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Colorado Mental Health Institute News for Colorado

Patient’s Death at Colorado Mental Health Institute at Pueblo Due To Staff Neglect

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.

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Colorado Mental Health Institute News for Colorado

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.

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Colorado Mental Health Institute News for Colorado

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.

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