Something horrible had happened to John McCloskey. Something so horrible his colon exploded, his intestines tore, and his liver almost ruptured in two. Something that 14 months of hospitals and nine surgeries couldn't repair.

Something.

But what? When? And by whom?

The answers, according to doctors, lay sometime between Dec. 15, 1994, when the mentally ill teen-ager was arrested by the Rockbridge County Sheriff's Office, and Dec. 18, when he awoke at Western State Hospital, screaming in pain and vomiting his own feces.

Three years later, authorities would be asking the same questions.

The Rockbridge sheriff didn't investigate his deputies for fear he'd be accused of a cover-up. Officials at the state's mental health watchdog, the Department for the Rights of Virginians with Disabilities, didn't investigate Western State because the incident was never reported to them.

So the investigation fell solely to the Virginia State Police.

But investigators first faced an unexplained delay. Then four different theories emerged of how the injuries occurred. Other problems included a victim who couldn't speak, a lack of witnesses, and everyone pointing fingers elsewhere.

And in the end, state police agents found themselves under scrutiny, accused of going easy on Western State, another branch of Virginia government.

A medical mystery

By the time Virginia State Police Special Agent Gary Pence got the case, a month had passed since allegations arose that John McCloskey was the victim of a horrible assault.

The reason for the delay is unclear. But during that month, Western State had already shifted blame from itself.

On Dec. 19, 1994, the day after John was taken to the University of Virginia Medical Center, a Western State social worker wrote in John's file, "Patient may have been physically and/or sexually assaulted prior to admission. (This may need further investigation.)"

In a memo dated Dec. 20, 1994, Western State Director Lynwood Harding wrote that he was conducting a "local investigation" and that "it appears patient was admitted with injuries."

(Years later, in court documents, Harding would admit, "I did not participate, personally, in any official investigation regarding John McCloskey.")

In a separate memo that same day, Harding said he had asked one of his security officers to notify state police.

On Dec. 22, Harding noted that he had sent his preliminary report to state police.

But the state police didn't officially open their case until Jan. 18, 1995. That was the day, state police records show, that Western State Security Chief John Arthur first called in the complaint. The McCloskeys would later say UVa doctors, not Western State, tipped off state police.

The delay was just the beginning of a problem-plagued investigation.

The story of most violent deaths is written on the body, punctuated by the bullet hole or slashing knife. But the author of John's injuries -- all internal -- had left no visible mark.

To pinpoint how and when John suffered his wounds, Pence consulted four physicians.

Dr. Jeffrey Young, the UVa surgeon who operated on John, said the hole in John's colon suggested that an object 10 to 14 inches long had been shoved up his rectum, even though the anus had shown no signs of trauma. Young put the time of injury at no earlier than Dec. 15, the day of John's arrest and commitment to Western State.

Dr. Michael Clayton, another UVa physician, said an object up the rectum would explain the colon perforation, but not the small intestine and liver damage. Those injuries were consistent with those of a car wreck victim who had slammed into a steering wheel, even though John had no external bruising. As to when, Clayton believed no earlier than Dec. 16 -- John's second day at Western State.

To Dr. David Oxley, deputy chief medical examiner for Western Virginia, it looked as if someone had hit or kicked John in the abdomen while his stomach muscles were relaxed. As to time, Oxley thought "the injuries were sustained while at Western State or shortly before he was admitted."

Months later, Dr. Marcella Fierro, Virginia's chief medical examiner, ruled that John suffered "multiple blunt-force impacts to the abdomen," most likely on Dec. 15. She didn't know how, but theorized that a "high-velocity force" had mashed John's bowel against his vertebrae.

Four different physicians. Four different theories -- none suggesting John had health problems or had hurt himself.

As Fierro would later explain, "This is the sort of case you solve on investigation, because the pathology isn't helping, because the pathology will only tell you what you already know, that there was an injury to the abdomen."

And so Pence investigated.

In the first two weeks, he questioned the deputies who arrested John. He questioned witnesses to the arrest. He questioned officers at Rockbridge Regional Jail, where John spent almost six hours, and staff at Western State Hospital. Thirty-five interviews in all.

As more people were interviewed, and as deputies' reports and Western State's medical records were obtained, a fuller, but not complete, story emerged of John's last three days spent outside a hospital room.

This is that story.

Three days

Thursday morning, Dec. 15, 1994, and the bizarre young man has shown up again at Arnold's Valley Trading Post in Natural Bridge Station. He'd come the day before and tried to buy beer, but when the clerks refused him because he had no identification, he cursed them and threw a six-pack onto the floor. By the time the deputies arrived, he was gone.

