When an 18-year-old patient in the neuropsychiatric ward of the UC Irvine Medical Center committed suicide on Dec. 14, the California Department of Health Services began an investigation to determine whether the hospital could have taken measures to prevent the incident.
On March 16, the Department of Health Services released a 16-page statement of deficiencies in the medical center, which faulted the hospital for not taking more careful measures to prevent the suicide.
The report criticized doctors, nurses and pharmacists at the UCIMC. State regulators said that the hospital did not properly monitor the patient, place him in a safe room, or prescribe him the appropriate medication.
Most notably, the report said that a UCIMC doctor had prescribed the clinically depressed patient two medications known to increase the chance of suicide in adolescents.
The antidepressant Zoloft and the attention-enhancer Strattera both carry ‘black box warnings,’ meaning that the drugs carry a risk of serious side effects. The patient was prescribed Strattera despite not having been diagnosed with ADD.
The patient, a Fountain Valley native, had a history of cutting his wrists and overdosing on medication, and was admitted to the UCIMC on Oct. 30 after his third suicide attempt.
Although UCI requires that a supervising pharmacist approve the prescription of a drug for non-FDA approved uses, such as the prescription of Strattera for a person who does not have ADD, the hospital failed to provide evidence of such approval, according to the Los Angeles Times.
Other deficiencies in the UCIMC include insufficient checks of the patient’s room and unsafe bathroom fixtures in the psychiatric ward.
According to the Orange County Register, the staff checked on the patient every 15 minutes when he first arrived, but reduced the checks to every 30 minutes in December.
The report also indicated that the hospital failed to install breakaway bathroom fixtures, which reduce the chances of a patient committing suicide.
In this case, breakaway bathroom fixtures would have likely prevented the patient’s successful suicide, since he hung himself with a bed sheet tied to a bathroom towel rack
This suicide was the first in the UCIMC neuropsychiatric ward’s history.
‘This was a terrible tragedy and we are deeply saddened,’ said a statement issued by the UCIMC on the day the Department of Health Services released its report. ‘UCI Medical Center is strongly committed to providing quality patient care and continuously improving its programs.’
The Department of Health Services required the UCIMC to submit a plan of correction to ensure that similar incidents do not occur again.
The suicide was the latest in a series of scandals at the UCIMC, which has been under increased media scrutiny ever since it was revealed last year that its liver transplant program was not performing at required levels.
It was also revealed that liver donations were being refused although patients were waitlisted for transplants.