As in any medical facility, people die at Texas' state psychiatric hospitals. Between 2005 and 2012, more than 170 patients died at state hospitals, with the number of deaths per year ranging from 16 to 29. Some of those people died after being transferred to a community hospital or shortly after discharge.Oct 27, 2017 › news › questionable-investigations-little-oversight...

Questionable investigations, little oversight in state hospital ...

Facility details
3102 E. Highland Avenue, Patton 92369
Parent Company
California Department of State Hospitals
Violations and incidents: 22 found
A patient drowned in a trash can full of water when safety rounds were not conducted every 15 minutes as they were supposed to be, according to state records. Staff found the patient had filled a trash can with water and immersed his head covered with a laundry bag in the can, killing him, records show.
A patient with depression attempted to hang herself with her shirt and was found by staff, not breathing, according to state records. Facility staff did not monitor her properly, state investigators found.
A 65-year-old patient died after he was shanked, beaten and kicked by another patient, according to state records. The facility failed to keep him free from abuse, state investigators found.
Staff failed to properly supervise a patient, allowing him to escape from the facility twice in one day, according to state records. The second escape was 45 minutes after he had returned from the first.
When staff put a patient in restraints, they covered the patient's face with a sheet, which "had the potential for Patient A to cease breathing and for possible death," according to a state investigation into the incident.
A staff member pulled a pink slipper away from a patient and smacked her on the head with it twice, according to state records.
When a patient asked a staff member for a piece of the staff's food, the staff member said no, and the patient, who had dementia, reached out to grab the food, state records show. The staff member then forcefully shoved the patient in the chest, and, using profanity, said, "Don't touch my ... food," state records show.
A patient on close watch for self-harming behaviors was able to ingest two batteries from a television remote control, according to state records. State investigators determined that the facility failed to properly monitor the patient, who had to undergo a surgical procedure to remove the batteries from her stomach, records show.
A staff member smiled while watching a patient be put into five-point restraints and then flicked the patient on the nose, according to state records. State investigators determined the hospital failed to protect the patient's dignity, according to state records.
A patient said she overheard staff members saying she was hurting herself because she was just seeking attention, according to state records. Afterward, she cut her arm and was found bleeding in the bathroom stall, the records show.
A staff member was assigned to continuously monitor a patient who had hurt his head by banging it against a wall, yet the facility failed to stop him from injuring his head further, according to state records.

*This facility does not accept voluntary admissions and primarily treats patients in the criminal justice system, such as those deemed incompetent to stand trial or found not guilty by reason of insanity.
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This project was written and reported by Soumya Karlamangla. Iris Lee produced the database.
The events reported are based on state and federal inspection records, coroner's reports, court records and L.A. Times reporting.
The facilities listed include all of California's psychiatric hospitals, general acute care hospitals with psychiatric wards and psychiatric health facilities. Also included are any health facilities in the state that are designated to receive patients who have been placed on an involuntary hold, or a 5150, because they were deemed a danger to themselves or others. The database excludes facilities overseen by the Department of Veterans Affairs.
The contents of this database will be updated as more information becomes available. If you know of an incident you would like to share with us, please email

