Another fatal failure in Florida

The Tampa Bay Times just published a horrifying report — an example of yet another person who slipped through the cracks of Florida's metal health system.

Driving the news: Reporter Michaela Mulligan tells the story of Julian Carter, an 11-year-old who was Baker Acted 44 times before he died by suicide.

Why it matters: Julian's death triggered an investigation by child welfare experts, who found failures by the state Department of Children and Families and its regional contractor, Eckerd Connects Community Alternatives.

• Yet no one was held responsible, Mulligan writes.

What went wrong: Mental health professionals recommended Julian for long-term residential treatment at least 20 times, but he never got it.

• Julian was treated by six health care systems and with 11 different diagnoses over his last three years. Mulligan writes that doctors prescribed medications that may have counteracted one another.
• No one assessed his needs or his mother's ability to care for him, despite all his medical interventions, and procedures to ensure coordination of care weren't being followed.

Go deeper: This story is worth your time.