Medication Nation

How it played out:

At 4:25 a.m., hospital staff found Burton facedown on the floor, short of breath and "shaking like a leaf."

Although times have been scribbled out and rewritten in the chart, the on-call doctor apparently was paged at 5:30, 6, and 6:35. There is no record of those calls being returned.

At 7:21, an ambulance called by the staff arrived and Burton was transferred to Kaiser Permanente, but it was already too late.

Burton was pronounced dead on arrival at Kaiser, at 7:36 a.m.

karenapics at 1:02 AM PST Thursday, September 11, 2008 said:

This autopsy

This autopsy may well be the honest truth as to the cause of death. It is not unheard of for certain patients to decease in a psychiatric hospital that also treats addictions. But the rest of the prima facie evidence is very clear that there is a problem with this facility and the operators should not be able to expand operations without positively addressing the existing issues there.


missinghim at 9:45 AM PST Thursday, September 11, 2008 said:

they neglected him

regardless of how he passed away. they did nothung to save him. nothing. they did not call 911 and he suffered for three hours before he died!


kemushi at 11:39 AM PST Thursday, September 11, 2008 said:

I don't see how this proves no fault, look at these statements

"A coroner's report released this week finds that Burton, whose widow earlier told The Bee that she took him to Sierra Vista because of drinking problems, died as a result of liver damage that led to a toxic buildup of prescription medicines in his body." AND "a calcium channel blocker, and duloxetine, an antidepressant" Was this a medication that was prescribed to him before going to Sierra Vista? Was he put on other medications while he was there? I think the question comes down to how much doctors knew about his liver condition, and whether or not precautions were taken to ensure this did not cause a problem with his medications (psychiatric or otherwise.) It is commonly known that psychiatric meds are NOT to be taken by someone who has liver problems as they will only become toxic or make it worse. It may or may not be our business, but I still don't think Sierra Vista can just wash their hands after this.


kemushi at 11:54 AM PST Thursday, September 11, 2008 said:

missinghim:

Sierra Vista clearly did ignore him if he was not seen or even evaluated for three hours before his death (regardless of the time of day or night). Often they do not take any kind of medical claims of emergency seriously because they are so callous towards ALL patients. I still cannot believe fully that they were not involved in his death. At the very least they can be implicated for not recognizing his serious physical condition and providing him emergency evaluation. Just because a person is trying to detox or recover does not mean they should just be shut away and ignored until they snap out of it or detox. He should have been treated at the ER first and then when he was stabilized possibly moved to SVH if it was even necessary. To me that seems like it should be MANDATORY basic procedure prior to admittance. I also aware that SVH does monitor things like blood pressure and they run other tests, they should have known something was wrong. I am so sorry for your loss...


kemushi at 12:35 PM PST Thursday, September 11, 2008 said:

FYI a watchdog group in Sacramento is forming a protest

On September 20, which is a Saturday, starting at 9 am a specific watch dog group in Sacramento is forming a protest against the facility. If anyone is interested please check out our site in the next couple hours for more information or an update. I wish to attend, and if anyone else would attend also we can brainstorm some ideas for signage, pamphlets and other information and strategies. Feel free to email me through the site if you are interested in attending, that way I would know how many people to expect. Thanks...


shilagirl at 5:42 PM PST Friday, September 12, 2008 said:

there's a big difference between causing and allowing...

just because their actions did not CAUSE his death I still think they should be responsible for ALLOWING him to die the way he did. maybe if he'd had the proper tests/diagnosis/treatment he could have been saved.


ajames2800 at 4:41 PM PST Saturday, September 13, 2008 said:

Take your prejudiced glasses off!

Some facts: *The death in 2000 was over 3 companies and 5 CEOs ago. Not relevant to today, unless you have something against the bricks and mortar in this hospital. The second death occurred outside this hospital 1 and 1/2 days after she left. The original autopsy said "natural causes" and over a year passed before the NEXT examiner looked at the documentation. He never viewed the body and all he did was to summarize the findings. This guy needs to be sued by the family and the hospital for his incompetence! The last death occurred as a result of a failed liver and only God could have saved this man's life. The 111 entries were not individual violations, which were only 28 and because these violations were only reporting errors, they translated through 4 of the different departments in this hospital. In other words, this was all over documentation policies and had NOTHING to do with direct patient care. No-one has ever died from med errors at this hospital. So SHUT UP!


