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Staff Covers Up Failure to Monitor Patient

$3,000,000 – Medical Malpractice/Negligence; Wrongful Death


33-year-old Mr. B died while in custody at a psychiatric facility. His records were falsified to cover up the failure to monitor him.

Mr. B went to the ER on three prior occasions for escalating acute psychotic episodes. Each time he presented to the ER, his electrocardiograms were abnormal. He was finally placed on a psychiatric hold on July 31, 2017, and then transferred to a psychiatric facility on August 2, 2017. Early on August 3, 2017, a doctor ordered an ECG to check for medication effects. His ECG was again abnormal. The results were communicated to a doctor. However, Mr. B’s low pulse rate of 44 bpm and elevated blood pressure of 145/89 were not reported.

At 11:30 p.m., Mr. B was in the halls asking to be moved, asking to see his doctor, asking who his doctor was, and asking staff members if they were his doctor. Staff contacted a doctor who ordered 50 mg of Benadryl and 10 mg Haldol, given intramuscularly. An hour later, the records reflect the medication was effective.

The records suggest Mr. B was then monitored every 15 minutes. However, videotape depicting the hallway outside of Mr. B’s room shows the last time he was checked was at approximately 1:00 a.m. on August 4th. At 7:47 a.m., Mr. B was found pulseless, lying prone on the floor. He had been dead for quite some time as his body demonstrated lividity and rigidity in his legs. He was pronounced dead at 7:57 a.m.

Doe Facility admitted that the medical records indicating Mr. B was checked every 15 minutes were false. Also, the director of the facility chose to preserve only portions of the videotape. What video was preserved provides clear evidence that the medical records made by the staff were forged after the fact to fraudulently cover up what happened to Mr. B. In fact, the video that was produced paints a much different picture of Mr. B’s demeanor and interactions with staff from what is reflected in the records.

The video shows not only an absolute disregard for Mr. B’s well-being, but it also demonstrates a level of callousness that is difficult to watch. Lastly, the video demonstrates that the staff wanted to chemically restrain Mr. B simply so that he wouldn’t bother them anymore. The video reflects the staff’s willingness to fraudulently manufacture medical records after the fact to attempt to cover up what they did. There was also evidence to suggest that key information was not provided to the Medical Examiner’s Office when it invoked jurisdiction.


Wrongful death; failure to supervise; falsification of medical records


Wrongful death claim brought by mother of a 33-year-old in facility for psychiatric care.

Special Notes

The case settled for $3,000,000 before a lawsuit was filed. The nurses who falsified the medical records were reported to the Nursing Board.




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