Tuesday, December 4, 2007

Patient dies after being restrained


Hospital says cardiac arrest; medical examiner says asphyxiation
Feds: Legacy Emanuel doesn’t meet safety rules; probe continues


The Portland Tribune

A state medical examiner has ruled that Glenn Shipman Jr. died of asphyxiation three days after being admitted to Legacy Emanuel Hospital & Health Center in August. Investigations since then have pinned his death on the unmonitored use of a nontypical form of restraint and identified other areas of concern.

Elaine Shipman liked to think that the one place her son, Glenn, would be safe was in a hospital with professionals trained to take care of him.

Glenn, who suffered from schizophrenia, had been in and out of a number of local hospitals since his disease was diagnosed when he was 30.

But a hospital was the last place Glenn wanted to be.

“Glenn said he was deathly afraid of hospitals,” said his mother, a Scappoose resident. “He’d rather be in prison than a hospital.”

Glenn Shipman Jr.’s fear of hospitals turned out to be warranted.

On Aug. 24, his 50th birthday, Glenn Shipman suffocated after hospital workers at North Portland’s Legacy Emanuel Hospital & Health Center restrained him by pressing the 450-pound man onto the floor, his arms underneath him, his face down.

They held him there for at least 10 minutes before discovering that Shipman had stopped breathing, according to an investigation conducted by the Oregon Department of Human Services a few weeks after Shipman’s death.

Hospital workers tried to revive Shipman, but he never regained consciousness. He was kept on life support for two days and died Aug. 26, according to the DHS investigation.

Legacy officials did not contact the Shipmans about their son’s condition until more than 18 hours after the Aug. 24 incident, when they told Elaine Shipman that her son had suffered a cardiac arrest.

But the state medical examiner determined in an Aug. 27 autopsy that Shipman died of “compression asphyxia” – asphyxiation.

Ron Prinslow, the official who has overseen the DHS investigation and a follow-up investigation relating to Shipman’s death, told the Portland Tribune, “It is my understanding that what the people (Legacy staff) were doing led to his death.”

A Legacy spokeswoman said late last week that the hospital could not comment on Glenn Shipman’s care or death due to federal privacy regulations.

After Elaine Shipman offered to sign a release that would legally allow Legacy Emanuel staff members to talk to the Portland Tribune, the hospital spokeswoman said even with that permission, they would be “unable to comment” because the case still was under investigation.

Portland police are reviewing Shipman’s death to see if any crimes occurred.

Meanwhile, Prinslow says, the report from the initial investigation following Shipman’s death found Legacy Emanuel out of compliance with the standards that hospitals must meet to be eligible for Medicare and Medicaid payments.

A second investigation of the hospital was conducted last week by DHS to determine if the hospital has made changes that it promised after the first report, or whether a process will continue that could cost Legacy Emanuel its ability to collect Medicare and Medicaid payments.

No door opens for code team

Legacy Emanuel failed Glenn Shipman in a number of ways, according to the initial DHS investigation, which was prepared for the federal office that oversees Medicare and Medicaid payments.

The investigation by DHS began because hospitals are required to report to federal authorities all restraint-related deaths.

The DHS report cites the hospital for not properly transferring Shipman from the hospital’s emergency department to the hospital’s psychiatric unit.

The facility also failed to have a “crash cart,” used to restart hearts, on the psychiatric unit. The hospital denies that charge.

According to one hospital staff member interviewed by investigators, the hospital code team, which responds to life-threatening emergencies and which was called by pychiatric ward staff, was pounding on a locked door leading to the psychiatric unit where Shipman lay on the ground, not breathing.

The members of the code team were unable to get in to provide help, and staff members who were surrounding Shipman could not hear them.

Another hospital staff member, unidentified in the report, told investigators that he or she was unable to access medication for Shipman because they did not know how to properly operate the hospital’s automatic medication distribution system in an emergency.

But the most explosive finding in the report deals with how Legacy Emanuel staff members restrained Shipman after he came out of his room in the psychiatric ward, ignored requests to return to his room, and pushed a nurse.

