Central State Hospital’s Failure to Report Patient Death Imbroglio

Just yesterday I wrote briefly of the contrasts between New Hampshire and Vermont who face difficult state wide mental health service care delivery tasks.

Today I feel I have to return to a story, or rather a sad saga, of Central State Hospital in Virginia. Virginia since the tragedy of State Senator Craige Deeds’ son Gus who was variously reported as bipolar or schizophrenia, committed suicide two years ago. The circumstances were unbelievably tragic, sad and preventable if, in my view, public and/or private psychiatric inpatient facilities had done their duty [more on that rant later below]. In brief summary, young Gus was in his very early 20’s and had been repetitively psychotically mentally ill for a few years illustrating the typical early adult onset of these illnesses, especially schizophrenia. He became psychotic again and stabbed his father. He was taken by his father to a nearby hospital ER, a hospital without a psychiatric inpatient unit. He was held in the ER for some period of time [the reports vary from hours to a few days]. He had to be released under less than clear circumstances because a bed could not be found for him in ANY psychiatric inpatient unit in the state, which to me is the first bad tip off in this saga. He very shortly thereafter, while apparently still quite symptomatic and actively ill, suicided. As is well known, his father Sen. Deeds has thrown his considerable talents, knowledge, energies and influence into crafting exemplary legislation in Virginia to correct many cracks and deficiencies in their combined state system of psychiatric care. Of note is the lingering issue that his bill is still not law in Virginia.

Now to the current unfolding tale of woe, and goodness knows what else that is week by week it seems, unfolding out of Virginia’s Central State Hospital. There have been a series of near damning articles in multiple minor and major newspapers in Virginia detailing the trial of failures it appears that resulted in the death of a woman named Valerie Anderson now buried on the campus of Central State Hospital since she died there.

Grave of Valerie Anderson
Grave of Valeria Anderson

The accounts from the various media, best summarized in the article, “State fails to notify family woman dies at Central State Hospital,” which appeared in the July 3, 2016 edition of the Culpepper Star-Exponent, shows that this woman was likely chronically mentally psychotic, a neighborhood recurring disturbing presence and was arrested for misdemeanor trespassing May 14, and was jailed as she was poor and could post a $1,000 bond. She was reportedly evaluated and cleared because of unspecified behavior in jail, and transferred May 24, 2016 to Central State Hospital. All without notifying her family but there were real issues with this part as she was out of follow up treatment and no one seemed to know where her family resided or how to contact them. She then died under unclear circumstances at Central State Hospital May 26th. The family as time went on, found they could not contact her. No one who knew her knew where to look. Meanwhile, the hospital for various and sundry reasons apparently did not do due diligence in following up and trying to establish more information about her and to contact the family. It finally took the Richmond Times-Dispatch in June bringing a Freedom of Information lawsuit to secure, confirm and establish that this lady had died in the hospital. This was prompted as described in the article thusly: “The search for answers in Valerie Anderson’s death was launched in earnest last month after the spokeswoman for the Department of Behavioral health and Developmental Services and other state officials declined to provide any details related to the transfer of an inmate from Hampton Roads Regional Jail to Central State Hospital.”

“Among the information officials initially would not provide about the Central State Hospital death: the patient’s name, gender, and age’ when he or she was transferred to the hospital; when exactly he or she died; and when and why the person had been incarcerated.”

Further, “Later, they to The Times-Dispatch that the patient was female, had been arrested for trespassing; was evaluated and medically cleared on May 24 for admission to a state hospital following mental health crisis at the Portsmouth jail; and was transported Central the following. she was found dead the morning of May 26 by a hospital worker.”

The intrepid reporters for the Times-Dispatch, then armed with the scant information they were able to gain from their Freedom of Information suit, did gumshoe, old-fashioned journalistic ‘detective work.’ and examined Newport News court records, found the record of a Valerie Anderson trespassing charge. And of things in the newspaper “morgue file,” as they used to be called, they found a sticky note marked “Important,” that gave the date of May 25 as her transfer/admission to Central State, and of May 26 as the date of her death.

