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State didn't investigate psych patient deaths after release from Detroit hospital

Notification of Death Report

State didn't investigate psych patient deaths after release from Detroit hospital
Lawmakers call for more review of post-release deaths

Oct 17, 2019
By: Ross Jones

 

LANSING (WXYZ) — Since 2017, at least four patients have died within two days of being released from StoneCrest Hospital, a private inpatient psychiatric facility in Detroit. Despite being notified of each of the deaths, state officials never investigated.

Officials with LARA, the Department of Licensing and Regulatory Affairs, say they’re not legally required to follow up on deaths like these, nor are they empowered to by statute. Today, in response to an investigation by 7 Action News, two state senators are calling for changes to ensure that post-release deaths are investigated.

At 162 beds, StoneCrest is one of the largest private psychiatric facilities in the state. 7 Action News first investigated the hospital earlier this year, after one of its patients, Joe Sadlak, admitted to murder only two days after he was discharged.

He had been treated at StoneCrest for less than a week.

“You put my son on four different kinds of medication and knew his drug history,” said Pamela Rowley, Joe’s mother, “and you let him go.”

In Michigan, when a psychiatric patient dies within two days of being released from a hospital, the state requires the hospital to report it. Those reports come to the Department of Licensing and Regulatory Affairs.

In September 2017, StoneCrest reported that a patient came to its hospital after stating he “was not happy in his life and wanted to die.” After treatment, he was released and died shortly thereafter. StoneCrest reported the death to the state, listing the cause as “not known.”

Less than a month later, another patient came to Stonecrest after saying he wanted to “jump off a bridge.” Within 2 days of release, he was found dead in his bathtub with his throat cut. State officials from LARA didn’t investigate.

A third death would be reported the following July. A woman came to Stonecrest with a history of suicidal behavior. She was treated, released and—the next day—found dead in a river. The cause of death was listed as “unknown.” Again, state officials didn’t investigate.

Then, this past June, a 29-year-old Detroit man came to Stonecrest after displaying severe psychotic behavior. He was deemed well enough to be released, but took his life the next day.

“Did your office ask any questions about that?” asked Channel 7’s Ross Jones.

“Again, we’ve been doing our statutory requirement,” said Larry Horvath, the Director of the Bureau of Community and Health System at LARA

“Did you ask any questions about that?” Jones asked again.

“We required the report to be filled out,” Horvath said.

“And that’s it,” Jones replied.

“Yes,” Horvath said.

Officials asked no questions, according to a spokesman, because “LARA is not by law or rule required to follow up on these reported deaths,” nor—they say— does the law give them the express authority to. State watchdogs are empowered to investigate only deaths that occur in restraints, Horvath said.

The death reports are reviewed during regular inspections, but no investigations are launched. Horvath said he hopes hospitals use the reports to guide their treatment.

"If they're starting to notice a pattern with a cause of death that occurs have discharge, hopefully they're starting to work with their medical directors, their nursing staff, their social workers to put corrections in place to address it," he said.

“It’s inexcusable,” said Mark Reinstein, President and CEO of the Mental Health Association in Michigan. “To hide behind, ‘It’s not our legal responsibility.’ Well then whose is it?”

By law, LARA is required to report all psychiatric deaths reported to them to the state legislature. But they haven’t been, 7 Action News has learned, for at least the last three years. In August, prompted by our reporting, the state submitted reports for 2016, 2017 and 2018, though they did not include post-release deaths.

Following our questions, LARA changed the reporting requirements for post-release deaths—no longer requiring that deaths occurring within 48 hours of discharge be reported. Spokesman Jason Moon said changing the policy aligns LARA with state law, which doesn’t require notification of post-release deaths.

The decision stunned multiple mental health advocates, including Andrea Rizor, the Director of Advocacy for Michigan Protection and Advocacy Services,.

“It looks like they don’t want to know if it’s a suspicious death or not,” she said. "It doesn't make sense."

This week, in response to 7 Action News' findings, the Democratic leader in the state senate is calling for changes.

“Stories like these are deeply concerning, and as a state we should be doing all that we can to help stop these preventable deaths,” said Senate Minority Leader Jim Ananich (D-Flint). “The department should have the ability to identify concerning patterns, and if it requires a legislative fix to make sure they are empowered to do so, we will write the bill.”

Contact 7 Investigator Ross Jones at ross.jones@wxyz.com or at (248) 827-9466.

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October 23, 2019