Now he's back, pouring a two-liter drink onto the floor, taking another outside and emptying it, too. He tries wiping it up with his shirt, but gives up and walks away. At the edge of the parking lot, he spins around, pulls down his pants and flashes his penis at the clerks.

One clerk, Christy Dawn Moore, calls the Sheriff's Office. Then she phones her grandfather, Calvin "Baldy" Thacker, the store's owner, who jumps into his truck and drives the three miles to his store. There, beside the road, stands the young man.

"Are you the one causing problems?" Thacker asks. Thacker grabs him by the arm and walks him back to the store.

Deputies Hugh Bolen and Richard Dudley get the call at 9:37 a.m. Same suspect as the day before: white male, about 20 years old, camouflage shorts, tie-dyed shirt, black high-tops. He is cursing at the store clerks, exposing himself, maybe has a gun.

At 9:46, the dispatcher reports the subject is starting to fight.

Bolen arrives first at 9:52. Outside the store, Thacker, Moore and a few others are eyeing a man who is standing next to an ice box.

Hand on his pistol, Bolen exits his car.

"You better have two of them f---ing guns!" the young man hollers, his right hand buried in his pocket.

Bolen draws, aims at the man's head and orders him to show both hands, which he does. Holstering his gun, Bolen approaches the suspect and turns him around. He has to push the struggling man against the ice box to cuff his wrists.

Dudley arrives at 9:54. By this time, the subject, John McCloskey, is in the back seat of Bolen's car, banging his head against the window.

The deputies move him to Dudley's car, which has a security cage separating the front and back seats. As soon as the door slams shut, John goes wild, kicking at the back windows and banging his head on the metal cage.

To keep John from hurting himself or damaging the car, the deputies cuff his feet to his handcuffs.

At 10:16, Dudley leaves with John, who is lying face down across the back seat, mumbling to himself and occasionally screaming. Twenty-two minutes and 18 miles later, Dudley pulls up to the Rockbridge Regional Jail, where John is placed in a holding cell.

Meanwhile, Bolen does a door-to-door search of the neighborhood until he finds John's mother. After learning from Rebecca McCloskey of her son's mental problems, Bolen returns to the store. He picks up Christy Moore to obtain misdemeanor warrants charging John with disorderly conduct and indecent exposure.

Weeks later, when questioned by Pence, both deputies insist they didn't harm John. The witnesses at the store tell the investigator they saw no abuse, one commenting that the deputies "acted very professional."

At 11:25 a.m., John is booked into the Rockbridge Regional Jail. For the six hours he is there, he never leaves the booking area. He is either at an interview desk in the middle of the room monitored by security cameras and guards behind a glassed-in booth, or alone in cell 211, where he is checked every few minutes.

The jail nurse notes John shows no signs of trauma.

Mark Sterling, a mental health worker called in to evaluate, writes in his report, "John was very agitated. He said he was with 3 cowboys when a man with a gun came and got him and brought him to the jail. He had the delusion that Marines were going to 'get you if you don't stop talking.' "

Sterling recommends John be sent to a psychiatric hospital "to help him be stabilized and back on his medication."

At 3:27 p.m., a magistrate signs a temporary detention order committing John to a state-run mental institution 30 miles away in Staunton -- Western State Hospital.

At 5:40 p.m. that same day, John arrives at Western State. He is given a physical examination. Temperature 98.4, pulse 80, blood pressure 142/90. Normal.

Dr. Randall Rolen checks John's eyes, ears, chest, and palpates his abdomen. Also normal. "No complaints by patient except bruises from handcuffs," Rolen writes.

Joyce Hoze is the admitting officer on duty. She later would tell state police that John "complained on numerous occasions that he had not been able to go to the bathroom in a week." Hoze would add that patients as talkative as John, who have been mistreated by police, are "very vocal about it." John had said nothing.

Instead, John laughs proudly about his confrontation with the police and cowboys. He suddenly gets up and acts like he's shooting Rolen with a shotgun.

John denies visual hallucinations, but says his mother speaks to him when he's asleep. He claims to have special power to control people's thoughts, but other people can't control him.

Diagnosis: Bipolar, manic with psychotic features. Hospitalization is appropriate, Rolen concludes. At 8:30 p.m., John is taken to the second floor, Ward B-2, and assigned a room.

B-2 is Western State's forensic ward. It typically houses about 24 patients who face criminal charges ranging from public urination to rape and murder.