Mother questions son’s unexplained death in state psychiatric hospital

On Christmas morning last year, Dorothy Berry got the gift she hadn’t dared wish for. Her only son was coming home.
Matthew Bohler had been locked up — first in jail, then in a state psychiatric hospital — for six months since his arrest during a psychotic episode. But on Christmas, he called Berry to say he would be released a few days later.
He never made it home.
Early on Jan. 2, an attendant at Georgia Regional Hospital/Atlanta tried to awaken Bohler to take his antipsychotic medicine. When the attendant called his name, Bohler didn’t answer. When the attendant tapped his shoulder, Bohler’s body was cold.
Why Bohler died remains as much a mystery now as it was last January. After an autopsy and toxicology tests, the state medical examiner’s office concluded only that Bohler’s was a “sudden death associated with schizophrenia.” He was 22.
Dorothy Berry has spent the past year trying to learn more about her son’s death. Her inquiry, however, has been mostly fruitless. With no one appointed the administrator of her son’s estate, neither she nor anyone else was entitled to his medical records. When she went to Georgia Regional looking for answers, she said, the only person who would speak to her was a security guard.
“I don’t know what happened to Matthew,” Berry said recently. “It’s killing me, Lord.”
Officials with the state Department of Behavioral Health and Developmental Disabilities, which runs Georgia Regional, said privacy laws prevented them from commenting on an individual’s case. The state’s investigation found no fault in how the hospital treated Bohler.
But public records obtained by The Atlanta Journal-Constitution show Bohler’s death followed a volatile 5 ½-month stay at Georgia Regional, where investigations a decade ago found numerous suspicious deaths.
Bohler once tried to escape by scaling a fence.
He committed what the records called an “aggressive act” on himself.
He attacked three hospital workers and one other patient.
He experienced neglect by the staff.
And he tried to kill himself.
The state’s investigative report barely addressed those issues. It also failed to reconcile conflicting stories by hospital workers about the morning they discovered Bohler’s body.
The report quoted a psychiatrist as saying Bohler’s condition had improved during the last two weeks of his life. “He had times,” the doctor said, “when he was smiling appropriately.”
But she also said Bohler still repetitively chanted several phrases:
“I’m ready to go back to jail.”
“I wanna go back to jail.”
“I wanna go home.”
Bohler first showed signs of mental illness when he was 20 years old. A DeKalb County woman alleged in court documents that Bohler had stalked her, and a judge issued a protective order. When the police arrested Bohler on a misdemeanor theft charge, another judge ordered him to undergo a psychiatric evaluation. He completed a year of treatment, and the judge dismissed the theft charge.
But the treatment, especially the psychiatric medicines that doctors prescribed, made Bohler feel worse, his mother said. At Berry’s house in Stone Mountain, Bohler regulated his moods by running up and down the street, as fast as he could. Sometimes he lay in bed with his mother so she could massage his head and hands. It was the only way she could calm him.
One day in June 2016, according to hospital records, Bohler became upset at home and broke the windshields on three cars with a baseball. When his stepfather intervened, the records show, Bohler responded with “aggressive gestures.”
“He was laughing like he was having fun,” Berry said, “like it was a game.”
Berry called a mental health crisis hotline. A counselor told her to ask the police to take Bohler to an emergency room for psychiatric treatment. Instead, Berry said, officers took him to jail.
“I wanted him to be seen by a doctor,” she said. “I didn’t know if he was physically sick or mentally sick or altogether.”
Bohler got out of jail 11 days later, only to be arrested again within hours. This time, MARTA police charged him with felony theft and criminal trespass.
His mother asked Bohler’s public defender to get the case transferred to DeKalb County’s mental health court. It is part of the state’s system of so-called accountability courts, intended to direct defendants to treatment rather than jail.
But DeKalb County requires defendants to plead guilty to their criminal charges before they appear in mental health court, said Cheryl Karounos, a spokeswoman for the Georgia Public Defender Council. And Bohler couldn’t enter any plea because a judge had declared him incompetent, she said.
“Once they’re deemed incompetent,” Karounos said, “we’re kind of out of the process.”

