The South Carolina state psychiatric hospital, historically called “Bull Street” for decades in the past, Brian (state) Hospital in Columbia SC, recently had a sad and tragic occurrence, a suffocation death of a patient apparently undergoing a hands on restraint for out of control behavior by multiple staff.

In a recent article written by Avery G. Wilkes of The State newspaper of Columbia SC, entitled: “Suffocation Death of SC Mental Health patient under review by group that accredits hospitals,” published July 17, 2019, the sad story of this tragedy is detailed. In this article, there is described the possibility that some of the staff involved in this patient’s restraint event, were not adequately trained in these highly complicated and at times, hazardous to all involved, events. I will try to comment on my own experience with these events below. In any case,

The results of such investigations are made public. This is not a closed process with no transparency. Sometimes the public can be overly suspicious that transparency is not being followed by officials at the state or hospital levels when the media note that officials could not and would not discuss details of these reviews at first until the results are determined and made public. An article published September 8 ,2017 by the Wall Street Journal authored by Stephanie Armour entitled: Hospital Watchdog Gives Seal of Approval, Even After Problems Emerge: The Joint Commission, which the government relies on to accredit most hospitals, rarely withdraws its approval in the face of serious safety violations,” gave a cursory overview of this issue which was taken up by the U. S. House of Representatives in 2018 with a request for documentation (House committee probes CMS, Joint Commission over accreditation process,” published in Modern HealthCare magazine). Unfortunately I have not been able through my searches to find left over record by that Commerce Committee of the House as to what eventually came of the initial inquiry.

But it is my opinion and experience, that one of the reasons the Wall Street Journal found that only 1% of hospitals nationwide are ever de-accredited is that wealthy private hospitals are de-accredited less than the state psychiatric hospitals. Medical hospitals are now usually huge conglomerates and rarely are penalized at such a level. Small poorer community hospitals seem to be more vulnerable to such review based censures. And they are closing across the nation now anyway for reasons of declining revenues but that is another story for another day. Suffice it to say that state psychiatric hospitals, as maligned as they still are, operate in a far more regulated and highly scrutinized environment than private psychiatric hospitals or units/services within large wealthy, private, or university medical center based entities.

States’ governmental laws regulating their health care facilities, as well as private hospitals, require investigations and review by various bodies locally and nationally, deaths of patients by unnatural causes. Local review bodies include legislative oversight committees, the states’ own departments that oversee state psychiatric and private medical/psychiatric hospitals, national bodies such as the Joint Commission for the Accreditation of Hospital Care Organizations (the famous “JCAHO”), CMS (the federal agency for Medicare and Medicaid)C etc. Investigations such as these are very important since failure and loss of accreditation by these bodies can result in loss of ability to receive reimbursements from various insurers, especially the federal ones, Medicare and Medicaid. And for state psychiatric hospitals, this is extremely important. State psychiatric hospitals serve mostly poorer patients on Medicaid and Medicare or the uninsured, and loss of these operating funds means that the state legislatures’ budgets then have to make all the lost funds until the hospital which has lost such accreditation and funding can regain such. This always involves submitting to the mandates the hospital must put into place. This process is always lengthy, detailed and usually requires “corrections,” “actions plans” etc. It is not a trivial event then when a state psychiatric hospital has such a tragedy, and when a “deficiency” is found. The investigative review process is arduous. It requires no questions asked cooperation by the hospital staff and leaders. Staff are subject to detailed interviews and scrutiny. Hospital policies are reviewed and the review personnel check to make sure that the policies are indeed followed and fully implemented. If there are deficiencies found, then the corrective actions are imposed and possible penalties such as loss of accreditation are imposed.

Now there are wealthy(ier) private psychiatric inpatient systems that have been de-accredited in the past few years and I would be remiss in my own ethical standards if I did not mention a couple of them. One was the Timberlawn Hospital of Dallas TX that in its heyday was truly a very good inpatient treatment facility. I had a former mentor from my long ago training days who migrated to work there and did exemplary work with adolescents. But the leadership and ‘mission’ of the facility changed a decade or so ago and it went rapidly downhill, quality of care suffered and tales/rumors of its bumblings, then deaths and such, began to emerge. It underwent investigation, lost accreditation which was a genuine shock to many who knew it in its heyday, and closed only a very few years ago. Another chain of psychiatric inpatient centers in the Boston area garnered such scrutiny, was loudly hectored in the media for a variety of missteps, some of them quite major and involved a lot of financial misdoings and lost its accredited standing also. So this does happen with some monied, strongly capitalized psychiatric inpatient entities, but I feel it does not happen enough and helps the explain the findings in 2017 of the WSJ article/expose.’

