One Death Too Many at East Bay Hospital

Having your body restrained so you are helpless is a method of control, a forcible intrusion on people. When it’s used against your will, I think it’s really wrong. It’s like rape, because you’re totally helpless in someone else’s control.” — Sally Zinman, Coordinator, Berkeley Drop-In Center
The restraints used to shackle patients in psychiatric hospitals are made of heavy leather, three inches wide. Patients are strapped to the bed spread-eagled, tied down at each ankle and wrist.
Seclusion and restraint can cause profound physical and emotional harm. According to Protection and Advocacy, Inc., a nonprofit agency designated by the federal government to investigate abuses of patients’ rights in California, “Risks include dehydration, exhaustion, cardiac arrest or respiratory collapse, fractures, muscle and kidney damage, self-mutilation, strangulation and a worsening medical condition as a result of being alone and isolated. The emotional impact of seclusion can be severe.”
On April 5, 1996, Robert Jackson began dying the loneliest death imaginable, undergoing acute psychological and physical distress while strapped by leather restraints to a bed in a psychiatric ward in East Bay Hospital in Richmond, a hospital with a long history of reported abuses and untimely deaths of psychiatric patients.
Although details of his death are still sketchy, Jackson was reportedly transferred to East Bay Hospital from Lake County, where he had come to an emergency room complaining of chest pains, possibly from a respiratory ailment or heart condition. Since he was also in an acute state of mental disability, Jackson was transferred to East Bay Hospital (EBH) in Richmond. He evidently was given an “anti-psychotic cocktail” of medications and placed in restraints.
He stopped breathing an hour later. At some point, Jackson was transferred to Brookside Hospital in San Pablo, and from there, he was taken for his last ride — to the County morgue. Reportedly, East Bay Hospital claims not to have been aware of the medical problems that led him to seek care in Lake County, although when hospitals place patients in restraints or administer anti-psychotic medications, it is of life-and-death importance that they carefully analyze any pre-existing medical problems.
Although the Contra Costa County Coroner’s office has not yet completed its investigation into Jackson’s death, Colette Hughes, Supervising Attorney for Protection and Advocacy, Inc. (PAI), said that her office has opened a preliminary investigation into whether abuse and/or neglect may have contributed to the death.
Hughes said, “Given the history of East Bay Hospital, at this time we automatically open a preliminary investigation whenever there is a serious physical injury or death there.” Hughes was careful to point out that it is too early to know whether abuse or neglect contributed to Jackson’s death. She added, “In terms of the range of problems at East Bay Hospital — seclusion and restraint, medication, monitoring of clients — I would say that it is below the norm compared to other facilities we have looked at because of its pattern of problems evident in a number of care areas.”
Robert Jackson’s death last month is hauntingly similar to other recent deaths of psychiatric patients at EBH.
Nancy Jane Turner died seven months ago, on November 3, 1995, while in physical restraints at EBH. Her family reportedly was concerned that she had been given medications she had never taken before that may have caused her death, in combination with the adrenaline-pumping, heart-pounding trauma of being bound in restraints.
Another man died at EBH last spring when hospital staff negligently gave a suicidal patient a plastic bag for his belongings that he used to suffocate himself.
And Marc Kiefer was found dead in a locked isolation unit at East Bay Hospital on February 3, 1993, after enduring nearly 18 torturous hours of physical shackles and shocking medical negligence.
For many years, the mental health directors of Alameda and Contra Costa counties have been sending hundreds of the poorest, most disabled and most vulnerable patients, including many homeless people, to East Bay Hospital.
The Alameda and Contra Costa County Boards of Supervisors continue to send Medi-Cal patients to the psychiatric unit at EBH despite a long trail of chilling tales of abuse from psychiatric patients and their families, and scathingly critical reports by the State Health Department’s Licensing Division, the Office of Patients Rights, PAI and local patients-right groups.
Why do patients keep dying in EBH’s psychiatric unit? Why does the hospital tie its patients down with leather restraints — the most restrictive and cruelest weapon in the psychiatric arsenal — more often than other Bay Area hospitals? Why have patients and advocates consistently reported for the past seven years that EBH is under-staffed and that its staff often are under-trained and disrespectful and hostile to mentally disabled patients in their care?
Why do county mental health directors keep ignoring one scandalous case of mistreatment after another? Why are they still sending clients to a hospital that Claire Burch, the mother of a former EBH patient, said “is the equivalent of jail. I can’t think of how anybody could ever get better in that environment with that neglect.”
Until there is a full investigation of the past several years of abuse and neglect at EBH, and a major overhaul of all aspects of its care delivery system for psychiatric patients, Alameda County and Contra Costa should stop sending any patients to East Bay Hospital at all.

