Watch For The Overdrugging Of Nursing Home Patients

Colorado Ombudsman Warns Medicare/Medicaid Cuts Threaten Quality of Care

Cuts in federal and state payments for Medicare and Medicaid patients provide yet another reason for monitoring the drugs given to a loved one in a nursing home or convalescent facility.

Medicare will cut payments for short-term nursing home stays by 11.1% starting on October 1. The state Medicaid rate has been cut 1.5%. The likely result is staff layoffs and reduced expenditures for care at the facilities.

Shelley Hitt, the Colorado state ombudsman for nursing home residents, says: “We’re very concerned about what [the cuts] might mean for quality of care and operational impacts.”

The Citizens Commission on Human Rights of Colorado echoes her concern, particularly with regard to any use of psychiatric drugs as chemical restraints to put nursing home patients into a zombie-like condition or to put them to sleep for the convenience of the reduced number of staff.

Ask Questions About The Psychiatric Drugs Being Prescribed

Here are some questions to ask the facility’s nursing staff about the psychiatric drugs prescribed to your loved one:

• What psychiatric drugs have been prescribed and in what amounts?
• Why was each drug prescribed?
• Is there any specific, measurable positive outcome for the patient of taking each drug?
• What are the risks and side effects of each drug?

You can check for the adverse reactions to psychiatric drugs, as detailed in research studies, warnings from international regulatory authorities, and reports to the FDA, by going to CCHR International’s psychiatric drug side effects search engine.

With all this information, you can determine whether there is any benefit to your loved one from psychiatric drugs, especially in light of the many dangerous and potentially deadly side effects of these drugs for vulnerable, elderly patients.

For more information about the dangers to the elderly of psychiatric drugs, and about how psychiatric drugs are used as chemical restraints on the elderly in nursing homes, click here.

If someone you know has been wrongly drugged with psychiatric drugs in a nursing home or convalescent facility, 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 also welcome your comments below.

Pueblo City Schools To Correct Non-Compliance With State Law Safeguarding Children

Two months after the Citizens Commission on Human Rights of Colorado (CCHR) first contacted the office of the Superintendent of Pueblo City Schools, the school district will begin to take action on adopting policy to safeguard schoolchildren that has been required by state law since 2003.

(See “Pueblo School District Fails To Explicitly Prohibit Teachers From Pushing Psychiatric Drugs.”)

C.R.S. 22-32-109(1)(ee) requires school district Boards of Education to adopt policy that explicitly “prohibit[s] school personnel from recommending or requiring the use of a psychotropic drug for any student.”  The law further mandates that behavioral testing of students requires prior written permission from the parents and prior written disclosure to the parent of what will be done with the test results.

The response from the office of Superintendent Maggie Lopez to CCHR’s initial public records request was slow and vague.  CCHR then sent a complaint to the president of the district’s Board of Education, in keeping with guidelines set by the Colorado Department of Education.  A complete response was received from the school district today.

The first reading of policy revisions containing the required statutory language will occur at the August 4 Board meeting, according to Greg Sinn in the district’s public relations office.  The third and final reading necessary for adoption is expected in September.

Psychotropic (mind-altering) drugs carry dangerous, even life-threatening side effects, especially for children.  (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.)

Psychiatric drugs also do not address the real, underlying problem(s) the child is experiencing, which may be a lack of additional instructional help, poor nutrition, or an undiagnosed physical condition.

Due to CCHR’s efforts, Pueblo City Schools becomes the twenty-first Colorado school district to date taking steps to remedy a long-standing non-compliance with this state law.

If you or someone you know has been pressured by school personnel to put a child on 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.

Pueblo School District Fails To Explicitly Prohibit Teachers From Pushing Psychiatric Drugs

Policy Protecting Schoolchildren Has Been Required By State Law Since 2003

Pueblo City Schools is apparently in no hurry to adopt policy safeguarding children that has been required by state law since 2003.

An examination of Pueblo City Schools Board policy by the Citizens Commission on Human Rights of Colorado (CCHR) found that the School Board is in violation of state law by not having adopted policy explicitly prohibiting school personnel from recommending or requiring psychiatric drugs for any student.

