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School where 13-year-old with autism died after being restrained violated state rules

As a grieving California couple shares photos of their 13-year-old son with autism, who died last month after being restrained by teachers, other parents have begun pulling their children from the inclusive private K-12 school where it took place. 

The parents of Max Benson, a student at Guiding Hands School in El Dorado Hills, shared photos of their son with Fox 40 in Sacramento to show his sweet demeanor, the news station said. The family, from Davis, is also fighting back at Guiding Hands, which a preliminary investigation by the state shows violated multiple rules in its handling of the boy. 

Max was allegedly placed in a prone restraint, face-down on the floor, Nov. 28 after school officials said he became violent. The El Dorado Sheriff’s Office, which is investigating the incident, said in a news release that Max was 6 feet tall and weighed about 280 pounds. 

An attorney for Max’s family, Seth Goldstein, disputed the claims of the boy’s height and weight, saying that Max was 5 feet, 4 inches tall. At most, he weighed 230 pounds, Goldstein said.

“He was not an unmanageable child in any sense of that term, in terms of that size,” Goldstein told The Sacramento Bee

The Bee previously reported that sources said Max was held in the prone restraint position for about an hour before he became unresponsive. 

“A teacher began CPR until medical aid arrived,” a news release from the Sheriff’s Office said. “The student was transported to Mercy Folsom in critical condition and later to UC Davis (Medical Center).”

Max died two days later. 

“At this time, there appears to be no evidence of foul play or criminal intent,” investigators said in the release.

Cherilyn Caler, whose own 13-year-old son witnessed the restraint used on Max, said the teacher and an aide restrained the boy, who had been a student there for just a few months, because he kicked a wall, the Bee reported. A second parent who asked to remain anonymous backed Caler’s account. 

Caler told the newspaper her son, who is also on the autism spectrum, told her Max became unresponsive, at which point those restraining him told him to stop pretending to be asleep. After about 30 minutes, they realized he wasn’t pretending, she said.

Caler has since removed her son from the school, the Bee reported

>> Related story: Teen with autism dies after being restrained at school

A Dec. 5 letter from the California Department of Education states that staff members at Guiding Hills violated multiple state rules when trying to get Max under control. The Department of Education’s own preliminary investigation found that the staff used an emergency intervention to stop predictable, or non-emergency, behavior.

It also found that an emergency intervention was used as a substitute for Max’s behavioral intervention plan, or BIP, which is designed to change, replace, modify or eliminate a targeted behavior. The intervention was also used for longer than necessary and it was used with an amount of force that was “not reasonable and necessary under the circumstances.”

The school staff’s actions also failed to take into account Max’s individualized education program, or IEP, which required specific intervention strategies that were not used, the letter says. 

Guiding Hands School’s certification has been suspended until the end of 2019, according to the letter. The school can continue to serve current students but cannot accept new pupils. 

“The (California Department of Education) is continuing to conduct its investigation into the actions of (Guiding Hands),” the letter reads. It is likely required corrective actions will be issued by the CDE resulting from this investigation.”

All corrective actions would have to be completed for the school to regain its certification.

Caler is not the only parent who has pulled their child out of Guiding Hands, which had an enrollment of 137 this school year, according to state records

Melissa Lasater told Fox 40 that she was appalled at how the school handled Max’s death. 

“When they were bringing the chaplains from class to class, instead of just letting the chaplains say, ‘We’re here for you,’ the staff also shared their message: ‘Just so you know, we didn’t kill anyone,’” Lasater told the news station

Lasater said her own 13-year-old son, who knew Max, did not realize his classmate died until his death made the news about a week later. 

“He immediately started to, like, cry and started to process, like, ‘Who’s been missing the last few days, who could it be?’” Lasater said. “And then his face just dropped and he’s, like, ‘Mom, mom, it was Max. They killed Max.’ And then he was petrified.”

Lasater said the school had used restraints on her son in the past, sometimes leaving him with bruises. In the wake of Max’s death, she initially revoked her permission for the school to use any force on her son. 

Ultimately, she chose to pull him from the school.

“They’re all still there with the same staff, who are trained in the same techniques, who are going to use them the same way. They use them as punishment,” Lasater told Fox 40.