In the middle of the ward are two adjoining day rooms, with a hall of 12 bedrooms branching out of each. Patients are free to roam the ward unless they act out. Then they are locked in "seclusion rooms" -- a window, a door with no inside knob, a 4-inch-thick vinyl mattress on the floor -- until they are calm.

By 9 p.m., John finds himself in such a room. He has been threatening the staff, yelling at a nurse.

Security is called. Rolen orders sedatives and seclusion for three hours.

While a patient is in seclusion, hospital policy requires staff checks every 15 minutes and that his condition be noted in "flow charts." The charts show that for the next three hours, John is tense, pacing, banging on the walls and doors. Once, he urinates on the floor. He yells at anyone who looks in on him.

By midnight, he is lying on his mattress, eyes closed, calm. At 1 a.m., his door is unlocked, but it's locked again 15 minutes later when he resumes yelling and banging on the door. More sedatives. At 2:30, he is lying on his mattress again, eyes closed and calm.

There is no flow chart notation for the next four hours -- an unexplained, yet common oversight for which Western State would be chastised in a later investigation.

Friday morning, 6:30, Dec. 16, 1994. John is lying on his mattress. He has been that way for an hour, and his door is unlocked.

At 7:30, he is let out of seclusion. Again, more yelling and "clapping fists together in threatening gesture." He's back in seclusion at 8:30, given more antipsychotics and sedatives.

At 10, a psychiatric team headed by Dr. Nickie Spears arrives to develop a treatment plan. John sits up. His movements are jerky despite the sedatives, his speech too slurred to understand.

Here's what is understandable: "I hate Clinton and Clinton hates me." "Don't call me McCloskey! Call me Chief."

Later to Pence, Spears would say that John didn't complain of any discomfort and that she doubted his psychosis and medications would have blocked him from feeling pain. A nurse would tell Pence just the opposite.

John spends most of the day in seclusion. He is released at 3:45 p.m., but he starts yelling and lashes out at a nurse. He is locked up again at 4:45. More sedatives and 15-minute checks.

He settles down by 11:30. The door is unlocked at 2:20 a.m.

There is no documentation for the next 4 1/2 hours.

Saturday morning, 6:55, Dec. 17, 1994. Nurse Peggy Climdent writes that John went to sleep at 3 a.m. Later, she writes, he bathed, took more sedatives and said "this was a good place for a young man like him to be."

There is no documentation for the next 2 1/2 hours.

At 9:30, he grabs a nurse's arm and asks her to take him "to the prison to get my coat. Just take me in the car, and we'll come right back." The nurse frees herself, and male staffers escort John to a "less stimulating environment" -- an unlocked quiet room. More drugs.

There is no documentation for the next seven hours.

At 4:55 p.m., John walks into the staff office and refuses to leave. He is "unmanageable," and is taken to seclusion.

He yells, curses and bangs on the door until 9:45, when he lies down and is calm. At 10:15, he is asleep and the door is unlocked.

There is no documentation for the next seven hours.

Sunday morning, 5:30, Dec. 18, 1994. Nurse Linda Mitchell writes that John has been up several times, wanting to smoke and make a phone call.

At 6:30, he is talking to staff and is "very cooperative." His vitals at this hour: temperature 97.6, pulse 98 beats a minute, respiration 24 breaths a minute, blood pressure 110/68.

Then at 9:10: "Oh my God, I've got to s--- and I can't! Don't anyone touch me!"

He is lying on the floor, holding his stomach. He has vomited three times, the staff notes. His temperature now: 99.2.

The psychiatrist on call, Dr. Tim Kane, orders a rectal suppository. An hour later, John expels "small, formed feces."

At 11:45, his temperature is 100.2, pulse up to 116. Decreased bowel sounds, and his abdomen appears distended. He keeps vomiting "brown-tinged phlegm" -- fecal matter.

At 12:45 p.m., he's put in ankle restraints and taken to the hospital's medical center. Abdominal X-rays are taken. Kane notes the film doesn't show any free air, which would indicate a hole in the intestine requiring immediate surgery. Kane sees a "large amount of stool & gas throughout large intestine," suspects constipation, and orders a soapsuds enema at 1:30.

(Doctors would later determine that Kane misread the X-ray. There was free air, there was a hole in the colon, and the enema only helped flush fecal matter out into the abdomen.)

At 2:45, John is still vomiting dark-brown mucous liquid. His vitals at 3 p.m.: temperature 100.7, pulse still high at 100, breathing rate up to 60, blood pressure 110/60.

