A state investigation has concluded that staff neglect was the cause of the choking incident last September at the Colorado Mental Health Institute at Pueblo (CMHIP) that caused brain damage leading to a patient’s death, according to the occurrence summary report recently released by the Colorado Department of Public Health and Environment (CDPHE).
The forensic pathologist who subsequently performed the autopsy on the decedent concluded that the brain damage was the cause of death.
The male patient in his 60s lacked bottom teeth and had a dietary restriction that required his food to be cut into small pieces. After being served whole food by CMHIP staff, he collapsed when it lodged in his throat and obstructed his breathing. Staff reportedly attempted, but failed to dislodge the food with the Heimlich maneuver, and then performed CPR, but the patient remained unresponsive.
He was rushed to a local hospital, where he was placed on life support, but his condition never improved. Eight days later the support services were discontinued and he was pronounced dead.
The autopsy report states the cause of death was brain damage due to the lack of oxygen from choking on food.
Three CMHIP staff members were suspended during the state investigation. Following CDPHE’s finding of staff neglect, one staff member was fired, one resigned, and one received corrective action that included additional training and supervision.
An accelerated response to the incident by CDPHE was triggered by a complaint filed by the Citizens Commission on Human Rights of Colorado.
If you or someone you know has been harmed by treatment at the Colorado Mental Health Institute at Pueblo or any other mental health facility, we want to know what happened. You can contact us by clicking here or by calling 303-789-5225. All information will be kept strictly confidential.
