Questionable investigations, little oversight in state hospital deaths


Ann Simmons knew she was headed for trouble.

Her bipolar disorder was spinning out of control again: the mania, the illogical thinking, the impulsive behavior. So one night in early 2012, the 62-year-old Pittsburg woman let her husband finish watching the Super Bowl, then insisted he immediately take her to the hospital for treatment.

On Feb. 15, 2012, she arrived at Terrell State Hospital in Northeast Texas. Three days later, she was dead.

Medical records show that Simmons was in wrist and upper body restraints when she died of a pulmonary thromboembolism, a blood clot associated with long periods of immobility and dehydration.

But while the cause of Simmons’ death calls into question the medical care she received at the state-operated psychiatric hospital, no outside agencies investigated until a year later, after the American-Statesman called it to the attention of federally empowered patient advocates, Disability Rights Texas, which is investigating the case.

“The fact that she died in restraints raises a lot of questions,” said Rosa Torres, an attorney with Disability Rights Texas.

The response to Simmons’ death points to a statewide lack of oversight. A Statesman analysis of about three dozen deaths that occurred between 2005 and 2012 at state mental health hospitals reveals that:

     
  • Deaths are rarely investigated by anyone other than the hospital in which the patient died and the state agency that runs it, leading to questions about the integrity and objectivity of such reviews.
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  • Internal investigations regularly clear doctors of improper care even when those same reviews point out problems like failing to recognize or properly treat major medical problems, such as congestive heart failure and delirium.
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  • Deaths in state prisons get more scrutiny than those at state hospitals. Except in cases of legal execution, the Department of Criminal Justice orders autopsies on every person that dies in its care and a state criminal investigation agency reviews every death. None of that is required at psychiatric hospitals.

The Texas Department of State Health Services, which operates the 10 state-run psychiatric hospitals, says it would have no problem with additional oversight.

“Our doors are wide open,” said State Health Services spokeswoman Carrie Williams. “We welcome scrutiny and feedback on how we can do better and improve the lives of our patients.”

Patient deaths are always difficult, and the hospitals examine each one to find ways to improve care, she said. After someone dies, a team of hospital professionals — doctors, nurses and administrators among them — reviews the case.

Clinical death and peer reviews focus on medical care. Administrative death reviews examine policies. Both are used to determine whether changes should be made. Deaths are also assessed by a medical committee at State Health Services’ central office, Williams said.

But those reviews are generally not available to the public. The Statesman obtained more than three dozen reviews from State Health Services last year that are the basis of this story. When the newspaper asked for more, the agency said it had erred in providing them and declined to release any more.

As part of its investigation, the Statesman hired Dr. Sidney Weissman — a psychiatrist and professor at Northwestern University’s Feinberg School of Medicine — to examine death reviews and other documents obtained by the newspaper.

The number of deaths in Texas hospitals didn’t strike him as excessive. But the records did indicate systemic problems with the investigations that are done by State Health Services, says Weissman, who noted lapses in leadership, flaws in medical care and a reluctance to take responsibility for shortcomings.

“There’s an attempt to attribute deaths to medical illnesses, not medical care,” Weissman said.

That lack of accountability comes through in a 2011 death review at Rusk State Hospital, he said. According to information in that document, doctors appeared to have missed signs of worsening congestive heart failure, he said. The committee that conducted the administrative death review noted that the hospital didn’t have a protocol for monitoring symptoms of congestive heart failure “but should (consider) developing such protocol.”

Still, the committee determined, there were no problems in medical care.

“This is a total breakdown in the care of this patient, and nobody wants to say it’s a serious breakdown,” Weissman said. “There’s always an explanation. There’s always an excuse.”

Williams defended the integrity of the investigations performed by the Department of State Health Services.

“As a state hospital, we take the toughest patients and open our doors to anyone,” she said. “There are multiple checks and balances and layers of external scrutiny, and we rigorously examine ourselves down to the fine-grain level so we can do better. … We are centered on the patient and trying to improve every day. We are never standing still.”

An unlikely patient

Few people knew that Ann Simmons had bipolar disorder.

The retired elementary school teacher had a stable family life, many friends and plenty of time to volunteer. She doted on her two children, went on dozens of cruises and loved to meet new people.

“If she went to the bathroom, she had three new friends when she came out,” said her husband, Bob Simmons, who was also a teacher.

But when Ann Simmons’ bipolar disorder flared up, the hallmark symptoms of the disease appeared: mania, sleeplessness, impulsive behavior. She volunteered for everything and spent too much money. Sometimes she became paranoid or delusional, believing that the president was coming to her house or that people were out to get her, her daughter said. Over the years, Simmons had been hospitalized in private facilities six or seven times, then recovered enough to continue life as usual.

Bob Simmons knew his wife was struggling, but he was shocked when on Feb. 5, 2012, she suddenly insisted he take her to East Texas Medical Center.

It’s Sunday night, he told her. Why not wait until tomorrow to see your doctor?

