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Gloria Huntley

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on January 22, 2007 at 10:44:43 pm
 

 

Patients suffer in a system without oversight

 

By ERIC M. WEISS and DAVE ALTIMARI

This story ran in The Courant on October 13, 1998 

www.pcma.com/crisis_intervention_news/deadly_restraint/day3.stm 

 

Had Gloria Huntley been able to move, had she not been bound to

her bed with leather straps for days on end, perhaps she would

have tried to draw the attention of the inspectors who were

conducting a three-day tour of Central State Hospital.

 

Had she been able to move, had she not been pinned down

by the wrists and ankles, she might have held up a sign, as

she had done before when a visitor came through Ward 7.

Her handwritten plea was simple: "Pray for me. I'm dying."

 

But the inspection team from the nation's leading accreditation

agency never noticed Gloria Huntley before leaving the

Petersburg, Va., psychiatric hospital.

 

The three inspectors from the Joint Commission on the

Accreditation of Healthcare Organizations issued Central State

a glowing report card -- 92 out of 100 points. They also bestowed

the commission's highest ranking for patients' rights and

care when they concluded their review on June 28, 1996.

 

The next day, Gloria Huntley died. She was 31.

 

Her heart, fatally weakened by the constant use of restraints,

had inflamed to 1 1/2 times its normal size. In her last two months,

she'd been restrained 558 hours -- the equivalent of 23 full days.

 

Nine months later, the Joint Commission gave Central State an

even better score in a follow-up review -- even though Huntley's

treatment would ultimately be labeled "inhumane" by the state

of Virginia and condemned by the U.S. Justice Department.

 

"How could JCAHO give Central State the highest rating

in human rights when they were killing people?" asked

Val Marsh, director of the Virginia Alliance for the Mentally Ill.

 

The way the country's health care system works, how

could it not?

 

The Courant's nationwide investigation of restraint-related

deaths underscores just how faulty -- how rife with conflicts

of interest, how self-protective, how ultimately ineffective --

the system of industry oversight and government regulation

really is.

 

The health care industry is left to police itself, but often doesn't.

 

Time and again, The Courant found, when it comes to the

quality and safety of patient care, the interests of the industry

far outweigh the public interest.

 

"One reason you have overuse and misuse of restraints is

because oversight is practically nonexistent," said Dr. E. Fuller

Torrey, a nationally prominent psychiatrist and author of several

books critical of the nation's mental health system. "And the

health industry doesn't want oversight."

 

The chain of agencies, boards and advocates that is supposed

to provide oversight -- the kind of oversight that might have

prevented Huntley's death and hundreds like it -- often breaks

down in multiple places.

 

But the heavy reliance on the Joint Commission -- an industry

group that acts as the nation's de facto regulator -- lies at

the core of the problem.

 

The federal government relies on the private nonprofit agency's

seal of approval for a psychiatric hospital's acceptance into

Medicare and Medicaid programs. And 43 states, including

Connecticut, accept it as meeting most or all of its licensing

requirements.

 

But the Joint Commission doesn't answer to Congress or the

public. It answers to the health care industry.

 

The Joint Commission was founded in 1951 by hospital and medical

organizations, whose members still dominate the commission's board

of directors. The commission is funded by the same hospitals it

inspects.

 

How tough are its inspections?

 

Of the more than 5,000 general and psychiatric hospitals that the

Joint Commission inspected between 1995 and 1997, none lost its

accreditation as a result of the agency's regular inspections.

 

None.

 

When extraordinary circumstances arise -- a questionable death, for

instance -- the Joint Commission may conduct additional inspections.

Even then, less than 1 percent of facilities overall lost accreditation.

 

Central State was not among them.

 

Joint Commission officials are the first to say they are not regulators.

Participation is voluntary, and 83 percent of hospitals inspected were

found to have shortcomings that needed to be addressed.

 

"Joint Commission accreditation is intended to say to the patient: This

is a place that does things well and is constantly working to improve

things," said Dr. Paul M. Schyve, a psychiatrist and senior vice president

of the Joint Commission.

 

If the industry is not adequately watching itself, neither is the government.

The nation's top mental health official says he has little latitude when it

comes to tougher regulation and oversight.

 

"Most rules governing health care have been left to the states," said Dr.

Bernard S. Arons, director of the U.S. Center for Mental Health Services.

 

When it comes to mental retardation facilities, in fact, inspection is left

largely to the states.

 

But their record is not much better.

 

The General Accounting Office, the investigative arm of Congress, has

found that state regulators are loath to punish state-run facilities.

 

In a study of state mental retardation centers, the GAO found "instances

in which state surveyors were pressured by officials in their own and

in other state agencies to overlook problems or downplay the seriousness

of deficient care in large state institutions."

 

When state regulators do show up, their inspections are scheduled

with such predictability that facilities can beef up staff, improve services

and even apply fresh coats of paint. Often, only the new paint remains

after the inspectors leave.

 

"These visits provide only a snapshot," said William J. Scanlon, director

of health care studies for the GAO. "And it may be a doctored snapshot."

