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Brattleboro Retreat ordered to release documents for lawsuit

BRATTLEBORO — A federal judge has ordered the Brattleboro Retreat to release documents related to attempted and successful suicides of juveniles who were receiving in-patient care at the mental health facility. The release of the documents is part of the discovery process in a lawsuit filed by a Northampton, Mass., family after their 15-year-old daughter attempted suicide at the Retreat in 2014.

The teenager, who entered the facility for depression and suicidal thoughts, was found unresponsive by Retreat staff on April 29, 2014. She was resuscitated and hospitalized in Massachusetts but died July 1, 2014, of injuries sustained as a result of the suicide attempt.

The suit was filed against the Brattleboro Retreat in March 2015 in U.S. District Court in Vermont.

"The injuries and death sustained ... were caused by the Retreat's failure to exercise reasonable care and skill in the care, monitoring, supervision and treatment provided ... in connection with her depression and suicide ideation," the lawsuit states. Since then, lawyers for both sides have been going back and forth in federal court, determining what should and what should not be made available to the lawyers for the teenager's family. At this point, no depositions have been taken and no experts have been named as witnesses for either the plaintiff or the defense.

"The family is doing the best they can," said Joel T. Faxon, of the Faxon Law Group in New Haven, Conn. "Despite their grief, the family is demanding the Retreat be held accountable. This is a situation where you feel you are doing your best to protect a child by putting them in an environment with professionals who you think are going to care for your child and this happens."

When the suit was filed, the Retreat had little to say about the case.

"This was a tragic event and the family has our deepest sympathy," stated Konstantin von Krusenstiern, a spokesman for the Retreat. "Since litigation has been initiated, further comment would be inappropriate."

"We are making more focused inquiries about the documents concerning attempted suicides, how they were handled and what the Retreat learned," Faxon told the Reformer on Jan. 14.

Previous incidents at the Retreat included the suicide of a 13-year-old girl in a residential home on Jan. 3, 2014. In the two preceding years, there were two other deaths at the Retreat, one of them a suicide, according to published reports.

According to information that was supplied by the Retreat to providers who cared for the girl prior to her death, "The Root Cause Analysis thus far showed that policies and procedures were followed."

According to the document, which was submitted on June 23, 2014, all patients in the Retreat's adolescent unit are checked every 15 minutes. "There were no changes in (her) demeanor or behavior the morning ... prior to the incident. She had not exhibited or voiced any self-destructive behaviors or voiced (suicide ideation) ..."

According to the document, a mental health worker checked on the girl at 10:15 a.m. the day of the suicide attempt. She was found unresponsive 15 minutes later.

Following the incident, an investigation was conducted and several changes were instituted, including adding a staff member, replacing and putting sensors on the doors of patient units and instituting new rules related to closed doors in the patient units. Staff also received further training on the monitoring of patients.

The report also stated that suicidal ideation in this group is hard to identify due to the "lack of available data and the impulsivity of patients. ... the CDC has recognized that suicide in adolescents is under-reported and difficult to assess, with a lack of effective tools available."

But, the document also stated that a registered nurse on staff failed to follow the Retreat's policies by not conducting a re-assessment of the teenager after concerns were raised by a mental health worker. While the patient did not indicate she would try to harm herself while in the Retreat, states the document, she said once released she would attempt to do so.

Nonetheless, noted the report, "Staff interviewed stated that they were shocked by this patient's suicide attempt; it was documented ... that she was smiling and happy ..."

The document admitted there were "regulatory violations" following previous incidents at the Retreat and "staff did not analyze and implement a corrective plan related to the potential safety risk posed ..." The document also noted that in two previous suicide attempts, patients used an item of clothing, which was also used in the case of the teenager on April 29, 2014.

In addition to the two incident reports ordered released by the judge, the Retreat was ordered to turn over documents for in-chamber review by the judge. After review, the judge will determine if Faxon can have access to them.

"There is a lot of work yet to be done," said Faxon. "I have uncovered material that will cast a significant amount of light on what knowledge the Retreat had on how to deal with in-patient adolescents who are at risk and whether or not the Retreat complied with appropriate standards of care."

Faxon said the incident reports will be redacted to remove all patient information, but should help him determine what the Retreat learned following the incidents. "The Retreat has a responsibility to care for these children. If they are not doing their job, it's a serious problem."

"Suicide is devastating for the family and others who have cared for that individual," said Ritchie Berger, of Dinse, Knapp & McAndrew in Burlington, which is representing the Retreat. "This tragic event was and remains terribly difficult for the people of the Brattleboro Retreat and we all have great empathy for the family."

Berger also told the Reformer that the Retreat disagrees with the allegations made in the lawsuit and is looking forward to its chance to defend itself in a court of law and "not in a newspaper."

The Retreat has undergone several surveys by the Vermont Division of Licensing and Protection on behalf of the Centers for Medicare and Medicaid Services, the federal entity that oversees how federal funds are being used in medical facilities. As the result of the surveys, the Retreat entered into a Systems Improvement Agreement to address deficiencies. In November 2015, CMS issued a report stating the Retreat was "in full compliance" with all of its "conditions of participation." In addition, CMS had no findings related to the April 2014 incident.

On an annual basis on average, the Retreat totals 45,000 in-patient days, 40,000 out-patient visits, 11,000 days in its children's program, more than 14,000 school visits. 10,000 in-patient child days, and 11,000 days in its addiction programs.