ajames2800 at 5:02 PM PST Saturday, September 13, 2008 said:

Final Comments

Only three deaths that happened in 8 years? With all of the hundreds of patients that SVH see every month? Compare that with ANY OTHER hospital in Sacramento or in the Nation. When you put it in perspective, this is an outstanding record! Does stuff happen in a psych hospital, yes it does! Why? It is because of the fluid an UNPREDICTABLE nature of the patients. I still give Sierra Vista a 5 star rating despite all of you and your prejudiced and politically motivated comments. There is ALWAYS the other side of an argument and somewhere in the middle lies the truth. I have presented what I believe are some rational points here. It comes back to the old saying,"There are three truths. One one you tell yourself, the one you tell others and the truth." The third truth is hard to take many times and contains elements outside the human perspective. My final comments. Good luck to the activists in tearing down the hospital system (until there are none left).


kemushi at 5:48 PM PST Saturday, September 13, 2008 said:

ajames2800

Your vague summary of the statistics are wrong. First there is Jennifer Jenkins (1), who died while under care due to lack of supervision, for a hospital designed solely for the purpose of psychiatric monitoring and prevention of self harm this is a serious failure. There is Ramona Knapp (2) in 2005 who was suffocated during a restraining session, SVH claims she was in poor health already, but this is further negligence as they should have been more careful due to her condition. There is an elderly man Shige Tateyama (3) who also died due to lack of patient monitoring, again under staffed and ill-equipt to handle the cases they specialize in. There is also Steven Burton (4) who could have lived if the hospital provided him the emergency treatment he needed in a timely fashion. Instead they kept him locked up, and did nothing to alleviate his pain. There is another patient who almost died due to an accidental overdose of medication.


kemushi at 5:54 PM PST Saturday, September 13, 2008 said:

As for your knowledge of the violations I question your position

whether you are just a "family member" of patients, as you previously mentioned your wife and daughter, or if you are REALLY just an EMPLOYEE of this company, in which case you should shut up yourself, as you will get no sympathy from anyone here who believes that these allegations and facts are true. You aren't talking to anyone who hasn't already considered the findings, and found based upon moral and ethical considerations that Sierra Vista is a corrupt hospital run by a corrupt corporation with seeds rooted firmly in pharmaceutical corporations and private institution management nightmares. This is NOT the only facility this company manages heinously and you would do well to look more into the facts before you start making blanket statements about their non-existent good will. I have a better idea, why don't you go work for NAMI, they love two-faced sympathizers like yourself.


missinghim at 5:16 PM PST Monday, September 15, 2008 said:

wrong, wrong, wrong...ajames

You are so wrong! You really have no idea! You go on ahead and keep admitting your "wife and daughter" and when they show signs of distress, when they show signs of needing medical help, I hope SV doesn’t just put them back in bed and let them die, I hope they don't treat them like they are second class citizens, and I hope they call the ER and do what any decent facility would do. Most of all, I hope no one goes through this again, not even you. But you go on ahead and take that risk. We'll see, it's just a matter of time before it happens again. Let's hope it’s not you, right?


fritz4114 at 7:02 PM PST Monday, September 15, 2008 said:

It's Not Over Yet

Sounds like he was neglected. There may be more to this than what is reported in this article. His liver should have been checked once he was admitted. Prescription drugs and alcohol really ravage the liver...... any good physician knows this. I understand Daniel Wilcoxen is one of the best lawyers in the field of medical malpractice, so it's not over yet..


georgiajenkins at 8:45 AM PST Tuesday, September 16, 2008 said:

To aJames2800

Where do you get off THINKING you know the facts of my daughters death, because you are WRONG,WRONG,WRONG! Were you there when my daughter was transported around noon and her chart had a nurses initials on 3-different meds she supposedly gave her at 1:30! Were you at UCMed hospital for FIVE days not 1-1/2! Were you there when the head dr. of the PCU said after my daughter passed away you need a FULL autopsy & to hire an attorney? Were you there when we took 30 depositions by witnesses that revealed how bad of care S.V. gave? The coroners decision means nothing in the Burton case and nothing in ours! S.V. was negligent, that's why they paid their way of going to trial. You can choose to hear the FACTS from THE FAMILY of Jennifer or you can choose to ignore the FACTS! But the facts are she died because of negligence on the part of S.V. Hospital. They were stilled owned by a Tennessee based co. then and still are today! Before you quote anything YOU should know what you are talking about!


