I have named the woman in this report
"Patient # 72". This does not tell much of who she was: a
mother, a grandmother, and a courthouse clerk. But it
does emphasize how little her life and death meant to the "system."
Real people become numbers. Paperwork is valued over people.
People with disabilities are
often seen by society as expensive and expendable. Abuse and neglect of
mental health patients is often not reported - or carefully
investigated by an independent committee. The lives of people with
psychiatric conditions seem to have less value than others.
Psychiatric patients have far fewer rights than other people with disabilities
such as physical, age or mental retardation. Mental patients have fewer
rights ... and fewer advocates.
Nothing
in this Report Is Intended to Discourage Anyone From
Seeking Help
At Blue Bayou Mental Health or Anyplace Else.
Mental
Health Treatment Usually Works Well.
Events
like Those Described in this Report Are Rare, But They
Do Happen
Agencies Need to Acknowledge Their Mistakes ... Not Cover Them Up
On May 20, 1996, Patient # 72 was discharged from the County Psychiatric Hospital, a short stay crisis hospital. She had been admitted several days earlier after taking an overdose of her prescription medication. The hospital's chart notes indicate that she was at very high level of suicide risk. Her doctor was worried that she would try to kill herself again. She was to have follow up care at Blue Bayou Mental Health where she had been a patient since the fall.
Patient # 72 was one of the more challenging clients in the local mental health system. She made many suicide "gestures." She was one of those people whom "everyone" thought was going to kill herself sooner or later." Everyone in the system - at all levels - was losing hope - and becoming burned out on her.
However, what her doctor at the psychiatric hospital did not know was that for months her Therapist had been helping her to stockpile out-of-date medications. When Patient # 72 felt she was suicidal, staff would take her pills from her. When she was feeling better, her Therapist would give them back to her (including out-of-date medicine). This is not standard practice with old pills. In fact, it is highly unusual because it is dangerous.
It was hoped that this arrangement would help Patient # 72 to feel in control of her life and treatment. Other Blue Bayou Mental Health staff, including the Executive Director and the nurse, knew of and approved the exchange of the pills. However, they never told her psychiatrist or hospital staff about the stockpile. It is unlikely that they would have approved of this because of its risk.
Her Therapist was being eased out of the agency due to other staff and client complaints. Patient # 72 was his last client. She had threatened to kill herself if he were let go from the agency. She refused to see another therapist. Her personal letters and statements indicate that she was infatuated with her Therapist. One letter from her says that she fears he is getting "burned out" on his job.
On Friday, May 24, 1996, Patient # 72 had her last encounter with her therapist at Blue Bayou Mental Health. She was believed to be at high risk for self-harm. The agency's suicide prevention plan was that her Therapist was to phone her Friday evening. If he got no answer, he would know that she had overdosed on the pills and he would call emergency personnel to go to her apartment. This plan was to be approved by both the nurse and executive director.
Usually when a person is thought to be suicidal they are given only enough medications for a day or two. However, on Friday morning, Patient # 72's therapist placed a "sack full" of pill bottles in the Business Manager's office. They were to be given to Patient # 72 when she came into the Blue Bayou office. In the late afternoon Patient # 72 came into the office. Her Therapist gave her the entire sack of medications.
Patient # 72's Therapist was to phone her and go to her apartment with medical help if she did not answer. The Director later said that the Therapist phoned her, and she did not answer. However, rather than calling an ambulance, or calling other Blue Bayou Mental Health staff, he did nothing - despite knowing that she had the pills. Patient # 72 overdosed that night.
Not more than a few
hours could have passed between when she picked up the sack of pills and when
her Therapist was supposed to have phoned her. She was found,
dead, the next day. If her Therapist had followed through with the suicide
plan, she might have survived. It is not known
why he failed to visit her to see if she had overdosed. These relevant
facts of her death were not reported to the police, mental health officials or to
her family.
For the next few months I tried to get Blue Bayou Mental Health to report the facts of Patient #72's death, as required by law. Their response ranged from "it would hurt the agency" to "it would hurt the family" and "she would have done it anyway, sooner or later." The executive director told me that I was "not a team player."
No one besides me believed that her family deserved to know the truth about her death. Most families want to know the truth - they resent having their feelings "protected" by professionals. Everyone was worried about the potential legal liabilities. The Therapist was fired - and never returned to the agency and did not in his notes for his last sessions with Patient # 72. The excessive director and nurse did not ask him for them.
It is true that all suicidal people are ultimately responsible for their own actions. However, they look to mental health professionals for HOPE. When we send them mixed messages, or worse, they believe their caregivers are "burned out" on them, what kind of message does that send? Patient # 72 fell into that category where some people said that she was "better off dead." This is a message that no one in the mental health field should ever send. We are paid to be the "hope of last resort" - and that is a responsibility we cannot abandon.
Just three years before, she had an active family life and job. She worked as a court clerk in the justice system. I could not believe what had happened to this woman in the public mental health system. Though she met several good doctors and therapists in the County, overall, I'd never seen such a case of poor treatment and injustice.
When I read her historical file, I was dismayed by the long string of failed treatments and
conflicting diagnoses. For example, she was given
electric shock for depression - which was stopped by her doctors for fear of
brain damage. Shortly after the electric shock treatments
she wound up in one of the toughest mental wards in the state hospital. In fact, some
of her best times and opportunities were through BBMH
and the County hospitals.