CCHR first brought the noncompliance to the attention of the office of Superintendent Maggie Lopez on June 6, following guidelines set by the Colorado Department of Education.  Since that time, agendas for the school district’s Board of Education meetings – including the meeting scheduled for this evening – have not included any mention of action on adoption of this policy.

Several readings of a policy are required at Board of Education meetings before it can be adopted for Pueblo City Schools.  Thus, it appears that some 23,000 schoolchildren in the district will be starting yet another school year without this statutory protection in place.

C.R.S. 22-32-109(1)(ee) requires school district Boards of Education to adopt policy “to prohibit school personnel from recommending or requiring the use of a psychotropic drug for any student.”

The law further requires policy that “School personnel shall not test or require a test for a child’s behavior without prior written permission from the parents or guardians or the child and prior written disclosure as to the disposition of the results or the testing therefrom.”

The law was passed by the Colorado State Legislature eight years ago to protect against teachers, principals and other school personnel pressuring parents to put their children on psychiatric drugs.  These mind-altering drugs carry dangerous, even life-threatening side effects.  (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.)

Psychiatric drugs also do not address the real, underlying problem(s) the child is experiencing, which may be a lack of additional instructional help, poor nutrition, or an undiagnosed physical condition.

CCHR has sent Colorado Open Records Act requests to school districts throughout the state, requesting copies of the policy or policies that comply with this state law.

To date, CCHR has identified 21 school districts that did not have Board policy with the clear language of C.R.S. 22-32-109(1)(ee).  Twenty of the 21 districts indicated to CCHR that steps were immediately being taken to remedy the long-standing non-compliance with state law.

Only Pueblo City Schools has been vague about when it will adopt the required statutory language.

Pueblo is home to the psychiatric drugging center known as the Colorado Mental Health Institute at Pueblo.

Because a response from the superintendent was unclear as to when Pueblo Schools will act to bring its policy into compliance with the 2003 law, CCHR forwarded a complaint directly to the president of the Pueblo City Schools Board of Education, again following guidelines set by the Colorado Department of Education.

If you or someone you know has been pressured by school personnel to put a child on 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.

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.

Elise Sannar: Did The Colorado Medical Board Discipline This Psychiatrist Appropriately?

Part of the ongoing series:
You Be The Judge

The state medical boards of Colorado and California handled the professional misconduct of an Aurora psychiatrist very differently.

Psychiatrist Elise Sannar signed stipulations with the Colorado State Board of Medical Examiners in 2007 and 2009, in which she admitted professional misconduct.  Because she was licensed in both Colorado and California, her conduct was the subject of reviews by the medical boards of both states.

According to the Colorado State Board of Medical Examiners’ Second Stipulation and Final Agency Order dated July 16, 2009 and available on the Colorado Department of Regulatory Agencies website, psychiatrist Sannar admitted to the following facts:

  • From July 2005 to July 2006, she took a leave of absence from a residency program in psychiatry at the University of Colorado Health Sciences Center so she could work as a forensic psychiatrist at the Colorado Mental Health Institute at Pueblo (CMHIP).
  • In August 2005, patient J.M., an inmate, was transferred to CMHIP with a legal status of Incompetent to Proceed in court with criminal charges against him.  Sannar was his treating psychiatrist from roughly the time he arrived at CMHIP through November 2005.
  • While in treatment with psychiatrist Sannar, J.M. informed her that he had developed romantic feelings for her.  Sannar did not transfer J.M. to another psychiatrist for treatment, as was required by generally accepted standards of practice.
  • J.M. left CMHIP in November 2005 with a legal status of Competent to Proceed, after which he was tried on criminal charges and ultimately sentenced to four years in prison.
  • Within six months of the end of treating him at CMHIP, Sannar began a romantic relationship with J.M., which continued until approximately February 2007.  The details were not specified in the public documents.
  • Sannar admits through the documents she signed that she “was aware at all relevant times of the ethical and medical impropriety of beginning and maintaining such a relationship with a patient.”

With a finding of unprofessional conduct, the Colorado State Board of Medical Examiners has a range of disciplinary actions it can take, including suspending, revoking, placing on probation or otherwise restricting, limiting or placing conditions on a license.