The tragic death of Marc Kiefer

For those aware of EBH’s sorry history of neglect and abuse, the recent deaths of Turner and Jackson have felt like one death too many. But then that’s what many folks said when Marc Kiefer died in 1993.
“Kiefer died alone in an isolation room following nearly 18 hours of being restrained to a bed with leather straps, belts and cuffs. According to the psychiatrist consulted by PAI, Kiefer likely died from the undiagnosed and untreated medical condition of anticholinergic toxicity from psychiatric medications as well as a prolonged period of improperly monitored seclusion and restraint.” — An Inquiry Into the Death of Marc Kiefer at East Bay Hospital, by Protection and Advocacy, Inc.
The PAI report concluded that Kiefer was not put in restraints in a locked room because he was dangerous, but simply because he was agitated and incoherent. “It thus appears that seclusion and restraint were used for the convenience of staff and in lieu of appropriate, less restrictive treatment.” He died of some pretty widespread conditions at EBH: the misuse of heavy doses of medication, the overuse of restraints, and the staff’s failure to adequately monitor patients.

Scarred for Life

Even when patients don’t die in restraints, they may suffer deep psychological damage and be scarred for life. On February 28, 1995, at East Bay Hospital, a female patient was found shackled to her bed, alone, unattended and entirely naked, in a room with a male patient only three to four feet from her bed. No staff persons were present in the room or the hallways, even though patients strapped to their beds are completely vulnerable and are supposed to be monitored closely.
On September 12, 1995, a woman who had been placed in restraints in the Two South ward of EBH for several hours, told the staff that she needed to use the bathroom. The staff wouldn’t allow her to use the bathroom or a bed pan, so the patient was forced to defecate and urinate in her bed with both hands and feet shackled.
Her debasing treatment was hardly an isolated instance of inhumanity at EBH. In a 1993 study, 20 percent of the patients interviewed had been forced to urinate while shackled in bed because bed pans were not provided when asked for; altogether, nearly half the patients interviewed either were forced to be incontinent or else reported fear and distress from being forced to hold back their bodily functions for prolonged periods while shackled.
Under California law, people receiving care in psychiatric hospitals have the right to be free from harm, including unnecessary or excessive physical restraint or seclusion. Restraints are permitted only when absolutely necessary to prevent physical injury to the patient or to others, and only if less restrictive alternatives are not available. Restraint cannot be used as punishment, for staff convenience, or in a routine way to calm down an agitated patient.
Reports show that a significantly higher number of patients were restrained and denied rights at East Bay Hospital in 1993 and 1994 than in any other hospital in Contra Costa County. And the average duration of patients’ time in seclusion and restraints was reportedly more than 15 hours at East Bay, far greater than the state-wide average of 3.87 hours. A 1994 report found that 70 percent of patients monitored at EBH had undergone seclusion and restraint for more than 12 hours.
A high percentage of restraints involved patients tied to a bed in the middle of an open ward, as in the case of the woman who was found strapped to her bed naked, in public view. This practice is unsafe and very degrading, because it makes a patient completely helpless and vulnerable to others. One patient-rights advocate called it “a real violation of privacy and dignity to be restrained in the middle of the hospital. No other hospital in the county would even think of restraining patients on open wards. It’s way off the map.”

Records lie and people die

The State Licensing Division found a consistent failure to monitor the medical condition of patients in restraints at EBH from 1991-1995. In 1993, Marc Kiefer became a fatality of this neglect.
EBH’s Seclusion and Restraint Record indicates that, on the night before he died, Kiefer’s circulation was supposedly checked every 15 minutes, as hospital regulations require, and that he was “sleeping”. The records at 7:45 a.m. claim that Kiefer’s “circulation” was checked and that “toileting and fluids were offered.”