Other parents and students tell stories of physical restraint being used as punishment. 

Josh Greenfield, 23, was a student at Guiding Hands until 2013, the Bee reported. Greenfield told the newspaper he was restrained twice during his time there and found the experiences frightening. 

The restraints were excessive and were done for dubious reasons, according to the former student. He told the Bee he was once placed in a prone restraint because he ignored a teacher calling his name in a hallway. 

Melanie Stark, of Elk Grove, pulled her 9-year-old son from Guiding Hands Thursday, the Bee reported. She also has a pending complaint with the Department of Education regarding the use of restraints in the school. 

Stark said her son was restrained on his first day at the school in September. She said a teacher’s aide wrapped her arms and legs around the boy so he could not get up from his desk. 

The reasoning was to keep him seated and guide him through the activity he was working on, she said. 

“That was too aggressive and it was happening about four times a week,” Stark told the Bee

Rebecca St. Clair, of Folsom, told the newspaper her son was put in a prone restraint two years ago. In that incident, staff members rolled him inside a gym mat and put their weight on the mat to keep him still. 

Despite being upset by the incident, it was not until the week before Max’s death, when she personally witnessed a student being rolled inside a mat that she realized how “alarming and unsettling” the practice is, the Bee reported

“I tried to assure myself that this was based on trust. I really trusted the teachers,” St. Clair told the newspaper. “That trust has been broken. I thought they were so careful. I feel so wrong about that now.”

Lasater and others protested outside the California Department of Education Monday, demanding that Guiding Hands be shut down. One of those protesting was Katie Kaufman, a former student there. 

According to CBS Sacramento, Kaufman said she also was restrained multiple times at the school.

“They always use the one where you throw the person on the floor in a body slam,” Kaufman told the news station. “It was a matter of time. Someone dies, and they finally start listening.”

CDC warns against eating raw cookie dough, cake mix

Christmas parties, work potlucks and family get-togethers mean a lot of baking in the coming weeks.

If you’re tempted to lick the bowl after mixing cake batter or dig into that raw cookie dough, however, you need to resist.

Consuming unbaked food that is supposed to be cooked can make you sick, according to the Centers for Disease Control and Prevention. Kids also can get sick from handling raw dough used for crafts, the CDC says.

Most people know that eating raw eggs can contain salmonella, which can cause illness if the eggs aren’t cooked properly.

>> Read more trending news 

The CDC estimates salmonella causes about 1.2 million illnesses, 23,000 hospitalizations and 450 deaths in the United States every year. Food is the source for about 1 million of these illnesses.

Bacteria aren’t lurking only in eggs, though. Flour, which is usually a raw product, usually isn’t treated for germs like E. coli. The CDC reported an outbreak of E. coli infections linked to raw flour made 63 people sick in 2016. Some E. coli can cause diarrhea, urinary tract infections, respiratory illness, bloodstream infections and other illnesses.

“Raw flour is a raw product, and it doesn’t go through any heat treatment before you get it,” Benjamin Chapman, an assistant professor and food safety extension specialist at North Carolina State University, told SELF Magazine in 2017. “You should treat that flour like you’re handling raw meat.”

It doesn’t mean you can never eat raw cookie dough. Dough that is commercially produced to be edible is safe. 

The CDC suggests the following safe practices to avoid getting ill:

  • Do not taste or eat any raw dough or batter, whether for cookies, tortillas, pizza, biscuits, pancakes or crafts made with raw flour, such as homemade play dough or holiday ornaments.
  • Do not let children play with or eat raw dough, including dough for crafts.
  • Bake or cook raw dough and batter, such as cookie dough and cake mix, before eating.
  • Follow the recipe or package directions for cooking or baking at the proper temperature and for the specified time.
  • Do not make milkshakes with products that contain raw flour, such as cake mix.
  • Do not use raw, homemade cookie dough in ice cream.
    • Cookie dough ice cream sold in stores contains dough that has been treated to kill harmful bacteria.
  • Keep raw foods such as flour or eggs separate from ready-to eat foods. Because flour is a powder, it can spread easily.
  • Follow label directions to refrigerate products containing raw dough or eggs until they are cooked.
  • Clean up thoroughly after handling flour, eggs, or raw dough:
    • Wash your hands with running water and soap after handling flour, raw eggs, or any surfaces that they have touched.
    • Wash bowls, utensils, countertops and other surfaces with warm, soapy water.

