A state investigation into Sage View Psychiatric Center, the behavioral health unit of St. Charles Health System, found patient safety concerns after a patient there hanged herself last fall.

The state found that Sage View failed in its requirement to give patients “the right to receive care in a safe setting.”

The woman had previously attempted suicide at least twice and was found by hospital staff to be at high risk of doing it again. Nevertheless, special precautions often taken in high-risk cases were not in this case, the report found.

The suicide occurred on Sept. 21, and the state investigation was completed shortly thereafter. The report also examined medical records from patients at Sage View during roughly the same time and found deficiencies in the care of those patients.

The hospital did not disclose the event publicly. The Bulletin recently learned of the investigation through a public records request.

Suicides that occur in hospitals are called “never events,” belonging to a group of medical errors that hospital quality organizations say should never occur while a patient is under hospital care.

Hospitals are supposed to be able to prevent suicidal patients from killing themselves and other “never events,” such as operating on the wrong patient or body part, through a combination of the hospital environment, staff monitoring and, sometimes, medications.

But clinical experts say patient suicides are very difficult, if not impossible, to prevent. Indeed, they are among the most common “never events” that occur in hospitals. In 2010, six patients committed suicide while in Oregon hospitals, according to the Oregon Patient Safety Commission.

Often, “patients are admitted to psychiatry units because they are suicidal,” said Dr. Jan Fawcett, a professor of psychiatry at the University of New Mexico School of Medicine and a national expert on suicide prevention. “How do you know if a person is at acute risk? That’s the hardest thing to know.”

This latest case at St. Charles occurred about 21⁄2 years after the public suicide of Cindy Powell, who leapt to her death from a hospital balcony.

This instance is the first patient suicide in Sage View’s seven-year history, hospital officials said.

Whether the deficiencies found in the state’s report contributed to the incident is an open question and one the report does not try to answer.

“You try to do everything in a hospital to keep everyone safe,” said Dr. Magnus Lakovics, a Bend psychiatrist and medical director for St. Charles’ behavioral health services. “That doesn’t prevent someone from committing suicide.”

A risky assessment

The woman came into the emergency department at St. Charles Redmond, where she was hearing voices and talking about committing suicide. The voices told the woman they hated her and wanted her to kill herself, according to a social worker’s report. The woman told the social worker she didn’t feel safe with herself. The voices wouldn’t leave her alone, the woman said.

The woman was transferred to St. Charles Bend, the only area hospital with an inpatient psychiatric ward. She was monitored in the hospital’s psychiatric emergency room for several hours after her Sept. 20 arrival and transferred to Sage View. As the patient left the emergency area, the nurse wrote a note in the medical record: “condition at discharge — serious.”

When the patient got to Sage View, another nurse took over, again assessing the woman’s condition. According to this assessment, the woman denied hearing voices. “Behavior is strange,” the nurse noted, according to the state report. “Poor judgment, poor insight and (her) mood is angry.”

The nurse noted that the patient had attempted suicide twice before and had scars on her arms from cutting herself.

Despite this, the nurse documented her risk of suicide as “low.” The nurse left the section labeled “recommendations” blank.

This documentation “did not meet organization standards,” the hospital said in a response submitted to the state. The nurse was fairly new, the hospital noted, and needed “additional mentoring in how better to approach this type of problem.”

Robin Henderson, the director of St. Charles’ behavioral health services, told The Bulletin that staff training was not an issue in the incident. In a later statement relayed through spokeswoman Lisa Goodman, Henderson said, “If it had been, we would have been cited by (the state) as negligent.”

Based on suicide risk assessments, staff at Sage View will decide how much observation a patient needs. Sage View staffers check in with every patient at least once an hour, but some patients are checked more frequently, sometimes every half hour or 15 minutes. The riskiest patients never leave the staff’s sight and occasionally are not allowed out of arm’s reach.

The woman was put on hourly checks, the lowest level of risk, according to the state report. The investigators note there were indications that should have sent up red flags, including previous suicide attempts and assessments that indicated the patient’s risk was high and her condition serious.