An instance of denial by hospital officials June 8, to the Times-Dispatch team working the story, prompted them to only dig further [my characterization of what appeared to happen] and her grave was located on the grounds of the hospital. The Times-Dispatch also then were the ones–get this folks!- to locate her family and notify them of her death. Unbelievable…

As it turns out Virginia DOES have good state laws and mandatory procedures for handling patient deaths in state institutions of any kind and they are detailed quite objectively in the above-cited article.There are well-defined time frames in which certain steps must be taken in order and that the steps must go up the state government’s chain of command in a certain order to the highest levels. But the article’s description of the halting effort the hospital made in its description of the events and refusals and declinations to give information makes for sad but also infuriating reading. To make matters worse, the family was rebuffed initially in their efforts to gain information regarding the fate of their mother. This makes for tough reading as the article details the obfuscating and self-justifying responses of the officials that were contacted.

I will end this story with a final slightly lengthy quote which I think emodies the then attitude of the protective state functionaries [a kinder word than I think the families or reporters would use] who were in a position to help the family and reporters: “Anderson had a personal Facebook page and was online frieds with her four children. But social media sites and internet search engines are not part of the process state workers use to locate family members [I would ask WHY NOT?] when someone dies in custody, according to Maria Reppas, spokeswoman for the Virigina Department of Behavioral health and Developmental Serivces…The facility does not take steps such as conducting Google searches or looking through Facebook sites to locate next of kind nor is it required to do so,” Reppas said in a email.

After the family learned through the newspapers’ reporters that their mother was indeed deceased and had been buried in the hospital cemetery, the daughter Jacqueline asked to visit her mother’s gravesite. The article states at its end that she was told she would have to make an appointment to do so.

 

 

 

 

 

 

 

 

New Troubles at Bridgewater State

A troubling development repeated itself at the famed Bridgewater State Hospital in Massachusetts, the place where the “Boston Strangler,” Albert DeSalvo, and the model for the cult classic movie of the 1860’s, “TheTiticut Follies,” occurred in late June. Another patient death by suicide within the facility.

In an  article entitled “Suicide spurs call for receivership at state hospital,” written by Katie Lannan of the STATE HOUSE NEWS SERVICE of the Newbury Port Daily News detailed the now repetitive tragedy. The Center had tardily reported on April 8, 2016 the death of Mr. Leo Marinio from Lawrence MA who killed himself by “ingesting large quantities of toilet paper while in isolation.” The local state advocacy organization, The Disability Law Center of Boston was calling for the entire facility to be placed into “receivership” and for the state to move on plans to transfer the control and operation of the hospital from the Department of Corrections to the Department of Mental Health.

Two aspects of this case are troublesome to this reader. First, the report of the death appears from this and media reports to have been delayed by weeks, and deceased had somehow in isolation been able to stuff enough foreign material into his throat to block his own airway and have time to die possibly unobserved.

Where I practice in the state of North Carolina, a death within any state institution whether it be a mental health, nursing home, hospital, or correctional facility, MUST be reported to the state authorities within a time limit of 24 hours. How this may have been delayed this long is astounding to this writer. Any unnatural or unexplained death even in any kind of hospital must so be reported within such a time frame to permit timely review and objective investigation of the cause of death and its circumstances, in a constant effort at self-correction of procedures and public airing of findings. We see the same kind of hush-hush delays nowadays in correctional, meaning police related deaths going on and receiving national news coverage when people die in police custody, being taken into police custody and it seems nowadays to take a judicial order to release timely records involved in such untimely deaths, such as on the spot videos that are so common now.

Second, this facility which has dealt with the forensically seriously mentally ill for generations, was run by the Department of Corrections, not an agency tasked with dealing with complexities of the mentally ill, though it must be stated that it is still possible and does happen also in mental health run forensic facilities that suicides occur. But it was a real surprise to this writer than Bridgewater State was not in my mind a “hospital,” as I had always thought, but a correctional facility with all that that circumstance can bring with it, such as overuse of isolation for corrective measures, and a lack of training in dealing with the seriously mentally ill.

The article sadly, in my mind reports that it had recommended such a move nearly two years ago the then Governor Duvall in 2014 because of similar issues detailed in this blog in which three deaths were involved.

This writer will watch this situation and monitor how the state machinery and political system handles this in the future and “report back” to the reader.