Report says State Hospital partly responsible for two patient suicides

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(Host) An advocacy group says the staff and administration of the Vermont State Hospital bear some responsibility for two suicides there last year. The group released a report on Wednesday that says the state violated its own procedures in the care of two patients who killed themselves while in state custody.

VPR’s John Dillon reports.

(Dillon) Amanda Menei was 19 years old when she was sent to the state hospital last July. Her short life was troubled. She had been sexually abused as a young child, and this was her sixth time at the hospital.

According to Ed Paquin, director of the Vermont Protection and Advocacy organization, a number of errors and communication breakdowns contributed to her suicide and that of another patient last summer.

(Paquin) “The reports point to the absence of a written, comprehensive suicide prevention policy, lack of adequate staffing, lack of an appropriate physical environment and failure to ensure that important patient safety information was communicated to and among staff.”

(Dillon) Paquin’s organization is empowered by law to investigate abuse or neglect of people with disabilities. He says that in Amanda Menei’s case, the hospital workers were supposed to remove anything she could use to hurt herself, including shoelaces. Menei used her shoelace to hang herself last September.

(Paquin) “It had been acknowledged and was in her new behavioral plan that anything with which she could harm herself should be removed from her possession. And that did specifically include shoelaces. So there was a communication breakdown there that we believe should not have occurred.”

(Dillon) Thirty-nine year old Christopher Fitzgerald also hanged himself at the State Hospital last summer. The Fairfax resident was sent to the hospital for a court-ordered evaluation after a DWI arrest. He had tried to kill himself in the past. He was desponded over a bitter child custody dispute, and the report says that the nurse who admitted him noted that he was suicidal.

An advocate who works for Paquin’s organization saw Fitzgerald the evening before he died. Fitzgerald told the advocate that he had been involuntarily restrained and medicated.

He was found dead the next day, and his suicide note says, “Today’s assault was the last degradation I can endure.”

Dick Gadbois is a lawyer who represents Fitzgerald’s family. He says the report shows that Fittzgerald’s death could have been prevented.

(Gadbois) “I think it clearly indicates that this tragedy didn’t have to happen. Unfortunately it did happen. There are a lot of victims here, including four of Mr. Fitzgerald’s children who are now not going to have any contact with their father for the rest of their lives.”

(Dillon) Mental Health Commissioner Susan Besio says the hospital has changed many of its procedures since last year. The medical director was also replaced, and she says the staff nurses and technicians have gone through additional training.

(Besio) “Their reports are on events that happened eight months ago. And we think we’ve made a lot of changes in the last eight months.”

(Dillon) In part because of the two suicides, the hospital lost its federal certification and federal funding last summer. Commissioner Besio says she’s hopeful that certification will be restored this fall.

For Vermont Public Radio, I’m John Dillon in Montpelier.

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