Arkansas DHS leaders grilled during emotional hearing on 2025 care facility death

LITTLE ROCK, Arkansas — A death at an Arkansas Department of Human Services (DHS) facility in 2025 that sparked firings, arrests, and a six-figure settlement with the state was discussed during an emotional meeting with lawmakers and state officials on Wednesday.

In September 2025, 21-year-old Zachary Moore died after being held in a face-down position for 13 minutes and chemically injected while he was a resident at the Southeast Arkansas Human Development Center, one of the five care facilities maintained by DHS.

The incident led to the firing of at least 12 employees, with DHS Secretary Janet Mann admitting there were “significant issues” in the handling of Moore’s case.

Six people have since been arrested for manslaughter and neglect in connection with Moore’s death, and DHS leaders said there is an ongoing criminal investigation into other staff.

Additionally, state lawmakers recently approved a $725,000 settlement with Moore’s mother, Angela Stephens.

On May 6, lawmakers gathered to hear from DHS officials about what went wrong and how they’re working to make sure it doesn’t happen again. Arkansas DHS Chief of Staff Lori McDonald was joined by division directors Melissa Weatherton and Jennifer Brezee. 

DHS leaders said that after Moore’s death, the agency brought in a consultant to review policies and procedures, complete retraining with staff members, and to conduct an analysis of the incident.

They said the consultants identified “even better opportunities for training” and de-escalation protocols, and that they hope to have the work with the consultant group wrapped up by June.

The DHS officials went on to explain to lawmakers that Moore’s death was the result of multiple policy violations within the chain of command of care.

Miscommunication between DHS staff, agency leaders, and Stephens took center stage at the meeting, with multiple lawmakers expressing concern about how DHS had communicated with Moore’s family in the wake of his death.

Stephens had said in a 2025 interview that when she received the call that her son had passed, their family was left searching for answers.

“We got the phone call, and the head nurse just told me that Zachary’s passed… that’s it, nothing else,” Stephens recalled. “We called for hours… it was nearly three hours before we got anybody who called us back.”

Lawmakers reported during the hearing that a DHS employee had initially told Stephens that the agency would involve her in discussions about the incident, but that agency leaders were not aware of that.

This frustrated legislators, as they viewed this communication mishap as an issue.

“This is really, really problematic,” Sen. Scott Flippo said. “I mean, this lady who has just lost her son has now got to go through this. And one person who works for this state is saying one thing, and the person above them, obviously, is saying, ‘I am unaware of that.’”

When DHS leaders said they would look into the communication, Flippo said this highlighted another issue.

“Here’s a problem now. You knew this meeting was coming today,” Flippo said. “This is something that, this would be like a ground zero of where I’m starting. What communications have we been having with this family?” 

DHS said the communication had been affected by ongoing litigation, referencing Stephens’ settlement effort, but Flippo replied that this did not appear to be an isolated incident.

“I don’t think that it’s isolated to this specific case, either, that I’m aware of instances in my district where things have been said by somebody employed by DHS, then somebody above them says, ‘No, we’re not in a position to do that,’ or ‘we can’t do that.’ Why would this person say that? I mean, there needs to be these very solid policies… there has to be accountability,” Flippo said.

Flippo added, “It’s a tough time for a parent, and so it just concerns me when they’re hearing one thing from state government, and then, you know, we have a meeting, and we’re hearing different… I’m just disappointed that we’re here today, having this meeting, and nobody can tell me whether or not this conversation even took place, or even what the context of the conversation was.”

Rep. Jeremy Wooldridge echoed Flippo’s remarks.

“I’m not here to point fingers after the fact. This is a tragedy… but I do want the agency to learn from it, to Senator Flippo’s point, there needs to be an ironclad process, because when a family suffers a tragedy like this, the state creating a second tragedy with how we handle the process is unacceptable,” Wooldridge said.

Rep. Howard Beaty then spoke, adding to concerns about DHS officials’ lack of preparedness at the meeting.

When Beaty asked about the last time the southeast center’s policies were reviewed, one of the DHS leaders said they would look for the information, prompting Beaty to ask why they were having the meeting at all if agency officials were not going to be prepared.