So on July 14, 2016, the DeKalb County Jail sent Bohler to the forensic unit at Georgia Regional, eight miles away on Panthersville Road. Bohler would return to jail, his doctor said later, once he completed “competency restoration.”
Bohler seemed to be in good physical health when he arrived at Georgia Regional, the doctor who examined him later told a state investigator. But even after several months of treatment, the investigation found, Bohler had made no progress toward restoring his mental competency.
He was “disorganized, confused and unaware of his charges,” a hospital report said. He avoided group therapy sessions and other activities and told nurses he thought he didn’t have a brain.
“I don’t know why I’m here,” he said repeatedly.
Bohler often became violent toward others, the investigator’s report said. One time hospital workers caught him climbing a fence in an escape attempt. At one point, hospital administrators substantiated that the staff had neglected Bohler. But the report gave no details about the neglect. Nor did it elaborate on Bohler’s suicide attempt. It said Bohler was last placed in seclusion on Sept. 22 — but did not say how many times he had been isolated before then, or why.
On New Year’s night, Bohler was one of 21 male patients in the forensic unit at Georgia Regional. Two nurses and seven attendants, known as forensic technicians, worked the overnight shift.
Bohler was assigned to a room with three other patients. His bed was in the corner farthest from the door.
Like most patients, Bohler was supposed to be checked on every 30 minutes during the night. A nursing manager later said the staff merely looked into the room every half-hour and used a flashlight to observe whether his chest rose and fell with each breath. (A hospital official later disputed the nursing manager’s description of the observations.)
What happened early the next morning is a matter of disagreement — one that the state investigator seemed to make little effort to resolve.
A nurse from the overnight shift said she twice tried, without success, to awaken Bohler between 6:15 and 7 a.m. When she sent a forensic technician into the room to try a third time by turning on the light, she said, Bohler moved but said nothing. The technician later denied entering Bohler’s room.
Another forensic technician said he made the first contact with Bohler between 8:15 and 8:30. As usual, he said, Bohler had slept with his covers pulled over his head. But on this morning, Bohler was unresponsive, his body cold to the touch — even though he supposedly had been awakened just an hour or so earlier.
The state’s investigative report said the accounts could not be reconciled. The time of Bohler’s death, the report said, was “unclear.” Officials had no more idea of when he died than why.
The morning of Jan. 3, at the Georgia Bureau of Investigation headquarters next door to Georgia Regional, a state medical examiner performed an autopsy on Bohler. A report said Bohler weighed 154 pounds — 27 pounds more than when he entered the hospital less than six months earlier. But at 6-foot-1, Bohler was hardly obese. The autopsy found a minor thickening of Bohler’s heart muscle, but apparently not enough to have caused his death. Toxicology results showed only a normal level of an antipsychotic medicine in his system.
“The cause of death for Matthew Bohler is not entirely clear,” Dr. Keith Lehman, an associate state medical examiner, wrote in a report.
But Lehman added: “Patients with schizophrenia who die are reported to have an increased likelihood of having an autopsy that fails to reveal a cause of death, giving evidence that schizophrenia may cause sudden unexpected death in some people.”
Despite the uncertainty, Lehman certified that Bohler died of natural causes.

Researchers have struggled to understand why people with schizophrenia sometimes seem to die for no apparent reason.
In 2010, a study published in the journal Progress in Neuro-Psychopharmacology & Biological Psychiatry suggested that older generations of antipsychotic drugs could interrupt the heart’s electrical cycle, sometimes causing cardiac arrest. But modern medicines, the study found, including the one Bohler was taking, seemed less likely to have that effect.
Another study, published in 2014 in the journal Schizophrenia Research, concluded that patients in psychiatric hospitals die of heart failure at a rate well above the general population. The study said an analysis of autopsy reports indicated that brain, heart and lung abnormalities could account for the disproportionate number of deaths.
Dorothy Berry still can’t believe her healthy, 22-year-old son simply died in his sleep. She thinks hospital workers withheld important details about his final hours.