New treatment gives hope for kids with polio-like illness

Cases of a mysterious illness that's leaving children paralyzed have nearly doubled in the last month.

>> Read more trending news 

A total of 116 cases have been confirmed across the country, including three in Georgia.

It’s called acute flaccid myelitis, or AFM. The illness starts off like the common cold and then leads to polio-like symptoms, including partial paralysis.

But now doctors are seeing new hope when it comes to restoring mobility. They’re trying out a surgical procedure that move healthy nerves.

They just performed the microsurgery on an 8-year-old who first had a sinus infection and then lost strength in his left arm.

>> What’s causing polio-like illness?

"Tahi had a droopy face, he lost his core strength, so he was unable to sit up without assistance," said the boy’s mother,” Trisha Toya.

Doctors are trying out the surgical procedure that moves healthy nerves.

What we're doing is microsurgery and disconnecting from one muscle and tunneling it to a new target,” said Dr. Mitchel Seruya of Children's Hospital of Los Angeles.

Doctors said timing for this surgery is critical because it must be done within the first 18 months of diagnosis.

There is no cure for AFM. The Atlanta-based Centers for Disease Control and Prevention launched a task force last week to investigate causes of the disease as well as possible treatments.

Even with the rise in cases, according to the CDC, “less than one to two in a million children in the United States will get AFM every year.”

Acute flaccid myelitis: CDC confirms 116 cases of polio-like illness, 286 total reports so far

The Centers for Disease Control and Prevention said in a Nov. 23 update that there are 116 confirmed cases of acute flaccid myelitis, a condition that affects the nervous system, causing a polio-like illness.

Although rare, the CDC said the 116 confirmed cases are among the 286 total reports the group received so far in 2018.

>> Read more trending news 

“It affects the nervous system, specifically the area of the spinal cord called gray matter, which causes the muscles and reflexes in the body to become weak,” the agency said. “CDC has been thoroughly investigating the AFM cases that have occurred since 2014, when we first noted a large number of cases being reported.”

The agency said it has not identified a confirmed cause for AFM. It said more than 90 percent of patients with AFM had a mild fever or respiratory illness consistent with a viral infection, such as enteroviruses, before they developed the condition. 

The CDC is continuing to investigate why a small number of people develop AFM and most others recover. 

Despite the illness being compared to polio, the CDC said it is not caused by poliovirus.

More information is at CDC.gov.

Woman accuses University of Colorado Hospital of removing 2 healthy kidneys

A 73-year-old Colorado grandmother is considering legal action after doctors at the University of Colorado Hospital removed both of her healthy kidneys in May, KDVR reported.

>> Read more trending news 

Linda Woolley, of Englewood, said doctors told her surgery was necessary because she likely had kidney cancer, the television station reported.

However, KDVR obtained a copy of a March 2018 biopsy that showed "no evidence of malignancy" and results "consistent with a benign process."

“I’m not real happy,” Woolley told the television station.

Because both kidneys were removed, Woolley requires four hours of dialysis three times a week, KDVR reported.

"My life was totally changed,” Woolley told the television station. “Dialysis is no picnic. No matter how used to it you get, it robs you of your life.”

Woolley now needs at least one healthy kidney, and the average waiting time for a transplant is seven years, KDVR reported. More than 95,000 people are on a waiting list, the television station reported.

At least five people have contacted KDVR, telling reporters they were willing to offer a kidney.

"People are wonderful. It’s wonderful to see good things happen," Woolley told the television station.

Woolley said she is not necessarily looking for an apology from the hospital, which has not commented on the incident. 

“(But) I feel like they owe me a kidney, that's for sure," Woolley told KDVR.

Minnesota mom convicted of murder now helps raise mental health awareness

Fifteen years after tossing her twins off a bridge into the Mississippi River, a Minnesota woman is using her story to raise awareness about mental illness, KARE reported.

