May 18, 2012

Five years ago, the federal government sued the State of California in order to force changes at four California state mental hospitals. The allegations included the overuse of patient restraints, the overuse of medications on patients, and poor patient safety. The lawsuit resulted in the federal government and California entering into a consent decree that provided for federal monitoring of the state hospitals. In November, 2011, a judge removed two of the state hospitals from the federal monitoring.

Recently, the federal monitor asked a judge to extend the federal monitoring at the other two California state hospitals subject to the consent decree due to alleged continuing inadequate medical and psychiatric care.

In one of the state hospitals that the federal monitor requested to be subjected to extended monitoring, allegations have been made that workers are sleeping on the job and failing to make required patient checks, including one instance where a patient was found on the floor with a broken neck. The subsequent delay in transporting the patient to a trauma center for several hours reportedly resulted in her becoming paralyzed. The patient died from respiratory complications due to her paralysis six months later.

The 52-year-old woman was schizophrenic and was placed in the California state hospital in 2009 in order to protect her from hurting herself and hurting others. She was known to exhibit strange and potentially harmful behavior, such as hurling herself onto the floor, that resulted in her requiring constant one-on-one supervision. On the night she suffered her broken neck, the nurse who was assigned the task of supervising the woman evidently was observed falling asleep and had to be awakened three different times. The doctor on duty that night delayed sending the woman for treatment for several hours, according to the federal monitor.

The federal monitor reported that employees of the state hospital tried to lie and cover up what had happened with regard to the woman in order to protect themselves and other employees. The federal monitor further reported that he had previously warned the state hospital that the doctor who was on duty the night of the woman’s catastrophic injury was failing to provide patients with “minimally adequate care.”

The woman’s case was one of about a dozen cases cited by the federal monitor in support of the request to extend the federal monitoring of the remaining two state hospitals under the consent decree. The judge’s decision whether to extend the federal monitoring at the two California state hospitals has not yet been made.


If you or a family member may have been injured as a result of psychiatric malpractice or while a patient in a mental hospital or other inpatient or outpatient psychiatric facility, it is important that a prompt and thorough investigation be undertaken by a medical malpractice attorney or other appropriate professional to determine what happened and why.

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