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HAMPTON VA ADMITS IT WAS LIABLE FOR PATIENT'S

DEATH IN 2001 -- Veteran overdosed on another

psychiatric patient's drugs.

 

Nancy Washabaugh

 

Background with backlinks here...
http://www.vawatchdog.org/07/nf07/nfAPR07/nf041507-4.htm

We have two related stories.

First story here... http://www.dailypress.com/news/
local/dp-10886sy0apr25,0,642922
9.story?coll=dp-news-local-final

Story below:

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VA blamed in patient's 2001 death

The Hampton veterans hospital admits it was liable for the death of a man who overdosed on another psychiatric patient's drugs.

BY STEPHANIE HEINATZ
247-7821

Late last month, the federal government paid $210,000 to settle a wrongful-death lawsuit by the widow of a patient who died June 10, 2001, of a drug overdose in the Hampton Veterans Affairs Medical Center's psychiatry unit.

Hospital officials have linked 35-year-old Glen Brennan's death to the blanket no-visitors policy that they had in place for the unit from the fall of 2004 until last week.

Dr. Priscilla Hankins, named chief of the hospital's mental health services in December 2004, said the no-visitors policy was for patient safety. The drugs that Brennan overdosed on were sneaked into the unit, she said.

But according to the wrongful-death suit and criminal court records, the drugs were smuggled by a patient with a history of bringing contraband into the unit.

Hankins also said there had been two overdoses in the unit - one in 2000 and one in 2001. Hankins didn't reveal Brennan's name, she did not mention the wrongful-death suit or the settlement, and she wouldn't confirm what court records have since made clear: Brennan was the person involved in both overdoses.

Hankins hasn't returned telephone calls seeking comment on the suit, the settlement and her unit's role in Brennan's death. "Dr. Hankins is not going to be available for an interview," a VA spokeswoman said. She said federal privacy laws prohibited the VA from discussing specifics of court cases, even if the veteran was dead.

But in settling the case, the government "admits it is liable" for Brennan's death, court records say.

Before the visitor ban was lifted, the Daily Press reported that it appeared to violate VA directives - which lists having or refusing visitors as a right of VA patients. It also seemed to violate medical practice - which states restrictions should be made case by case.

One patient, Floyd "Chip" Washabaugh, died in January of a pulmonary embolism two weeks after he was admitted to the psychiatry unit at the hospital. A pulmonary embolism is a blood clot in the lungs that can be caused by prolonged inactivity or a long bed rest.

Washabaugh was suffering from severe depression. In the last two weeks that he was alive, his wife was allowed to see him only once, during a consultation with physicians.

According to the lawyer who represented Brennan's Virginia Beach family, faulty procedures - not a lack of visitors - led to Brennan's death.

"Mr. Brennan would not have died on June 10, 2001, were it not for the negligence of the Hampton VA and its employees," said Benjamin J. Razi, a Washington, D.C.-based attorney. "During Mr. Brennan's stay at the Hampton VA, patients on the ... psychiatric ward were not searched properly upon entry, they were not supervised properly and, at least in Mr. Brennan's case, were not cared for properly."

The assistant U.S. attorney defending the VA in the suit did not want to comment. In the court records, though, the U.S. attorney argued that it wasn't possible "in all circumstances to stop a drug addict from acquiring and taking drugs when ... the addict is intent on doing so."

Brennan's father - retired Marine Corps Col. Ian "Scotty" Brennan, who lives in Florida - said the suit wasn't intended to "paint a rosy picture of my son. The lawsuit was because the federal government was negligent. The VA at Hampton was responsible for his death."

The VA hospital's staff "assumed a legal duty to protect and care for Glen," according to the suit. "The employees ... failed to fulfill this duty, and as a result, Glen died needlessly of a drug overdose."

Glen Brennan voluntarily admitted himself to the psychiatric unit at the Hampton VA hospital March 15, 2001. It wasn't the first time that he sought help for his addiction. Brennan, who spent four years in the Army, had long battled a drug addiction. In 1994, according to the suit, Brennan was admitted to the VA hospital in Richmond, then transferred to Hampton and "placed in an inpatient substance abuse training program."

For a few years, Brennan stayed clean. He attended Old Dominion University and held steady jobs, according to the suit. But in 1999 and 2000, Brennan again admitted himself to the VA hospital in Hampton, asking for help. About that time, he married Lisa Hundley Brennan. They later had a son.

During his October 2000 stay in the psychiatry unit in Hampton, Brennan overdosed on heroin smuggled into the hospital. The court records are unclear whether those drugs came from a visitor. Brennan's father couldn't say with any certainty how Glen Brennan got the drugs. "Despite this overdose, Glen was released from the ward less than a month later," according to the suit.

Brennan returned to the hospital in March 2001, "seeking treatment for depression and asking for assistance in fighting the urge to use drugs," according to the suit. "Glen checked himself into the ... unit because it was the one place where Glen expected to be safe from his drug addiction."

According to medical records cited in the suit, Brennan "complained constantly of severe back pain. His complaints were dismissed as mere drug seeking and were not taken seriously by the ... staff."