georgiajenkins at 9:04 AM PST Tuesday, September 16, 2008 said:

To aJames2800

As far as their record and people dying at S.V. DO NOT COMPARE what is done at other hospitals except OTHER ACUTE CARE FACILITIES, which S.V. has the WORSE record!!! My daughter did not go to Sierra Vista for a surgery, or was she Terminally ill, she was hearing voices. We were never told they put her in restraints or given Thorazine 4 times in 10 days. My daughter WAS NOT on a Line Of Sight and watched when she was in a vulnerable state of depression! THAT IS WHAT Sierra Vista was there to help her with! She needed time to heal and be sent home healthier than how she came in. NOT DIE DUE TO THEIR NEGLIGENCE! It haunts me everyday that another will die because of continued bad practices of untrained & uncredentialed staff! Obviously you are overwhelmed with your family situation & I feel sorry for you. But do not quote or act like you know the facts of what happened to my daughter! That is just WRONG, WRONG, WRONG!!! Have some compassion for the loss many of us have suffered.


georgiajenkins at 9:51 AM PST Tuesday, September 16, 2008 said:

To all of you that care to change S.V. practices

Thank you for caring. We sued to never have this happen to another & to get some facts we could never know any other way! Things are not cut & dry with the law and please don't believe those reports are all that! We had to sue to find out much of the truth & still don't know how my daughter was able to harm herself. I have lived with this 8-yrs because S.V.was never thoroughly investigated by the Coronor or State. This was like 1/2 a car wash, they looked at the shine outside - not the dirt inside! I hope for the Burton & Knapp family this doesn't occur. It's unreal the police were never called to investigate or ask questions of what happened that day, we have many depositions that helped piece some things together, but please do not let S.V. continue injuring patients & not be accountable. They must pay for credentialed care! Fight to help others that can't do this for themselves. Even "aJames2800" loved ones need us, regardless if he is in denial about S.V.'s bad record since 1991.

The bottom line is that SVH did not provide the proper patiant care that my dad desearved. They have no polocies or procedures in wich they follow. My dad desearved to be treated as a human being. Why couldnt they have just taked him to Kaiser right across the street? It shouldnt be that tough of a decision.

You are totally right, it would be literally LESS than 15 minutes to get him into an ambulance and bring him over to their emergency room. They are RIGHT ACROSS THE STREET!! How they could justify NOT doing that to me is a complete mystery.

Sorry I missed the protest. I'd like to be notified of the next one. How do I find out date/time.

SV was negligent if nothing else. They were the professionals and they chose to do nothing when Steve needed care. Given their job was to help him, they failed, plain and simple.

That is worth something.

Just because the Bee stopped writing about my dad and what happened to him at this hell hole doesnt mean that this is over! They sat back and watched my dad die, THEY killed him. Two on call doctors were called several times and either one bothered to respond and for some unexpained reason the nurses didnt make the decision to send him to Kaiser (literally right across the street)untill after he had already died. Too little,too late!!! My dad was the sweetest man on earth and desearved to be taken care of. Thats not much to ask for from a "hospital". My sister and I no longer have a dad, my mom no longer has a husband, and our kids were robbed of a wonderful grandpa!!