But records lie, and people die, and hospitals only pretend to monitor patients to cover up their own neglect.
Two minutes after the hospital claims Kiefer was offered fluids and toileting, the 7:47 a.m. hospital record states, “Patient found with no pulse. Neck still warm, finger tips turning blue.” A few minutes later, at 8:15 a.m., Kiefer was pronounced dead. A nurse was called in, and she wrote in the Nursing Notes: “I found patient lying in restraints, he was ashen in color, had no pulse palpable, was not breathing. Rigor mortis has begun, his hands were stiff and cold as were his extremities.”
Rigor mortis does not begin in a few minutes — it requires several hours for stiffness and coldness to set in. So all those 15-minute reports where the staff pretended to take Kiefer’s “circulation”, all those fabricated stories of offering him “fluids and toileting” were all lies. The truth is that Marc Kiefer was left dead in restraints for hours while East Bay Hospital’s negligent staff ignored him in death as they had in life.
According to the report by PAI, Kiefer likely died of untreated “toxicity from psychiatric medications as well as prolonged seclusion and restraint.” EBH “chose exactly the wrong course of treatment” by giving him dangerously high levels of Haldol, Thorazine, Benadryl and Cogentin which “were not safe to prescribe.”
As one patients’ right advocate put it, “East Bay typically gives people an anti-psychotic cocktail of Haldol, Ativan and Cogentin. The problem is they use them without knowing the pre-existing medical problems, and they often use big doses that drop them to their knees. It’s called a ‘chemical restraint.’”
A highly consistent picture of neglect pours forth from EBH patients, their families, advocates and attorneys, and from reports and documents compiled by State Licensing, the Office of Patients’ Rights and Protection and Advocacy Services.
An attorney who has investigated conditions at EBH in the recent past said: “East Bay Hospital is the worst hospital around for psychiatric clients. It’s a private hospital living off Medi-Cal patients. They just cram as many patients as they can into overcrowded wards, spend as little money as possible and provide almost no care at all.
“Two South, the locked unit, is really a hell-hole. They have the most disturbed people in the tiniest amount of space. Twenty people in five tiny dorm rooms, with nothing to do but pace the hallway or lie in bed all day. It’s very demoralizing to have nothing to do.”
Claire Burch, whose daughter was a patient at East Bay Hospital, said, “There was literally no therapy; there was nothing but custodial care. A psychiatrist would see my daughter for maybe five minutes every few days.
“I remember when I visited, I was in shock. Everybody was sitting around with absolutely nothing to do, and with no communication from the staff. It was like a nightmare. I didn’t see any signs of treatment for my daughter, so I tried to get her out. She was miserable, and she wasn’t the only one — everyone on the ward was miserable. It had the feel of a board-and-care instead of a hospital.”

Crayola Therapy

A former patients’ rights advocate said that while many other hospitals in the Bay Area offer enriching music, art and occupational therapy to patients on psychiatric wards, East Bay Hospital was highly deficient in its programs. “The occupational therapy is a joke. Once in a great while, someone would bring in little pages like from a coloring book and some crayons. What is that supposed to be — Crayola Therapy?” This advocate added that she had heard that some domino sets were now being passed out on the ward.
The attorney noted that EBH had been criticized so severely about its seclusion and restraint practices that it recently has made some improvements in monitoring, but added that the changes are superficial and cosmetic. “The staff doesn’t effectively monitor and handle people. A good hospital would use the least restrictive alternatives and talk people down when they’re agitated rather than overdo the use of seclusion and restraints.”
A 1995 report by the Office of Patients Rights opens the lid on a Pandora’s Box by revealing multiple problems that are widespread, overlapping and dismaying. The report charged EBH with inadequate and delayed medical care; undiagnosed and untreated medical conditions; failure to appropriately prescribe and monitor the effects of psychiatric medications; failure to provide for patient safety; lack of adequate bedding; unclean and unsanitary indoor and outdoor areas.
The report finds faults with EBH in several other major areas:

• Two South Unit, the acute locked unit, “has exceptionally crowded space but the other locked units also have very small common areas.”
• EBH offers the patients little or no privacy, so doctors interview patients in common areas about the intimate details of their lives.
• The day rooms are crowded, stark, institutionalized and lacking in activities and equipment.
• “The space is dark, closed and uncleaned. There is often a detectable odor.” Repairs are delayed for prolonged periods of time.
•  The outdoor area is concrete with high concrete walls, devoid of plants, grass, trees, walkways. It is very uninviting and provides very little area for physical activity.”

