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State Mental Hospital Death Not Investigated
CALL7 Investigation Shows Patient Died After Receiving Multiple Medications
POSTED: 4:31 pm MDT May 11,
2009
UPDATED: 11:10 pm MDT May 17,
2009
PUEBLO, Colo. -- When 21-year-old Josh Garcia entered the Colorado Mental Health Institute at Pueblo, his family was hoping that the he would receive treatment for his bipolar disorder.Instead, his family is charging the treatment he received led to his death."I just assumed he was OK -- He was in good hands," said his mother, Bonnie Garcia.
But Bonnie Garcia said Josh was drugged and neglected.Records and interviews show Josh received a number of powerful psychoactive drugs, such as Haldol and Thorazine, which can cause severe constipation. Josh complained to his mother and his grandmother that he wasn't feeling well."He used to tell (his grandmother) that his stomach hurt and she used to say, 'Tell them that your stomach is bothering you Josh,'" Bonnie Garcia said. "He said, 'I do and they don't do anything for me.'"When Josh complained, medical records show that hospital staff would give him Maalox, but that medicine can also cause constipation. Eventually, Josh started vomiting dried blood, which medical records say looked as if he were vomiting "coffee grounds."Doctors at the mental health clinic knew the danger of the drugs but apparently did nothing to prevent the problem, Josh's family said.Bonnie Garcia said she spoke directly to the person responsible for Josh's care, Dr. James Sewell."He said, 'Unfortunately, there's side effects to that and one of them is constipation,'" Bonnie Garcia said. "He says they do monitor it as best they can."But Josh complained for weeks about stomach problems and eventually was transferred to St. Mary Corwin Hospital in Pueblo. Josh's bowels were so impacted that he had to undergo emergency surgery but his bowels burst during the procedure. He suffered a massive infection that raised his temperature to 108 degrees and eventually caused brain death."He wasn't breathing on his own anymore," Bonnie Garcia said. "He was breathing through the ventilator and so we just decided that, I told my husband, that if he's ever not breathing on his own and that machine's breathing for him, I don't want him connected to it."Arapahoe County Coroner Dr. Michael Dobersen performed an autopsy on Josh and said Josh shouldn't have died."He had been taking the drugs and becoming symptomatic," Dobersen said. "He became bloated with abdominal pain and bowel obstruction."CALL7 Investigator John Ferrugia asked, "So over a period of weeks, you would notice this in a patient?""Oh, yes," Dobersen said. "The complaints are so obvious and the treatment is relatively simple that these types of problems are taken care of relatively quickly and they don't progress normally to the extent they did in this case.""If you're monitoring somebody, you don't have this problem," Ferrugia asked."I think that's a fair statement," Dobersen answered.The Pueblo Coroner noted on the death certificate that Josh's death was caused in part by "medical misadventure."State officials declined to allow 7NEWS to talk to Sewell, the psychiatrist caring for Josh, or the superintendent of the mental health center, so CALL7 Investigators found Sewell in Pueblo and briefly spoke with him."We asked for an interview, and we were told we couldn't talk with you or the superintendent. And what I wanted to know is, do you routinely monitor patients?" Ferrugia asked Sewell."I can't do it right now," Sewell answered. "I'm on my lunch break."CALL7 Investigators found that the Colorado Department of Human Services, which runs the mental hospital, never investigated Josh's death and never posted an incident report of fatality. CDHS spokeswoman Liz McDonough said a mortality review was done but state law does not require a full investigation because Josh died outside the state facility. A mortality review is conducted within the Pueblo hospital to monitor performance. But, there is no oversight or accountability required by such in-house reviews and such reviews are not public."There is no requirement beyond the mortality and morbidity review," McDonough said. "It's not something we're required to report."Bonnie Garcia said she is suing the state in federal court to force state doctors to pay more attention to patients. She is alleging that Pueblo Hospital and the state violated Josh's civil rights."I want them to investigate because I just feel like my son couldn't have been the first one that this has happened to," she said. "There's just no way, and I just don't want it to happen to anybody else."
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