After several visits to the hospital's emergency room, Brennan was sent May 30, 2001, to the Richmond VA to get a magnetic resonance image, or MRI. The MRI revealed a compression fracture in Brennan's back.

Col. Brennan said his son broke his back in 1988, while he was in the Army. "The failure to treat this pain may have driven Glen to try to alleviate his pain by using contraband drugs," according to the suit.

The VA hospital acknowledges that Brennan complained of back pain, but in its response to the suit, it "denies that it failed to provide care within the applicable standard of care with respect to ... his complaints." Psychiatry unit staff gave him Motrin and a muscle relaxant.

Five days before Brennan died in another ward of the Hampton VA hospital, a patient named Clyde Williams received a prescription for 240 10-milligram methadone tablets.

Three days later - June 8, 2001 - Williams was back at the VA. In the emergency room, he said he was hearing voices. He was sent to the psychiatry unit.

When psychiatry unit staff searched Williams for contraband - among other items, drugs, cigarettes, lighters, money - they didn't check his groin area or inside his prosthetic leg, according to court records - even though Williams smuggled in contraband previously, often using the same technique.

On June 9, 2001, according to court records, a fellow patient claimed to see Brennan exchanging cigarettes for Williams' methadone. Another witness claimed to have heard Brennan say he was planning to get morphine pills from yet another patient. Both drugs were found in his system after he died.

Brennan was found unresponsive in his bed June 10, 2001.

Williams pleaded guilty to one count of illegal distribution of a controlled substance.

Two years after Brennan died, the Department of Veterans Affairs' inspector general investigated his death. The report's findings, according to the court records, "confirm that even though the Hampton ... staff knew about the problem of contraband drugs for years, the facility had not developed a way to fix that problem."

Staff researcher Tracy Sorensen contributed to this report.

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Second story here... http://www.dailypress.com/news/
local/dp-11786sy0apr25,0,6494
765.story?coll=dp-news-local-final

Story below:

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Supervision added to visitor policy

sheinatz@dailypress.com 247-7821

HAMPTON -- The Hampton Veterans Affairs Medical Center's revised visitor policy for the inpatient psychiatry unit appears to be in line with standard medical practice and U.S. Department of Veterans Affairs regulations.

For nearly three years, the hospital banned visitors from the unit. VA regulations give patients the right to have or refuse visitors, but hospital officials in Hampton said their no-visitors policy was for patient safety.

In 2000, Glen Brennan, a patient in the unit who was dealing with drug addiction, overdosed on heroin smuggled inside. In 2001, during another stay in the unit, Brennan fatally overdosed on methadone and morphine pills that he received from other patients, according to a wrongful-death lawsuit filed against the hospital. The hospital settled the lawsuit with Brennan's family last month and admitted that it was liable for his death.

After a Daily Press report this month - which prompted congressional inquiries and the threat of a lawsuit from the American Civil Liberties Union of Virginia - the VA hospital rescinded its no-visitors policy for the psychiatry unit.

"As an organization, we realize that there may be room to adapt a more flexible visitation policy under certain circumstances, using the standards of professional judgment," Wanda Mims, the hospital's director, wrote U.S. Sen. Jim Webb, D-Va.

Under the new policy, patients are allowed visitors during posted hours - from 6:30 to 8 p.m. Monday through Friday, as well as from 1 to 3 p.m. and 6:30 to 8:30 p.m. on weekends and holidays.

Eastern State Hospital in Williamsburg - the country's first public mental health institution -- has similar visiting hours.

At the Hampton hospital, there will be a designated visitor room.

That room, a hospital spokeswoman said, "will be under direct observation of our staff, in person and by video surveillance."

Mary Cesare-Murphy is executive director for the Joint Commission on Accreditation of Healthcare Organizations' Behavioral Health Program. She said it's "very common for there to be a room in which clients can visit with their family."

The commission is the organization from which the Hampton VA hospital receives its accreditation.

Visitors at the Hampton hospital will be required to leave their belongings - purses, bags, coats - with staff, who will keep them locked up.

Drugs, cigarettes, lighters, food and drinks are prohibited.

Visitors at Eastern State also have to sign in and allow nursing staff to inspect all personal property. Visitors there, however, can bring packages to patients. Those packages are inspected by the staff before delivery.

At the Hampton VA, under its new policy, patients denied their right to visitors will have the reasons explained to them and the restriction documented in their medical records.

That, too, appears to be in line with standard practice.

According to the Joint Commission's written standards, "when an organization restricts a client's visitors, ... the restrictions are determined with the client's participation and, when appropriate, his or her family."

If a restriction is imposed, the commission says, it should be evaluated for therapeutic effectiveness and documented.

"We see that a more individualized approach to visitation may be required for patients when deemed clinically appropriate and when they desire such visitation," hospital director Mims said in her letter to Webb. The new "policy will continue to focus on clinical appropriateness and the safety of patients, visitors and staff," she wrote.



Staff researcher Tracy Sorensen contributed to this report.

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Larry Scott  --