What did the Colorado Medical Examiners Board do?  It gave her five years probation, dating from November 16, 2007, with certain treatment and monitoring required for Sannar and certain restrictions on her treatment of patients, as detailed in the Second Stipulation and Final Agency Order.  Her license remained active.

What did the Medical Board of California do with the same set of facts and admissions from Sannar?  It got a signed Stipulation for Surrender of License from her.  (The document can be accessed on the Medical Board of California website by entering license #96357.)  Sannar can no longer practice as a psychiatrist in the state of California.

Last month, the Colorado State Board of Medical Examiners took yet another action, this time to terminate Sannar’s Second Stipulation after just 3½ years of probation, apparently on Sannar’s petition for early termination.  Her license is now active without any conditions in the state of Colorado.

According to her online Physician Profile, Sannar is currently employed as a psychiatrist by the Children’s Hospital in Aurora, and has faculty affiliations at both Children’s Hospital and the University of Colorado Hospital.

What do you think?  Did the Colorado State Board of Medical Examiners act appropriately under the circumstances?

Suspect In Gruesome Murder Reportedly Has History Of Psychiatric Treatment

Part of the ongoing series: Killers On Psych Drugs –
Psych-Drugged Accused Or Convicted Killers

Add another grisly killing to the long list of sudden, violent crimes committed by individuals with a history of taking psychiatric drugs.

Edward Romero, 27, is charged with killing a 16-year-old girl as she walked home from a party, after which he cut up her body and packed it away in a container in his garage.  He recently pleaded not guilty by reason of insanity to a charge of first-degree murder in Denver District Court.  According to the Denver Post, a judge had earlier ordered Romero to keep taking psychiatric medication.

While we don’t know the details of those psychiatric drugs, we do know that the current, rising wave of violence that is rocking our homes, schools, and communities parallels the soaring use of psychiatric drugs in American society.

Research studies, international regulatory authority warnings, and reports to the FDA, have linked the use of, and/or the too-rapid withdrawal from, numerous psychiatric drugs to violent behavior, including homicide.

High-profile Colorado killings with links to psychiatric drugs include Stephanie Rochester smothering her 6-month-old son in Superior in 2010.  She has pleaded not guilty by reason of insanity.  She reportedly was taking the antidepressant Zoloft at the time, and had intended to take her own life.

Rebekah Amaya, of Lamar, was also reportedly on antidepressants when she drowned her 4-year-old daughter and 6-month-old son in 2003.  She was found not guilty by reason of insanity in 2004.

Of course, the granddaddy of Colorado psychiatric drug-related violence is the deadly assault on Columbine High School in 1999.  Shooter Eric Harris was taking the antidepressant Luvox at the time he and Dylan Klebold opened fire at Columbine High School, killing 12 students and a teacher and wounding 26 others before killing themselves.  Harris reportedly became obsessed with homicidal and suicidal thoughts within weeks of starting to take antidepressants.  (See The Real Lesson of Columbine: Psychiatric Drugs Induce Violence.”)

At least one public report exists from a friend of Klebold, who says she witnessed him taking the antidepressants Paxil and Zoloft and urged him to come off the drugs.  Officially, Klebold’s medical records remain sealed.

Both the U.S. FDA and Health Canada have issued warnings that many antidepressants are linked to a greater risk of suicide, aggression and violence.

CCHR International’s documentary DVD, “Psychiatry’s Prescription for Violence,” containing interviews with experts, parents, victims, and a killer himself, can be viewed online by clicking here.

If you or someone you know has had suicidal or homicidal thoughts or committed sudden violent acts while taking or in withdrawal from 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.

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.

