Report Blames Camarillo Hospital Workers in Patient’s Death

A federally funded watchdog group for the mentally disabled on Tuesday said that drugs administered by state hospital employees caused the deaths of three patients, including one at Camarillo State Hospital.

A report issued by Sacramento-based Protection and Advocacy Inc. charges that state hospital staff gave three young men potentially lethal combinations of psychiatric drugs and other medications and then failed to monitor them properly.

“While it may never be definitively determined that the deaths of these three men were caused by the psychiatric drugs . . . there is good reason to believe that it was, in fact, the case,” the report said.

The Camarillo patient, an unnamed 28-year-old man, died the day after Christmas, 1989, while he was locked in his dorm room without supervision for 3 1/2 hours, the report charges.

In addition to lithium and Valium, he had been given Cogentin, which can cause vomiting, and Thorazine, which can suppress the body’s natural coughing reflex. He suffocated on his own vomit and a piece of Christmas candy, the report said.

The other two deaths, at Patton State Hospital in San Bernardino County, involved a 24-year-old patient who collapsed and died after he was given five different medications, and a 21-year-old man who had a fatal heart attack after he was given an injection of the psychiatric drug Haldol, the report said. Both deaths occurred nearly two years ago.

The report asks that the Department of Mental Health investigate the deaths and issue a response, outlining proposed changes in procedure and training for state hospital employees who administer drugs and monitor patients.

“Our concern is not so much an indictment of the entire system, but that these kinds of problems be addressed and looked at to ensure they don’t happen again,” said Arthur Rosenberg, an attorney for the advocacy group.

John Fortner, a spokesman for Camarillo State Hospital, declined to comment and referred questions to state mental health officials.

Lauren Wonder, a spokeswoman for the Department of Mental Health, said the department has complied with licensing regulations in each of the three cases and plans no investigations into any of the deaths.

But she said the department plans to issue its own report by Friday in response to the advocacy group’s findings.

In the case of the 21-year-old Patton patient with developmental and mental disabilities, the hospital was cited by the Licensing and Certification Division of the state Department of Health Services for failing to perform regular respiratory checks of the patient, Wonder said.

The licensing division reviews cases where there is a death under unusual circumstances in state hospitals, Wonder said.

As a result of the Patton review, the hospital filed a revised plan for monitoring patients that includes regularly checking a patient’s breathing, Wonder said.

However, reviews by licensing regulators after the other two deaths found no problems in how those patients had been handled, Wonder said.

“In terms of wrongdoing, there was nothing found to be wrong, so there were no corrections to be made,” Wonder said.

The group’s report also asked for training of state hospital staff members in the use of psychiatric drugs.

“This is not saying these drugs should not be taken,” Rosenberg said. “But when people are in a locked environment, the risk of danger heightens if people aren’t properly monitored or taken care of.”

Wonder said the department does not intend to change its use of psychiatric drugs. “They have been very helpful for thousands of patients,” Wonder said.

As for staff training, she said, “we do recognize there can be staffing problems with vacancies and the increasing numbers of disturbed patients in state hospitals. We’re constantly training new employees.”