The report also faults the hospital for having inexperienced, under-trained and inadequately supervised staff. As a result, the report said, “Staff attitudes and behaviors toward patients have been a continuing problem. Exchanges with patients have been observed which demonstrate staff impatience, insensitivity, racism and hostility to patients and their needs.”
The report charged the hospital with inadequate staffing levels, and as a consequence, with neglecting patients’ requests for medical attention, failing to monitor patients in seclusion and restraint and failing to provide purposeful activities for patients. This criticism hits home powerfully when read in conjunction with the PAI report on the complete neglect demonstrated by the staff medical response to Marc Kiefer:
“Marc Kiefer never received a proper medical evaluation, including a physical examination, while at East Bay Hospital. Despite Kiefer’s deteriorating condition (including the fact that he reportedly fell out of the bed twice while still in restraints), there is no indication that a physician was ever called to evaluate him medically. Nor is it documented that his vital signs were taken every four hours while he was secluded and restrained, as required by East Bay Hospital policy.”
What keeps hindering the righting of wrongs at East Bay Hospital? The State Licensing Division was hot on East Bay’s trail in 1991 when the agency received 30 complaints and responded by conducting eight separate investigations. A medical consultant to State Licensing told PAI that the State’s “intensive licensing activity at East Bay Hospital during 1991 was the result of a ‘concerted effort’ to close the facility.” The consultant also said that this intensive investigation of EBH abuses was halted in 1992 “because the word came down from Sacramento” (Licensing headquarters) that East Bay’s license was not to be revoked.
Similarly, in March, 1995, former EBH patients and patients-rights advocates literally begged the Alameda County Mental Health Advisory Board to stop referring patients to East Bay Hospital in the wake of several serious abuses. The county board turned a deaf ear to their pleas, stating that John George Psychiatric Pavilion in Alameda County also had its own problems in terms of patients’ rights.

Alameda County’s neglect

Yet by their inaction, Alameda County officials washed their hands of the fate of their own poor and disabled residents, and sentenced them to live in the insufferable conditions at East Bay Hospital. The consequences of this official inaction are grave: in 1994 alone, EBH reported 650 seclusion and restraint episodes just among its Alameda County patients.
County officials who repeatedly have sent their poorest, most disabled residents into conditions of abuse and neglect have maintained their precious neutrality. Aren’t the hottest places in hell reserved for those who maintain their neutrality in a moral crisis?
Recently, East Bay Hospital has attempted some limited improvements in seclusion and restraint policies. Almost pathetically, it has put up a couple umbrellas to shade the sun-baked asphalt on the prison-like, chain-link-enclosed outdoor area. All this falls under the heading: “Too little, too late.” EBH has been an abomination throughout the 1990s, and has abused far too many patients to be worthy of the public trust.
The mental health directors of the counties sending clients to EBH — Alameda, Contra Costa, Lake, Santa Clara, Solano and Napa — should be indicted for their role in this scandal. They have read all the reports I have read and more, and they know that EBH endangers, neglects and abuses the patients they refer. County mental health directors serve people who are voiceless and powerless — people who don’t have a choice as to where they are sent, people slammed down on the floor and hog-tied in cruel restraints and left in isolation and agony.
Alameda and Contra Costa Counties should not merely cut down on the number of referrals they make to EBH. They should halt the practice of referring any more vulnerable patients to this hospital, now and for good. The counties have the authority to halt referrals to EBH tomorrow. If they fail to do so, the counties are morally and legally liable for sending patients there who die or are injured.
Marc Kiefer had successfully coped with his mental disability for nearly 20 years, building a full, independent life with close family and friends. He played semi-pro baseball after high school. He graduated from the University of California at Berkeley and earned teaching credentials at Cal State in Hayward.  He was a sports writer for the Alameda Newspaper Group.
When he was sent to East Bay Hospital, it was the first time in his life that he had ever been on a locked psychiatric unit for in-patient care. It was also the last time. That one referral ended his life.
That’s the lesson here, county mental health directors. Even one more referral may be one too many. “How many deaths will it take till we know that too many people have died?” sang Bob Dylan.
End all referrals to East Bay Hospital immediately.

Editor’s Note: This report was compiled by studying dozens of reports and documents from State Licensing, Protection and Advocacy, and the Office of Patients Rights, and interviews with members of the California Network of Mental Health Clients, activists affiliated with the patients’ rights movement, psychiatric patients, attorneys and patients rights advocates. Most sources spoke on the condition of strictly protecting the rights to privacy of mental-health clients.