A Pueblo Grand Jury has found that staff members at the Colorado Mental Health Institute at Pueblo, the states largest public mental hospital, committed official wrongdoing in the death of a patient.Mental patient Troy Geske suffocated when left alone while strapped facedown on a gurney.The grand jurors did not find any criminal conduct in Geske's death, which could have included criminal negligence charges.Yet, citing a "systematic failure" in staff training and enforcement of patient-safety policies, the grand jury report found the hospital staff committed "misfeasance and malfeasance with regard to a governmental function, and abused their authority resulting in the death of Mr. [Troy] Geske."Under Colorado law, malfeasance involves official misconduct, including unauthorized exercise of official duties, failure to perform a legal duty or violating state laws or rules.A 7NEWS investigation first revealed that Geske, a mental patient, died while strapped facedown, his arms and legs restrained with leather bindings, and a leather strap placed over his back to hold him firmly to the gurney.State hospital staff, including a police officer, then left him alone in seclusion, the CALL7 investigation found. After nearly ten minutes in restraint, the overweight Geske suffocated.He was being monitored periodically from a window in the door to the room, but the grand jury found that from that vantage point, he could not have been monitored properly."It is apparent that Mr. Geske was not under direct observation at all times," according to the grand jury report.The grand jury stressed that hospital management and staff have "a statutory duty of care," which they did not meet in the death of Geske."The grand jury finds that there was a systematic failure to adequately train staff, to insure staff followed policies for seclusion and restraint and patient safety related thereto, and to disseminate safety information concerning restraint procedures that was readily available, and if put into practice would have prevented the death of Mr. Geske," the report said.The grand jury report also noted that hospital administrators failed to train staff to properly consider the health and safety of transferring Geske to the higher security unit where he died."There was no prior contact with either the receiving unit lead nurse or the psychiatric nurse-practitioner to discuss the rationale for the transfer, the patients care needs and the capability of the receiving ward to manage the patients needs and behaviors," the report noted. The grand jury also stated that "there was conflicting testimony concerning whether Mr. Geske was an appropriate patient" for the higher security unit.The grand jury report noted that on August 10, 2010, the day Geske died, he became "stiff and resistive," refusing to take his medication and to be moved to seclusion and restraint. Yet, grand jurors found "there is no evidence of the previously described combative behavior, but this may be because the staff has him effectively restrained during the move."The grand jury also makes clear that poor execution of the actual prone restraint contributed to Geskes death."The staff member controlling the patients torso was using a disapproved control technique by using his forearm to apply pressure to the patients back during the entire restraint process," the grand report said. "During the restraint process, Mr. Geske appeared to be struggling by trying to lift his head and torso off the bed."In addition, the report said, "During the process of applying the restraints, a staff member used inappropriate pressure to the back of the patient's head, holding his face at or near the surface of the mattress" that covered the surface of the gurney where he was restrained. Once the staff outside the door realized Geske had stopped moving, they rushed in to try to turn him over to begin life-saving CPR, the grand jury report said. However, they could not immediately remove the leather straps from his wrists and ankles, and there were no shears available in the room to cut the restraints, as there should have been. That cost valuable time in trying to revive him, the report said.The state Attorney General's Office, representing the Colorado Department of Human Services and the Pueblo hospital, rejected the findings of the grand jury, writing in a response: "The findings and conclusions of the grand Jury are refuted as to the alleged misfeasance and malfeasance, abuse of authority and breach of duty of care."Even so, the attorney general's response noted, "The accidental death of Troy Geske ... led to an evaluation of systems by both external and internal entities, which has improved services and programs."That is a reference to an outside, third-party review prompted by the Call7 investigation into the deaths of four patients, including Geske. After the review that confirmed the deficiencies, lack of training and incompetence detailed in CALL7 reports, the Director of CMHIP, Dr. Anthony DeQuardo resigned.The new executive director of the Colorado Department of Human Services, Reggie Bicha, has committed to adopt the sweeping changes at the Pueblo state hospital that were recommended by the outside review. He is now in the process of searching for a new executive director of the hospital.