Four Colorado Psychiatrists Surrendered Their Medical Licenses In 2015 – Was One Of Them Yours?

Three psychiatrists permanently surrendered their licenses to the Colorado Medical Board in 2015 in order to avoid formal disciplinary hearings on complaints filed against them with the Board, according to the Colorado Department of Regulatory Agencies online listing of Board actions. A fourth psychiatrist agreed to a non-permanent surrender of his license.

The psychiatrists who permanently surrendered their licenses are:

  • Wallace R. Arthur (Denver) – The Board alleged Arthur violated the Colorado Medical Practice Act by engaging in a sexual act with a patient within the six months immediately following the termination of his treatment of the patient, which constitutes unprofessional conduct under Colorado law.
  • Lawrence L. McReynolds (Ridgway) – McReynolds surrendered his license in the state of California after allegations of repeated acts of negligence and failure to keep proper records in his treatment of a patient there, then failed to notify the Colorado Medical Board of that fact, as required.
  • Walter C. Young, Jr. (Colorado Springs) – The Board alleged that Arthur failed to take any steps to ensure the safety of a patient who expressed suicidal thoughts, prescribed the same patient pain medications and large quantities of high-dose opiates over periods of time between prescriptions that were too short, and terminated treatment of the patient the same day he received notice of the complaint in this case without giving her proper notice or helping her find another provider.

The psychiatrist who agreed to a non-permanent surrender of his license is:

  • Steven P. Miller (Louisville) – The Board alleged that Miller was treating a female patient who was an exotic dancer and, on returning from an out-of-town trip, he drove to the place his patient was performing. She sat on his lap without recognizing that he was her psychiatrist, she left when she realized who he was, and Miller allegedly stayed on the premises and talked to her later.  Several months later, the patient overdosed on drugs, but before passing out put her parents in contact with Miller by phone.  Miller allegedly got the parents to bring their unconscious daughter to his residence, put her in his bed, allowed her to live with him for a period of 7 to 14 days, fed her, took her out to dine with him, and had an inappropriate relationship with her during that time.

Six more Colorado psychiatrists received other forms of disciplinary action from the Medical Board in 2015, based on complaints the Board received about treatment they had given their patients:

  • Peter U. Berndt (Denver) – Berndt provided psychiatric treatment to a patient he then included in his family life, including but not limited to dinners at Berndt’s home and Berndt’s wife helping to decorate the patient’s home. This constitutes unprofessional conduct under Colorado law.  The Medical Board sent Berndt a letter admonishing him for these boundary violations, placed his license on probation indefinitely, and ordered him to take an ethics course.
  • Matthew J. Burke (Chandler, AZ) – Burke failed to respond to complaint letters the Colorado Medical Board sent him concerning a patient’s complaint against him. Failing to respond in an honest, materially responsive, and timely manner to a complaint sent by the Board is unprofessional conduct under Colorado law.  The Board then sent him a letter, stating the Board “must assume that the allegations raised in the complaint may have merit” and cautioning him that “complaints disclosing any repetition of such practice may lead to the commencement of formal disciplinary proceedings against your license.”
  • William W. Dodson (Greenwood Village) – The Board sent Dodson a letter admonishing him for prescribing a patient high doses of a controlled substance that exceeded FDA-approved dosages, then failing to monitor the patient adequately, having documented only two appointments with her over a roughly five-month period. He was warned that any similar complaint in the future could lead to formal disciplinary proceedings against his license.
  • Natalie M. Hogan (Littleton) – In a letter admonishing Hogan, the Board found she failed to properly assess a patient and prescribed Valium to him, in spite of his documented history of drug dependence and abuse of multiple drugs. During the hospitalization of another patient for alcohol withdrawal and behavioral problems, Hogan also failed to properly assess the patient and prescribed addictive narcotic substances, despite the patient’s history of alcohol and drug abuse and dependence.  The Board also expressed its concern that Hogan failed to coordinate both patients’ discharge from the facility where treatment occurred, when both were taking multiple psychiatric drugs.  She was warned that any similar complaints in the future could lead to action against her license.
  • Frank E. Leone (Thornton) – The FDA requires that patients taking clozapine be registered with the drug’s manufacturer and monitored by both the company and the psychiatrist. When the drug company notified Leone to discontinue clozapine for one of his patients who had developed a severely low white blood cell count, he falsely claimed he had secured a waiver from the company allowing him to continue prescribing the drug to the patient.  The patient was suffering side effects consistent with use of the drug and was unable to advocate for herself.  The Medical Board sent Leone a letter admonishing him for unprofessional conduct and required him to take an ethics course.
  • Halbert B. Miller (Alpharetta, GA) – Miller failed to renew his Massachusetts license in 2013 or update his address, so he did not receive a letter from the Massachusetts Medical Board notifying him that his license had expired. He continued to practice psychiatry without a license.  He also fraudulently claimed in his license renewal application that he was Board-certified in addiction psychiatry, but the certification had expired in 2008.  The Massachusetts Medical Board publicly reprimanded Miller and fined him $2,500 for his misconduct.  The Colorado Medical Board then sent a letter of admonition to Miller, stating that his actions were also unprofessional conduct under Colorado law and warning him that any similar conduct in the future could lead to formal disciplinary action against his Colorado license.

