2 Suicides Are Linked to Beleaguered Hillcrest Mental Hospital

Two men who were seen by psychiatrists at the county’s Hillcrest mental hospital in separate incidents killed themselves shortly after their contact with the hospital in September, The Times has learned.

One victim hanged himself in his room in a board-and-care home after the home’s manager tried in vain for several days to have him admitted to the Hillcrest hospital, commonly known as CMH.

The other man plunged to his death from the Laurel Street bridge over California 163 a day after he was screened and released from CMH. A San Diego County coroner’s investigator said he isn’t certain whether the man jumped or fell from his perch atop the bridge railing.

The two cases are examples of what police and private mental health providers have warned could happen more often as a result of the county’s decision a year ago to eliminate a third of its beds at the Hillcrest facility as a way to provide better care to those who remain. The county, which had been under harsh criticism for substandard care, now enforces stricter criteria to determine which severely mentally ill patients are admitted and which ones are turned away.

“When CMH doesn’t have the beds, we don’t get our patients in,” said Richard Thomson, public conservator for the county with responsibility for about 1,600 mentally impaired clients who are unable to provide for their own food, clothing or shelter.

Karenlee Robinson, Hillcrest’s administrator, declined to comment on the cases, citing confidentiality of patient records. Dr. Harold Mavritte, the hospital’s acting clinical director, would only discuss the hospital’s handling of suicidal patients in general, pointing out that not every suicidal person can be prevented from killing himself.

“What causes a person to suicide or not suicide is a highly individualized thing,” Mavritte said. “What you have to go on in evaluating people is your assessment of how this person is acting, what you see, hear, smell and feel, basically what the individual tells us and what other individuals might tell us. You do all that to weave a picture and come to a decision . . . and you make an educated judgment based upon those facts.”

Jose Travers, 30, a ward of the county, hanged himself in his room Sept. 15 at the Central Manor Board and Care home on Elm Street. Travers had been in and out of CMH since 1978 and had threatened at least once to kill himself.

Marco Flores, manager of the home, said in an interview that Travers was admitted to Central Manor in early September. Flores said Travers suffered from almost daily seizures, and was taken to CMH for additional medicine on Sept. 10, a Wednesday after his supply had run out. Flores said the doctor on duty at the hospital took Travers off that medication and substituted two different drugs not specifically designed to prevent seizures.

The next day, Travers walked out of the board and care home and did not spend the night there. Flores said Travers returned on Friday, after having suffered an accident of some kind.

“Somehow he lost control of himself (and) was hit on the back,” Flores said.

That day, Flores called CMH and told a doctor there that he wanted Travers to be reevaluated and placed again on the medication he had used before.

“Travers was complaining that he was hallucinating and his head was about to explode,” Flores said. But the doctor said there were no beds available at Hillcrest, Flores said.

Flores then called Travers’ conservator, who called CMH and relayed instructions from the doctor to give Travers increased dosages of the tranquilizer and the anti-psychotic drug that had been prescribed in place of his earlier medication.

But as Travers’ condition did not improve, Flores said, he called CMH on both Saturday and Sunday but the hospital still refused to see Travers.

“The following Monday, at 4 a.m., we found him hanged,” Flores said.

Travers had been a patient at CMH several time since 1978, when he was diagnosed as schizophrenic, according to court records filed in connection with his conservatorship. Travers also was hospitalized at Patton State Hospital in February, 1985, and had lived in several board and care homes over the years. In October, 1985, Travers was placed at a private mental hospital after threatening to kill himself, records show.

Hospital administrator Robinson would say only that she “disagreed with the statements made by Mr. Flores in regard to the events as he relates they transpired.”

In the second case, Jon Gerald Kloos, a Pennsylvania native thought to be living on the streets of downtown San Diego, died Sept. 9 of chest and abdomen injuries suffered in his fall off the Laurel Street bridge, also known as the Cabrillo bridge.

Kloos, 20, was taken to CMH by police on Sept. 8 after he ran into a downtown Cedar Street business and hid under a desk, claiming that someone was trying to kill him, according to San Diego Police Officer Rick Carlson, a department spokesman.

Carlson said police were called and took Kloos to CMH at 10 a.m. and CMH doctors took custody of the man. While CMH officials refused to comment on any aspect of the case, a deputy coroner said that Kloos was cited by police for jaywalking on the following morning, Sept. 9, indicating that he had been released from Hillcrest.

At 6:45 p.m. that evening, a couple driving eastbound on Laurel saw Kloos climb onto the bridge’s railing and straddle it. By the time they turned around and drove back, Kloos had gone over the edge and lay in the bushes alongside the freeway below.

The deputy coroner investigating Kloos’ death said the cause is listed officially as undetermined--either suicide or accidental. Deputy Coroner Charles Kelley said a witness walking along the bridge saw Kloos straddling the railing and yelled out at him, asking Kloos what he was doing there.

“It appeared that the boy may have slipped off the bridge, that he may have been out there contemplating suicide, and the guy may have startled him off the bridge,” Kelley said.

Kelley said that the jaywalking ticket that he found on Kloos’s body was the only form of identification found. Kelley was not aware that Kloos had been seen at CMH the previous day until he was told by a Times reporter.

“If not for that ticket, he’d be a ‘John Doe’ case,” Kelley said.

Robinson had no comment on the Kloos case.

The two incidents resemble others that occurred at CMH in 1984 and 1985 and helped prompt inquiries into patient care at Hillcrest. One such investigation prompted the federal government to stop reimbursing the hospital for its costs in caring for patients who qualify for the Medicare program.

In one such case, in September, 1984, a patient who had earlier been admitted to CMH for threatening suicide was taken to Hillcrest by police after threatening to jump from the Coronado Bridge. Doctors at CMH determined that the woman was not suicidal and refused to admit her. She jumped to her death from the bridge 12 hours later.

In another case, in April, 1985, a woman with a long history of mental illness severely injured her husband and set his car afire not long after a county psychiatrist discharged her and told her husband that the woman was not dangerous, but that she was “a good, caring, loving person.”

Mavritte, the acting clinical director at the hospital, said care has improved dramatically since those cases occurred.

“But even given that, you can have the best state-of-the-art practice and these same things can and will occur,” he said.