October 17, 2010|By Yeganeh June Torbati, The Baltimore Sun
The strangulation death of a patient at the Clifton T. Perkins Hospital Center in Jessup last month was the first apparent murder in the facility's 50-year history, but the third death there since 2008 to raise questions about staffing and operations at the state-run psychiatric hospital, according to documents reviewed by The Sun.
On the morning of Sept. 26, nurses discovered the body of patient Susan Sachs lying face-down on her bed with a shoelace wrapped around her neck. State police charged her hall mate, El Soudani El-Wahhabi, with first-degree murder, and he was indicted on Friday.
A year earlier, a patient was found dead under his bed, which staff had allowed him to use as an exercise weight. The prior year, a woman complaining of pain received limited treatment until she fell unconscious and later died.
The three deaths, along with a recent spike in patient-on-patient attacks at the hospital, reveal shortcomings about operations at Perkins, Maryland's lone maximum-security hospital, a review of records and interviews shows. The facility holds more than 200 patients, many of whom are under evaluation for their competency to stand trial or who have committed felonies and would otherwise be sentenced to prison if not for their mental illness.
Doctors, nurses and security workers face chronic staffing shortages and tight budgets, and operate under what some describe as pressure from administrators to move patients quickly from high-security rooms to less-restrictive settings and eventually out of the facility, hospital and state investigative reports and interviews with former employees show.
State officials are reviewing the Sachs case to determine how and why hospital employees decided to place El-Wahhabi, a killer with a history of violence against women, in a room near the victim.
In the two earlier cases, investigators concluded that staff errors and oversights contributed to the deaths. Details of the incidents are contained in subsequent reports from the Office of Health Care Quality, the state agency that licenses and regulates Maryland health facilities. According to the reports:
• Investigators examining the May 30, 2008, death of a Perkins patient found that staff did not check a woman complaining of deep pains in her leg for blood clots, even though the 41-year-old was obese, sedentary and HIV-positive — which can all lead to blood clots — and was taking medication that increased the clotting risk. After falling unconscious, the woman, whose identity was not revealed in reports, was rushed to another hospital, where she died nearly three hours after her initial complaints. An autopsy determined that the cause of death was pulmonary artery blockage, often caused by a blood clot originating in a leg or pelvic vein. "The lack of a complete assessment," the report on the incident concluded, "contributed to the delay in obtaining necessary emergency interventions for the patient."
• In September 2009, a man under evaluation for his competency to stand trial was found unconscious underneath his bed. Staff originally thought the man had committed suicide by dropping the bed on himself, but an autopsy discovered that he suffered a cardiac arrhythmia because of a rare heart condition while using his bed as a makeshift bench press. An autopsy report revealed that staff knew the man used his bed for exercise, a violation of hospital protocol, but did nothing to stop him. The review concluded that while the man died of "natural" causes, "[w]hen the patient encountered a health crisis, the 78-pound bed was left resting on his neck/chest acting to impair his chances of resuscitation following the crisis."
Perkins administrators conducted internal reviews after each incident and took corrective action, said David Paulson, a spokesman for the state Department of Health and Mental Hygiene.
While the investigative reports identified concerns about the care provided by hospital staff, the agency "did not conclude, and could not have concluded from the facts, that the identified concerns were the cause of these unfortunate tragedies," Paulson said.
Incidents not rare
Roy Praschil, director of operations for the National Association of State Mental Health Program Directors, said the incidents at Perkins are tragic, but not rare in hospitals that treat violent patients.
"It's very difficult often to mix security with treatment priorities, although that's what these facilities are forced to do," Praschil said. "This is not unique to Perkins or any other forensic facility."
Kenneth Powers, a spokesman for the Joint Commission, the national body that accredits hospitals and has recognized Perkins for meeting standards, said the patient deaths indicate that some of the organization's protocol are not being followed, although he added that bad incidents can happen even when proper procedures are in place.
