Parents file grievance with Retreat after child's untimely death


BRATTLEBORO -- The parents of an adolescent patient who died weeks after a May 5 suicide attempt at the Brattleboro Retreat have filed a formal grievance against the psychiatric hospital for the untimely death of their child.

In the grievance letter obtained by VTDigger, the parents write that their child was able to hang himself or herself while an inpatient at the Retreat, and that the child died July 1 as a "direct result of (their) injuries."

The parents, both doctors who live out of state, could not be reached for comment.

The Brattleboro Retreat said in an emailed statement that it had received the grievance and would respond according to its grievance policy, but offered no further comment.

An incident report filed by the Retreat with the state Department of Mental Health confirms the suicide attempt by hanging on Tyler 3, a ward for adolescent patients, and says the patient was taken by ambulance to Brattleboro Memorial Hospital and transferred to an out-of-state hospital later that day.

An official cause of death for the patient, who later died at the out-of-state hospital, is not included in the letter or the incident report.

When Brattleboro Retreat officials were asked about the incident at a July 22 meeting of the joint Mental Health Oversight Committee, Linda Nagy, interim vice president of patient care for the Retreat, suggested it would be easier for a patient to take their own life at a non-psychiatric facility.

But when asked directly if she knew whether the patient died as a result of injuries sustained at the Retreat, Nagy said, "We do not know that."

The suicide attempt triggered a June investigation by the state Division of Licensing and Protection, which carries out surveys and investigations of federally certified hospitals on behalf of the Centers for Medicare and Medicaid Services (CMS).

That investigation resulted in a July 8 termination letter from CMS, which later accepted the Retreat's plan of correction. The parents describe the plan in their grievance letter as "woefully inadequate."

The parents requested more detail on the correction plan, and information on a similar event that occurred in 2013, the letter shows. The June DLP report mentions another attempted suicide or self-harm incident, but does not provide a date.

The letter was sent to the Retreat, its board chair, the Department of Mental Health, CMS, the Joint Commission -- a hospital accrediting agency -- and Rep. Anne Donahue, R-Northfield, a member of the Mental Health Oversight Committee.

Even if a plan of correction is accepted by CMS, follow-up site visits must show that the plan is working or a hospital can still lose its certification. Other incidents at the Retreat this summer have put its certification under scrutiny again.

A July 20 brawl on Tyler 3 injured several staff and one patient. The subsequent DLP investigation found no violations related to the fight; however, in late-July a patient with a history of sexually assaultive behavior made "inappropriate sexual contact" with another patient on Tyler 3, the DLP report said.

The Retreat violated patient rights in the incident, and was not in compliance with its quality improvement plan, according to the DLP report.

The Retreat filed an amended plan of correction Monday, which CMS must reapprove. The amended plan won't be public until it is approved. A letter from regulators says there will be a follow-up site visit by Oct. 6.

If the Retreat isn't in compliance with federal rules by Oct. 6, it will lose its federal certification.

That would seriously affect mental health care in Vermont, because the state's decentralized system relies on private psychiatric hospitals to treat many of the most ill psychiatric patients.

Those services are paid for with federal Medicaid dollars under Vermont's global commitment waiver.

The new state hospital in Berlin is meant to take pressure off an inpatient psychiatric system that can't keep up with demand, but its 25 beds won't be sufficient if the Retreat can't take patients who are in state custody.

The Retreat has a 14-bed unit that houses many of the most acute cases in state custody. The unit had an average of 22 patients throughout July, and has never had a monthly average of fewer than 14 patients in the past year-and-a-half.

There were roughly seven people waiting for inpatient admission on any given day during that same period, according to figures from the Department of Mental Health.


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