>> Read more trending news 

Naomi Gaines was 24 when she threw her 14-month-old sons, Sincere Understanding Allah and Supreme Knowledge Allah, into the river near St. Paul on July 4, 2003, and then jumped into the water, the Star Tribune reported in 2003. Sincere drowned, and Gaines was convicted of second-degree murder and second-degree attempted murder, KARE reported.

Gaines, now 39, served 15 years in prison and spent time at a mental health treatment center, 

After the death of her son, Gaines was diagnosed with postpartum psychosis, bipolar and schizoaffective disorder, the television station reported.Now, Gaines is reaching out to help people with similar mental conditions.

“If there is another Naomi Gaines out there, you are not alone. Mental illness is not a character flaw. It is not a weakness to ask for help. It is a strength,” Gaines told KARE. “What I wouldn't give to go back and say, 'I am not OK, and I need help.'”

Gaines now works part-time at the National Alliance on Mental Illness in Minnesota.

“I got the most help for my mental illness while incarcerated," Gaines told KARE. "That is when the prevention classes, groups, therapy and medication happened, after it was already too late for my son."

New Mexico author sues hospital for reviving her 

A lawsuit filed on behalf of a New Mexico author alleges that a Santa Fe hospital revived the woman in violation of her “do not resuscitate” directive while she was in the facility’s care in 2016, the Albuquerque Journal reported.

>> Read more trending news 

The lawsuit filed in New Mexico state district court against Santa Fe's Christus St. Vincent Regional Medical Center alleges that the hospital was negligent twice in its treatment of Jamie Sams, a writer known for her books about spirituality. 

The lawsuit also alleges that Sams was given the painkiller Dilaudid, a medicine she claims she is allergic to, the Journal reported. Sams suffers from Dercum’s, a rare disease that produces tumors all over the body, the newspaper reported.

According to court documents obtained by the Journal, Sams went into cardiac arrest after receiving the drug in the emergency room on Feb. 5, 2016, and the hospital’s negligence was compounded when she was resuscitated -- something she did not want. Sams had signed a “Double DNR (do not resuscitate)” form, the newspaper reported.

“As a result of being revived, Plaintiff continues to experience severe pain, disability and limitations and further, will incur extensive expenses throughout the remainder of her life,” the lawsuit against the hospital and emergency room doctor Jamie Gagan states. “This condition is extremely debilitating and painful and, moreover, requires frequent hospitalization and medication at great expense.”

Christus spokesman Arturo Delgado told the Journal that Gagan works for HealthFront, which does emergency services work for the hospital. He said he could not comment on the lawsuit.

Sams is a Native American author who co-wrote “Medicine Cards: The Discovery of Power Through the Ways of Animals.” According to her author biography on the Amazon website, she is a member of the Wolf Clan Teaching Lodge. Sams is half French and half American Indian, with ancestors from the Cherokee, Seneca, Choctaw, and Mohawk tribes according to her profile at Spirituality & Practice

What is seasonal affective disorder?

People who get more than just blue in the winter months may find they have seasonal affective disorder, or SAD. Before self-diagnosing, it’s important to research the disorder and speak with a health care provider.

Here are some things to know about SAD.

>> Read more trending news 

What is it? 

According to the National Institutes of Health, SAD, also called seasonal depression or seasonal mood disorder, is a type of depression that typically starts in late fall and early winter and goes away during the spring and summer.

For some it starts in the spring and summer and goes away in the fall or winter, but that’s very rare.

The cause of the disorder is not known, but researchers say those who have the disorder are found to have an imbalance of serotonin, which affects mood, and not enough vitamin D, which comes from sunlight, among other places. They also have too much melatonin, which regulates sleep, according to the NIH. 

What are the symptoms?

Symptoms may include feeling sad, irritable, hopeless or worthless, having low energy, difficulty eating or sleeping, a gloomy outlook, losing interest in activities you used to enjoy and thoughts of death or suicide. According to the Mayo Clinic, symptoms specific to winter-onset SAD include oversleeping, wright gain and appetite changes, particularly craving high-carb foods. Symptoms specific to summer-onset SAD include insomnia, agitation or anxiety, loss of appetite and weight loss.

People with those symptoms and who feel depressed for days at a time should see their doctor.