At this point I would like to comment on my own experience with at least the aftermath of a state hospital-based investigation regarding the patient death undergoing a take down manual restraint.

After serving as stint for approximately 4 1/2 years is the first psychiatrist at a newly established Native American tribal mental health clinic and substance abuse services, and in the approaching twilight of my psychiatric practice career, I was looking for a more balanced and salaried position for essentially the rest of my career. As I had started out my post residency and fellowship practice career in a the North Carolina state hospital helping to start a new 44 bed acute relatively short-term adolescents psychiatry unit, I made the decision to apply for a position that my current state hospital site of employment. I initially applied through a locum tenons psychiatry job placement firm. I had a few long-term friends, fellow psychiatrists I had known through professional contacts over the years who worked there as well. I had some knowledge that this state hospital provided excellent high quality care and I was eager to apply and see if things would work out for all parties.

I’m was not prepared by the two-way exchange that I was given during the several week application and review process. I was prepared for essentially one way process in which I would furnish information and references about myself and to be judged regarding meeting the qualifications for employment at this facility and providing evidence, references and the best representation of my qualifications that I could. Instead, toward the end of the application and interview process which lasted more than one interview session and multiple visits to the hospital, I found myself being informed by the CEO psychiatrist of the hospital, of the relatively recent traumatic experience that the hospital itself had gone through. He did so for the purpose of complete transparency and honesty so that I would know fully what the hospital had gone through and be exposed to any possible negative information about the hospital organization, its own level of confidence etc. As he began to relate the history of the death of the patient within the previous two year period, I was floored by his openness. Gradually I came to understand that this incident had been traumatic for everyone involved and was witness to the extraordinary links to which the clinical leadership and staff involved at all levels, went to in order to be cooperative with the ensuing mandatory investigations, the patient’s family and the media to the extent that they were permitted by the confidentiality laws. There was no hiding of the incident, no minimizing, no bureaucratic obstruction etc. It did turn out that part of the basis for mandating corrections and deficiencies based on the circumstances of the death by virtue of the physical nature of the episode of manual restraint of a truly aggressive and supremely uncooperative patient were erroneous. I was permitted to find out and review the incident myself and learned with confirmation from the CEO that for instance, the initial pathology exam was erroneous and efficient and that a repeat exam later on in the process essentially demonstrated that the cause of death was a previously unknown cardiac condition of the patient and not the air of the hospital staff in affecting the physical restraint and control measures. But this was not accepted or validated by the investigators and sanctions were imposed including the loss of accreditation for the hospital that lasted approximately a year and a half.

I was simply ethically amazed that the hospital clinical leadership worked actively with the investigators and without any protest whatsoever submitted to the corrective actions in a dutiful accepting way seeing them as an opportunity for positive change. By the time I arrived on the hospital’s staff, the changes had been actively implemented and I was exposed to the most detailed and helpful training course in physical restraints procedures that I had ever witnessed at any hospital at which I had practiced in the past. The hospital had contracted with an outside training and consulting agency in another state and at great expense to itself, instituted a mandatory training policy for every single staff member who has any sort of clinical contact with the patient population, from behavioral nursing assistants on up through psychologists and psychiatrists without exception. This training is mandatory and is repeated annually for all clinical staff and stands witness to the openness, cooperation and commitment to high quality of patient care.

So when I read of other hospital organizations undergoing such thorough reviews and investigations by outside bodies have more appreciation for the difficulty of the task that is endured by both the reviewer in investigators and by the hospitals themselves mutually. I also am somewhat dismayed when I read accounts of hospital organizations who seem to resist these investigations and outside reviews in an almost reflexive defensive manner. I can understand usual human reactions in which we all get defensive about having our professional actions critiqued and criticized and if need be, having to submit to a professional disciplinary action especially if it involves public censure and procedures that create a negative image in the eyes of the public who cannot ever fully appreciate how difficult these processes are.

I hope that this small effort at sharing and observer’s long-term perspective and experience can help any reader more fully understand these very difficult and periodically inevitable said events and their aftermath.