File a Complaint

How do you know if the Medical Board has ever taken action against your mental health provider?  Actions taken by Colorado licensing boards against psychiatrists, psychologists, marriage and family therapists, registered psychotherapists, professional counselors, and psychiatric technicians can be found by searching the provider’s name on the Department of Regulatory Agencies (DORA) website. DORA encourages consumers to check for disciplinary actions so they can make more informed decisions about healthcare providers.

DORA also encourages you to file a complaint about any unprofessional conduct you experienced.  If you want to make a complaint against someone who has harmed you with psychiatric drugs or mental health treatment, we want to talk to you.  Contact the Colorado chapter of the Citizens Commission on Human Rights by clicking here or by calling 303-789-5225.

Colorado Medical Board Takes Emergency Action to Suspend The License of Lakewood Psychiatrist Harry Taub

Part of the ongoing series:
You Be The Judge

The Colorado Medical Board took emergency action in January to suspend the license of Lakewood psychiatrist Harry Taub after reviewing information that he deliberately and willfully violated the Medical Practice Act and/or that he has a physical or mental condition that makes him unsafe to practice with reasonable skill and safety to patients.

Documents related to the case, which date back to 2003, are posted on the Colorado Department of Regulatory Agencies website.  The documents detail a history of substance abuse that started with Taub’s addiction to cough syrup, which began sometime after he was issued a resident’s Training License to practice medicine in North Carolina in 2001.

In 2003, Taub was arrested in North Carolina on a felony charge of obtaining a controlled substance by forgery.  Taub admitted he had written prescriptions for Percocet for himself under a fictitious name for about a year.  He entered into a deferral agreement, under which the charge against him would be dismissed if he followed his treatment plan and submitted to drug testing while on supervised probation for one year.

In 2008, Taub was arrested again and charged with two counts of obtaining a controlled substance by fraud/forgery.  He pled guilty to the charges, was given a suspended sentence of four to five months and was placed on supervised probation.  He entered a substance abuse treatment program.  The North Carolina Medical Board indefinitely suspended his license to practice, and records show the license subsequently became inactive in 2009.

In 2011, Taub applied for a license to practice in Colorado.  An evaluation by the Colorado Physician Health Program concluded Taub was safe to practice if he was under treatment and monitoring.

In May 2012, the Colorado Medical Board granted a restricted license that required Taub to comply with numerous conditions for a period of five years, including treatment monitoring and abstinence from addictive substances, monitoring of the prescriptions he wrote, and monitoring of his psychiatric practice.

Taub treated children and adolescents.  In June 2013, a monitor’s review of Taub’s practice found his treatment and medication management of three child and adolescent psychiatric patients fell below generally accepted standards and that he failed to make essential entries in the records of seven patients.  This is unprofessional conduct, as defined in Colorado law.

The Medical Board found that the situation required emergency action.  Instead of an immediate suspension of Taub’s license, it allowed Taub to enter into an agreement not to practice, pending further evaluation and investigation by the Board.

In July 2013, the Medical Board placed Taub’s license on probation for five years and required him to meet a lengthy list of conditions, including treatment and drug monitoring, keeping a log of prescriptions he wrote, practice monitoring, an education program, and quality reviews.

On January 8, 2016, the Colorado Medical Board received information that Taub had used alcohol and a controlled substance and that he has a physical or mental condition that renders him unsafe to practice.  The Medical Board concluded the situation required emergency action and suspended Taub’s license to practice, pending further resolution of the matter.

You decide.  Has the Medical Board handled this psychiatrist’s case appropriately?

Patient Allegedly Kidnapped by State Hospital Staff

Civil Rights Lawsuit Filed in Denver Federal Court

A lawsuit has been filed in U.S. District Court in Denver alleging that a woman languishing in legal limbo at the Colorado Mental Health Institute at Pueblo (CMHIP) was kidnapped by CMHIP staff and forcibly transported to a Denver area hospital to undergo a surgical procedure against her will.

