State Blames UCI Hospital in Patient Suicide

A psychiatric patient who hanged himself at UCI Medical Center in December was treated with an unapproved drug known to increase suicidal thoughts and was not monitored properly, state health regulators said Thursday.

The report from the Department of Health Services criticized the patient’s UCI doctor, nurses and pharmacists.

The patient, an 18-year-old Fountain Valley man suffering from clinical depression, hanged himself with a bedsheet he had tied to a bathroom towel rack, according to the report.

The Orange hospital failed to install breakaway bathroom fixtures to reduce the risk of suicide, the report said.

UC Irvine officials issued a brief statement Thursday: “We are in the process of reviewing the report and will determine what corrective action, if any, might be appropriate. This was a terrible tragedy, and we are deeply saddened.”

State officials found several violations of health regulations in the patient’s care.

A UCI doctor gave the patient Zoloft, an antidepressant, and Strattera, a drug used to treat attention-deficit/hyperactivity disorder. But the patient didn’t have the disorder, the report said, and both drugs carry warnings of a possible increase in suicidal thoughts or behavior in adolescents.

The doctor, who was not named, prescribed Strattera because of “procurement issues, such as cost for the family,” even though “medical staff knew there was no FDA approval” for its use in this situation, the report said.

To use a drug for non-FDA-approved functions, UCI doctors are supposed to fill out a form and get approval from a supervising pharmacist at the hospital. Investigators said they found no such documentation.

Moreover, the hospital nursing staff didn’t properly monitor the patient for suicide despite warning signs in his behavior and possible side-effects from the medicine he was taking, the report concluded.

The patient was admitted to the hospital’s psychiatric ward Oct. 30 with cuts on his right arm, the report said.

He had a history of overdosing on pills and cutting his wrists and had been admitted to UCI twice before, the report said. The man was immediately put on suicide watch.

During safety checks Dec. 2, 3 and 8, his chart was marked “self-harm,” but no orders were issued to check the patient more frequently than once every half-hour, regulators said. The reason for the notations was not explained.

On Dec. 14, the night of the suicide, a part-time hospital aide entered the patient’s room at 7:45 p.m. and noticed his bedsheets were in disarray, which was unusual, because the patient “always” kept his bed neat, the aide told state investigators.

The patient’s roommate told the aide that the patient was in the bathroom.

Under UCI policy, nurses are supposed to knock on the bathroom door every five minutes and ask if the patient is OK, the report said.

The aide knocked on the door and heard sounds that he said resembled noises made by someone “on the toilet.” The aide returned five minutes later, knocked again and heard no response. He found the door was locked and went to find the nurse who had the key.

About 10 minutes later, after finally finding the key, a nurse unlocked the door and found the patient sitting on the floor with a sheet around his neck tied to a towel rack, the report said.

The report is the latest blow to UCI’s medical program, which has come under fire in recent months for serious problems in its liver, kidney and bone-marrow transplant programs, questions about cardiologists’ credentials, turmoil in the anesthesiology department and alleged nepotism in hiring.

UCI declined to release the names of the doctor and staffers who treated the patient, citing confidentiality laws.