Veteran Roy Cohoe moved into Sunrise Metro Apartments to start a new life with the help of the Salt Lake City Housing Authority.
He was required to abstain from alcohol by the veterans program supporting him. But on the afternoon of Jan. 4, 2010, a Sunrise property manager discovered him severely inebriated, unable to speak clearly and surrounded by bottles of alcohol, according to Jessica Morales, Cohoe's case manager at the time.
The 55-year-old American Indian was found dead in his bed the next day.
Morales, a whistleblower, is now urging a broader investigation into Sunrise Metro, a call that comes as the Department of Veterans Affairs is threatening to withhold funding from the Housing Authority for "endangering the health and safety" of veterans.
In a September inspection at Sunrise Metro and another facility, the George E. Wahlen Department of Veterans Affairs Medical Center found frequent use of alcohol and drugs by veterans who are expected to remain sober. It also found that current and former case managers withhold information about such use because they fear being fired, according to a VA letter to the Housing Authority.
Morales said housing authority staff raised similar issues in the wake of Cohoe's death last year. Veterans Affairs declined to comment Tuesday on any investigation it conducted into Cohoe's case or related concerns.
Instead, it said in a statement that it relies "on the professional relationships with our partners and the checks and balances in place to ensure quality services. When we feel that care has fallen short, VA, of course thoroughly scrutinizes every aspect of that partnership."
The Housing Authority did not respond to repeated requests for comment.
On the afternoon of Jan. 4, 2010, the property manager who saw Cohoe sent an email to Morales and others noting he had failed an apartment inspection but it said nothing about his intoxication, Morales said.
No other staff entered his room that day, according to Morales and Salt Lake City police, who said he was last seen at 1 p.m. Morales said she knocked on Cohoe's door after receiving the email, but Cohoe didn't answer and Morales left.
She said she returned the next day and when he again didn't respond, she went into his room. He was in bed and she believed he was breathing, she said. Morales acknowledged she did a poor job of checking on Cohoe's welfare, but insisted that the property manager had not alerted her to the gravity of his condition.
Later that afternoon, a Veterans Affairs social worker and Morales checked on Cohoe and found him dead. There were empty liquor and beer bottles and more than 30 pill bottles in his room, a police report said.
"I was shocked," Morales recalled. "When they touched him and he was cold, that's when they were like, 'He's gone.' "
Morales said she heard the property manager tell police that during the inspection the previous day, the manager had initially thought Cohoe was dead. Morales said the manager told police she roused him and although his speech was not coherent, she took it to mean he was OK.
That was the first time she heard those details, Morales said.
The conversation she described is not contained in the police report.
One week after Cohoe's death, Morales said, she and another case manager, Anjanae Merida, were concerned that other veterans were abusing substances and alerted Veterans Affairs.
The Housing Authority's director of homeless programs told the women she was "beyond furious" about the report, Morales wrote in an email at the time.
Morales and Merida were reprimanded by housing authority officials later that month, according to letters to both women, provided by Morales. Merida confirmed Morales' account and verified her own discipline.
Morales' Jan. 27, 2010, discipline letter states that when issues arose she was expected to meet with her supervisor, seek guidance "and report immediately any issues that increase the liability, potential for negative media coverage or could otherwise cause damage to the reputation of Sunrise Metro, the Housing Authority or its staff members."
She defended her decision to discuss treatment issues with the VA.
"We're supposed to [tell the VA]," she said last week. "They are the ones that assist us in getting our clients our treatment."
Twenty months later, the VA is insisting the housing authority allow case managers to report substance abuse "without fear of discipline or termination."
Sunrise Metro, which opened in 2007, was Utah's first large housing complex where the homeless, including veterans, get support from caseworkers. Morales said she felt management was preoccupied with maintaining its reputation.
"It's all how Sunrise looks on paper it's all how the community thinks things are," Morales said. "What's important to me is the successes my clients have."
Morales said she resigned at management's request last month after working at Sunrise almost four years. Merida said she quit in April 2010 after changes were made to her caseload that she felt were punitive.
Lisa Solis, Cohoe's daughter, questions why her father did not receive help the day before he died. Officials did not clearly explain to her what happened, she said. "It was very vague," Solis said.
She wonders if her father's race played a role. "Me and my brother felt throughout this whole process, we felt something wasn't right," Solis said.
She said she had to wait weeks to collect Cohoe's belongings. Instead of the family dismantling his room themselves, they were given garbage bags stuffed with his things in the Sunrise lobby, she said.
"Even when I wanted to dress his body [for cremation] ... they wouldn't give me clothing [from his room] until I begged them," she said.
Tribune reporter Kristen Moulton contributed to this report.
Caring for homeless veterans
The Department of Veterans Affairs partners with the Salt Lake City Housing Authority to serve nearly 200 veterans in three housing complexes and scattered apartments across the city. Sunrise Metro is home to dozens of formerly homeless Utahns, including 20 veterans under the VA's care.