New State Human Services Director Promises Change

CDHS Director Wasn't Aware Hospital Didn't Express Sympathy To Family Members Of Dead Patients

The new Colorado Department of Human Services executive director promised major changes at the state’s mental health facilities prompted by a series of CALL7 investigations that highlighted mistakes that led to patient deaths.

Reggie Bicha, who was appointed by Gov. John Hickenlooper to head CDHS, said problems at the Colorado Mental Health Institute At Pueblo contributed to a series of patient deaths at the facility in the past few years.

“I have been expressing my desire and commitment to build a new culture for the hospital,” Bicha told CALL7 Investigator John Ferrugia in an exclusive interview.

Families of patients have long complained about treatment of their loved ones and the seeming lack of compassion if a family member dies at the hospital.

“No one called from the state hospital,” said Rex Geske, whose son Troy died while being held in a prone restraint position that CALL7 Investigators found had previously caused deaths and was banned at other CDHS mental health facilities.

Bicha said he wasn’t aware that no one from the hospital, which is run by CDHS, called to express condolences.

“Do you find this disturbing or do you find this business as usual,” Ferrugia asked. “We can have liability. We don’t talk to people.”

“Well, I wasn’t aware of that,” said Bicha, who seemed visibly upset.

A two-year investigation of the hospital found that four patients died because policies were not followed, procedure banned elsewhere in the mental health system were used, medical issues were not treated or warning signs of suicide were ignored.

After the 7News reports, the legislature asked for an audit of the hospital, CDHS conducted a third-party review that led to policy changes and legislation banning prone restraint is making its way through the General Assembly.

“We have developed a new suicide risk protocol,” Bicha said. “We have trained our staff throughout the hospital on that protocol.

“I look at the third-party report as the way business was done in the past, and I use that as a barometer, if you will, or compass about where we need to go for the future,” he said.

The hospital director, John R. DeQuardo, also recently resigned his administrative post and returned to working with patients.

“Do you think the resignation of Dr. DeQuardo presents an opportunity for you?” Ferrugia asked.

“Well certainly,” Bicha said. “In order to create a cultural change, it begins with good effective leadership. There is certainly an opportunity that I want to take advantage of to make sure we get the right superintendent to move the institution forward.”

And, as a result of the Call7 investigation, the Pueblo district attorney started a grand jury investigation into the deaths.

“Anytime I am responsible for an institution that had problems in the past that could result in criminal prosecutions, that would be very concerning,” said Bicha, adding he has not been asked to testify before the grand jury.

In addition to Geske, Josh Garcia died after the hospital did not monitor side effects to powerful medicine doctors administered to him. His bowels burst from constipation caused by the drugs, records show. Sergio Taylor committed suicide by suffocating himself after staff failed to remove plastic bags, which were banned on the unit, and Edward Benge also killed himself and staff did not know how to use a device to open the door in time to save him.

“The institution had not stayed current,” Bicha said. “There were practices that were lackadaisical. There are morale issues in the hospital. There was a need for revising policies and practices to bring them in line to provide better quality care.”

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