Mental Hospital Could Have Prevented Suicide

CALL7 Investigation Questions Whether Patient Was Properly Monitored

The suicide of a Colorado Springs man at the Colorado Mental Health Institute at Pueblo could have been prevented if staff had followed procedures, a CALL7 investigation found.

Sergio Taylor, 23, killed himself on Sept. 10 by putting a plastic bag over his head after he was denied additional privileges at the C.M.H.I.P., records show.

A month earlier, Taylor had written to the hospital director about morale at the institution.

“History has shown here at C.M.H.I.P. when patients are feeling bored, hopeless and warehoused, that assault and suicide attempts transpire,” Taylor and another patient wrote.

Yet, hospital officials never put Taylor on a suicide watch. And when they found him with plastic bags, which are banned at the facility, they never checked his room for additional plastic bags, police records show.

In doing the required check on Taylor, a staff member saw he was under a blanket in his bed but didn’t enter the room to check on him.

“Someone should have entered the room to inquire as to why this patient was sleeping and to do a vitals check as is written in the rules,” said Dr. Bert Furmansky, a forensic psychiatrist and an associate professor at the University of Colorado Health Sciences Center.

When staff found Taylor unconscious with the plastic bag on his head, they repeatedly called for a doctor, but the physician never responded.

And when the family tried to get information about their son’s death, the hospital refused to provide any documents.

“He just told my husband that Sergio had committed suicide,” said his mother Lilia Taylor about a social worker's call to the family on Sept. 11. “That was it. I mean they basically didn’t want nothing to do with us.”

The Taylors adopted Sergio when he was 6 years old even though they knew he would likely have problems.

“We drove up to the foster home and he was looking out the window and he was jumping up and down,” she said. “You could tell he really wanted a home.”

As he grew up, Sergio had mental problems, being diagnosed with bi-polar disease and possible schizophrenia.

“It wasn’t like he wasn’t aware,” Lilia Taylor said. “He knew it was happening to him and he had no control over it.”

When Sergio was arrested on the charge of assaulting police officers at a convenience store during a psychotic episode, he was sent to the C.M.H.I.P. His family thought he would get help at the state hospital.

“I was relieved that I knew where he was,” Lilia Taylor said. “I knew he wasn’t going to get hurt. He wasn’t going to hurt someone else. He was somewhere where I knew he was going to be watched.”

But Furmansky, who is also a board member of Mental Health America of Colorado, said the hospital repeatedly violated standard procedures designed to protect patients.

“Basic 101 is to remove the plastic bags immediately from the patient,” he said. “And there should be a unit search to clear the unit and make sure there are no other plastic bags on the unit. (A plastic bag) is a potential weapon against somebody else and it is also an instrument to commit suicide”.

Furmansky and Lilia Taylor both said Sergio could have been alive today if the hospital had done its job.

“If policies and procedures had been followed, could this suicide have been prevented,” CALL7 Investigator John Ferrugia asked Furmansky.

“Yes,” Furmansky said.

Lilia Taylor said: “I trusted that they were doing what they had to do to make sure he was okay, and they didn’t.”

She worries about what happens to patients who have no family.

“Somebody who didn’t have a family, nobody would know,” she said. “It would just be brushed underneath the carpet and just go on to the next” patient.

CALL7 Investigators reviewed the summary of a Colorado Department of Public Health and Environment investigation into Sergio Taylor’s death. The report said the hospital failed to provide “a safe environment” for Sergio Taylor, but state officials have denied 7News access to the complete report.

The Colorado Department of Human Services, which runs the facility, declined to have an official do an on-camera interview. A spokeswoman said there has been no disciplinary action, policy changes or retraining after the suicide.

This is the second recent death at Pueblo state mental hospital where CALL7 Investigators found significant mistakes in the care and treatment patients received. Josh Garcia died after his medication wasn't monitored and his bowels burst from constipation caused by the drugs, according to a lawsuit and medical records.