A grand jury investigation, prompted by this KMGH-TV investigation, found the staff of the Colorado Mental Health Institute at Pueblo responsible for the suffocation of a patient. The investigation, headed by investigative reporter John Ferrugia uncovered mistakes, lack of training, incompetence, and possible criminal neglect that have led to the deaths of several patients at Colorado's largest mental hospital.
The series was honored with a 2011 RTDNA National Edward R. Murrow Award.
Our investigation has spanned more than two years and led to the resignation of the hospital's superintendent. It has also resulted sweeping changes in the legal requirements for lawyers who represent mental health patients; prompted an outside independent review of the high security unit at Pueblo where patients have died and mandated extensive reforms in policies and procedures. It also caused the Colorado legislature to commission a broad and detailed audit of patient care. The initial audit report confirmed the KMGH-TV reports that patients are often involuntarily medicated without proper documentation, and are not properly monitored. These actions have come as the KMGH-TV investigation has detailed a pattern of misinformation, stonewalling, and cover-up by state human services officials who have tried to hide mistakes.
Our investigation has so far detailed the deaths of four patients, three in the new high security forensic unit. The deaths include that of 41-year old Troy Geske who died in an isolated room after being tied face-down to a gurney in what is known as a "prone restraint." Our investigation revealed staff responsibility in the death and the subsequent grand jury investigation confirmed it.
Our investigation caused the state legislature to hold hearings on the procedure that can result in "positional asphyxiation." While lawmakers deadlocked on whether to outlaw the procedure statewide, the new director of the Colorado Department of Human Services has now banned the practice in state operated facilities and is proceeding with an administrative rule to stop the practice in both public and private facilities.
Our ongoing reports have so far documented four preventable deaths:
-Josh Garcia was so overmedicated with drugs that caused constipation (and so poorly monitored) that when he was taken to an emergency room his impacted bowels burst, causing his death.
-Sergio Taylor suffocated himself in the high security forensic unit. He had plastic bags in his room even though they are specifically forbidden because they can be used as a weapon. Our investigation found that the staff knew it, but did nothing.
-Troy Geske was put in what is known as a "prone restraint" that caused his suffocation. Our investigation uncovered documents showing the procedure was banned in 2004 in other divisions of the Colorado Department of Human Services, the agency responsible for the state mental hospital. Yet, the agency director did not know of the ban in her own department until we uncovered the department memo.
-Edward Benge hanged himself in his room at the forensic unit and jammed his door lock. Our investigation found the poorly trained staff saw him hanging but did not know how to use a simple tool nearby to remove the door and save his life.
While the newly hired director the state department of human services has begun to make needed changes, our investigation into needless deaths continues.
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Fatal Errors (Part 1) .movby JohnFerrugia119 views
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