During an interview with state investigators, the nurse who had done the assessment said that he or she (the state report does not specify the nurse’s gender) had a “gut feeling” the patient was “OK.”

The last recorded observation of the patient was at 11 a.m. on Sept. 21.

Before the 12 p.m. check, the woman broke a plastic hanger and wedged it in the upper corner of her bedroom door, according to a hospital report on the incident. She used the hanger and a bedsheet to form a ligature and hanged herself.

The hospital’s report indicates she died at 11:55 a.m.

Hospital response

The hospital responded to the incident in a number of ways. It notified the patient’s family as well as state and local officials.

The Bend Police Department opened an investigation, which is still ongoing.

The hospital also began a process known as a root cause analysis, delving deep into hospital processes and trying to learn what went wrong.

“Whenever any type of incident occurs … you want to as quickly as possible interview everybody who might be involved,” said Henderson, “and really figure out, were there breakdowns that occurred?”

This was an “everybody boots on the ground” investigation, said Leslie Ray, a patient safety consultant at the Oregon Patient Safety Commission who read the state report. She guessed that the investigation took at least 500 hours, “just because of how deep and thorough it is.”

A patient suicide, Ray said, “is one of the more complex (issues) that a system has to deal with.”

Coming out of the investigation, the hospital changed a number of practices, Henderson said. “I think it would be fair to say … what we found were opportunities for improvement.”

In particular, the hospital changed the program it uses to assess risk. The new program more clearly lays out and weighs the risk factors for a given patient, Henderson said.

The hospital also gave staff more training around how to assess risk in potentially suicidal patients.

In addition, the hospital changed some things in the rooms at Sage View. The hospital no longer allows patients to use hangers. Though a chair was not used in the suicide, those are gone from rooms as well, according to the hospital’s report to the state.

The hospital also investigated whether to install pressure-sensitive alarms on doors though for now has decided they cost too much and are not reliable enough. It has changed to thicker, harder-to-knot bedsheets.

But it’s unclear whether any of these changes would have prevented this suicide or will help to prevent another one, Lakovics said. “The thing you have to realize is, even if we make all these changes … there’s a very good chance it will happen again,” he said. “It’s the nature of the problem.”

Lakovics said the system of assigning patients risk is imperfect, and medicine is not able to predict the future.

“We do the best we can,” Lakovics said. “We put certain people in high-risk categories, and guess what? The ones that aren’t in the high-risk categories still do it.”

Public disclosure

When state investigators came to St. Charles at the beginning of October, they found additional breaches of patient safety in at least two other patients.

Though those cases did not result in grave harm, they did indicate that the hospital was not following federal and state regulations in some instances. Among other findings, the investigators noted that just one day before the suicide occurred, staff at Sage View had given a razor to a woman who had a history of cutting herself.

The hospital, according to its response to the state, has discontinued the use of razors.

When the suicide occurred, the hospital did not disclose it or the investigation to the public because officials did not feel the risk extended to the wider community, Goodman said.

“Our threshold for disclosing some of these events publicly would be whether there’s a risk to other patients,” she said.

In this case, said hospital attorney Gary Bruce, patient privacy trumps a right to community knowledge. “Our first obligation is to the patient and his or her right to privacy. And then shortly after that set of rights is our obligation to the community to keep them safe.”

The hospital has previously disclosed cases in which there was grave harm to a patient while in the hospital. In 2008, the hospital held a press conference after the death of Cindy Powell, the woman who leapt to her death in the lobby.

Later that same year, the hospital issued a news release after a patient died when his tracheostomy tube was inadvertently sealed off by a staff member at the hospital, suffocating the man.

Both Lakovics and Henderson expressed concern that disclosure of the current patient safety issues would discourage people from using the hospital. “I don’t want the community to get frightened and scared of mental health care,” Lakovics said. “The hospital is like anything else. There’s many things we can’t help, but there’s so much we can do.”