The investigation found that hospital workers pressed Shipman’s face to the floor for at least those 10 minutes, until they noticed one of his hands turning blue.

The investigation found that while Shipman was down, no one was monitoring his condition, not even checking to see if he was breathing until it was too late.

‘Prone restraint’ put to use

The only available record of what occurred at the hospital comes from the DHS investigation report.

Shipman had been brought to the Legacy Emanuel emergency department late in the evening of Aug. 23 by Scappoose police responding to a call from Elaine Shipman.

Her son had been acting agitated and “out of control,” and believed his sister was trying to kill him, according to the DHS report.

Six officers responded, and a resisting Shipman was Tasered as officers wrestled him into a squad car and delivered him to the hospital.

According to the investigation record, Shipman was alert and cooperative when he reached Legacy Emanuel. He was admitted to the emergency department talking about the world coming to an end and saying that “Satan is coming.”

He slept unobserved in the emergency department, and the next evening he was transferred to the hospital’s psychiatric unit, where the events that would lead to his death transpired.

According to the DHS report, at about 6:30 p.m. Aug. 24, Shipman refused to cooperate with staff in the psychiatric unit in changing his gown, and he started walking down the hall toward the nurses’ station.

A hospital employee (the report does not distinguish between nurses, doctors and security personnel) tried to block Shipman’s way.

Shipman pushed one staff member, according to the report, and squeezed that staff member’s hand.

Staff members then took Shipman facedown into a prone position on the floor, with hospital security staff arriving to help.

According to the report, “Staff asked the patient if he could walk to the quiet room. There was no verbal response.”

After at least 10 minutes with his face to the floor, according to the report, one staff person “noted that the patient’s left hand was blue.” A staff member asked another if Shipman was breathing.

In checking, they “noted the patient’s face to be cyanotic (bluish) and the patient’s tongue was protruding from his mouth.” By that time, according to the report, Shipman had no pulse.

He never regained consciousness.

The face-down technique used to subdue Shipman, which in the end killed him, is called prone restraint.

According to Bob Joondeph, executive director of the Oregon Advocacy Center, a nonprofit organization that advocates for people with disabilities, the use of prone restraint is well-known for increasing the danger of asphyxiation.

He also said that staff should have known that using it on a 450-pound patient was even riskier.

Joondeph said that most hospitals have trained staff to try to eliminate prone restraint, or restrict its use to only the most dire situations – when an out-of-control patient might bite staff or spit on them.

And when it is used, Joondeph said, patients’ vital signs need to be constantly monitored.

“A person is not going to talk to you if they can’t breathe,” Joondeph said. “You can’t rely upon them to say, ‘Hey, down here, I’m not breathing.’ ”

Patient called a ‘gentle giant’

Glenn Shipman’s mother and his sister, Kathy, also question whether any such restraint was necessary, with Kathy calling Shipman “a gentle giant.” He had no record of violence or violent arrests.

“He was like a puffer fish,” mother Elaine Shipman said. “I think what he tried to do was look as big and tough as he could to intimidate people, but he wouldn’t hurt a thing.”

Elaine Shipman said that in an Oct. 23 meeting requested by the family in search of an explanation for Shipman’s death, hospital staff gave no indication that her son had been acting violently or out of control before they took him down.

“They said he clenched his fists and moved in the direction they didn’t want him to go, toward other patients,” Elaine Shipman said. “I think he had a panic attack.”

While hospital officials acknowledged they restrained Shipman at that point, according to Elaine Shipman, they never acknowledged in the Oct. 23 meeting that their restraint of him was in any way responsible for his death.

Prinslow said that there were reasons he doubted the need for hospital staff to use prone restraint on Shipman. He points out that Shipman had been in the hospital a full day without observation and with no problems before the altercation.

“They left him in an unlocked room by himself, so I would question the violence,” Prinslow said. “On the other hand, my experience tells me that sometimes a mental patient is subdued just by the presence of a show of force.”