Gabriele Gundlach, 57, of Boulder, was found incompetent to proceed by Boulder County Court in October 2011 in cases involving minor traffic-related offenses and was sent to CMHIP.         

While there, physical conditions requiring that she receive medical treatment were detected, including possible breast cancer.  Gundlach, who has never been found incompetent to make decisions concerning her own body, researched treatment options and medical facilities.  She arranged to receive treatment at Rose Medical Center and lined up funding to cover the cost.

However, Gundlach was told by CMHIP staff that University Hospital was the only facility to which CMHIP patients can be taken for medical treatment, and that patients are treated there at state expense.  These are “bare-faced lies,” according to the complaint filed in the district court by Gundlach’s lawyer, Boulder civil rights attorney Alison Ruttenberg.

Gundlach told CMHIP staff she would not consent to undergo treatment at University Hospital, explaining that for continuity of care reasons, Rose Medical Center would refuse to treat her if she received any part of the treatment for her condition at any other facility.  It also would not meet federal guidelines for funding her long-term care.  She also explained she had chosen a less invasive treatment option available only from a doctor at Rose.

In direct opposition to Gundlach’s wishes, CMHIP staff allegedly scheduled a surgical procedure for her at University Hospital without her consent or knowledge.  When Gundlach was finally informed, she cancelled the appointment.  Ruttenberg called CMHIP Assistant Superintendent Beverly Fulton, who allegedly assured the attorney that CMHIP would never transport Gundlach to a medical procedure she did not want.

But that is exactly what happened on the morning of January 3, 2013.  According to the lawsuit, CMHIP charge nurse Pamela Jones forced Gundlach to get out of bed and prepare to be transported.  Gundlach was driven under guard and against her will to University Hospital for a surgical procedure that had been cancelled and that, if administered, would have destroyed her chance to receive her preferred treatment from her chosen doctor at Rose Medical Center and to receive federal funding for her long-term care.

Because the CMHIP staff had no court order or other authority to transport her against her will, the civil rights complaint asks the U.S. District Court for damages from those responsible for kidnapping her and unlawfully seizing her body (under the color of law) for the purpose of having a surgical procedure performed that she did not want or consent to.  Color of law refers to an act done under the appearance of legal authority, when in fact no such right exists.  It further asks the court to declare it a violation of her Fourteenth Amendment right to be free from unlawful seizures of her body without due process of law.

Gundlach alleges she suffered enormous emotional distress.  She also says she was informed at University Hospital that she would have had to pay for the procedure herself if it had been done there.

According to Ruttenberg’s civil rights complaint, “Ms. Gundlach has a Constitutional right to refuse any medical procedure she does not want, and the bullies at CMHIP have no right to force her to undergo invasive surgical procedures that she refuses, for their financial convenience or otherwise.”

The complaint continues: “She has the capacity and ability to make an informed decision regarding what is going to happen to her body and who is or is not going to have the privilege of cutting into it.  Her decisions regarding the course of care for the suspected breast cancer are reasonable, rational and hers alone to make.”

When Gundlach arrived back at CMHIP, her psychiatrist, Myra Kamran, M.D., allegedly threatened Gundlach with having a guardian appointed who would agree to Gundlach being forced to have the medical procedure either at University Hospital or on-site at CMHIP.

(Myra Kamran is not currently listed on the Colorado Department of Regulatory Agencies website as a licensed physician or listed under any other licensed profession.  The Citizens Commission on Human Rights of Colorado has asked the Colorado Medical Board to investigate the matter.)

Again in violation of Gundlach’s rights, the medical procedure was scheduled to be performed on-site at CMHIP.  According to the lawsuit pending in Boulder County Court, on the morning of Monday, January 7, 2013, the charge nurse allegedly told Gundlach to get ready to be taken to the CMHIP clinic for the procedure.  Gundlach was left with the clear impression that she would be put in restraints to receive the procedure if she refused to cooperate.

It was only cancelled by last-minute intervention by a member of the Colorado chapter of the Citizens Commission on Human Rights, who called the Superintendent’s office to draw their attention to the civil rights lawsuit that had been faxed to the Superintendent the previous Friday evening.

The legal complaint alleges that the psychiatrist for Gundlach’s ward at CMHIP, Thomas Ingraham, M.D., admits Gundlach is not gravely ill, is not a danger to herself or others, and that he is not treating her for any illness or condition.