“That’s what we don’t want to hear. You knew what you were coming here to talk about… you’ve heard the frustration from other members,” Beaty said. “You come in here, and you don’t have information for us, and you can say you’re sorry, you can try to say the right things, but in the end, you’re not even prepared for this meeting.”

Sen. Jimmy Gazaway then joined in questioning the DHS leaders’ lack of knowledge on the situation. After he asked about how Moore died, Weatherton answered, “I believe asphyxiation.”

“To be clear, your answer was, ‘I believe it was asphyxiation.’ As Representative Beaty said, you guys have known for a long time we were going to have this meeting today. This is the central issue that we came here to talk about, specifically, Mr. Moore’s death, why it happened, how it happened, the policies that are in place, and how it can be avoided in the future. And I asked the cause of death, and it’s, ‘I believe it was asphyxiation.’ Do you not know?” Gazaway said.

Weatherton went on to explain that she had not seen Moore’s death certificate, blaming the ongoing criminal investigation.

Moore’s death certificate is public record, as it’s attached to the petition Stephens filed for the settlement. His death was ruled a homicide due to “physiologic stress associated with struggle and prone restraint.” 

DHS leaders had also incorrectly stated that the number of former employees charged in connection with Moore’s death was five. As of the time of the meeting, the number was six, a clarification later made by McDonald.

The meeting closed with remarks from Moore’s mother, who pleaded with lawmakers and DHS officials to make changes.

“I know that there has been a settlement said, but money does not bring back Zachary. And I’m here because the next Zachary that is in the facility right now is not safe, and that next Zachary needs to be protected for the future,” Stephens said.

Stephens said she felt not enough meaningful change had happened, or been communicated, in the eight months following her son’s passing.

“Where’s the change? [It has] been eight months. What has changed? What improvements for the other Zacharys out there are being done?” Stephens said. “Zachary paid the price for this to be noticed… Is his death in vain?”

Some lawmakers said the incident involving Moore’s death is possibly indicative of bigger problems within DHS, including staffing. Rep. Julie Mayberry said care waitlists are growing, but care worker salaries are not.

“Most often, the care for individuals with disabilities in the state is being provided by some of our lowest-paid people working in the state of Arkansas,” Mayberry said.

Mayberry claimed that over 2,000 people are on a state waitlist to receive in-home disability care.

“Families, when they have a child who has these profound, aggressive behaviors, they sit on a waiting list now,” Mayberry said. “Many are having to make the decision; I can’t provide that care in my own home. And so, they then put them in a human development center.”

Mayberry continued, “As one who has had a daughter at home, I went through six people in my home to provide care. They wouldn’t show up on time, and they didn’t provide the right care. I can go through a long list of things. So, this is a real problem, and I believe a lot of it starts with the funding that we’re giving your department to provide this care.”

Mayberry suggested that in 2027, the legislature should try to fix some of these issues, including providing a way to get people off the waitlist for in-home care.

DHS leaders said they agreed with some of the concerns and that they hear from providers and families that there is a shortage of quality workers for their centers.

When asked by Senator Kim Hammer how the labor pool is in Warren, where the Southeast Center is located, DHS said it was one of their problem areas where they were facing challenges in hiring qualified CNAs.

Rep. Ryan Rose said that there needed to be more concrete plans for recruiting better staff.

“What I will say, just to conclude, is that we are eight months later, and it does sound like there’s a lot of talk and maybe ideas, but there’s nothing actionable in terms of making sure employees like this are not hired again, making sure we’re not 10-11% understaffed,” Rose said.

Weatherton replied, “I think it’s coming across like a lot of talk, but there has been a lot of work completed the last eight months that is actionable and in place right now.”

DHS officials said they were working on a retention and recruitment plan to ensure better hiring practices. Beaty joined in, pressing further on what was being done.

“We’re talking about human life, and if we’re waiting on a study to implement changes, that’s unacceptable.”

Weatherton ultimately said there were warning signs at the Warren center, and that they should’ve seen them, but they’re confident the changes they’re making will have better outcomes.