(4-6-16) A state agency in Virginia investigating the death of a 24 year-old prisoner with mental illness, whose feces covered body was discovered in his isolation cell August 19, 2015, reported yesterday that records kept by medical personnel who were responsible for watching him were “incomplete and inconsistent.”
But the long anticipated report does not assess blame on any individual. Rather it makes five recommendations about system changes that its authors claim could prevent future similar tragedies.
The 16-page report’s recommendations are bound to frustrate and disappoint the family of Jamycheal Mitchell who have asked for details that would explain what happened to Mitchell during the 101 days that he was languishing in jail waiting to be sent to Eastern State Hospital for a mental evaluation and competency restoration.
Mitchell died of “probable cardiac arrhythmia accompanying wasting syndrome of unknown etiology,” according to Donna Price, an administrator for the Medical Examiner’s Office in Norfolk. Wasting syndrome is defined as a profound loss of weight, greater than 10 percent of a person’s original body weight. Put simply, he had a heart attack caused by starvation.
The IG report stated that its investigators decided to not investigate who might have been responsible for Mitchell’s death. Nor did the IG investigate “every element of prior investigations.” (Jail officials already had conducted their own internal, confidential investigation and found themselves innocent of wrongdoing. State mental health officials released a report last month in which they acknowledged clerical errors were made.)
Instead, the IG said it focused on system errors rather than human ones. Just the same, the report contained several troubling revelations, most notably about the for-profit company NAPHCARE which was responsible for providing medical care to Mitchell in the jail but has since been replaced.
The report noted that Mitchell weighed 178 pounds when he was booked into jail on April 22, 2015 after he was arrested for allegedly stealing $5 worth of snack food from a convenience store.
According to the records that NAPHCARE kept in the jail and later provided to the IG’s office, Mitchell supposedly gained weight initially in jail. During the week of June 15-21, NAPHCARE claimed his weight was 190 pounds.
On July 30, Mitchell’s deteriorating medical condition led to him being taken to a hospital emergency room where his weight was checked by hospital employees. Their records show he weighed 145 pounds — 33 pounds less than when he was arrested. But on that same day, NAPHCARE records at the jail listed his weight at 158 pounds, or 13 pounds heavier. An autopsy showed he weighed 144 pounds. The IG investigators said it was “beyond the scope of their review” to investigate why NAPHCARE’s records were so different from the hospital’s and the autopsy.
Mitchell’s weight is an important issue because rapid weight loss is believed to have caused his heart attack. The IG noted that NAPHCARE employees never noted Mitchell’s dramatic weight loss in their jail medical records.
Even more alarming, the IG report revealed that on July 15, 2015, a NAPHCARE worker wrote in Mitchell’s records that he had “4+ pitting edema in the lower extremities.” Pitting edema is a sign that fluids are accumulating in a person’s body. Edema is ranked in seriousness from number 1, the lowest, to number 4, the highest. It is a warning sign that a patient could be experiencing possible heart failure.
The IG noted that NAPHCARE did not take any action of that medical issue despite the severity of the pitting edema until 15 days later, when another nurse noted that Mitchell was showing more advance evidence of 4-plus pitting edema in his knees. The nurse wrote in the jail records that Mitchell was, “disheveled, psychotic, and uncooperative.” At that point, NAPHCARE sent Mitchell to an emergency room at a local hospital for evaluation.
What happened? Unfortunately, the IG report doesn’t say.
“There was no mention in the (NAPHCARE) treatment planning notes that were provided (to investigators) of psychosis, inability to care for self, meal refusal, or weight loss. Documentation provided for sick calls …only addressed medication management. No mention was made of the individual’s weight loss.”
The report concluded:
“Review of NaphCare records raised significant concerns regarding the quality of assessment, care, follow-up, and documentation. It is those professionals who are trained and licensed to provide clinical care who have a duty to provide that care and the agency that contracts with the provider is responsible for ensuring that care is provided.
“Although NaphCare is no longer the contract agency providing medical and mental health services at (the jail), a change in provider offers limited promise of improvement in care or documentation in the absence of a change in oversight practices.”
In the IG report, investigators confirmed earlier reports published in the Richmond Times Dispatch that beds at Eastern State Hospital had been available when Mitchell was supposed to be sent there for evaluation but wasn’t. The IG also confirmed that a state mental health employee, who was responsible for checking on Mitchell in the jail, never met with him while he was incarcerated. But the report did not name her.
Instead, the report quoted liberally from a study entitled To Err is Human: Building a Safer Health System that was published in November 1999 by the U.S. Institute of Medicine. The report cites passages that argue that tragedies such as Mitchell’s are not the fault of bad employees but of systems, adding that disciplining employees often ” is not an effective way to correct a system or process problem or to prevent recurrence of similar events.”
“A panel of national experts in healthcare and safety authored the 2000 book entitled To Err Is Human. The publication challenged prior assumptions surrounding medical errors and their consequences — not by placing blame on the backs of individual healthcare professionals who make honest mistakes. Instead, the book called for a more sensible and effective plan for reducing errors and improving patient safety through the design of a safer health system. In order to accomplish that, the book recommended that a careful examination should be made of how the surrounding forces of legislation, regulation, and system activity influence the quality of care provided by healthcare organizations and before reviewing the handling of healthcare mistakes.
“To Err Is Human asserts that the problem is not bad people in healthcare; rather, it is that good people are working in bad systems that need to be made safer.
“In Chapter 3 of the book entitled Why Do Errors Happen, the authors describe the difference between active and latent errors. Active errors are defined as being those caused by individual front line staff and whose effects are noted almost immediately. Such was the case of the admissions director at ESH placing (Mitchell’s transfer orders) in a desk drawer. Latent errors are those that are removed from the control of front line staff and include such things as poor process design, poor policy, and poor management. Latent errors are also those that pose the greatest threat to safety. Often, superficial corrective actions focus on disciplining or re-educating an individual, usually a staff member lower down the organizational chart. At times, this may be appropriate as a part of the action if it is determined that there was a deliberate negative action by the individual staff member. According to the book’s authors, it is not an effective way to correct a system or process problem or to prevent recurrence of similar events.”
G. Douglas Bevelacqua, the former IG for mental health in Virginia, who has been critical of the state’s handling of the Mitchell case, issued a statement late last night about the report.
“Regrettably, after reading the OSIG Critical Incident Report … I cannot answer the basic question of how did corrections staff and mental health workers allow Mitchell to waste away in plain sight for 3½ months…The Inspector General’s mandate is to investigate complaints of abuse, neglect, or inadequate care – not conduct seminars on behavioral health process issues.”
The OSIG report is posted on the agency website (http://osig.virginia.gov/) by going to the Reports section and clicking on the Investigation of Critical Incident at Hampton Roads Regional Jail.