It further alleges Gundlach’s continuing, unlawful confinement at CMHIP is not only a violation of the due process and equal protection clauses of the Fifth and Fourteenth Amendments, but is also life-threatening, and asks the court to order the woman’s immediate release.

Troubles Began with Minor Traffic-related Offenses

Gundlach’s troubles began when she was arrested in Boulder in 2010 and charged with minor traffic-related offenses after allegedly being involved in an auto accident. 

After telling Boulder County Court she did not want to be represented by the public defender with two large black eyes and a large lump on her forehead who visited her in jail, she was not provided with another public defender and subsequently represented herself pro se in court proceedings.  The lawsuit alleges that she never was properly advised of the charges against her or her right to a new attorney. 

In September 2011, the Court ordered a competency evaluation.  Based on a CMHIP psychiatrist’s report, the Court found Gundlach incompetent to proceed in her court cases and sent her to CMHIP in October 2011.

Six months later, during which time Gundlach refused psychiatric drugging, another evaluation at CMHIP found that Gundlach was competent to proceed and had a good understanding of her legal situation.

Inexplicably, however, her Boulder County public defender asked for yet another competency evaluation to be done.  Gundlach refused this and all subsequent attempts to re-evaluate her because she already had received a finding of competency.

Nevertheless, two subsequent competency reports, one by a psychiatrist and the other by a licensed psychologist at CMHIP, were sent to Boulder County Court, each concluding Gundlach was not competent to proceed.  According to the lawsuit, neither doctor ever interviewed or even met with Gundlach, who continued to refuse to be re-evaluated.

In October 2012, a third Boulder County public defender moved to terminate all criminal proceedings against Gundlach.  The motion was denied in December in Boulder County Court when the Boulder District Attorney wrongly represented to the Court that Gundlach was no longer refusing treatment, including medications, at CMHIP.

Not only was Gundlach continuing to refuse to be medicated at the time, but CMHIP in November 2012 sought a court order to forcibly drug Gundlach against her will.  The lawsuit alleges that the list of drugs Gundlach’s psychiatrist wanted to give her were variously at a dangerously high dosage, meant for mental or physical conditions for which Gundlach had never been diagnosed, or prescribed solely for the purpose of patient control, which is a violation of  ethical standards for physicians.  The motion for a hearing in Pueblo County Court on the issue of involuntary drugging was eventually withdrawn.

During this time, Gundlach contacted the Colorado chapter of the Citizens Commission on Human Rights, which started an investigation of her complaint, following which three legal pleadings were filed in separate actions by Ruttenberg.

A petition filed in the Colorado Supreme Court for Gundlach’s immediate release was denied, apparently on jurisdictional grounds.

A renewed motion to dismiss charges against Gundlach is currently pending in Boulder County Court.  This motion additionally challenges the constitutionality of the state law [C.R.S. 16-8.5-116(1)] that permits a defendant to be incarcerated at the state hospital up to the maximum amount of time the person could be sentenced if convicted, when in actual practice a maximum sentence would not be imposed on each of multiple charges and would not be imposed consecutively.  Therefore because Gundlach is being held as mentally ill, CMHIP is interpreting the law to allow them to involuntarily incarcerate her for 33 months, which is from 21 to 30 months longer than for someone who is not held at CMHIP.

Gundlach’s plight has been made worse by the fact that neither she nor her attorney have been given access to legal records relating to her court cases.  The civil rights complaint pending in U.S. District Court in Denver cites Debra Cross, Clerk of the Boulder County Combined Courts, for her unconstitutional policies of denying Ruttenberg, as Gundlach’s counsel of record, access to any portion of Gundlach’s prior court file, and asks the court for relief.  It further asks the court to declare that Crosser’s refusal to ensure that Gundlach’s legal mail is sent to her at CMHIP instead of her prior home address, then throwing it into the court file when it is returned as undeliverable, violates Gundlach’s constitutional rights to due process and access to the courts. 

The complaint pleads that Gundlach’s “continued incarceration at the CMHIP without due process, without a hearing, given the fact that she is competent, is not only unconstitutional, it is life-threatening.”

If you or someone you know has experience with the Colorado Mental Health Institute at Pueblo, we want to talk to you. You can contact us privately by clicking here or by calling 303-789-5225. All information will be kept in the strictest confidence. We welcome your comments on this article below.

Sleeping Patient Stabbed In Eyes At Pueblo Psychiatric Institute

 

Image by Cyril Bosselut
Image by Cyril Bosselut

An act of violence at the Colorado Mental Health Institute at Pueblo has cost a patient one eye and possibly her sight in the other.

