| Jo Ann Henrie Foreman |
 COUNTY OF MENDOCINO Grand Jury |
Telephone: (707) 463-4320 |
GRAND JURY |
INVESTIGATION OF A SUICIDE AT THE MENDOCINO COUNTY ADULT DETENTION FACILITY A suicide in the Mendocino County Adult Detention Facility (Jail) was investigated by the Grand Jury. As the deceased was a frequent patient of the Psychiatric Health Facility (PHF). and h~. been jailed following a physical altercation at the PI-IF. the Grand Jury inquired into the policic~. procedures. and personnel of the Jail, the PHF. and the California Forensic Medical Group (CFMG). which provides medical services to the inmates of the Jail. Findings include the procedures followed and the outcomes of those procedures in P1-IF and the Jail surrounding the sequence of events. Recommendations are made for improvement of PHF, CFMG, and Jail training and procedures. General oversight investigations of the PHF, CFMG, and the Jail were also conducted and have been reported separately. REASON FOR INVESTIGATION This investigation was initiated in response to a citizen complaint that the deceased in particular, and mental health patients in general. were not being treated appropriately at either the Jail or PHF. METHODS OF INVESTIGATION Documents reviewed were the policies and procedures of the Jail, PHF, and CFMG. Also reviewed were documents pertinent to the deceased, including medical records of St. Helena Psychiatric Hospital, administrative records of PHF, and CFMG; the Coroner's Report; Jail records, and some documents belonging to the deceased. Interviews were conducted with representatives of the psychiatric and administrative staffs of PHF and CFMG; members of the Ukiah Police Department; an attorney; probation officers; friends and relatives of the deceased; representatives from patients' rights grzups; and professional investigators. FINDINGS I. The death was a suicide. Prior to a motor vehicle accident in January. 1995. the deceased had been employed. She had also been a student at Mendocino Community College where she was involved in extra-cumcular activities. Following the accident, her level of functioning decreased and behavioral and psychotic symptoms appeared. After six psychiatric admissions (two at St. Helena Psychiatric Hospital and four at PHF), PHF changed her primary diagnosis from a psychosis to a behavior disorder, even though there was no documented change in her symptoms, behavior, or laboratory tests, nor was psychological testing done. 3. The deceased had voiced suicide threats to numerous persons, including her attorney, her probation officer. a Ukiah Police Officer, a Jail Correction Officer, a CFMG nurse, a CFMG Psychiatric Technician, and two members of the PHE mental health staff. 4. On January 25, 1997, the deceased was brought to the Emergency Room of Ukiah Valley Medical Center by a Ukiah Police officer. She was held under the Welfare and Institutions Code, Section 5150. following a reported suicide attempt. She was then taken to the PHF by the same officer. She was denied admission to PHF under Section 5150 (involuntary admission). She then sought voluntary admission, which was again denied without adequate assessment of suicide potential. She was forcibly removed by PHF personnel, resulting in a significant physical altercation. Following her removal, she allegedly committed an act of vandalism at the PI-IF. was placed under citizen's arrest b\ a PHF staff member. and then iailed. As a result. focus shifted from treating the deceased as a mental health patient to treatment as a criminal. 5 The CFMG employee (also employed by PHF) responsible for assessment and treatment decisions in the Jail, was a participant in the physical altercation at PHF and was one of those assaulted by the deceased. Being involved in the altercation could have potentially affected this employees later professional judgment and decisions regarding the deceased. The deceaseds suicide potential was not adequately assessed by this CFMG employee. resulting in her removal from a secure isolation cell. 6. Jail policies and procedures were violated when the deceased received the inappropriate jail classification of 'M" ("Medium range risk potential with no currently identifiable major risk characteristics'), even though the deceased's history of psychiatric hospitalization met the criteria for "5" ("History of psychiatric hospitalization ... history of suicide attempts, use of psychotropic medications, symptoms of mental/psychiatric/psychological conditions ). She should have been given the classification of "S." 7. The deceased's requests for administration of her prescribed medication were repeatedly refused by CFMG staff. 8. Both PHF and CFMG failed to regard the deceased's suicide threats as serious, increasing the likelihood of her eventual suicide. 9. There were contradictions between the oral testimony and the written medical records of CFMG. There was also contradiction between oral testimony of PHF and CFMG personnel. 10. The minimal standard for a walkthrough (inmate check) for the administrative segregation cell by a Correction Officer at the Jail is once per hour. On February 4, 1997. there was no walkthrough from 1330 to 1630. The deceased was found dead in her cell at 1630. 11. The PHE Quality Improvement Committee consists of nine members. Seven of these are DMH employees and two are contract providers. In spite of the requirement to hold meetings on the last Wednesday of every month, the meeting concerning the 1/25/97 altercation at PHF was not held until 5/28/97. four months later. It did not assess deficiencies in the way the deceased had been dealt with by PHF staff, nor did it provide practical ways for reducing similar events in the future. RECOMMENDATIONS All PHF and CFMG personnel responsible for patient assessment and/or care should receive further training in the assessment of suicide risk. This training should be conducted by an agency accredited by the California Medical Association or the California Psychological Association and should be repeated annually. (See Findings 1, 2. 3, 4, 5, 6, 8, 11.) 2. All P1-IF and CFMG personnel involved with patient assessment and/or care should receive additional training in dealing with difficult clients with a particular emphasis on nonphysical methods of behavioral restraint. (See Finding 4.) Corrections Division. Policy and Procedures Manual.' Mendocino County Shenffs Office, I. Inmate Classification Policy 410 00. 10.0 & 15.0.3 Any CFMG or PHF mental health staff member who has been assaulted or otherwise misused by a patient should consult with the appropriate medical director before making significant decisions regarding that patient. (See Finding 5.) 4 Membership of the PHF Quality Improvement Committee should include at least one individual appointed by the County Public Health Officer. This should be a member of the professional mental health community in the County, should not be a County employee. and should be changed annually. (See Finding 11.) 5. The Mendocino County Sheriffs Department should follow its policies and procedures regarding inmate classification and inmate walkthrough checks. (See Findings 6, 10.) RESPONSE REQUIRED 1. Mendocino County Director of Mental Health (Recommendations 1 - 4.) 2. Clinical Manager Acute Treatment Services (Recommendations 1 -4.) 3. Program Manager for the medical department at the Jail. (Recommendations 1, 2. 3) 4. Mendocino County Sheriff (Recommendation 5.) 5. Mendocino County Board of Supervisors (Recommendations 1 -4.) |