She would not. Reluctantly, Bob Simmons drove her to the Tyler hospital. Instinct told him to turn the car around, wait until Monday and take her to her doctor in Dallas, but he honored his wife’s wishes.

When she was sent to Terrell State Hospital, it was over the objections of her family, Bob Simmons said. Throughout his wife’s stay at East Texas Medical Center, Simmons said, he unsuccessfully tried to have her transferred to a Dallas facility. But Terrell was where the medical center sent her, so that’s where she arrived on the evening of Feb. 15, 2012.

Terrell State Hospital, located in a small city about 200 miles northeast of Austin, provides short-term treatment for people with serious mental illnesses such as schizophrenia, depression and bipolar disorder. The facility offers a range of services to its patients, medication and general medical care among them.

State mental hospital patients tend to be in poor health. In addition to psychiatrists and nurses, each of the hospitals has general practitioners on staff. The state also spent $9.1 million in 2012 for medical costs incurred from sending patients to specialists, general hospitals and other settings.

Simmons was an exception. Before being hospitalized at East Texas Medical Center in early February, her only medical problems were high blood pressure, high cholesterol and acid reflux, her husband said.

Simmons had insurance, access to medical care and a family that was invested in her future.

But by the time Simmons arrived at Terrell State Hospital, she was too sedated for staffers to get a good handle on her medical and psychiatric history, according to a hospital review conducted after Simmons’ death.

She wasn’t eating or drinking well, so she was transferred to the hospital’s medical unit, records state. While there, a nasal gastric tube was inserted to provide nutrition and keep her from becoming dehydrated; a catheter was used to monitor her fluid levels.

But Simmons was psychotic, pulling out her tubes and refusing to sit still, the document states. Staffers strapped down her wrists and put her in an upper body restraint to keep her from sliding around.

Her family questions the accuracy of the hospital’s reports about her behavior and the need for the restraints.

On the day before her death, Simmons’ husband and daughter, Sherri Bowman, visited her separately at the hospital. Both say she was calm and lucid during those times.

“When I visited, she was restrained in a chair,” Bob Simmons said. “They untied one hand for her to sign a paper. She did not fight or make any threatening gestures, yet they tied her back up immediately. A couple of hours later, when Sherri visited, she was restrained on a gurney.”

During her visit, Bowman said, a staffer released Simmons from restraints to accompany her to the bathroom. When they returned, Simmons was immediately strapped back onto the gurney, even though she was relaxed, cooperative and hadn’t caused any problems, Bowman said.

Neither family member complained about Simmons’ restraints at that time because they assumed the medical professionals knew what they were doing, Bob Simmons said.

Williams said the agency can’t specifically comment on Simmons’ case, but that it has protocols to protect restrained patients. The hospitals do regular assessments of the patient’s circulation, hydration, mental status, range of motion of extremities and readiness for restraint release, she said.

In some cases, a staffer is assigned to monitor one patient exclusively. Medical records show that Simmons was under such supervision.

Documents obtained by the American-Statesman don’t say how many hours or days Simmons was restrained. They do, however, show that on Feb. 18, 2012, a staffer saw Simmons having a seizure in her bed. Her face was blue. She wasn’t breathing, and she had no pulse. According to the death review, “the restraints … were removed and she was moved to the floor where cardiopulmonary resuscitation was initiated.”

Late that night, Simmons died at a local hospital. A doctor and chaplain called Bob Simmons, but they couldn’t explain what had happened to his wife, he said.

‘The doctor kept telling me that she simply stopped breathing,” he said. “Well, that’s not a cause of death. I could have come up with that.”

Little oversight required

At Texas’ state psychiatric hospitals, unexpected or unusual deaths must be reported to a justice of the peace or county medical examiner, who weigh in on whether an autopsy should be conducted. By law, autopsies aren’t required for all deaths at state psychiatric hospitals, but Williams says hospitals are encouraged to seek them.

Simmons said that’s not what happened in his case.

After hearing about his wife’s death, he asked whether an autopsy was scheduled. The doctor, Simmons said, replied that one wasn’t planned and asked which funeral home the family wanted to use.

“She kept changing the subject,” he said. “I asked her like three or four times. An autopsy would not have been done if I had not insisted upon it.”

Williams said that doesn’t jibe with hospital protocol.

“There is zero basis for us discouraging an autopsy, especially if a family wants one,” she said. “Usually our discussions with a family involve us providing details about the death, answering questions, and providing explanation about autopsies and the consent requirement. We explain how an autopsy may give us additional details about the person’s death.”

Simmons’ autopsy showed she died of a pulmonary thromboembolism “associated with relative immobility from hospitalization for psychosis.”

Out of the 34 cases the American-Statesman reviewed, the state said it knew for sure that autopsies had been done in 15 deaths, but state officials said they didn’t have complete records for all of the cases the newspaper inquired about. Records show autopsies often don’t occur because family members refuse to give permission.

