A Psychiatrist is Tracking The Tragedies of Her Patients

TREATMENT NOT TRAGEDY

"These are my two patients who died in connection with problems in the system. Names and identifying features have been changed for reasons of confidentiality.?

Lucille was a 37-year-old Black woman whose schizophrenia was adequately controlled on medication, but who suffered from extreme weight gain. Before Christmas? we changed her medication and she changed her eating habits.? The last time I saw her, just after Christmas, she had lost 10 lbs. She was ecstatic.?

Lucille lived at a board and care home where she felt the board and care operator treated her rudely out of racial animosity. Hurt and angry after one incident, she left the home, went off her meds and became street homeless. A few days later she became short of breath and went to the closest hospital ER for help.?

There she was seen by several doctors and PA’s, who gave her a diagnosis of urinary tract infection. Her shortness of breath went unremarked. They noted that she carried a diagnosis of schizophrenia and bipolar disorder, and they had our clinic number, but they made no attempt to start her back on her medication, and sent her out with a prescription for antibiotics and a list of homeless shelters. ?

The next day she returned and reported that she was passing out. She was so short of breath that she spoke with difficulty. A CT angiogram showed extensive pulmonary embolism, an enlarged heart and a collapsed lobe in one lung. The appropriate intervention would have been to hospitalize her in the ICU. However, she was discharged with a bus ticket and instructions to make her way to Highland Hospital. It was February and she was dressed in hospital scrubs. She never made it out of the hospital parking lot, where she was found by a passing EMT crew, face down in the bushes. She was returned to the ER and pronounced dead.?

I wrote a detailed letter to the ACBH administration about Lucille’s experience but received no response. ? Aside from the shocking lack of ordinary good medical care, this history reflects two chronic problems in our system.? One is the isolation of each agency from all the others, and lack of communication between agencies regarding patient care.?

The ER should have called our clinic right away and started Lucille back on her antipsychotic medication. They should have gotten a psychiatric consult as well. I should have gotten a response from the ACBH administrators and all of us who were involved in her care should have gotten together to process what went on and take steps to prevent such occurrences in the future. Instead, I was told that we can’t initiate a complaint because “that would violate her confidentiality;? only her family can do that.” HIPAA is invoked inappropriately to cover mistakes and to avoid the hassle of communicating with families and with colleagues about patient care, sometimes with tragic results.

Another weakness is our system of board and care homes, where over-worked, under-paid operators struggle to make ends meet and provide for their residents. These homes are what constitute “supportive housing” for our patients, but in most homes the support is limited to room and board. When Lucille left the home and didn’t return no one called us to report that she’d left the home, or the police to report a missing person.? She was 37 years old and died a needless death.?

Patrick was a 42-year-old man who told me when I first met him that he was addicted to opiates, used heroin and fentanyl on a regular basis and had already OD’d once and been rescued with Narcan.? He was coming for help with his addiction, and I knew it was a window of opportunity that would close before long.? What he needed was treatment that day for his addiction.? He could have gotten Suboxone or methadone that day, at a clinic not far from ours. But none of us knew about those resources. He thought he was in line for an interview with an agency that actually has no services in our county. Six weeks later Patrick OD’d again and died. ?

His medical record was promptly removed from our system. We had no way of looking back at our mistakes and learning from them.? What would have saved Patrick’s life would have been a directory of services for the county, including mental health and addiction treatment, with contact information and a person to answer the phone at each agency.? Such a directory would be simple to compile, and the information could easily be displayed on a website and made available to everyone in the county. If we’d had such a directory I would have seen right away that Patrick could get help that day. We would have called the agencies listed and gotten him relief and a path to sobriety.?

Again, there is a lack of collaboration and information sharing, between the client, the family and agency staff, and between different agencies."