According to the Pueblo Chieftain, a sleeping female patient was stabbed in the eyes and face with scissors last Wednesday by another patient at the state psychiatric facility.  Both were living in a unit that houses patients that psychiatrists have deemed ready to be transitioned back into society.

Police have arrested Lamar Del Ray Davis on suspicion of attempted first-degree murder.

According to an affidavit, Davis said he was feeling “aggressive” and “just wanted to lash out at somebody.”

While it is not known what psychiatric drugs, if any, Davis was taking (or was in withdrawal from) at the time of the attack, mind-altering drugs widely used by psychiatrists at CMHIP and other psychiatric facilities are known to have adverse effects that include aggression, acts of violence, and homicidal thoughts.

If you or someone you know has been harmed in a psychiatric facility or by psychiatric drugs, we want to talk to you. You can contact us privately by clicking here or by calling 303-789-5225. All information will be kept in the strictest confidence. We welcome your comments on this article below.

Research studies, warnings from international regulatory authorities, and reports to the U.S. Food and Drug Administration on the harmful side effects of psychiatric drugs can be accessed through CCHR International’s psychiatric drug side effects search engine.

WARNING: Anyone wishing to discontinue psychiatric drugs is cautioned to do so only under the supervision of a competent medical doctor because of potentially dangerous withdrawal symptoms.

Shocking Video Released Of Man Suffocating in Prone Restraint

Man Struggles In Vain To Breathe While Strapped Down at Pueblo Psych Hospital.

RestraintsCall7 Investigators in Denver obtained the surveillance video of a man, strapped face down in restraints and left alone in an isolation room, struggling for air and slowly suffocating at the Colorado Mental Health Institute at Pueblo.

CMHIP staff are seen forcibly putting the man in prone restraint, then leaving the room.  They fail to monitor him adequately during his fatal asphyxiation.

Troy Geske, 41, was obese and suffering from a respiratory infection when he was forced face down on a table, then held down by four CMHIP staff while being strapped so tightly that he is unable to move, his own weight pressing down on his lungs.  During the take-down, one employee is seen pressing Geske’s face onto the table, and another has his elbow in Geske’s back, further impairing the man’s attempts to breathe at a time he was clearly panicked and in need of oxygen.

The reason for the restraint that ultimately led to this cruel and inhumane death?  Geske was refusing to take the psychiatric drug(s) staff were trying to administer to him.

The state had gone to court to try to block release of this shocking video.

Just as shocking is the fact that a Pueblo grand jury failed to return any criminal indictments against any of the staff involved.  (See our article, “You Be The Judge: Pueblo Grand Jury Returns Findings In Death of State Hospital Patient.”)

The Call7 Investigators report and video can be seen by clicking here.  WARNING:  This an extremely disturbing video.

If you or someone you know has been put in restraints at a psychiatric facility or has any experience with CMHIP, we want to talk to you. You can contact us privately by clicking here or by calling 303-789-5225. All information will be kept in the strictest confidence. We welcome your comments on this article below.

Pueblo DA Skeptical of Changes At Colorado Mental Health Institute at Pueblo

Says Whole Scrapping Of The Culture Is Needed.

Pueblo County District Attorney Bill Thiebaut publicly expressed his skepticism of claims by the Colorado Department of Human Services that improvements have occurred at the Colorado Mental Health Institute at Pueblo (CMHIP) in the wake of a patient death there last August.

According to the Pueblo Chieftain, Thiebaut said “I don’t have a lot of confidence that there’s been a change out there.”  He went on to say that change would require a whole scrapping of the culture at CMHIP.

“We have a culture that has permeated the institution for years,” Thiebaut said.

That culture was the focus of a report issued by a Pueblo County grand jury that investigated the August 2010 death of patient Troy Geske.  The 41-year-old, who was obese and suffering from a respiratory infection, suffocated while being restrained face down and left unattended in a seclusion room at the facility for refusing to take psychiatric drug(s) prescribed to him.  See a summary of that report in our article “You Be The Judge: Pueblo Grand Jury Returns Findings In Death of State Hospital Patient.”

“The grand jury said things need to change from the top down,” Thiebaut continued.

Geske had been readmitted to CMHIP in July 2010 because he was experiencing mental symptoms that included auditory hallucination, depression, worsening confusion and aggressive behavior.

All of these behaviors are side effects of psychiatric drugs.  Geske’s ultimate death while under the control of CMHIP staff may well have been the direct result of the psychiatric drugs he was prescribed by psychiatrists at CMHIP – drugs that he was struggling to refuse at the time of his death, drugs he may well have known were destroying him.