 

Brighton School District 27J In Violation For Eight Years Of State Law Safeguarding Students

An examination of Brighton School District 27J Board policy by the Citizens Commission on Human Rights of Colorado (CCHR) found that until today, the superintendent’s policy did not contain language prohibiting school personnel from recommending or requiring psychiatric drugs for any student, a policy that has been required by state law since 2003.
This means that for the past eight years, some 15,000 children in the district have not been protected by district policy from teachers, principals and other school personnel pressuring parents to put their children on behavioral drugs, especially ADHD drugs, which may endanger their health and mask the real problems students are experiencing in the classroom.
C.R.S. 22-32-109(1)(ee) requires school district Boards of Education to adopt policy “to prohibit school personnel from recommending or requiring the use of a psychotropic drug for any student.” The law further requires policy that “School personnel shall not test or require a test for a child’s behavior without prior written permission from the parents or guardians or the child and prior written disclosure as to the disposition of the results or the testing therefrom.”
One in nine boys between the ages of 6 and 14 in the U.S. is already being treated with ADD/ADHD drugs (methylpenidate). These drugs are amphetamines, which are highly addictive, which lab rats cannot distinguish from cocaine, and which a government study found greatly increase the risk that children taking them will end up on street drugs – especially cocaine. The last thing we need is schools pressuring parents to pressure their doctors to put even more of our kids on these drugs.
In 2006 the U.S. Food and Drug Administration began to require ADD/ADHD drugs to carry the FDA’s strongest, “black-box” warning that the drugs can cause heart attacks, strokes and sudden death. Cardiologist Steven Nissen, on the FDA advisory panel that recommended this warning, explained the urgency of the warning: “This is out-of-control use of drugs that have profound cardiovascular consequences. We have got a potential public health crisis. I think patients and families need to be made aware of these concerns.”
Drugging may make children easier to control, but it comes at the cost of putting children’s health at tremendous risk. It also does not address the real problem the child is experiencing, which may be a lack of additional instructional help, poor nutrition, or an undiagnosed physical condition.
CCHR Colorado brought the policy omission to the attention of Brighton 27J officials early today. District chief legal officer Janet Wyatt reported that district Board policy was revised later in the day to bring it into compliance with state law.
The Brighton Standard Blade covered this story, which is available online to subscribers.

Denver Post Fails To Address The Role Of Psychiatric Drugs In Suicides

Psychiatric Drugs Are Linked To Worsening Depression and Suicide

A story in today’s Denver Post about suicides in Colorado failed to address a key issue:  How many of these individuals had been taking psychiatric drugs, known to worsen depression and increase the risk of suicide, before they took their own lives?

We know that individuals seeking help from psychiatrists will almost certainly be prescribed one or more psychotropic (mind-altering) drugs because, according to a recent article in the New York Times,drugging is so much faster and more profitable to the psychiatrists than taking the time to listen to their patients’ problems.

We also know that psychiatric drugs are known to cause serious, even life-threatening side effects.  (For international studies and warnings on the dangerous side effects of psychiatric drugs, as well as adverse drug reactions reported to the FDA, go to CCHR International’s psychiatric drug side effects search engine.)

Antidepressants in particular are known to cause worsening depression, birth defects, sexual dysfunction, anxiety, panic attacks, hostility, aggression, psychosis, violence, suicide and many, many other adverse events.  Long-term antidepressant users frequently report that their emotions have been deadened so much that they feel like zombies.

With drugging having become almost the only psychiatric “treatment” available, no wonder the rate of suicides in Colorado has shown no improvement whatsoever in the 22 years for which data is available from the Colorado Department of Public Health and Environment’s online death statistics database.

CCHR International’s award-winning documentary, “Dead Wrong: How Psychiatric Drugs Can Kill Your Child,” is the powerful story of one mother’s quest to understand her child’s suicide.  Six months after her son Matthew died, Celeste Steubing discovered the link between psychiatric drugs and suicide.  Feeling betrayed over having been denied these facts, she testified before the FDA in 2004, along with many other parents whose children had been driven to suicide by antidepressants.  That same year, the FDA issued its strongest, black-box warning that antidepressants can cause suicide, a warning that came 18 months too late for Matthew.  Click here to view the DVD and hear what parents, health experts, drug counselors and doctors have to say about the deadly dangers of psychiatric drugs.

If you have experienced increased depression, thoughts of suicide, or any other adverse side effect while taking a psychiatric drug, report it to the FDA by clicking here.

If you or someone you know has been harmed by psychiatric treatment or 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 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.