can't physically hold someone down. There are other ways, you know."'
Houghton, now licensed as a dentist in Florida, told prosecutors he had never force-medicated anyone in nine years as a dentist. The prosecutors asked him: Why would a professional do such a thing without medical advice or consent?
"You're talking about aspirin and Benadryl," he responded. "You're talking about something that anybody could walk into Albertsons and pick up and buy."
"That's true," responded chief assistant prosecutor Doug Crow. "But Lisa didn't do that, did she?"
On the evening of McPherson's death, Kartuzinski and Johnson, the church medical officer, called Minkoff at the emergency room at Columbia New Port Richey Hospital. She had a severe infection, had suddenly lost 12 pounds and had diarrhea, they said. Johnson asked Minkoff to prescribe penicillin but he declined.
He told them McPherson should be seen by a doctor immediately. He advised them to take her to Morton Plant Hospital, just five minutes from the Fort Harrison. But Minkoff agreed to see McPherson when Kartuzinski expressed fears about the Morton Plant psychiatric ward. Plus, Johnson assured him the situation was not dire, he said.
Minkoff viewed Kartuzinski as highly competent and thought Johnson had her Florida medical license. In fact, she let it lapse in Arizona after an inquiry into her alleged drug use. "I thought I knew these people," Minkoff said. There was more he didn't know. McPherson was limp earlier that day and unable to walk. Her breathing was labored. Her eyes were fixed and unblinking. Her face was gaunt, a sign of severe dehydration. Minkoff was never told, he said, how violent and delusional she was, or that she had resisted food and liquids.
"I think if any of these things would have come up," he said, "it would have been a completely different ballgame." That night as Lisa McPherson lay dead in his emergency room, Minkoff said he screamed at Johnson for bringing someone to his door in such "horrific" shape.
He told prosecutors: "I was shocked out of my wits."