Who does SAD affect?

Anyone can be affected by SAD, but it is more common in women, young people, and people who live far from the equator, in areas where there is less sunlight throughout the day. People who have bipolar disorder or major depression, as well as those with blood relatives with SAD or other forms of depression, are more likely to be at risk of the disorder.

How can it be treated?

Light therapy is typically the main treatment for SAD. According to the National Institute of Mental Health, other treatments include medication, such as selective serotonin reuptake inhibitors, and psychotherapy.

Lawsuit: Florida surgeon removed woman’s kidney by mistake during back surgery

A Florida woman recently settled a medical malpractice lawsuit against a surgeon who removed her fully-functioning kidney during a 2016 spinal surgery. 

Maureen Pacheco’s lawsuit against Dr. Ramon Vazquez was settled last month, according to Palm Beach County court records. The terms of the settlement were not disclosed. 

>> Read more trending news

Pacheco, a West Palm Beach resident, was 51 years old and suffering from back pain due to a car crash when she was scheduled to undergo anterior lumbar interbody fusion surgery in April 2016, the October 2017 lawsuit said. The surgery, which took place at Wellington Regional Medical Center, is described by the American Academy of Orthopaedic Surgeons as a “welding process,” in which problematic vertebrae in a person’s spine are fused together into one larger bone. 

The term anterior meant that doctors would go in from Pacheco’s abdomen instead of her back. The academy explains on its website that an anterior procedure allows more direct access to the discs between the vertebrae, which are removed during the procedure, and offers a quicker recovery time. 

Surgeons are also able to access the spine without moving nerves out of the way, but they have to move organs and blood vessels to the side to reach the spine, the website says

Pacheco told WPTV in West Palm Beach there were no signs of what would go wrong when she prepared for the operation. 

“There was no red flags or anything,” Pacheco told the news station

Pacheco’s orthopedic surgeons that day were Dr. John Britt and Dr. Jeffrey Kugler, who was the treating physician. Vazquez, a general surgeon with staff privileges at the hospital, was assigned with opening the patient up and providing access to the surgical site so the other doctors could perform the fusion. 

An administrative complaint against Vazquez filed with the state medical board by Florida Department of Health officials -- the outcome of which is still pending -- described what happened next.

“During the surgical procedure, (Vazquez) noted a pelvic mass and provided a presumptive diagnosis of a gynecologic malignancy, lymphoma and/or other metastatic disease,” the December 2017 complaint stated. “The pelvic mass was clipped, transected and removed in its entirety.”

A few days later, a hospital pathologist discovered that the mass was not cancer -- it was Pacheco’s left kidney. 

It turned out that Pacheco had a “pelvic kidney,” which occurs when a person’s kidney does not ascend like it should as the organs develop in utero. The kidney remains in the pelvis instead of settling in the flank. 

Read the administrative complaint against Dr. Ramon Vazquez below.

Pacheco’s lawyers argued in the lawsuit that Vazquez was provided with MRI images taken of their client’s spine in February 2015 and February 2016. The images showed that Pacheco had a pelvic kidney. 

The MRIs also showed that the kidney was functional, the document said. 

“If he would have looked at the MRIs that were given to him, he would’ve realized it,” Pacheco told WPTV

Vazquez never confirmed what was on the images or discussed the images with Kugler and Britt before removing Pacheco’s kidney, according to the lawsuit. He also failed to biopsy the “mass” before deciding to remove it, the health department complaint stated

Pacheco was not consulted about the removal or given options for treatment of what Vazquez thought he found, the lawsuit said. 

The lawsuit stated that Kugler and Britt were negligent because they failed to exhaust all “conservative pain management options” before recommending surgery, and that they should have confirmed that Vazquez consulted with Pacheco and looked at the MRIs before opening her up. 

The doctors also failed to ensure that Vazquez knew she had a pelvic kidney prior to surgery, the lawsuit said. 

The Palm Beach Post reported that the medical malpractice insurers for Kugler and Britt settled the case for $250,000 per doctor. 

Wellington Regional revoked Vazquez’s privileges following the incident. Hospital officials told WPTV that all necessary and appropriate steps were taken to ensure it did not happen again. 

