In a front-page story in Sunday’s editions, the American-Statesman’s Andrea Ball chronicles the death of Ann Simmons, a 62-year-old woman from the northeast Texas town of Pittsburg who died of a blood clot last year in Terrell State Hospital. Simmons, who suffered from bipolar disorder, was in wrist and upper body restraints when she died.
We know Simmons’ cause of death because her husband and daughter insisted that an autopsy be performed. The autopsy showed that the retired elementary school teacher died of a pulmonary thromboembolism “associated with relative immobility from hospitalization for psychosis.”
No medical panel or group outside the state hospital system reviewed Simmons’ death to examine whether her care had been adequate or followed proper procedures. Simmons’ story illustrates the need to independently review the deaths of patients in state hospitals.
As Ball reports, most deaths in state hospitals are investigated by a team of doctors, nurses and administrators at the hospital where the patient died and by a medical committee at the Department of State Health Services, the agency that runs the state’s 10 psychiatric hospitals. The internal reviews regularly clear doctors of providing improper care, even when the reviews find that medical problems weren’t properly diagnosed or treated. Questions of objectivity lie in the contradiction.
Ball acquired the death reviews of 34 patients who died in state-run psychiatric hospitals between 2005 and 2012. The Statesman hired Dr. Sidney Weissman, a psychiatrist at Northwestern University’s Feinberg School of Medicine, to analyze the documents.
Weissman did not find the number of deaths at state mental hospitals unusual but he did find problems with the care given some of the patients whose reports he reviewed. Terrell hospital staffers, in Weissman’s opinion, failed to recognized that Simmons was dehydrated and at increased risk of a blood clot. Further, Weissman found a general reluctance by officials in state hospitals to take responsibility when inadequate care is indicated.
“There’s an attempt to attribute deaths to medical illnesses, not medical care,” he told Ball.
A spokeswoman for State Health Services told Ball the agency’s “doors are wide open” and that it would have no problem with additional oversight. Nor should it.
It should be noted, though, that when Ball requested additional patient documents, the agency refused to release them and told her it had made a mistake releasing the reviews it had released.
Ball’s story is the latest in a series reported by her and the Statesman’s Eric Dexheimer that have uncovered numerous failures within the state psychiatric hospital system to protect patients. The case of former Austin State Hospital psychiatrist Charles Fischer, indicted last year on charges of sexual abuse of adolescent patients in his care, pointed to inadequate supervision of physicians with histories of sexually inappropriate behavior.
Other stories raised questions about how hospitals handle rape allegations by patients and the lack of protocols for treating patients with eating problems. Ball previously reported the story of a patient at Rusk State Hospital who, despite her eating disorder, did not have additional attention paid to her food intake and hydration. She died from blood clots, which can form when a patient is dehydrated.
The woman’s case prompted an inquiry by a federal Medicare investigator who concluded the hospital failed to provide adequate nursing care.
As with Simmons’ case, the cause of the Rusk patient’s death is known because an autopsy had been performed. Autopsies, which are essential to determining cause of death, are not required and a patient’s family often refuses to grant permission to do one.
Autopsies were performed in less than half the cases reviewed by the Statesman. And only a handful of cases acquired by the Statesman had been reviewed externally. When they were — as the Rusk patient’s case was — problems with patient care were found.
This month the Texas Senate passed a bill by Republican Sen. Jane Nelson of Flower Mound that would require hospitals to report cases of abuse or neglect, require criminal background checks of prospective employees and create an independent position in the state hospital system to assess patient care. Nelson’s legislation awaits consideration by the House.
A measure filed by Democratic state Sen. Judith Zaffirini of Laredo would require the Department of State Health Services to create a database to keep track of abuse complaints against hospital staff. It sits in committee.
Both bills deserve support. They help repair a state hospital system that the Statesman’s reporting has shown is full of holes.