A former director of a psychiatric hospital — which controlled the release of information to the state — failed to report that a death of a patient might have involved negligence, according to a state investigation.
Details of the investigation on Kalamazoo Psychiatric Hospital by the Michigan Department of Community Health's Office of Recipient Rights were obtained by WOOD TV via the Freedom of Information Act.
"That is something we are very concerned about," said Department of Community Health spokeswoman Angela Minicuci. "We acted as quickly as we could to address it."
The state suspended Director James J. Coleman in May, acting on complaints about patient treatment, which included the March 6 death of 68-year-old Majel Youdell of Kalamazoo.
Video surveillance shows she removed her own oxygen tube and walked to a bathroom.
When Youdell returned, she didn't re-attach the tube. About three minutes passed before staff noticed her oxygen wasn't connected, and she died about an hour later. Her death certificate attributes her death to natural causes, noting she had other health problems.
The death was reviewed by several committees and the Joint Commission, an accrediting body, and the hospital was not found culpable.
Coleman, who disputes the state investigation's findings, later resigned from the post he held since 1987.
A nurse and a nursing director who was suspended in May were fired.
Coleman said he resigned in part because state officials weren't dealing with him fairly.
According to the report, Coleman knew of allegations that a nurse's failure to follow hospital procedures may have contributed to the death, but didn't report that to the Office of Recipient Rights, as required.
Some nurses also weren't properly informed about the patient's health issues, the report said.
Youdell's family is deciding what to do next.
"My aunt's life was in the hands of the people at the hospital, and she deserved the very best care as every patient does," Youdell's niece, Gretchen VanNess, told WOOD TV.
The facility is one of three state hospitals in Michigan that provide adult inpatient psychiatric services. It has an average of 160 patients.