Without an autopsy, hospital doctors are forced to make an educated guess about the cause of death. The lack of an autopsy could make it difficult for the death review to analyze a patient’s medical care because physicians don’t have all the information they need, said Dr. Ben Druss, a psychiatrist and professor at Emory University.

“It would be hard to accurately assess the medical care without knowing the cause of death,” he said.

As in any medical facility, people die at Texas’ state psychiatric hospitals. Between 2005 and 2012, more than 170 patients died at state hospitals, with the number of deaths per year ranging from 16 to 29. Some of those people died after being transferred to a community hospital or shortly after discharge. Heart attacks, respiratory problems and cancer were among the causes of death.

When people die, a number of outside agencies can review those deaths: Medicare, which provides money to the state psychiatric hospitals; the Health and Human Services Office of Inspector General; the Texas Medical Board and law enforcement.

Those agencies rarely look at state hospital deaths. Of the nearly three dozen cases examined by the Statesman, Medicare examined two. The inspector general’s office scrutinized three. It is impossible to know how many deaths the Texas Medical Board investigated because the agency doesn’t disclose that information.

But when those agencies have gotten involved, they have spotted problems.

The Texas Medical Board, for example, punished a doctor at San Antonio State Hospital in 2010 for failing to arrive at the hospital until two hours after nurses first called him about a sick patient who later died. Medicare cited Terrell State Hospital in 2008 for failing to properly treat a woman who vomited blood multiple times during the day. Last year, Medicare faulted Rusk State Hospital for its nursing care of a woman with an eating disorder who died after refusing most food and water for 16 days.

In some cases, the hospitals acknowledge problems in patient care. In its examination of a 2011 case at Big Spring State Hospital, state hospital reviewers acknowledged that staffers had failed to keep timely and accurate medical records, perform required hall checks and follow procedures for responding to changing medical conditions.

Simmons care questioned

After Simmons died, Terrell State Hospital conducted multiple reviews, looking at the facts of the case to determine what systemic problems might have contributed to the death, records indicate. But the conclusions of that review haven’t been divulged to her family or the public because those documents are considered private

Weissman says staff at Terrell State Hospital made several glaring mistakes based on a review of the limited documents available in Simmons’ case.

Weissman said he understood the hospital’s decision to restrain Simmons if she was pulling out her tubes. Medical restraints are often used in such situations. But Terrell failed to recognize that the patient was both dehydrated and suffered severe sodium loss, he said, and treating her with the nasal gastric tubes didn’t correct the sodium deficiency.

Simmons’ mental confusion might have been related to low sodium, Weissman said. She needed an IV, which not only would have hydrated her, but would have allowed doctors to more accurately track her sodium levels, he said. Records indicate an IV wasn’t used.

The combination of the dehydration and restraints increased the risk of the pulmonary embolism that killed her, he said.

Other agencies that could have weighed in on Simmons’ death never did.

State records show that State Health Services contacted Medicare, but the federal agency has no record of receiving that information, said David Wright, deputy regional administrator for the Medicare office in Dallas, which covers a five-state area. The state recently re-sent that information to the agency after the Statesman called it to the attention of officials.

Unless it receives a complaint, Medicare’s regional office rarely conducts investigations of the 3,500 to 5,000 medical restraint deaths that are reported to it each year from the five-state area, Wright said. The federal agency is now deciding whether Simmons’ case meets the standard for an investigation.

According to the autopsy, the Kaufman County Sheriff’s Office was given the restraints removed from Simmons’ body, but the agency has no record of investigating her death.

The Health and Human Services Office of Inspector General — a law enforcement body that reviews hospital abuse, neglect or death cases — only scrutinizes cases referred to it by the hospital or other sources. Simmons’ was not.

A push for answers

Erman Smith Funeral Home was packed on Feb. 22, 2012.

More than 100 admirers had come to say goodbye to Ann Simmons: friends, family members, teachers, fellow volunteers from the Republican Women’s Club and the Texas Retired Teachers Association. They told her husband how much they loved her, how they would miss her smile and generous nature.

Bob Simmons never complained to the state health department or law enforcement after his wife’s death. He didn’t know he could file a complaint with Medicare or talk to a patient rights officer at State Health Services. He didn’t ask for her medical records or talk to the hospital for fear that he might jeopardize a possible lawsuit. A few weeks ago, while working on this story with the Statesman, Simmons requested his wife’s medical records from Terrell State Hospital, as well as those from East Texas Medical Center.

A year after Simmons’ death, her family remains devastated. Ann Simmons was the glue that held them together, her daughter said.

Sometimes, Bob Simmons sees his wife’s white Cadillac in the driveway and thinks, “Oh, Ann’s home.” And when Bowman was at a store and saw a woman who looked like her mother, she followed her around. It brought her some kind of comfort.

Those moments amplify the gnawing questions about what happened to Ann Simmons, Bowman said. And she suspects her family isn’t the only one searching for answers about a loved one who died while in the care of the state.

“If mom had people there fighting for her, what’s happening to all those other people who don’t have that?” she said.



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