Hundreds of patients died at DC psychiatric hospital before death by neglect was discovered

Hundreds of patients died unnecessarily at America’s largest city-based psychiatric facility before the city decided to pull out of the network in 2008. Federal authorities said it took years of mismanagement and delays in…

Hundreds of patients died at DC psychiatric hospital before death by neglect was discovered

Hundreds of patients died unnecessarily at America’s largest city-based psychiatric facility before the city decided to pull out of the network in 2008. Federal authorities said it took years of mismanagement and delays in detecting problems before it finally shuttered the facilities.

An investigation by The Washington Post and WJLA found that the deaths – some of which happened shortly after nurses detected an overdose of a popular psychiatric medication – prompted efforts by the city’s health officials and A&E Networks to deflect criticism and avoid the label of death by neglect. The same problems continued to plague the city’s hospital psychiatric services for years, causing hundreds of further deaths and thousands of injuries, the investigation found.

Robert Coughlin, A&E’s general counsel, said in a statement that the Post report “is a self-serving snapshot of a very sad episode for residents of the DC area who tragically died while experiencing crisis in psychiatric services at the George Washington University Hospital.” Coughlin’s statement called the deaths the “direct consequence of a long-term operational failure by a hospital and its improper management that showed little regard for patients’ well-being and safety.”

In February 2014, a mental health employee at George Washington University Hospital found a patient on the floor in a corridor, with a small dose of amphetamine far below legal and required doses. After the employee called hospital security, the patient was revived but died three days later. A technical review, by the emergency department’s use of barbiturates, found “serious incompetence in the use of barbiturates.” The employee was fired.

Federal and local officials uncovered similar problems later that year. A DC resident who had recently arrived at George Washington Hospital’s DCIOM Center for Psychiatric Evaluation and Treatment called 911 while strapped down to a bed in an unattended room. DC Fire and EMS found a man who was having a psychotic episode but had no history of self-medicating with amphetamines.

DC’s local Medical Examiner’s Office concluded that the man died due to lack of oxygen and ruled his death a homicide. Federal authorities filed charges against the hospital under the federal False Claims Act, accusing hospital officials of concealing deficiencies in supervising and training staff.

The DC Independent Oversight Board, which oversees George Washington’s state-of-the-art state-of-the-art $340 million psychiatric hospital, asked then-DC Health Care Agency Director Dr. Sonia Kumar, a psychiatrist, to shift into a judicial role on how the hospital is managed. Kumar told The Post that she wanted to stay in that role “so we had the most difficult scrutiny possible.”

“I became the commander of the force,” she said, “because I was the one who put the guns into the fire, so to speak.”

But Kumar later resigned after being accused of sexually harassing female colleagues, including amid allegations of improper conduct toward the hospital’s chief psychiatrist, Dr. Jennifer Chin. Her former chief of staff, Dr. Jennifer Goldman, also resigned, claiming that Kumar’s actions were “worsening rather than improving” patient care at the hospital.

The DCHealth Care Agency announced an independent autopsy for the deceased patient to examine drug use in his system. Then the board asked the University of Washington Center for Forensic Toxicology to do that autopsy and issue a report at its own expense.

The board opted to appoint Dr. Peter Breggin as the new director of forensic toxicology at the hospital. His background was serving as deputy chief forensic toxicologist for the King County coroner’s office, where he identified no drug-related deaths – or among the “markedly fewer” that were screened and identified.

Breggin told The Post that no deaths were identified at the hospital “by any kind of screening tool” at the time he was appointed.

Even after finding problems related to management practices and vigilance, DC’s Medical Examiner ruled that the man’s death was an accident, and was not criminal. Then, in 2015, Breggin released his report, which exonerated the hospital, concluding that the patient’s physical health, adjusted and depleted diet, and the combined effect of drugs and lifestyle “resulted in an eventual buildup of the man’s system” but that overdoses were largely a consequence of the man’s mental illness. He did not name any specific medication as a contributing factor.

In a statement to The Post, DC Attorney General Karl Racine said that the city received the final autopsy report

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