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July 12, 2008
About New York

After a Death Seen on Tape, Change Is Promised
By JIM DWYER

At 6:51 on the morning of June 19, a doctor in the psychiatric
emergency room at Kings County Hospital Center wrote an order for a
chest X-ray and blood tests on Esmin Elizabeth Green, as well as
“sedation/restraints if needed.”

If needed, that is, on a corpse.

By the time that entry was made on her chart, Ms. Green had been lying
on the floor of the waiting room for 80 minutes, with no sign of life
for the last 44. See the chart [pdf] Resuscitation efforts were coming
to an end.

Ms. Green had been sitting in the waiting room for 24 hours when,
videotapes showed, she toppled out of a chair at 5:32 that morning.

Waiting may have killed her: The medical examiner said on Friday that
Ms. Green developed blood clots in her legs from a long period of
physical inactivity, The Associated Press reported. These clots
traveled to her lungs. Many people spend four or five days in the
Kings County psychiatric waiting room, patient advocates say. The
medical chart from Kings County for the last hours of Ms. Green’s life
is a hive of fictions. Handwritten entries say that Ms. Green was “up
and about, went to the bathroom” at 6 a.m. and, 20 minutes later,
“sitting quietly in the waiting area.” For good measure, the chart
includes supposed figures for her blood pressure (76/3 Cool

, respiratory
rate (1 Cool

, and pulse (100).

Videotapes showed that actually, she was sprawled on the floor at
those times, not up and about. And if Ms. Green, 49, still had any
vital signs, no one was taking them at the times recorded on the
chart. Her first contact with a medical staff member that morning came
at 6:35, more than an hour after she hit the ground, and it consisted
of a woman nudging Ms. Green’s body with her toe.

The mayor announced that he was disgusted. The president of the Health
and Hospitals Corporation revealed that he was shocked and distressed.
Heads not only rolled: a half dozen were publicly punted clear out the
door and across Clarkson Avenue. The city has promised to pay Ms.
Green’s family, and to fix the hospital.

“I can’t explain what happened there,” Mayor Michael R. Bloomberg
said.

Someone may need to clue Mr. Bloomberg in. This death appears to be a
result of systemic failure in two areas in which the mayor is credited
with great expertise: public health and public management.

The psychiatric service at the hospital — the only mental health
provider for many poor people in Brooklyn — has been under criminal
investigation by the Department of Justice since December; it was the
subject of a critical report by a state oversight agency last summer;
and it is the target of a detailed federal lawsuit filed in May 2007
by patient advocates.

One serious problem, the city acknowledged, is that more than 60
percent of all patients who came to the Kings County emergency room
for psychiatric services were being admitted to beds, rather than
being sent to other services outside the wards. With so many people in
the psychiatric wards, the human traffic jam spilled back to the
emergency room.

The advocates’ lawsuit said the psychiatric center was a “chamber of
filth, decay, indifference and danger.” Patients waited for days to be
admitted to a bed, the lawsuit charged, often without any toiletries
to clean themselves, and usually without any place to sleep besides a
chair.

Those who managed to get on a bed in the waiting area could not risk
leaving it even for a minute, because they were sure to find someone
else in it when they came back, the lawsuit said.

Here is what the city had to say about the lawsuit when it was filed:
“The lurid allegations in today’s lawsuit are grossly inaccurate,
irresponsible and an affront to the dedicated and caring staff of
Kings County Hospital Center,” said Alan D. Aviles, president of the
Health and Hospitals Corporation, which runs the city’s public
hospitals.

Given that the lawsuit reads like a chronicle of a death foretold, Mr.
Aviles was asked on Friday whether he wanted to revisit his comments
of a year ago. Ana Marengo, a spokeswoman, said he had been speaking
dismissively of claims in the lawsuit that there was feces on the
floor and no toilet paper — conditions that the city says did not
exist. Mr. Aviles did acknowledge the overcrowding, Ms. Marengo said,
and the city is trying to address it.

The city has been in discussions for months with the advocates who
brought the suit — lawyers with the New York Civil Liberties Union,
the law firm of Kirkland & Ellis, and the Mental Hygiene Legal
Service.

Although some changes have been made — clean linen is now supplied on
a regular basis, a staff member has been assigned to distribute basic
toiletries, more workers are being hired — Ms. Marengo was unable to
say on Friday how long patients must wait for a bed. The goal, she
said, is to bring it down to 12 hours. The admission rate dropped to
40 percent in June, she said.

“We are committed to a transformation there that will address all
aspects of the operation — including environmental, staffing, the
culture, training, processes, security, etc. — to help prevent
something like this from happening again,” she said.

Beth Haroules and Robert Cohen, two of the lawyers who brought the
lawsuit, said the city had already had ample time.

“I have a question for Mr. Aviles,” Mr. Cohen said. “Would he be
comfortable sending his loved ones to the psychiatric emergency room
at Kings County?”

It is a question that everyone in the city ought to consider.

These are changes the city says it has made in recent months to the
psychiatric services at Kings County Hospital Center, as provided by
the office of the president of the city Health and Hospitals
Corporation, Alan D. Aviles:

Expanded space in the Comprehensive Psychiatric Emergency Program
(CPEP)

Created a separate child waiting and treatment area

Improved the lighting in the CPEP

Added thirty nurses and a new nurse educator

Contracted with a variety of agencies that provide temporary nurses in
order to enhance staffing.

Hired a consulting psychiatrist and a consulting nurse to make
clinical changes and improvements at the hospital

Added activity therapists, and has increased the hours of programming
provided in both the CPEP and on inpatient units.

Provided additional training in a number of specialties, such as
treatment of the chemically addicted mentally ill.

Added a new specialized support team assists in the treatment of
developmentally disabled or mentally retarded patients.

Trained 200 staff in non-violent crisis intervention

Reduced the number of restraints, in part by implementing a new
protocol for emergency response.

E-mail: dwyer@nytimes.com

Copyright 2008 The New York Times Company
http://www.nytimes.com/2008/07/12/nyregion/12about.html?_r=1&ref=nyregion&oref=slogin