Seclusion, restraints and screams marked man’s final hours at psychiatric unit

September 22, 2010

Cliff Detty – family photo

By LARA COOPER, a Noozhawk reporter

(Note: This is part two in a three part series. Part one highlights how the father of a mentally ill man fought for his son. Noozhawk followed the ordeal of Rich Detty, a Santa Maria man whose son, Cliff, died while under restraints at a Santa Barbara County psychiatric health facility in April.)

After hours of screaming, Cliff Detty wasn’t breathing. His chest lay still beneath the restraint that held it down. His limbs, also strapped down, stopped thrashing. Under the clinical lights of the room in which he was placed for observation, the 46-year-old Santa Maria man was alone when he slipped away.

It’s unclear how much time passed before nurses noticed he wasn’t breathing, and the CPR they began wasn’t enough to ward off death. The voice that had been screaming out for release from the straps was now quiet. Paramedics arrived, but after a time, the chest compressions stopped. Now, only silence.

The events of that night in late April, revealed through the medical reports left behind, didn’t take place in a jail or a prison but in a local psychiatric unit run by Santa Barbara County’s Department of Alcohol, Drug and Mental Health Services. Detty, diagnosed with paranoid schizophrenia, had been transported to the county’s Psychiatric Health Facility in Santa Barbara from the emergency room of Marian Medical Center in Santa Maria.

When Detty arrived in Santa Barbara on the evening of April 28, 2010, PHF staff noted that he was aggressive, to say the least. Almost immediately, staff made the decision that he needed to be restrained. Putting patients in restraints is a risky practice, even when everything is done correctly, and the procedure can cause injuries to staff, as well as injuries, or worse, to the patient.

And something else may have set Detty on the path to his early death that night: He had a high level of methamphetamines in his system, a situation that is known to greatly increase the risk of sudden death while under restraint.

The fact that Detty was placed in restraints is not surprising. That’s because the 16-bed Santa Barbara unit to which he was taken keeps patients in restraints almost three times as long as other similarly sized California facilities that submitted quarterly reports to the state Office of Patient Rights, according to OPR data. While large mental institutions throughout California, and the nation, are choosing to phase out the practice for safety reasons, Santa Barbara’s facility has continued to use the procedure.

ADMHS officials have refused to comment on Detty’s specific case, so what happened to him that night has been taken directly from the medical documentation logged at the time at the Psychiatric Health Facility. The reports reviewed by Noozhawk reveal a grim picture of what unfolded that night, with Detty becoming more agitated the longer he was kept in restraints.

Before the night was through, the reports appear to indicate that Detty, who was 6 feet tall and 187 pounds, had been confined in restraints continuously for nearly 11 hours. Although officials won’t confirm this, none of Detty’s documentation notes that he had been released from restraint. Upon arriving at the PHF unit, “patient was agitated, screaming at staff during transfer from gurney to bed, aggressive and combative,” one report reads.

The seclusion restraint form, filled out at 9:45 p.m., stated that the “patient is very aggressive and combative upon arrival to the unit, unable to follow directions, yelling and screaming at the staff, threatening staff ‘Leave me alone, you f****, I’ll kick your asses.’”

Criteria for release was listed as “able to calm down and follow directions, no threatening remarks, no yelling or screaming.” The form says Detty was “instructed to calm down, and listen,” given several doses of anti-psychotic medications, and placed in an observation room, where a microphone and camera were kept on so staff could observe him.

But several discrepancies in the report raise questions. The report stating that seclusion and restraint had been initiated was only signed by a nurse on duty, and not a medical doctor, who should have signed the order within 24 hours, as required by the California Code of Regulations.

Detty continued yelling, urinated on himself, had his linens changed and a diaper placed on him, and was “uncooperative” to care, the report states. Lead nurse Reyn Bugay lamented in her notes that Marian Medical Center ER staff should have administered more drugs prior to transferring Detty to Santa Barbara.

Detty continued screaming, pulling at his restraints and saying “I want to go back to my place,” the report states. Another report for seclusion and restraint was filled out at 10:30 p.m., and reported that Detty would wake up agitated, between periods of sleep. At this point, he was naked and held by a five-point restraint, the maximum secured restraint with straps across each of his limbs and midsection. A PHF worker wrote that Detty didn’t appear able to understand the criteria of his release from the restraints, much less be able to discuss it.

“Agree with Seclusion and Restraint until able to vow compliance or maintain behavior,” the caretaker wrote.

Another discrepancy pops up at that time. At 10:30 p.m., a group of nurses, lead by Bugay, had a debriefing session. Under the state Health and Safety Code, debriefing should occur after the patient has been released from restraint, in order to evaluate how to avoid a similar incident in the future. The system was designed to create a feedback loop between patients and caregivers.

But these nurses held the debriefing while Detty was still in restraints, and not responding well. Patient participation is voluntarily, but it’s apparently highly unusual that nurses indicated Detty had chosen not to participate in the session.

Meanwhile, Detty’s agitation grew. Another page, also filled out at 10:30 p.m., describes all the strategies staff used to try to calm him down. Eight boxes are checked, including “active listening” and “offer medication.” But from the reports, it appears that release from the restraints was never considered, in spite of increasing panic from the patient. State law requires that staff check every 15 minutes to ensure the restraints have been applied correctly, and that they remain in their line of sight for observation in the meantime. One report describes each check: Detty’s screaming and “pulling at restraints” is mentioned 13 times.

It’s unclear how much time had elapsed when attendants noticed that Detty was no longer yelling, around 1:15 a.m. on April 29. “Patient noted to have no respiration,” and then a quick succession of events records Detty’s last moments alive:

“911 called, CPR started, paramedics arrived, patient expired.”

Four months later, Detty’s father, Rich, doesn’t have many answers about what happened that night. Although a toxicology report has been issued detailing what was in Detty’s blood when he died, the Sheriff’s Department still hasn’t issued a cause of death in the case. The Coroner’s Office is part of the Sheriff’s Department.

When Rich Detty was finally able to read the PHF medical reports, he was disturbed.

“It bothered me a lot that all he did was scream and yell and just wanted to be free,” he told Noozhawk. “I hope when people die they go out in dignity and class, and on their own terms … but that was pretty miserable.”