(Watch) “I have learned some very shocking information.”

September 26, 2018

Please watch and share my comments after co-chairing an emotional Wednesday hearing at the State Capitol.

Then, please read and share the Hartford Courant story attached below.


Child Advocate: 6 Suicide Attempts Preceded Pregnant Teen’s Death At Psychiatric Center

(Hartford Courant)

There were six suicide attempts by residents of Solnit South children’s psychiatric center, run by the state’s child protection agency, between November 2017 and March 2018 — but the agency never publicly disclosed findings of dangerous conditions at the facility until after a pregnant teenager named Destiny killed herself there in June and The Courant published a story that looked at the past incidents.

Then in July, there was another suicide attempt, bringing to eight the number of suicidal incidents at the Department of Children and Family’s Albert J. Solnit Children’s Center – South Campus in Middletown in eight months.

On three occasions, in March and twice in July, Solnit South was found by public health inspectors to be placing vulnerable patients in “immediate jeopardy” — normally an exceptionally rare condition at a children’s mental health center.

So begins a sobering report, released Wednesday morning, on the events surrounding Destiny’s suicide by the office of Child Advocate Sarah Eagan.

What I read, I found very concerning … not only at the conditions that prevailed at Solnit, but the response” to the findings by DCF, said state Sen. Len Suzio, R-Meriden, who chaired a hearing on Destiny’s death and the conditions at Solnit South later Wednesday morning.

He said the documents he reviewed showed weaknesses in the way Solnit South assesses the risk of suicide in the children under the agency’s care.

In testimony at the hearing, Eagan traced the eight suicidal incidents, the increasingly serious findings by the Department of Public Health, the multiple corrective plans that were ordered, and the directive that DCF commission an outside review of Solnit South.

“The chronology raises enormous and urgent questions about why a state-run facility can amass so many serious findings” that mandated reforms and outside reviews are required, Eagan said.

DCF Commissioner Joette Katz said Destiny’s suicide was a “horrible blow” and that staff members have been grieving even as they implement a range of safety and treatment improvements.

Eagan said that DCF should have made at least a limited public disclosure, without revealing confidential medical information, about the crisis at Solnit South.

“The dearth of public information … regarding … the adequacy of care and safety of residents at Solnit South occurred despite the involvement of three state agencies” — DCF, the Department of Public Health and the Department of Social Services, Eagan writes in the Solnit report.

This was troubling, she said, not just because outside child protection experts would want to know that children were trying to kill themselves at a state-run facility, but because the legislature and its public health and children’s committees were in session. There was testimony given at public hearings and new laws passed in response to a range of serious issues at most of the state’s human service agencies, including patient abuse at Whiting Forensic Hospital and deficient medical care in the state’s prisons.

In short, the timing was right to hear about Solnit South, Eagan said.

Instead, a bill to increase outside monitoring of DCF, which passed the legislature, was vetoed by Gov. Dannel P. Malloy.

Katz opposed the bill.

In response to the inspection findings at Solnit South, Katz added equipment and made policy changes. The changes include more nurses, better communication among the nursing staff and with doctors, surveillance cameras, oxygen canisters, suction devices, more frequent suicide-prevention checks, and emergency-response training.

Katz commissioned the outside review, later required by the Department of Social Services, and appointed William Rosenbeck, former superintendent of the now-closed Connecticut Juvenile Training School, ordered shut by Malloy, to run the Solnit North facility for boys in East Windsor.

Katz assigned Michelle Sarofin, who had been in charge of both Solnit facilities, to concentrate solely on Solnit South.

It costs $2,957 a day, or $1.079 million a year, to treat one child at the 74-bed Solnit South center, according to DCF.

Destiny committed suicide moments after a staff member checked on her. She was due to be released to a foster family the next morning. She was eight months pregnant and the baby did not survive. Legislators remarked that the suicide took two lives.

A public health investigation found flaws in the way the staff members performed in the minutes before and after the suicide.

Inspectors found that a DCF staff member did not conduct the required face-to-face check of the teen during the 8:30 p.m. observation period. Instead, the staff member opted not to enter the room, but “visualized [the teen] through the window in the door, moving back and forth in the closet area,” according to the report from the state Department of Public Health.

Ten minutes later, at 8:40 p.m., the staff member returned to the room to escort the teen to a pizza party and found her hanging. The worker “screamed for assistance” but “did not remove the resident from her hanging position, nor were emergency resuscitation efforts immediately initiated,” the inspection documents state. A second worker responded to the cry for help “… and started chest compressions immediately.”

In addition, a supervisor was called, “rather than the EMS system as problems were noted with the communication system earlier,” the report states.

A $5 million wrongful death claim has been filed against DCF on the teen’s behalf.

Most of Eagan’s team — Mickey Kramer, a registered nurse, Faith Vos Winkel, a child-death investigator, Heather Panciera, an expert in residential facilities, and the staff lawyer, Virginia Brown — worked on the report. It also found that:

Destiny at first only “minimally participated” and then ultimately refused to engage in her clinical treatment at Solnit South from her admission in February to her death in June. Despite a lack of any evidence of progress, outbursts of anger, and demonstrations of depression, frustration and hopelessness, the teen, who had a history of suicide attempts before her most recent hospitalization at Solnit, was scheduled to be discharged to a foster home on June 29.

“[The teen’s] record lacks adequate documentation as to her readiness to leave Solnit,” the report states.

It goes on to say that “the persistence of serious occurrences and repeated findings by [public health] … raise significant concern about the functioning of the facility, and the adequacy and monitoring of the successive corrective-action plans.”

Several legislators were troubled by the notion that Destiny was on track for release even though she had stopped talking to her clinicians, who had taken to communicating with her by writing letters and leaving them at her door.

Sarofin said psychiatry “is not a concrete science” and defended the decision to release Destiny rather than place her under heightened observation.