Blue Bayou is a small area. After Patient # 72's funeral I learned that some of her closest family friends were also some of my closest friends. They would ask me what happened to her. I could not tell them. This became a greater burden on me as this family had been part of our wedding party many years before.
Also, at the same time I was also giving state-sponsored trainings to other mental health workers on mental health law and treatment issues. I was on an advisory board that reviewed such "unfortunate events." I was supposed to be helping ensure "patient rights" in the system. It became more difficult to withhold the truth.
As the months went on, and I kept the details of her death secret, I felt ever more guilty and angry with myself. But, I was worried about the consequences for my agency and myself. Then, something happened.
In early October 1996, a Blue Bayou staff person reported receiving a phone call from a person who knew details about Patient # 72's death that only the staff knew. Once again the agency I worked for did nothing. I was stunned - it was obvious to me and others that the story was getting out. After one more urging to the executive director and the nurse, I made my report about her death to local mental health authorities. And, just about everything in my life began to change.
After I made my report, I learned that Patient #
72's daughter had already requested an investigation. The state's Advocacy
Center investigates cases of suspected abuse and neglect. After the death of
Patient # 72, the Therapist's qualifications began to be
questioned. He only had a Bachelor's degree in Sociology - yet did
"psychotherapy" under Medicaid. He was clearly not qualified to
be treating her - but, had been certified by the
County, apparently without any background check.
The Advocacy Center concluded that Blue Bayou Mental Health had been following the patient's wishes. However, Patient #
72 had left notes saying she did not want anything bad to happen to Blue Bayou
Mental Health or her Therapist. The Patient herself,
was quite pleased with the help she had gotten from Blue Bayou. The Advocacy
Center recommended the agency change their policies for holding medications for
at-risk clients. They referred Patient # 72's daughter to an attorney to pursue
her case further.
Under our state's law, people who report suspected cases of abuse and neglect are supposed to have 90 days grace period before they can be disciplined by their employer. Two months before reporting Patient # 72's death I was given a merit pay raise - and, then two months after I reported the death, I was put on a "work plan."
One
major component was my "not being a team
player." I appealed the work plan to the agency's Personnel Committee.
However, they said that they were "unable and unwilling" to review
the death, calling it an "unfortunate event." In fact, they said that
I had "violated confidentiality" and needed to understand
"management prerogative and employee duties." One main point was that
"once a decision is made by the agency; staff must be loyal."
This may never have happened if I had been protected by a union.
I was not at all prepared for the harassment that happened after I made my report on the death of Patient # 72. Long before their "paperwork investigation" I had requested to use the agency's portable laptop computer to update my chart notes. I was recuperating from foot surgery and could not get out of bed for nearly a month. The agency denied my request - even when it was supported by a doctor's note saying that I needed the laptop.
Finally, after a 2-month "investigation" of my paperwork, I was fired. The irony of being fired for paperwork is that I developed the computer database that does the agency's chart notes and summaries. My income billings and level of client satisfaction were among the highest at Blue Bayou Mental Health.
Blue Bayou Mental Health still billed Medicaid for my work and accepted payment for the same notes they fired me over. This case shows what many consumers and their family members have long said - the system cares more about its paperwork than its people.
Since being fired I have
learned that although there is supposed to be "protection under the
law" for whistle blowers - it is almost never enforced. While several
mental health officials were shocked at my story, no one could help me get my
job back. My co-workers mostly refused to get involved. People tend to protect
their paychecks rather than a patient's rights.
* A patient's primary doctor should be kept informed of all relevant facts about their patient's mental health treatment - not as happened in the death of Patient # 72.
It is unlikely that her psychiatrist would have approved the hoarding of out-of-date medications when the patient had a long history of overdosing on pills. A treatment team must act like a team and share information together.
* Families and local mental health authorities deserve to know the facts of how a person dies. The law has no teeth for false or misleading reporting by staff. Family members should have a right to know how their loved one died. That has to be an absolute value - not some families told and others not.
* When people are on a suicide watch - or are at risk - they should only be given enough medicines for a day or two - certainly not enough to overdose on. This should be standard policy - it is common sense.
* There should be stricter laws about hoarding out-of-date medications. The practice of a therapist holding medicines and then giving them back should be reviewed.
* We need to give people with psychiatric conditions the same civil rights in treatment as we give to every other group of people with disabilities. Among these rights are the right to be free from financial exploitation and the responsibility to notify officials when Critical Incidents happen.
* People who report cases of suspected abuse and neglect need to be protected by tougher laws and a longer grace period
before an agency can retaliate against them. It needs to be clear which agency
has responsibility for investigating whistle blower complaints. Staff may need the protection of a union.
* The mental health profession needs to do a better job of policing
itself and disciplining its members who violate basic standards of care and
ethics. The public sector needs to improve its methods of reporting and
punishing cases of abuse and neglect.
If Patient # 72 had been seeing a counselor in the private sector
there may have been ethical guidelines and peer review committees to
review her
care. However, therapists employed by taxpayer funded mental health offices
are
largely exempt from such ethics codes, formal peer reviews and
continuing
education requirements. This needs to change.
Return to the Opal Whiteley Mental Health Report
Mission Therapy & Other Placebos - actual photo