Prinslow said that he talked to the DHS nurse investigator who compiled the report about the incident. “She’s been trained never to restrain a patient prone on the floor,” he said.

Investigators had doubts

Prinslow said state officials were suspicious of the version of events initially presented by hospital officials, including that Shipman died of cardiac arrest.

In fact, according to the DHS report, a hospital worker told the DHS investigator, “Procedurally, we didn’t do anything wrong.”

Prinslow and his investigators disagree. “We took all the facts, and it just didn’t add up,” he said. What appeared most inexplicable, according to Prinslow, was the hospital’s insistence that Shipman died of cardiac arrest.

In essence, everybody has cardiac arrest when they die because their hearts have stopped beating.

But cardiac arrest is not necessarily the cause of their death. Their hearts may have stopped beating for any number of reasons, including asphyxiation.

Prinslow said he believes the actions of the hospital workers – not cardiac arrest – are what killed Shipman.

“I would say the restraint process led to the patient suffocating,” Prinslow said.

And that is something Prinslow said he finds hard to reconcile. “If a hospital is in the business of taking care of psychiatric patients, then I just don’t see how this happens,” he said. “I just don’t understand it, because they’re the experts.”

Prinslow’s job is to oversee hospital inspections and certification for Oregon.

In 20 years of working in the hospital inspection field in Oregon, he can’t remember another case of a patient dying while being restrained in one of Portland’s hospitals.

Hospital not forthcoming

Elaine Shipman now says she never really believed that her son died of cardiac arrest. She cites a number of reasons.

The family went to the hospital, Elaine Shipman said, and found Glenn Shipman on life support. But what they heard didn’t sound right to them, Elaine Shipman said.

“The doctor didn’t say he had a heart attack,” she said. “He just said his heart stopped beating.”

Two months after Shipman’s death, Elaine Shipman, Kathy Shipman, friend Jim Morud and a pastor from the family’s church went to Legacy Emanuel and met with staff members at the hospital.

According to Elaine Shipman, across the table were the chief of the hospital’s psychiatric department, a patient safety representative, a nursing supervisor, the hospital’s head of security and a nurse.

Elaine Shipman couldn’t understand why the physician across the table from her didn’t talk about what had happened in his department.

“The doctor never had anything to say,” she said. “It was like it was canned. The head doctor sat there, and his expression never changed. He just sat there looking at everybody. I felt like he was monitoring the situation to make sure nobody said anything out of turn.”

But someone did say something out of turn, she now thinks. According to Elaine Shipman, a nurse called her from the hospital, shortly after Glenn Shipman’s death.

“She said, ‘We’re sorry,’ ” Elaine Shipman said. “But what I thought kind of strange is she said, ‘In cases like this the hospital likes to send flowers, unless the family objects.’ What does she mean, ‘In cases like this?’ ”

The hospital’s flowers were on display at Glenn Shipman’s Sept. 9 memorial service.

Elaine Shipman and her family did not know the details of what caused Glenn Shipman’s death until Friday, when the Portland Tribune showed them a copy of the DHS report. That report was completed sometime after Sept. 19.

On Friday, having read the investigation report, Elaine Shipman, Kathy Shipman, and Morud stood around a kitchen table, bowed their heads and said a prayer of gratitude that finally the truth had come to them.

And Elaine Shipman said that the family had no intention of seeking out an attorney to file a lawsuit against Legacy Emanuel.

“Glenn’s memory isn’t for sale, and we aren’t either,” Kathy Shipman said.


TIMELINE - Truth slow to come

Glenn Shipman Jr. is brought to Legacy Emanuel Hospital & Health Center in North Portland in handcuffs by police “after becoming out of control at home,” according to a report from the Oregon Department of Human Services. He is admitted to the emergency department.

6:15 p.m. Aug. 24

Shipman is transferred to the hospital’s psychiatric unit.

Between 6:15 p.m. and 6:30 p.m.

