National regulators warned Eastern State Hospital about the dangers of patient access to cords years before one patient allegedly strangled another in November 2012, according to a recently filed lawsuit.
The wrongful-death suit, filed in federal court last month by the family of Duane Charley, cited letters sent to the Spokane County psychiatric hospital in 2006 and 2009 by the Joint Commission, a national accreditation organization.
Both letters, sent after routine inspections, mentioned long cords. The 2009 letter specifically noted telephone cords that “could have been used for strangulation.”
Administrators did not change the hospital’s policies regarding cords until the findings of another routine inspection — this one a month after Charley’s death — endangered Eastern State’s accreditation.
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“Unfortunately, this was after Mr. Charley had already been murdered as a result of Eastern’s failure to remedy the obvious hazards identified by the Joint Commission,” according to the lawsuit, which claims that “as a direct and proximate result of Eastern’s failure, Mr. Charley was savagely murdered.”
Hospital spokesman John Wiley declined to comment on “cord policies,” citing a state Department of Social and Health Services (DSHS) practice of not commenting on pending litigation.
But Wiley noted that Eastern regained its full accreditation a few months after a preliminary denial last December.
He added that Eastern and the state’s other psychiatric hospital, in Lakewood, Pierce County, limited patient access to long cords this year.
Western State Hospital now prohibits most cords that are not supervised by staff at all times, spokeswoman Kris Flowers said. Previously, access had been determined on an individual basis.
The last death not of natural causes at Western was a suicide in April 2012.
“Both of the state’s psychiatric hospitals have new administrators who are working diligently to move forward with patient safety recommendations,” Wiley wrote in an email. “State institutions have been through some lean budget times and staff reductions in the last five or six years.”
Eastern has 272 patients and 693 staff members.
Its new CEO, Dorothy Sawyer, took over in August. She also would not comment on Charley’s killing.
Charley, an Okanogan County native, was committed to Eastern in 1995, when he was in his late 30s, according to the lawsuit. He had been diagnosed with mental retardation and schizo-affective disorder, according to the lawsuit.
He had also been found not guilty by reason of insanity of indecent liberties, according to court records.
He was placed in a forensics unit with other patients who have been found incompetent to stand trial or not guilty by reason of insanity.
Charley was found on the floor of his room in the early morning of Nov. 20, 2012, after patient Amber Roberts told a hospital employee that she had killed someone.
According to court documents, Roberts told the staffer, “I murdered someone, but you’re going to have to find him,” and as the employee moved down the ward, said, “You’re getting warmer.”
When the staffer neared Charley’s room, Roberts allegedly said, “You’re hot.”
Charging documents accuse Roberts of strangling Charley with a belt, although a police report alleges that she admitted to using an electrical cord.
Roberts had been committed to the hospital after being found not guilty by reason of insanity of killing a woman in Yakima in 2003. She faces a charge of first-degree murder in the Charley case.
The recently filed lawsuit claims the death could have been prevented.
The suit seeks an unspecified amount of money in compensatory and punitive damages for the family.
“Nothing can bring back their brother, obviously,” attorney Kelly Konkright said. “But what they do want is the hospital to take this situation seriously, and they don’t want it to ever happen again.”
The lawsuit cites five hospital practices: Patients could freely roam the ward and cover their room windows; patients were not locked in their rooms and not prevented from entering other rooms; access to potentially dangerous items, including cords, was not restricted.
The Joint Commission had noted some of the same issues in its inspections.
In the inspection after Charley’s death, the commission found Eastern out of compliance on 32 standards, including one requiring that “the hospital establishes and maintains a safe, functional environment.”
It issued a preliminary denial of accreditation based on the “existence at time of survey of a condition, which in the Joint Commission’s view, poses a threat to patients or other individuals served.”
Wiley said the hospital quickly put together an action plan to regain the accreditation.
Brian M. Rosenthal: 206-464-3195 or firstname.lastname@example.org. On Twitter @brianmrosenthal