“In the 30-year history of Wellington Regional Medical Center, an incident of his nature has never occurred, before or since,” a hospital statement read

Vazquez’s attorney, Mike Mittelmark, told the Post his client did not admit wrongdoing in settling with Pacheco.

“The case was settled on his behalf for a nominal amount due to the uncertainty of litigation and in no way did Dr. Vazquez admit liability by agreeing to this settlement,” Mittelmark told the newspaper

Read the entire lawsuit filed by Maureen Pacheco below. 

Florida law subjects a doctor to discipline for performing or trying to perform a procedure on the wrong patient, a procedure at the wrong site, a wrong procedure or an unauthorized procedure that is medically unnecessary or otherwise unrelated to the patient’s diagnosis or condition. That includes while preparing the patient, the health department’s complaint stated

“Respondent performed a medically unnecessary procedure on (Pacheco) by removing a pelvic kidney during a lumbar fusion,” the complaint said. 

The recommendation of Florida Surgeon General Celeste Philip was for Vazquez to suffer permanent revocation or suspension of his license, restriction of practice, imposition of a fine, a reprimand, probation, corrective action, refund of fees collected, remedial education “and/or any other relief the board deems appropriate.”

Pacheco’s attorney, Donald Ward III, said he didn’t expect Vazquez to lose his medical license over what happened. 

“It’s unlikely that he would lose his license over something like this,” Ward told WPTV. “What is most likely is that he would face a fine and possibly be required to do some continuing medical education so that he could learn not to make the same mistake in the future.”

There were some oddities about the case, however, on top of Pacheco losing a healthy kidney. 

“What is not common is for you to meet that general surgeon the morning of (surgery) and be told that if something were to happen to you, that general surgeon doesn’t carry any health insurance whatsoever,” Ward said

Vazquez did not have malpractice insurance, which means if he is fined by the state, the fine will have to be paid out of the doctor’s own pocket, the lawyer said.

Pacheco said she harbors “no ill will” against Vazquez.

“Everyone is entitled to their livelihood, but you should have consequences when gross mistakes and negligence are made,” she told the news station. “I just wish that he learns a lesson from the consequences. It’s always in the back of my mind -- lifelong kidney transplant or dialysis.

“Now I’m always fearful.”

Report: Mentally ill California inmate ripped out own eye, ate it

A female inmate at a California prison last year gouged out her own eye and ate it during a psychotic break, according to an internal report blasting the state’s prison system for inadequate care of mentally ill patients. 

The report, released last week as part of an ongoing, decades-long federal lawsuit over inmate care, was written by Dr. Michael Golding, the chief psychiatrist for the California Department of Corrections and Rehabilitation. The Los Angeles Times, which reported on the document Monday, said that Golding accused prison officials of hiding the truth about the subpar mental health care they provide to those in custody. 

“This group has created a biased and inaccurately positive picture of what is actually a troubled system of care,” Golding wrote in the report, which was obtained through federal court documents. 

>> Read more trending news

The Associated Press reported that U.S. District Judge Kimberly Mueller, who made the 161-page report public Oct. 31, is considering appointing a special investigator to look into Golding’s claims. 

Golding, who wrote the report based on his own visits to prisons across California, alleged that officials lied to Mueller and attorneys in the case about how often inmates were seen by psychiatrists, boasting in 2017 and 2018 that inmates were seen on time by their doctors at least 90 percent of the time. Golding said the actual percentage of on-time appointments was less than 46 percent. 

The chief psychiatrist wrote that inmates were denied appointments in confidential offices, instead being seen by a psychiatrist in the prison yard or through a crack in a solid metal door, where other inmates could hear the details of their conversation. 

The corrections department also has a “resetting-the-clock” strategy in which a mental health patient’s psychiatric care is “reset” each time he or she is transferred from one facility to another, Golding wrote in the report. The strategy was used to “deem as compliant appointments occurring later than the maximum interval” permitted, he alleged. 

“They reset the clock every time a patient is transferred, irrespective of when the patient last saw a psychiatrist,” the report states. “A…patient transferred more than once might not have another psychiatry appointment for eight months.”

