Health Dept Finds Serious Mistakes At State Hospital

State Human Services Refuses To Talk About Patients' Deaths

The CALL7 Investigators have discovered patients at the state hospital in Pueblo were found to be in "immediate jeopardy" following the suicide of a 21-year old man.

Sergio Taylor asphyxiated himself with a plastic bag while being held in the high-security forensic unit of the hospital.

The Colorado Department of Health detailed serious errors by hospital staff, and investigators were concerned other patients could die.

The health department’s report confirmed the findings of CALL7 Investigator John Ferrugia who, for months, has been reporting on deaths at the state hospital, which is overseen by the Colorado Department of Human Services.

“We just had questions about not only how the occurrence had happened and what the conditions were at the facility, we thought we needed to see it firsthand,” said Howard Roitman of the Colorado Department of Health.

Roitman explained that when his department received word that Taylor’s suicide, with a plastic bag, occurred in a high-security unit, it was an immediate red flag suggesting other patients were in danger.

“We found a condition that needs to be fixed before we're even comfortable leaving,” said Roitman.

The health department’s October 2009 investigation found there were no controls on plastic bags and that nursing staff was not properly checking on patients during required monitoring.

“We told them they had to get complete control on the plastic bags,” Roitman said.

In May, the health department conducted an unannounced visit to ensure the necessary changes were in place to protect patients, but a top official with the Colorado Department of Human Services has consistently denied that any changes were made because of Taylor’s death.

Instead, Joscelyn Gay claimed the health department’s investigation was routine.

“They come because we are on a three-year cycle. It's our turn,” said Gay.

But, according to Roitman, that statement is not accurate. He confirmed to Ferrugia that the unannounced inspection in May was a direct result of Taylor’s death.

Gay also told Ferrugia that the death of another patient at the Pueblo hospital, Josh Garcia, was promptly reported to the health department.

“We report the death to the health department and the health department does its own investigation, and those reports are public,” said Gay.

But Roitman said Garcia’s death was not reported. “Our staff actually heard the media report and this was some 18 months, I think, after the actual incident had occurred.”

Garcia died after he was overmedicated and not properly monitored by hospital staff.

“Our staff contacted the hospital and requested the medical records to review what had happened,” said Roitman.

But it was too late.

“It was difficult, 18 months or so after the fact, to reconstruct everything that might have happened and [determine] whether there were problems,” said Roitman.

The investigation was made more difficult because Garcia’s death certificate and autopsy report were never seen by health department officials.

“It was not part of the record,” said Roitman.

For several months, 7NEWS has requested interviews and information from officials with the Department of Human Services concerning the two deaths. They have repeatedly refused, citing federal privacy laws, even though 7NEWS has obtained signed authorizations from the families of Garcia and Taylor permitting Human Services to discuss the cases publicly.

“It is a common thing in my experience for covered entities to throw up HIPAA as a blanket excuse not to disclose,” said former assistant U.S. attorney Michael Theis. “An authorization [from the family] overcomes the otherwise prevailing rule of privacy.”

“Basically, they can talk to me?” asked Ferrugia.

“Correct,” said Theis.

But, as Ferrugia pressed Gay for information and answers regarding the deaths of Garcia and Taylor, she and a lawyer for the Department of Human Services walked out of the interview. They claimed they only agreed to a 30-minute interview but CALL7 Investigators were never informed there would be a time limit.

An audit of the Pueblo facility is scheduled for next year.