Hospital staff see Shipman walk out of his room and down the hall. Shipman pushes a staff member who tries to block his advance. That staff member and another staff member take Shipman to the floor.

6:40 p.m.

After several hospital security workers arrive and help restrain Shipman on the floor, a hospital staff member notices Shipman’s left hand has turned “blue” and he apparently has stopped breathing.

7:05 p.m.

After Shipman is given cardiac drugs through an intravenous line, Shipman has a heart rate of 130 beats per minute, and is transferred to the hospital’s intensive care unit.

Sometime on Aug. 25

Hospital officials perform a computerized scan on Shipman’s brain. The scan shows that Shipman’s brain was damaged by lack of oxygen.

2 p.m. Aug. 26

Doctors meet with Shipman’s family to “discuss the patient’s condition.” According to family, they say Shipman suffered cardiac arrest.

3:38 p.m. Aug. 26

Shipman dies.

Oct. 5

State medical examiner issues death certificate, listing cause of death as “compression asphyxia,” or asphyxiation.

Oct. 18

DHS report notes several failures in Shipman’s case, including that the “facility staff restrained a patient to the floor in the prone (face-down) position without adequate monitoring of the patient’s condition.”

Oct. 23

After the family’s request, the Shipman family, its pastor and another family friend meet with Legacy Emanuel staff and officials. Hospital staff say Shipman died of cardiac arrest and make no mention of the DHS findings.

Nov. 30

Shipman family learns for the first time that the restraint incident probably caused Shipman’s death — after being given a copy of the DHS report by a Tribune reporter.
‘Gentle giant’ had many soft spots

Glenn Shipman struggled with mental illness, building a life


Glenn Shipman Jr. struggled all his life not to be defined by his mental illness or his size, according to his family. In the end, his illness and size might have cost him his life.

Shipman was asphyxiated on his 50th birthday while a patient in the psychiatric unit of Legacy Emanuel Hospital & Health Center in Portland.

A schizophrenic, Shipman could be delusional, even paranoid, said his mother, Elaine Shipman. And he weighed well over 400 pounds, the result of weight gain that began when he started taking psychiatric medications at age 30, according to his mother.

Elaine Shipman thinks that the combination of her son’s size and his illness probably was frightening to Legacy Emanuel workers who, she said, might not have realized that he wasn’t a violent man.

Frightened, he might not cooperate with hospital staff, she believed. He would have tried to walk away from them, she said, but he would never attack them or intentionally try to hurt them.

But false assumptions had long been made about Glenn Shipman. Elaine Shipman recalled that a high school football coach, certain that a husky, teenage Glenn would excel at the sport, repeatedly asked her to convince Glenn to come out for the team.

But Glenn, she said, abhorred physical contact. Finally she persuaded him to try one practice, which he did before quitting.

Glenn Shipman’s talent was with computers — he set up and repaired computers for friends and family and for a while ran a small computer-repair business.

And he liked to cook. His mother recalled the first meal he prepared.

She said that she had gone back to work after a number of years staying home with her children. When she returned to the house one evening Glenn had made dinner — baked chicken with orange sauce, baked potatoes and a salad. He was 14.

When a family at Cedar Mill Bible Church had a baby, according to Elaine Shipman, Glenn on his own began preparing meals three times a day and delivering them to the new mother, without telling anyone.

Glenn Shipman attended a number of technical and computer schools but could never quite complete them. He even went to a technical school in Phoenix one year. But he returned home, unable to conquer his mental illness.

At his death Glenn Shipman was in debt from unpaid school loans. He was living on a $10 to $15 weekly allowance from his Social Security disability checks allocated by a credit counseling company.

His mother said that she went through his effects.

“I found his receipts,” she said. “As little money as he had, he had one receipt that was for 40 Bibles sent to Russia.”

And when he looked inward, Glenn Shipman seemingly faced the same problem that others did when they looked at him — he could not in his own mind construct a self-image free of his disease. He longed to have a relationship with a woman, his mother said, but never felt he was worthy.

“He never went on a date,” she said.

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