 

It is only when the system utterly collapses, as in the Gloria Huntley

case, that the federal government intervenes to set rules for patient

care.

 

Justice Department abuse investigators, who have authority to

intercede when civil rights violations are suspected in publicly run

facilities, often find these same facilities were recently given clean

bills of health by licensing agencies or the Joint Commission.

 

"The use of restraints is clearly a very big problem and a very significant

issue in nearly all of the institutions we investigate," said Robinsue

Froehboese, the top abuse investigator at the Justice Department.

 

But with a staff of 22 attorneys, Froehboese's office can undertake

only a handful of major investigations each year.

 

"Nineteenth-century England had a better oversight system than

we have now," said Torrey, describing an English system that used

full-time government inspectors to check every psychiatric facility

without prior notice.

 

At Central State, the warning signs should have been apparent. But

Joint Commission inspectors review just a sampling of patient

records -- a sampling that may not include problem cases like Gloria

Huntley's.

 

Anyone who did look at Huntley's records would have known her health

was failing -- and that heavy use of restraints was a primary reason.

 

Two years before Huntley's death, a doctor warned officials at Central

State that she would die if they didn't change her restraint plan.

 

"Staff members should watch their conscience, and those in charge

must always remember that following physical struggle and emotional

strain, the patient may die in restraints," stated the ominously titled

"duty to warn" letter.

 

Even if the Joint Commission inspectors had missed Huntley in particular,

there were other cases at Central State that should have raised red

flags. One patient was restrained for 1,727 hours over an eight-month

period, yet another for 720 hours over a four-month period, according

to a U.S. Justice Department report.

 

So, in many respects, the investigation into Huntley's death is most

remarkable in that it happened at all. When she died on June 29, 1996,

the police were never called.

 

It took a hospital employee's anonymous call to a citizens watchdog

group, days after Huntley's death, to tip off the outside world that she

died while being restrained -- and not in her sleep as hospital officials

told family members.

 

The Courant's investigation found at least six cases in which facilities,

wary of lawsuits and negative publicity, tried to cover up or obscure

the circumstances of a restraint-related death.

 

"It's sort of a secretive thing," said Dr. Rod Munoz, president of the

American Psychiatric Association. "Every hospital tries to protect

itself."

 

"The incentive is to settle with the family, fix it internally and move on,"

said Dr. Thomas Garthwaite, deputy undersecretary of health for the

U.S. Department of Veterans Affairs.

 

Many states, including Connecticut, have laws that shield discussions

among doctors that explore what went wrong. The laws are designed

to promote candid discussions, but the solutions often don't leave the

closed hospital conference room.

 

Garthwaite and other experts said hospitals need to share problems

and solutions to prevent deadly errors from being repeated. Just a year

ago, the VA began a comprehensive system to track all deaths and

mistakes.

 

But a plan by the Joint Commission to do the same all across the nation

has been stymied so far by the powerful American Hospital Association.

 

The AHA notified the Joint Commission in January that the proposal had

created a "firestorm" among its members, who worried that they would

have to turn over "self-incriminating" documents.

 

"We've tried to make the program workable, so people would not be

afraid to report on a voluntary basis," said Dr. Donald M. Nielsen, a

senior vice president of the American Hospital Association. He said

the two groups agreed last month on some ground rules regarding

the issue.

 

With the industry failing to monitor itself, with government regulators

unwilling to challenge the industry, uncovering abuse is left to "protection

and advocacy" agencies established by Congress in each state.

 

Despite $22 million in federal funding this year and broad authority to

root out and litigate cases of abuse, even some advocates turn a blind

eye to investigating deaths.

 

Desperate for help, Gloria Huntley turned to one of these organizations

in her last months of life.

 

Not only was her complaint not investigated, but three weeks after her

death Huntley was sent a letter saying the advocacy agency was dropping

her case because it hadn't heard from her in 90 days.

 

The letter ends: "It was a pleasure working with you to resolve your complaint.

I wish you the best of luck in your future endeavors."

 

Advocates say they have too little funding for their broad charge, and are fought

every step of the way by hospitals and doctor groups. Scarce money and staffing

are used just to secure basic information.

 

"It's a David and Goliath battle," said Curtis L. Decker, executive director of the

group representing advocacy organizations nationwide. "And Goliath is winning."

 

Hospitals see no need for drastic change, let alone more government intervention.

 

"Given the speed of government, it is often better to allow the private market to

work issues out," said Nielsen of the AHA. "Joint Commission standards have been

revised recently and are continually being improved."

 

Huntley's family might take issue with that assessment. They have filed a civil rights

lawsuit in federal court seeking $2 million, and a wrongful death lawsuit in state

court seeking $450,000.

 

"We knew from the get-go things weren't right when they told us she died in

her sleep," said Paige Griggs, Huntley's sister-in-law.

 

"We thought she was being taken care of."

 

Courant Staff Writers Kathleen Megan and Dwight F. Blint contributed to

this story.

 

 

 

 

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