Microsoft word - death of ar.doc

CONFIDENTIAL REPORT
AN INVESTIGATION INTO THE DEATH OF AR
Fifty-seven year-old male resident of Western State Hospital, dies after being struck
by an oncoming tractor-trailer while walking along Interstate 81, near WSH, in
Staunton, Virginia.
DRVD CASE# 96-4808M
Department For Rights of Virginians With Disabilities
Fishersville Field Office
Beth Chadwell, Advocate
April 1997
INTRODUCTION:
This report is a summary of the findings from the Department For Rights ofVirginians With Disabilities’ (DRVD’s) investigation into the death of AR, a 57year-old, white male, who was a resident at Western State Hospital (WSH) inStaunton, Virginia. AR was struck and killed by an oncoming tractor-trailer whilewalking along Interstate 81, near WSH, in the early evening at approximately 6:10PM, on 6/5/96.
This investigation was undertaken as part of DRVD’s responsibility pursuant toUSC 42 10805 et.seq., to investigate incidents of abuse and neglect when reportedor if there is probable cause to believe they have occurred.
DRVD’s investigation has included the following: 1. Reviewing AR’s medical records at WSH.
2. Interviewing WSH Risk Manager.
3. Reviewing WSH Security Report.
4. Reviewing Virginia State Police Investigative Report.
5. Reviewing Virginia Medical Examiner’s Report.
6. Reviewing eyewitness testimony of the incident.
BACKGROUND:
AR was a 57 year-old, white male, who was transferred on involuntary status4/24/96 to WSH from Prince William Hospital in Manassas, Virginia, where hehad been a patient since 4/21/96. He initially went to Prince William Hospital with a complaint of chest pain and received a complete cardiac work-up. AR waslater transferred to WSH based on his need for further evaluation of psychiatricmedications, exacerbation of his mental illness, and inability to care for himself.
AR had been disoriented, delusional and paranoid, and non-compliant with anti-psychotic medications, in the community, for sometime before his admission toWSH. His most recent psychiatric hospitalization was at NVMHI from 1/9/95-3/29/95 as a result of transfer from Northern Virginia Doctor’s Hospital forevaluation and treatment of his bipolar disorder. AR had a long history of bipolardisorder with multiple psychiatric hospitalizations and noncompliance withtreatment, dating back to the 1970’s. He had been treated with Lithium since theearly 1980’s and had approximately 13 years of treatment with Haldol. AR’sphysical problems included muscular spasticity, dysarthia, and residual visual fielddeficits.
AR’s wife resides in Manassas, Virginia, and maintained a somewhat closerelationship with AR until his death. Prior to admission to WSH, AR had beenevicted from his apartment due to delusional and paranoid behaviors, but AR’swife was allowed to stay. AR’s wife was not planning for AR to resume livingwith her when discharged from WSH, although AR did not know this. She feltshe was incapable of providing the supervision AR would need when dischargedand was being pressured by her sister to leave her marriage to AR.
According to records from WSH, AR’s psychiatric diagnoses were as follows: 1. Axis I: Bipolar I Disorder, Most Recent Episode Manic; R/O Schizoaffective 3. Axis III: H/O meningitis with residual visual field deficits, dysarthia, and His medication records as of June 1996 reflect that AR was being treated withthe following medications: III. CIRCUMSTANCES SURROUNDING THE DEATH OF AR:
Care Provided to AR at WSH
AR was transferred to WSH from Prince William Hospital as a result ofexacerbation of his mental illness and inability to care for himself. Upontransfer to WSH, AR was admitted to Ward B1 Admissions Unit. Hereceived treatment for his mental illness and had medical follow-up of hisphysical condition on B1 through 5/22/96. AR was then transferred to C1Psychosocial Unit due to the his need for further stabilization. AR wascompliant with both ward programs while a resident at WSH.
June 5, 1996 Sequence of Events
AR was last seen by WSH staff while eating his dinner on Ward C1/2, atapproximately 5:00 PM on 6/5/96. Ward C1/2 staff stated that after ARfinished his dinner, he left the ward. He had been approved, per histreatment plan, for unescorted, on-grounds privileges daily until 8:00 PM.
AR was next observed by the driver of the tractor-trailer, which struck him.
The driver stated he was driving Southbound on Interstate I-81, near WSH,when he saw AR on the right southbound shoulder of the road. The driverthen observed AR, in his rearview mirror, to appear to be waving at thetruck and then lunged at the side of the truck. The driver stated he realizedsomething was wrong when he noticed, in his rearview mirror, the driver ofthe small truck which had been behind him on the interstate, had pulledover to the side of the road.
The driver of the small truck behind the tractor-trailer, which struck AR,stated he saw AR walking Southbound on Interstate I-81. He stated ARjumped into the rear of the tractor-trailer, three-quarters way down the sideof the tractor-trailer.
Another witness to the incident stated he saw AR walking down theshoulder of Southbound Interstate I-81 and then next in the middle of theinterstate. He stated it looked to him that AR rolled out from under apickup truck with a spare rig on the back.
AR was pronounced dead at approximately 6:15 PM, by the medicalexaminer and the body was transported to Augusta Medical Center inFishersville, Virginia by the Staunton/Augusta Rescue Squad.
Interstate 81 South is straight and level with no defects in the roadway. It isa four-lane divided highway. There were no skid marks at the scene.
Investigations
The Virginia State Police was at the scene of the incident and conducted aninvestigation into AR’s death. They ruled the death as accidental and nocharges were brought.
FINDINGS AND CONCLUSIONS:
There was a discrepancy in the documentation relating to AR’s mental status at thetime of his transfer to WSH from Prince William Hospital. The transfer formfrom Prince William Hospital listed suicidal ideation as one of AR’s diagnoses fortransfer, but the Prince William Community Services Board prescreening formcompleted prior to transfer to WSH, did not identify suicidal ideation as clinicallyindicated. There was no evidence found in the documentation reviewed fromAR’s WSH medical record, which indicated he was suicidal upon transfer or atany point in his hospitalization at WSH.
AR’s wife reported to WSH staff after his death that AR had told her he was"going to meet his maker," during their phone conversation the night before hisdeath. WSH had no knowledge of this conversation until after AR’s death.
This investigation discovered no evidence that abuse or neglect was involved ineither AR’s care and treatment at WSH or in his death on June 5, 1996. AR hadbeen deemed capable of handling unescorted, on grounds passes by his treatmentteam and physician. No recommendations were made to WSH due to theaccidental nature of AR’s death and lack of evidence substantiating abuse orneglect on behalf of Western State Hospital.
RECOMMENDATIONS:
Prince William Community Services Board and Prince William Hospital wereinformed of the discrepancy found in the documentation relating to AR’s mentalstatus at the time of his transfer to WSH.
WSH subsequently developed Hospital Instruction Number 4075 on June 21,1996, which established parameters to assure patient pedestrian safety both on andoff hospital grounds (See Appendix I).
Due to a lack of sufficient evidence substantiating either abuse or neglect it isrecommended this investigatory case be closed.

Source: http://disabilitylawva.org/wp-content/uploads/2012/12/Death-of-AR.pdf