The Miami Herald

Florida hospital ignores pregnant mental patient’s pleas, and tragedy ensues

Held against her will at Florida’s largest state mental hospital, and fearing that she was about to give birth, a 34-year-old woman became so frantic in her efforts to get medical care that she called 911, twice. “There’s nobody here that can help me right now, and I’m pregnant,” she said.

But when the emergency dispatcher asked to speak with a caregiver, she was told there was nothing to worry about: “This is a mental hospital,” a supervisor, Eddie McMillian said. “She says she’s going into labor; she’s not going into labor … Can’t send her nowhere right now.”

But she was, indeed, in labor. And her son was born hours later with profound brain damage. He remains on a ventilator, perhaps permanently.

In a just-released 88-page report by the inspector general of the Department of Children & Families — which operates Florida State Hospital in Chattahoochee — state mental health administrators acknowledged the facility was poorly equipped to handle a high-risk pregnancy, and lacked policies to ensure the woman was well-cared for.

Though many details of the December tragedy were removed from the report, records show the mother was eventually airlifted to a Tallahassee hospital, after Gadsden County emergency workers arrived at the psychiatric hospital to check on her welfare.

Torn apart

“This thing has torn our family apart,” said Ken Wills, the baby’s grandfather. “It’s really been difficult; it’s been a strain. This has been a horrendous time for our entire family.

“It just seemed like people did not care — from the top down,” said Wills, 54, of Tallahassee. The Miami Herald is not naming Wills’ daughter, who suffers from schizophrenia, in order to protect her privacy.

Wills’ grandson, named Elon by his mother, is not expected to breathe, walk, or talk on his own, and likely will require lifelong complete medical care, Wills said. “He is not doing well. He is on life support.”

Said one of the family’s lawyers, Ben Crump of Tallahassee: “As long as he has life, there’s hope.”

The report, released Friday, faults hospital administrators and staff for several missteps:

•  Though caregivers repeatedly told the Tallahassee woman she was not expected to give birth for another month or two, the hospital’s pregnancy records were badly inaccurate. Caregivers had repeatedly entered incorrect information in her chart, suggesting a shorter gestation period than was the case, and making it appear she was due to deliver in February.

Caregivers believed the woman was only 28 weeks’ pregnant, based on a host of notations in her medical file. She was “adamant,” however, that her doctor had told her she was 36 weeks’ pregnant, and, thus, capable of delivering at any time.

•  Though the mother was suffering from pregnancy-induced hypertension, which can be life-threatening, nurses and other direct-care staff did not “consistently” document her vital signs, such as blood pressure. Though her blood pressure fluctuated greatly, caregivers did not always notify nurses or doctors when such readings should have raised a red flag.

•  The woman was given psychiatric medication without first obtaining the consent of her father, whose permission was required since he was acting as her medical guardian.

•  Florida State Hospital had no procedures in place to guide the healthcare of pregnant women — or for obtaining outside medical care, in general. At the same time, “direct care and nursing staff expressed that they lacked knowledge and experience in working with pregnant residents.” Some caregivers said they were not even told that Wills was suffering from hypertension.

•  As has long been the case, staffing at the 959-bed hospital was woefully short, and several workers said they had been forced to work double shifts.

Joe Follick, a DCF spokesman in Tallahassee, said the agency has struggled with staffing problems at the North Florida mental hospital for many years.

“Staffing is always an issue at Florida State Hospital; that’s true,” Follick said. “This is partially a consequence of the nature of the work, and partly a consequence of the hospital’s geographic location, and it is certainly an ongoing challenge.” Follick said turnover has declined in recent months, though the facility still has perhaps two dozen vacancies.

“It is a priority of ours to find qualified people to work there,” Follick said. “It is one of our top priorities.”

After the baby’s birth, DCF either launched or cooperated with several investigations of the incident, Follick said. DCF’s internal investigation resulted in the discipline of four department employees: Licensed Practical Nurse Kathryn Cottle was placed on administrative leave on May 24 and given notice of intent to dismiss her; caregiver Eddie McMillian was fired on March 13; Rosalee Peckoo, a doctor, was placed on administrative leave on Jan. 16 and returned to her position May 24; caregiver Maryland Clopton resigned on Feb. 1.

Hospital Administrator Diane James, a 40-year employee who had, one day before the incident, announced her intention to resign, was allowed to do so, Follick said.

Immediate action

“The actions in this situation do not meet the standards we expect of all our employees,” Follick said. “We immediately took the necessary personnel actions in this case, and immediately began working with law enforcement officers, the state attorney’s office, the Department of Health — as well as our own internal investigators — to make sure that, whatever occurred here, we took the steps to make sure it doesn’t happen again.”

Follick said prosecutors in North Florida are continuing a criminal investigation of the incident, as well.

Florida State Hospital, with nearly 2,000 employees, is the oldest and largest psychiatric hospital in the state. Nearly 40 percent of all state mental health patients — some are civilly committed and others are either facing criminal charges or have been ordered into treatment there by a criminal-court judge — are housed at the facility in rural Chattahoochee.

Wills’ daughter was involuntarily committed to the hospital under the state’s Baker Act by a Tallahassee judge on Aug. 2, 2011. The petition said she was not eating well, had poor hygiene and was not making sense. Her home had no electricity, was unsafe, and had not been cleaned in more than a year. Records said she had a long-standing history of mental illness.

In the weeks before she arrived at the Gadsden County hospital, the state’s abuse hotline received several calls that the woman had been abused by staff at a Tallahassee-area mental health clinic. The reports all were closed as unfounded.

Admission records indicated the woman could have been 27-weeks pregnant when she entered the hospital the first week in October — which means she could well have been full-term by late December.

The woman began complaining she felt ill as early as 3 a.m. on Dec. 23 — the Friday before a long Christmas weekend, records show.

Though the inspector general report is heavily redacted, making it difficult to piece events together, it is clear she informed caregivers before 7:30 p.m. she believed she was in labor and needed an ultrasound.

At 7:28 p.m., the woman called 911. The woman told a dispatcher “[I’m] feeling a lot of pressure and I just asked the nursing staff if they could give me an ultrasound to see how low it is and if I’m in labor, and I’m having a lot of discomfort.”

“They told me ain’t nothing gonna happen till Tuesday,” she said.

But when the dispatcher spoke with her caregiver, McMillian, he suggested she was receiving all the care she needed. “This is a mental hospital,” the report quotes him as saying. “I called the nurse and everything, and they said they can’t get an ultrasound today. Today’s Friday.”

The woman called 911 again, one minute later. The results were the same. She said she was told no doctors were on duty at the hospital, and she should “just go lay down.” McMillian, she told the dispatcher, “laughed in her face and walked away.”

One nurse told investigators that another nurse who was dealing with the pregnant woman suggested “the resident had been complaining, but that she was one of the constant complainers.”

And another caregiver, Gloria Cladd, told the woman to stop calling 911. She replied “that she would continue to call 911 as long as she and her child were in danger,” the report said.

Cladd told investigators the woman “told her that she had been informing staff all day, not just the evening shift, that she was hurting and that her water had broke.”

“You do not need to go to [the clinic],” another nurse told her. “You need to go lay down, because you [won’t] have your baby until the middle of January.”




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