Adverse reactions to psychiatric drugs, as detailed in research studies, warnings from international regulatory authorities and reports to the FDA, can be accessed through CCHR International’s psychiatric drug side effect search engine.

   If you have experience with “the culture” at CMHIP, we want to talk to you.  You can contact us privately by clicking here or by calling 303-789-5225. All information will be kept in the strictest confidence. We welcome your comments on this article below.

State Psychiatric Facilities Abuse Emergency Drugging

State Audit Finds Lack of Documentation Supporting Involuntary Drugging Of Patients

Patients in the state psychiatric facilities at Pueblo and Fort Logan were drugged against their will without sufficient documentation to justify the action, according to an audit report just released by the Colorado Office of the State Auditor.

The review of some patient files at the Colorado Mental Health Institutes at Pueblo and Fort Logan found that a number of them “lacked sufficient clinical documentation to substantiate that a psychiatric emergency existed warranting an emergency medication order.”

Additionally, the audit uncovered patients whose legal rights were violated when they were involuntarily drugged on a claimed emergency basis for more than 72 hours without the proper documentation of a second opinion and/or a written request for a court hearing, as required by state law.

The report further criticized the psychiatric institutions for lacking documentation to substantiate that the condition of patients warranted psychiatrists’ petitions to courts for, or their continued use of, court-ordered involuntary drugging.

Some patients’ current medications were not discontinued before they were involuntarily drugged on a claimed emergency basis, which resulted in patients having two sets of drugging orders in effect at the same time, with an increased risk to them of serious side effects.

Significantly Higher Error Rates in Administering Drugs

Average error rates in administering drugs in 2010 were significantly higher at the Institutes than the average rate for a comparable peer group of facilities.  Specifically, Fort Logan averaged 4.50 errors per 100 drugging episodes, and Pueblo 4.93, as compared to an average of 2.71 in facilities in the peer group.

Further, there were cases in which the psychiatrist ordered two or three psychiatric drugs, including antipsychotics, on an as-needed basis for the same condition without sufficient documentation substantiating the need for multiple medications.

According to the report, several patients were found to have been put on the drug clozapine, an antipsychotic that has a potentially life-threatening side effect, without clear and sufficient documentation that less risky treatments had been tried first.

The psychiatric institutions also failed to do recommended medical follow-up on a number of patients to test for the dangerous side effects of certain antipsychotic drugs, such as the metabolic monitoring recommended by the American Diabetes Association for patients on certain antipsychotic drugs with well-known links to the onset of diabetes.

The facilities were found to have inconsistent guidelines and monitoring protocols for administering high-risk drugs, and in some cases, established guidelines were not followed.

The full audit report, “Psychiatric Medication Practices for Adult Civil Patients, Colorado Mental Health Institutes,” is posted in the June 2011 reports of the Office of the State Auditor.

If you or someone you know has experience with the Colorado Mental Health Institute at Pueblo or Fort Logan, we want to talk to you.  Please contact us privately by clicking here or by calling 303-789-5225.  All information will be kept strictly confidential.  We also welcome your comments below.

 

Pueblo Grand Jury Returns Findings In Death of State Hospital Patient

Part of the ongoing series:
You Be The Judge

A Pueblo grand jury has found official wrongdoing, but no criminal conduct in the death of a patient at the Colorado Institute of Mental Health at Pueblo (CMHIP) last August. Troy Geske, who was obese and suffering from a respiratory infection, suffocated while being restrained face down and left unattended in a seclusion room at the facility after refusing to take psychiatric drug(s) prescribed to him.

According to the grand jury report, staff at the institution committed “misfeasance and malfeasance with regard to a governmental function, and abused their authority resulting in the death of Mr. Geske.” Malfeasance includes the failure to perform a legal duty or the violation of state laws or rules. But the grand jury declined to hand down any indictment, which could have included a charge of criminal negligence.

Geske reportedly was taken to a seclusion room after he resisted taking prescribed psychiatric drug(s). There he was put facedown in prone restraint, with leather straps binding his arms and legs to a  gurney, and an additional leather strap across his torso to hold him down. He was then left alone in the room and was improperly monitored by staff outside the room. He slowly suffocated during nearly 10 minutes of struggling to breathe while in restraint.