The maximum amount of time the federal court allows a patient to wait to be seen is three months, the report said.

Golding wrote that the Department of Corrections and Rehabilitation has a “broken system” because information is not accurately reported and “reliable commonsensical action” is not taken. 

“I have documented that patients are not getting to appointments on schedule and in confidential spaces, that appropriate consultation is not occurring, and worse, appropriate medical decision-making by psychiatric physicians has been overridden,” he wrote. 

The lack of a proper medical decision was part of the problem for the woman who removed and ate her eye at the California Institution for Women in Chino, the report alleged. Golding wrote that the woman, who he identified as Patient X, presented “relatively well” when she entered the prison system, but she stopped taking the anti-psychotic medication she had been prescribed on the outside. 

“Arguably, in situations like this, longer transitions for patients at higher levels of care should be insisted upon when medication from the community is discontinued, even if the patient appears to have the legal right to discontinue medication because of presenting in a logical way,” Golding wrote. 

The patient was well for as long as the medication stayed in her system, but eventually, those positive effects wore off and she “did not stay well,” the report stated. Four hours before the April 20, 2017, incident, she was evaluated by a psychiatrist and found to be “gravely disabled,” so the psychiatrist wrote orders for her to be taken to the licensed psychiatric crisis bed unit. 

“These admission orders were being followed, except for the order for the patient to go to a crisis bed,” Golding wrote. 

Instead, the patient was being monitored in an unlicensed setting that was more like an urgent care facility and, although she was on one-to-one suicide watch as ordered, she was not placed in a “strong gown” because she refused to comply with that order. 

Documentation indicated she was actively psychotic at the time of admission, the report said. 

“Documentation from the one-to-one observer noted ‘screaming’ every 15 minutes for most of the four-hour period,” Golding’s report said.

Golding wrote that staff members did not contact the psychiatrist on call and the woman did not receive any medication during those four hours. The woman, who was lying face-up on the floor, then touched her left eye for several seconds before removing it from her head. 

“The alarm was sounded and two correctional officers entered the cell,” the report stated. “The (inmate patient) was asked to relinquish the eye, however, she put the eye in her mouth and ingested it.”

Read Golding’s entire, 161-page report below.

Golding alleged that multiple psychiatrists who subsequently heard about the incident agreed medication should have been forced on the woman to keep her out of harm’s way. State prison psychologists who evaluated how staff handled the incident, however, determined the failure to contact the psychiatrist on call was not the root cause of the woman’s self-harm. 

A psychiatrist, who is a medical doctor, has the ability to prescribe medications, while a psychologist does not. Golding wrote in his report that psychiatrists in the prison system routinely report to psychologists, who make the majority of decisions about system-wide care. 

The psychologist in the woman’s case made the decision not to contact the psychiatrist on call, Golding wrote. 

He further wrote that the psychologist did not have admitting privileges to the crisis bed unit and that “despite this horrendous event,” the state licensing board was never informed of what happened because the inmate was being held in an unlicensed facility instead of where she should have been. 

“The tragedy is that any competent psychiatric physician or general medical physician would have medicated the patient, and likely the patient’s eye would still be in her head had that happened,” Golding wrote. 

A Department of Corrections and Rehabilitation spokeswoman denied Golding’s allegations in a statement issued Friday, the Times reported

“The department strongly disagrees with this individual’s allegations and looks forward to a fair and thorough review and hearing of all the facts,” press secretary Vicky Waters said. “We have worked closely with lawyers representing prisoners, as well as the court appointment monitors, for many years to improve the mental health of inmates, and our dedicated and well-trained staff will continue to provide appropriate care and treatment.”

Michael Bien, the attorney for California prisoners receiving mental health care, told the Times that the report could throw off the headway made in recent years in improving the programs offered by the prisons. Bien said he had been poised to accept a proposal that would have slashed psychiatric staffing in the facilities by 20 percent, but the agreement has been nixed since Goldberg’s report was released. 

“The bigger impact is we felt we were ticking off the last couple of issues before we could end the case,” Bien told the Times. “Now I have to go back and check all those assumptions. The most serious thing is the allegation that misrepresentations were made to the court. That really forces all of us to question what’s been going on.”

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