At 3:45, he's put back into ankle restraints, loaded into a security van and taken to the University of Virginia Medical Center in Charlottesville. For the hour-long trip, he is seated and calm.

He arrives at 4:45 and is rushed into exploratory surgery. He will never recover.

The 22 staff members interviewed by Virginia State Police said they never saw John being abused. No one heard him complain of being injured, until the van ride to UVa.

In what would become the most incriminating evidence gathered by Pence in the Western State interviews, a security officer, Shawn Brown, said that as he helped John into the van, John asked, "You're not going to beat me like the men in brown suits?"

The brown suits, to Pence, meant the deputies.

A bedside interview

In the year that followed, the investigation advanced fitfully.

In April 1995, Pence obtained accident reports from Carlisle, Pa., where John had been in two car wrecks in the fall of 1994. Pence sent these and all other reports to Fierro, the state's chief medical examiner. In May, Fierro concluded that "multiple blunt-force impacts to the abdomen," not the car wrecks, caused his injuries.

After a meeting with the medical examiner, Pence informed superiors that Fierro "advised the injuries could have and most likely came from someone holding the victim down on his back with their knee pressed in the stomach with the victim struggling."

(Fierro would later say this wasn't her theory. "I wouldn't begin to speculate on a position," she said. "So often you're asked, 'Is that possible?' and you say yes, and the next thing you know that's translated into how it happened.")

In September, Pence returned to Rockbridge County to interview the store owner, Baldy Thacker, and an employee he hadn't questioned before, Silas Foster.

In his first interview, Deputy Dudley had mentioned that Thacker had said "he had to hold him [John] down until our arrival." Had Thacker done anything violent?

To Pence, Thacker again said the deputies had done no wrong, that they "went out of their way not to hurt the boy." As for his own actions, Thacker said all he did was stand in John's way when he tried to walk off before the deputies arrived.

Foster told the investigator he never saw Thacker touch the boy. As for the deputies, Foster said, he "felt they treated him very nice for the way he was acting."

Another round of interviews, and still no suspects.

The mysterious cause of John's injuries wasn't the only obstacle Pence faced. From the beginning, he hadn't been able to question perhaps his most important witness -- the victim, John McCloskey.

Doctors hadn't expected John to survive his first night at UVa. In the year that followed, John's injuries had kept him confined to his bed, where he'd drifted in and out of consciousness, and from surgery to surgery. The breathing tube down his throat kept him from speaking, and his damaged brain and body allowed him to communicate, in the best of times, only with his eyes -- one blink yes, two blinks no.

But in December 1995, John's mother called Pence to say her son could finally speak. What he could remember, and the reliability of his recollections, was another story.

On Dec. 15, 1995 -- exactly one year after John's arrest -- Pence went to the hospital, donned mask and gown, and questioned John alone in his room.

In the 15-minute interview, John lay motionless and spoke with difficulty, Pence noted. His speech was slurred, sometimes incomprehensible, and of that year-ago day, he remembered nothing about Western State.

"Do you remember anyone hurting you?" Pence began.

"Yeah."

"You don't remember?" Pence asked, apparently not understanding John's answer.

"They were rough with me," John answered.

"Who was rough with you, the deputies or who?"

John: "Yeah, the deputies."

Later, Pence asked, "Did anyone do anything to you?"

"I don't remember."

"You don't remember? You can't remember anybody hurting you?"

"I felt a large push. It knocked the wind out of me."

"Before they cuffed you?"

"Yeah."

"You felt a large push and they knocked the wind out of you?"

"Yeah.

"When was that, John?"

"At the store."

"At the store . . . and was that somebody that worked at the store, or was that one of the policemen?"

"No, a deputy."

On Feb. 7, 1996, less than two months after interviewing John, Pence shared his findings about the deputies with Rockbridge County's new commonwealth's attorney, Gordon Saunders.

From all he had heard, Saunders believed Western State should have been viewed as the likely place of the assault. True, the victim had implicated the deputies, but Saunders doubted John's mental health and believed Pence had asked leading questions; indeed, the investigator was the first to mention "deputies."

After Pence presented his case, Saunders decided there wasn't enough evidence to accuse anyone of the assault.

"When I saw all that, it just didn't amount to anything," Saunders would later say.

On Feb. 15, Pence closed his investigation "after consultation with the Rockbridge County Commonwealth's Attorney, who declined prosecution."

Nine days later, he would have to reopen it. On Feb. 24, 1996, John McCloskey died.

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