While it is not known what psychiatric drug(s) Geske had refused, he reportedly had been re-admitted to CMHIP from a community placement in July for hallucinations, confusion, passive-combative behavior and depression. All of these conditions are common and well-known side effects of drugs routinely prescribed to psychiatric patients. (For more information on the dangerous side effects of psychiatric drugs, click here.) It is unknown what psychiatric drugs he was taking when he was readmitted, what increased dosages or additional drugs he may have been prescribed after being readmitted, or what side effects may have led him to refuse to take the drug(s).

The incompetence and extreme indifference of CMHIP staff towards Geske in the final minutes of his life were cited in the grand jury report, according to Denver’s 7News and the Pueblo Chieftain:

• “The staff member controlling the patient’s torso was using a disapproved control technique by using his forearm to apply pressure to the patient’s back during the entire restraint process,” while at the same time “Mr. Geske appeared to be struggling by trying to lift his head and torso off the bed” to breathe.

• “During the process of applying the restraints, a staff member used inappropriate pressure to the back of the patient’s head, holding his face at or near the surface of the mattress” on the gurney.

• Once restrained and unable to move or breathe sufficiently, Geske was left alone in the room, with staff failing to monitor him carefully: “It is apparent that Mr. Geske was not under direct observation at all times.”

• When staff finally realized Geske had stopped breathing, they rushed into the room but had difficulty undoing the restraints, losing precious time before CPR was started and a defibrillator used, both ultimately unsuccessful.

• Metal shears that were supposed to be available in the room to cut the leather restraints were not used “because staff either were unaware of their location or believed the shears were locked at the nursing station.”

• When staff tried giving Geske oxygen, the oxygen tank was empty. The report said, “CMHIP policy mandated oxygen tanks be tested every shift and documentation showed the tank in use had been checked off as full during the previous shift.”

• The report stated that “it appeared that no one had authority to assume – or did not assume – control of the efforts to revive Mr. Geske.”

The grand jury report concludes that “there was a systematic failure to adequately train staff, to insure staff followed policies for seclusion and restraint and patient safety related thereto, and to disseminate safety information concerning restraint procedures that was readily available, and if put into practice would have prevented the death of Mr. Geske.”

While insufficient funding or staffing continue to be blamed for ongoing problems at CMHIP, the grand jury report “finds the problems leading to Mr. Geske’s death could have been corrected with little or no impact” to CMHIP’s budget.

The grand jury also found overarching failures at CMHIP: “Public servants of the CMHIP breached their duty of care to adequately train its employees,” to “effectively communicate,” “effectively document evidence for patient care,” and “effectively investigate the death of Mr. Geske.”

CMHIP’s own investigation of the incident was reportedly carried out by a member of the facility’s public safety department, who himself had taken part in the restraint of Geske. While two top officials of the public safety department testified they didn’t believe the investigator had a conflict of interest, the grand jury disagreed. It found that the investigator never interviewed all the staff involved in the incident and did not even review the video surveillance of the incident before completing the investigation report.

Prone restraint had been banned by the Colorado Department of Human Services in its Division of Developmental Disabilities, but the rest of the divisions within the department were not notified that the procedure was banned until after Geske’s death. Other state departments, including the Department of Corrections and the Department of Education, have not banned prone restraints.

The grand jury found no criminal wrongdoing, so no one involved in the incident has been criminally charged.

Linda Stephens, mother of Troy Geske, made it clear that no one person could be blamed for her son’s death because they were all responsible. “It was the system [at CMHIP] that killed my son.”

What do you think? Did the Pueblo grand jury come to the right conclusion?

Restraint “procedures” are the most visible evidence of the barbaric practices that psychiatrists choose to call therapy or treatment. For more information on restraints, click here.

If you or someone you know was put in restraints in a psychiatric facility or has been harmed by psychiatric drugs, you can contact us privately by clicking here or by calling 303-789-5225. All information will be kept in the strictest confidence. We welcome your comments on this article below.

Man Died in Restraints at Colorado State Psychiatric Hospital

CMHIP withholds data requested by the district attorney and county coroner

An obese man who died in the custody of the Colorado Mental Health Institute at Pueblo (CMHIP) suffocated while being restrained face down on a table. He may have been hog-tied.

Troy Allen Geske, 41, died August 10 at the psychiatric institution. An affidavit for a search warrant says that Geske died after he was put in four-point restraint, in which the feet are attached to the hands behind the back.

