June 17, 2016
June 10 was the second anniversary of Maxwell Chorak’s death by suicide less than 2 1/2 hours after having been released from the psychiatric unit at the UCI Medical Center in Orange, California.
We knew that there were problems with his treatment. It took the State Department of Public Health 14 months to respond to our complaint. The reply was a copy of a corrective action report by the hospital itself. So much for oversight. A patient died because of lapses in policy and procedures and the indifference of staff, and there has been no accountability. It is now clear that the hospital was complicit in Max’s death.
When he was found in Laguna Niguel Regional Park in a catatonic state on May 29, 2014 he was taken to Mission Hospital in Mission Viejo. His mother was first told that Max would be sent to a long term care facility and would be placed under conservatorship. That didn’t happen.
He was instead transferred to the UC Irvine Medical Center, the county hospital. The psychiatric unit has 48 beds and it is a teaching hospital. In addition to the faculty and those psychiatrists with privileges there are residents and students as well. One would think that the care of patients would reflect that level of staffing.
When he was evaluated on June 1 at for a 5250 (up to 14 day involuntary hold) it was noted that Maxwell had a long standing history of schizophrenia. He exhibited disorganized behavior and speech and was unable to formulate a plan for self care, all of these critical criteria for an involuntary admission. Maxwell couldn’t even sign his name to the forms when he was brought in. He had also been diagnosed with Bipolar Disorder and had addiction. Co-occurring disorders affect approximately 35% of our mentally ill.
As soon as his mother was notified of his admittance she immediately contacted the doctors and nurses, informing them among other things that Maxwell had a serious adverse reaction to Haldol. Haldol is a first generation antipsychotic used in acute cases of schizophrenia. She recommended the Risperdal that he had taken in the past and that he had done much better on over the years. The attending nurse replied that “it doesn’t make any difference since they don’t stay on their meds when they leave here anyway”. They put Maxwell on the maximum 30 day injectible dose of Haldol.
The corrective action report is the official finding of the State Department of Public Health and yet no state investigation as performed. The summary is a statement of deficiencies in care and procedure as assessed by the hospital compliance department, presumably.
Beyond the jargon and acronyms, the findings are listed as specific actions taken or not taken. These include:
1 – A registered nurse shall directly provide ongoing patient assessments. Such assessments shall be documented for each shift. This was not done.
2 – A registered nurse shall directly provide the planning, supervision, implementation, and evaluation of the nursing care of the patient. This, also, was not done.
3 – The patient was never assessed for suicide risk.
4 – The nursing staff failed to conduct the Suicide Risk Assessment using the SADS Persons Scale per hospital procedure.
5 – The hospital failed to follow its own discharge procedures in that:
A – The hospital failed to coordinate a family meeting to discuss the patients care and discharge plan.
B – The physician, RN, or Case Manager failed to inform the patient’s family member of the discharge date and time.
C – The RN who noted the discharge failed to recognize the change in discharge destination from the original discharge plan and refer to the Case Worker or Case Manager for resolution.
6 – The hospital received informed consent from the patient referring two family members to be notified of his admission to the hospital, his prognosis, and progress in treatment. The only contact with family was when family members called to request information and status updates. These were communicated from the nursing station, not the persons directly responsible for his care.
7 – The medical student who handled the case did not communicate whatsoever with the family regarding the discharge and discharge plan.
In his discharge instructions the standard jargon about light physical activity and instructions that if he had suicidal or homicidal thoughts he should dial 911 were included. His discharge diagnosis this time was antisocial personality disorder and schizoaffective disorder. It’s perverse, because Maxwell’s file was extensive and the diagnoses had long been made. Max had experienced catatonia before and had also had a habit of pushing back when people were trying to restrain him.
He was prescribed a monthly intramuscular dose of Haldol as well as 5mg/day of the same; 1200 mg of lithium/day (used to treat mania), 5mg of benztropine, which controls the Parkinson’s like side effects of the Haldol, and Ativan, a benzodiazepine used to control anxiety. Maxwell was an addict. One does not prescribe benzo’s, as they are known, to addicts. Quite a cocktail.
Maxwell was discharged from the hospital at 1:51PM with the clothes on his back, $55.80 of his own money and a bus pass provided by the hospital. By 4:30PM he was dead. Just enough time for a bus ride to the main campus of UC Irvine and then an end to his pain.
His parents had specifically requested that they be notified prior to Maxwell’s release. It never happened.
The hospital violated its own procedures and policies time and again. After Maxwell had died, his mother called the hospital and informed them of his death. She asked why they had not called her or Max’s father. There was silence on the other end. No apologies. No condolences. Just silence.
In the end, the hospital made a number of recommendations for ”retraining and reeducation”. Policies were reviewed and revised. New job descriptions were developed. The reporting structure was changed. The discharge planning process was adjusted. No one was held accountable.
We are not asking for much. We are asking that the hospital act with simple decency and provide every patient with the human dignity and care that they deserve. We are asking that the families be informed and involved in the care for their loved ones.
Those suffering from mental illness can be the most difficult of patients and yet that is why we are called to act with even greater compassion and grace. Hospitals are by definition clinical, but in mental health we must heal the unseen biological, the psychological and the spiritual diseases of the individual. Maxwell Chorak was warehoused and then discharged to his death. By all that is holy please don’t let this happen again to anyone’s child.