“I just want a little justice,” she said. “I just want to know what happened to my son, my only son. Shouldn’t nobody have to go through this, shouldn’t nobody.”
Last Christmas, after her son called, Berry didn’t tell anyone he was coming home. She was afraid of jinxing the good news. Quietly, though, she began planning a celebration that, as it turned out, would never occur.
She learned the truth only after her son’s death: The hospital had no plans to send him home, after all.
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A staff member fell asleep while watching a patient with violent tendencies, including a history of murder, according to a state investigation.
Napa State Hospital
Deaths 6 Primary service Psychiatric County Napa Psychiatric beds 1255
Facility details Address 2100 Napa-Vallejo Highway, Napa 94558 Ownership
State Parent Company California Department of State Hospitals
Violations and incidents: 47 found
After Death at a Texas Psychiatric Hospital, Family Kept in the Dark
When he began exhibiting signs of schizophrenia, Keith Clayton's family agonized over sending him to a state-run psychiatric hospital. Days after his arrival, the 55-year-old was dead — the victim of a restraint gone wrong.
Keith Clayton, pictured here in 2013, died after being restrained at the North Texas State Hospital in Wichita Falls. Family members say the state has kept quiet about the circumstances of his death. Samantha Clayton
Shortly before noon on April 14, 2014, while their adult son slept in the next room, Anna and Daywood Clayton decided to call the police.
It was not a spur-of-the-moment decision for the elderly couple from Borger, Texas. They had agonized for days over what to do about 55-year-old Keith Clayton, who was hallucinating, talking about suicide and showing symptoms of schizophrenia.
They had asked a local judge how to get their son hospitalized. And they had called their 28-year-old granddaughter Samantha Clayton in San Antonio to ask for her blessing to send her father to one of Texas' state-run psychiatric hospitals. Having Keith Clayton committed seemed the best option to his parents, who were approaching their 80s and felt ill-equipped to care for a grown man with a serious mental illness and a history of alcoholism.
"We knew he needed help," Anna Clayton would later tell a police detective. "We just had no other choice."
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It was an unseasonably cold day when the officers arrived; a light snow sprinkled the high plains of Texas Panhandle country. Daywood Clayton recalled trying to get his son, before he was handcuffed by the officers and loaded into their car, to put on a sweater.
It would be their final interaction.
Four days later, Keith Clayton was pronounced dead in an emergency room. He had stopped breathing after employees at the North Texas State Hospital in Wichita Falls forcibly restrained him for allegedly picking a fight. An autopsy found he died of a ruptured spleen caused by blunt trauma to the abdomen. He suffered internal bleeding and several fractured ribs.
It took five months for a medical examiner to rule the death an accident.
What happened during Keith Clayton's short stay at the psychiatric hospital hundreds of miles from home is still a mystery to his family members, who say the state has refused to give them an explanation. Anna Clayton said she didn't even know state hospital employees were involved in her stepson's death until a Texas Tribune reporter called her last month. For two years, she said, she'd been told he died in a "scuffle."
"We didn't have any idea if it was a patient that did it, or if it was a staff member, or not," she said. "They wouldn't tell us what happened. They wouldn't tell us anything."
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"There is no other publicly releasable information available on the patient death."— Christine Mann, state health department spokeswoman
Asked why Keith Clayton's family wasn't given complete information on his death, officials from the state hospital directed questions to their parent agency, the Texas Department of State Health Services. Officials there said they could not discuss specifics of the hospital's dealings with the family.
Keith Clayton's death is an example of the sometimes-fatal effects of restraints used to subdue patients at Texas' state-run facilities for people with mental illness — institutions that face an uncertain future due to unpredictable funding, crumbling infrastructure and a growing demand to house patients from an overcrowded criminal justice system. At a time when the state claims to be reducing its reliance on forcible restraints, Keith Clayton's case raises questions about the secrecy around such incidents, particularly when they end in death.
Keith Clayton's parents, daughter and stepsister said they wrote letters and made dozens of phone calls to state hospital administrators and other officials in the year after his death. At every turn, they said, they were told the information they sought was secret.
For Samantha Clayton, this was particularly hard to stomach. Despite her father's struggles with alcohol, he had been in good physical shape, she said, roller-blading for long distances and doing manual labor for his job at a trucking company. "Him just dropping down and dying, it just doesn't make sense," she said.
Keith Clayton was cremated. His family held a memorial in Borger. Two years passed. Anna Clayton, now 86, said the family eventually gave up on trying to discover the circumstances of his death.
"After a while, at our age, we're just not able to keep it going," she said.
The "Scuffle"
The Claytons weren't the only ones who struggled to get information on their son's death.

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