A spokeswoman for the Colorado Department of Human Services, which oversees the psychiatric facility, denied Geske was in four-point restraint. But Pueblo County District Attorney Bill Thiebaut said the information in the affidavit is corroborated by evidence that has been collected, including video of Geske in restraints, according to the Pueblo Chieftain:
http://chieftain.com/news/local/article_f75a23c2-b72f-11df-9494-001cc4c002e0.html
http://chieftain.com/news/local/article_59e5ca9c-b653-11df-8d64-001cc4c002e0.html

At 5-feet-8 and 265 pounds, Geske was at greater risk of “positional asphyxiation” when he was restrained on his stomach with his own weight pressing down on his lungs and diaphragm. Federal law requires constant, close monitoring of anyone face down in restraints to prevent suffocation.

The results of an autopsy and toxicology tests have not yet been released.

After Geske’s death, hospital police could have called in the 10th Judicial District’s critical incident team (CIT) for an independent investigation of the incident by a team of investigators from outside law enforcement agencies, but did not do so, according to the Pueblo Chieftain: http://chieftain.com/news/local/article_b4e5d92e-b7f1-11df-abf2-001cc4c002e0.html

The CIT investigates serious incidents involving police officers under an agreement to which CMHIP is a party. Hospital police were reportedly present when staff attempted to revive Geske.

CMHIP has also refused to turn over certain information requested by investigators. District Attorney Thiebaut says he will go to court if necessary to get information he believes his office is entitled to, according to the Chieftain.

For more than 40 years, the Citizens Commission on Human Rights has advocated against any form of psychiatric treatment that is torturous, cruel, inhuman or degrading, as laid out in its Mental Health Declaration of Human Rights.

Another Death at Troubled State Psychiatric Institution in Pueblo

Facility received 1,100 patient complaints in 2008-09, reported 11 patient deaths in 2009

Another person has died while in the custody of the Colorado Mental Health Institute at Pueblo (CMHIP), according to the Denver Post: http://www.denverpost.com/news/ci_15822489. The cause of death of 41-year-old Troy Allen Geske, who died several days ago, will not be known until an autopsy is complete.

His death is being closely followed because of recent revelations of other deaths at the psychiatric facility, including the suicide of Sergio Taylor.  An autopsy report indicated 23-year-old Taylor died of asphyxiation in September 2009 after complaining about conditions at the CMHIP.  He was found by law enforcement officers under blankets with a plastic bag over his head in a supposedly high-security area of the psychiatric facility.  About a month earlier, Taylor and 19 other patients had signed a petition that said, “The sense of hopelessness has set in….  History has shown here…that when patients are feeling bored, hopeless and warehoused, …assault and suicide attempts transpire.”

As a direct result of Taylor’s death and citing concerns that other patients could die, the Colorado Department of Health conducted an immediate investigation of CMHIP in October 2009, according to The Denver Channel (KMGH): http://www.thedenverchannel.com/print/24085289/detail.html. In its report, the health department found patients at the state hospital in Pueblo to be in “immediate jeopardy” and detailed serious errors by the institution’s staff.  The department conducted an unannounced inspection of the facility again this past May.

CALL7 investigators from The Denver Channel, who have been reporting on deaths at the state hospital for months, also uncovered the death of another patient of the CMHIP, whose death was never reported to the state health department by CMHIP.  Josh Garcia died after being overdrugged and neglected by staff at the psychiatric institution.  According to his family, Garcia was given a number of powerful psychiatric drugs and suffered serious adverse effects, including severe abdominal pain.  He complained to the staff but was ignored, according to his family.  By the time Garcia was taken to a hospital, it was too late.  His bowels burst, severe infection set in, and he was brain dead within hours.  His family sued and recently received a settlement from the state over his death.

The Colorado Legislative Audit Committee has also called for repeated investigations of the CMHIP in recent years, due to complaints it receives.  In a report released in December 2009, the Office of the State Auditor found numerous deficiencies in the operations of the CMHIP that compromised safety and proved costly to the state.  Among these deficiencies, the institution did not adequately record, investigate or resolve patient complaints.  For 25 percent of the 1,100 patient complaints relating to staff behavior and quality of treatment issues the facility recorded in fiscal years 2008 and 2009, the database did not even contain the names of the 270 staff members who were the subject of the complaints.  The report also revealed that there were 11 patient deaths at the facility last year, the highest number in the three years covered in the report.  How many of those were suicides, besides the suicide of Sergio Taylor, is unknown.  Another audit is underway currently, again at the request of state legislators, to determine if there are other patients who have died of neglect at the state psychiatric hospital.

The CMHIP also has a history of failing to keep the public safe from the mentally ill housed there who have been found not guilty by reason of insanity in connection with serious crimes.  Nine such patients escaped in 2009, with patient escapes at a three-year high.