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Shodair Death Raises Questions About Staffing, Training

Shodair Children's Hospital sign
Corin Cates-Carney
Montana Public Radio
Shodair Children's Hospital sign

A 15-year-old patient died by suicide earlier this year while under the care of Shodair Children’s Hospital in Helena. A state health department report released to Montana Free Press outlines insufficient staffing and inadequate monitoring in the hospital’s residential psychiatric unit may have contributed to the child’s death in May.

MTPR’s Freddy Monares spoke to Montana Free Press Reporter Mara Silvers to break down her reporting on the incident.

Freddy Monares Thanks for joining us, Mara.

Mara Silvers Hey, Freddy, thanks for having me.

Monares What stood out to you in the health department's report detailing the suicide at Shodair?

Silvers Yeah, there's a lot to unpack in this inspection report. It came from the quality assurance division within the state Department of Public Health and Human Services. And it highlights a couple of main issues. So inspectors said that the staff members who were on the residential unit that night missed one of the routine checks on the patient. It happened between 5 and 6 p.m. She died when she was in the bathroom. And investigators also said that there were issues with a safety light that's outside the bathroom that's supposed to turn on and alert staff members if there's a problem. Part of the issue there may have been that the staff had some inconsistent training about how to properly use that safety mechanism. But beyond the possible problems with building infrastructure, the state also indicated that this resident's treatment plan wasn't as comprehensive as it could have been. They said that it didn't reflect that she had repeatedly expressed some suicidal ideas and feelings during her therapy sessions. So in the big picture, inspectors were focused on how training and the strain and stress on the hospital's workforce might have contributed to this really tragic situation.

Monares Yeah, tragic indeed. How often are hospital employees required to check on patients?

Silvers So on the residential unit, those verbal or visual checks are supposed to happen every 15 minutes, which might sound like a lot, but we have to remember that the children and the adolescents who are on this residential unit often need a lot of care and they need a lot of support throughout the day. So the hospital really does need to have enough staff to adequately be checking on patients routinely throughout any given shift.

Monares Yeah. I wonder, what's the hospital saying about the death?

Silvers Yeah. Hospital CEO Craig Aasved has said that the death has, you know, understandably been tremendously hard on the staff and the hospital as a whole. He said the hospital is taking this very seriously, that they understand the weight of somebody having lost their life when they were there. In terms of what they're going to do differently going forward, the hospital also told state investigators that they'll be revising some of their processes for training employees, conducting safety checks — those 15-minute checks — and communicating information about patients between teams. They also said that they'll be adding a tool for measuring and assessing any suicidal thoughts that come up during a therapy session to reevaluate treatment plans that need to change.

Monares Right now, we're hearing about strains on hospital capacity. Do we know if that played into this at the time of the incident?

Silvers Yeah, that definitely has come up in the hospital's response. And I should say that this isn't just a problem that's unique to Shodair. This is something that behavioral health specialists and residential programs have been bringing up for months and months and months, that there's just not enough qualified staff to run the behavioral health programs in the state of Montana right now. And that staffing shortage, it comes from a lot of different, a lot of different places, including COVID; that hasn't made the situation better. But that is something that Craig Aasved acknowledged and that the hospital is dealing with as best they can. They've actually said that rather than immediately being able to hire more staff, their solution in the short term is actually just to lower the census population of their patients to make sure that they don't have more patients than their staff can currently handle at a given time.

Monares Does that mean referring patients to other places?

Silvers It might, but Shodair also occupies a very unique role in the state of Montana. They're basically the only- the primary place for children and adolescents with acute psychiatric needs to go to stay for long amounts of time. So they also operate an acute unit, something that's more short-term and for crisis situations. But the residential unit is pretty unique in the state of Montana. There is the possibility for kids and family to go out of state if they need psychiatric care elsewhere. But in Montana, the options are fairly limited.

Monares Is there anything that remains unknown about the staffing details and logistics leading up to the patient's death?

Silvers Sure. In general, I would just say that there's a lot that's still not known about the situation. State investigators did say that Shodair did not preserve all of the evidence related to this incident. So they said that the hospital destroyed a staff communication form that was completed by the overnight nurse on the morning of the day that the patient died. They said that that form included pertinent information about the root cause of the event. And Shodair confirmed that those documents typically include information about staffing assignments, information about, you know, video calls with families, but they told me that shredding those documents is pretty standard and that they did that before state investigators requested they be turned over. The hospital said it did not think that the assignment sheet specifically included any information about the patient who died, but that it will change its document retention policy for situations like this going forward.

Monares What's the family of the 15-year-old saying about the incident?

Silvers At this point, very little. When I called the patient's mom, she said that she had retained a lawyer and that she didn't want to talk to a reporter. That lawyer later contacted me — Jim Hunt in Helena — and he confirmed that the patient's mother has contacted him to discuss potential legal actions, but that they have not filed anything at this point.

Monares And what about hospital employees?

Silvers That's a good question and one that I would like to learn more about in terms of their reaction to this event. So far, I really only know what some of the hospital staffers told state investigators. They said that the suicide was extremely surprising and concerning. And more broadly, they just expressed the need for more hands-on training around some of these safety precautions that we mentioned and what to do in certain scenarios when something like this happens. They also told the state investigators that the current staff-to-patient ratios are really hard to operate on. There may be one staff member for eight patients or sometimes investigators said that might increase to 12 patients during night shifts. And employees told the state that it was just impossible to safely supervise patients at that staffing level.

Monares So what happens now? Is the health department's investigation ongoing?

Silvers At this point, I haven't heard anything about more documents or reports expected to come from the health department. But going forward, you know, Shodair is going to be working to implement these changes and to keep the population of its patients low enough for its current staff to handle. The hospital has about 18 open job titles listed on its website right now, including nurses, therapists and mental health specialists that they're trying to hire. I think it's safe to say that the hospital is going to have to build back from this both with their current and future staff, but also the families that depend on them.

Monares Mara, thanks for sharing your reporting with us.

Silvers Thanks for having me, Freddy.

If you or someone you know is thinking about suicide, call the National Suicide Prevention Lifeline at 800-273-8255. Or text “MT” to 741-741. Both are open 24 hours.

Copyright 2021 Montana Public Radio. To see more, visit Montana Public Radio.

Freddy Monares
Freddy Monares is a reporter and Morning Edition host at Montana Public Radio. He previously worked for the Bozeman Daily Chronicle, covered the 2017 Legislature for UM Legislative News Service and interned with the station as a student. He graduated from the University of Montana School of Journalism in 2017.