Comment to "My dad sgb" - I only had time to read your comment posted 11/06/08 and would someday be very moved to meet you, since I also was a victim of sexual assaults (2x), sexual harrassment, repeatedly denial of medical care and illegally being restrained in seclusion when I had a second bout of life-threatening Periodic Paralysis, for which I was in Sacramento to get the final medical authorization needed to become a clinical patient for clinical trials at the National Institute of Health in Bestheda, Maryland because I had been soooo seriously ill for so many years with bouts of repeated paralysis, seizures, endocrine disorders, respiratory illnesses, Chronic Fatigue, and what now (and even then) was diagnosed as radiation illness and Gulf War Syndrome because of my years and years of exposure to military harzardous, toxic and radioative waste as the daughter of a civilian metallurgist who worked for the US Military and who worked for my father on our family business since age 4 both on both airplane crash sites and on our family metallurgy business-- with stored US Military aircraft salvage which my father regularly melted into aluminum ingots in a furnace on our rural property in Northern California. Despite the fact that I wore a medical alert bracelet with the most serious physical medical conditions documented, carried with my a physician signed prescription with my well-established medical conditions and concurrent medications, repeatedly showned pictures and evidence to my doctors, gave numerous names of physicans and verifying contacts, such as a retired FBI close friend, had my boyfriend/fianace testify to the Truth and facts of my life (he came 44 days straight as an EOD Specialist and Military Expert Witness in Harzardous Toxic Radioative materials with compelling evidence to Heritage Oaks, where I unconstitutionally was denied notice of a hearing and was also court-ordered on a LPS Conservatorship on perjuried and false information (admitted by Dr. Lloyd Benjamin) in a locked unit of a nursing home for 1 year, when I solely only have my Social Security Disability PTSD and Dissociative Disorder NOS (since 1989)-- plus raped twice in their facility on my second and third night by a psychotic, violent criminal with a long arrest record for violent crimes, Douglas Farrell, (now reported case Sac. City No.08-320775 in which NOTHING has been done except for SCP to call the Marin local police to defame and harass me as "an unbalanced woman"-- whom SCP believed was allegedly pscyhotic, delusional, on anti-psychotics and suicidal, when in fact, when they came into my home, they found that I was quite normal, living in an upscale condo in Marin County and, although disabled, am the Executive Director/President of a nonprofit social justice organization since 1992 and have a juris doctor since 1989 from UC Hastings and working diligently and religiously daily on my case against Sierra Vista, Heritage Oaks and PSI. FYI, I was told at Sierra Vista that they "did not treat physical illnesses." And my medical discharge records state that I do not have any physical illnesses (these are "delusions and pscyhosis," and I was almost institutionalized at Heritage Oaks later despite ample medical evidence to the contrary that I was "delusional and pscyhotic" about believing I was physically ill and disabled. I was also pulled off of at least 7-8 or more medications (all previous meds) and refused my prior my physical speciality medications the entire time I was at both hospitals. Clearly, this further contributed to my physical and mental deterioration, as well as NOT being taken in for emergency sexual assault treatment and for my life-threatening periodic paralysis attacks. See Mary Smith v. Serra Vista, Case No.34-2008-00001953. God Bless you and your family as I understand well how they treat their patients and how your Father died given the normal, daily and regulard conditions, attitudes, and procedure of SV. And I would testify for you and advocate for you in a nanosecond because I have been inside that facility through forced 5150's three or four times, and in fact, once after an arrest when I tried to report the rapes at the Capitol Building because no one would do it from inside the hospital as mandated by state and federal law. Mary

I would just like to express my deepest sympathies to those of you that have also suffered at the hands of this facility and are dealing with the loss of a cherished family member and loved one. I am speaking on behalf of my cousin Jennifer Jenkins who is no longer with us and is very much at the heart of this tragedy. A beautiful, vibrant, caring and community minded young woman, who was active in her school and her church, who had the strength and courage to ask for help with an illness she did not understand, nor was she equipped to deal with on her own, and was ultimately victimized by poor, at best, hospital policies and procedures. As well as a staff who approached their jobs with an extremely cavalier attitude to the well being of others. It still baffles me to this day how and why this happened not only to Jennifer, but still seems to be common practice in this facility. They do not need more funding, a larger facility or more staff members. The pulling of any and all government and state funding would be a great start towards rectifying the situation. Followed by the closure of their mental health departments. I read the articles, hear the comments, and the one thing I would like everyone of those politicians, doctors, nurses, lobbyists, hospital board members, and the Governor himself to know is, Jennifer is not and will never be just a statistic. Just ask her family and friends. We know the reality behind the tale. Look my Aunt and Uncle in the eyes and ask them to fill the void of losing a child with some damn number, pamphlet, support group or some half ass study. I know. This is very much a part of my life, not only as Jennifer's cousin and family member, but as someone who also suffers with a severe mental disorder. Walk in one of our shoes. As many as 1 in 5 Americans suffer from some kind of mental illness at some point throughout their life. Chances are you know someone yourselves. Would you trust your life or your loved one's life in the hands of these clowns? I highly doubt it. We are all equipped with the God given right to make our own choices, have and share our opinions, disagree with one another, pick and choose what and who we want to be in life. That's what makes us individuals. All of you out there, every single one of you, have had or do have something or someone over the course of your lives that is your favorite. She was mine. Aaron