State health officials won't disclose reports on Arizona State Hospital patient deaths

State health officials won't release incident reports for Arizona State Hospital patient deaths, which means it's unclear how many have died by suicide.

Because of ongoing criticism about the way the state hospital is treating its patients, The Arizona Republic on Feb. 9 asked the Arizona Department of Health Services for incident reports and data on patient and staff assaults at the state hospital, as well as for patient deaths, and for salaries of ASH behavioral health technicians and nurses.

On Oct. 27, more than seven months after The Republic's request, state health officials provided some but not all of the requested information, and they would not provide incident reports for any patient deaths.

After The Republic submitted a follow-up request, health department officials on Nov. 7 confirmed with The Republic that 15 Arizona State Hospital patients have died since the 2015 fiscal year and that 10 of those deaths were "from medical conditions." They would not say how the other patients died. The state operates on a July 1 to June 30 fiscal year.

The Republic has reports of one homicide, two apparent suicides, and one possible accidental death since 2015, but could not find reports involving a fifth nonmedical patient death since that time.

In addition to the Arizona Department of Health Services request, The Republic on Jan. 10 asked the Phoenix Police Department for a copy of all police calls for service to the Arizona State Hospital over a five-year period between 2018 and Jan. 31, 2023. As of Dec. 12 — more than 11 months later — the records request remained unfulfilled.

The 390-bed state hospital, known as ASH, is the last resort and highest level of care for patients in Arizona with serious mental illnesses. It sits on 93 acres at 24th and Van Buren streets in Phoenix and dates back to Arizona's territorial days in 1887, when the facility was known as the Insane Asylum of Arizona.

The state health department is responsible for operating the hospital, which critics say is like the "fox watching the henhouse" because it does not allow for adequate outside scrutiny, including when addressing grievances from patients and their families.

The grievance issue has been so significant that Arizona passed a law in 2022 forbidding ASH staff from retaliating against patients because the patient or the patient's family participates in ASH Independent Oversight Committee meetings. Complaints of staff retaliation have continued, Oversight Committee minutes indicate.

The all-volunteer ASH Independent Oversight Committee holds monthly meetings and reviews operations at ASH, including hearing about problems like assaults and treatment issues. The committee's role is to make recommendations to the health department director but not to override the director.

'A tragic accident': Patient choked on a hot dog and died

State health officials provided incident reports for 534 assaults that occurred at the hospital that required first aid and/or medical treatment between July 1, 2015, and Feb. 15, 2023. Officials also provided the salary information, but it denied the Republic's request for any information about patient deaths, including any information about when the deaths happened, other than to say they occurred between the 2015 and 2023 fiscal years.

The Republic has previously reported one instance in 2019 of a patient death at ASH, an apparent homicide when a 58-year-old resident was accused of killing an 83-year-old fellow resident, reportedly because the older man's radio was too loud. That leaves the cause of four other patient deaths unclear, though at least two may be due to suicide.

Laurie Goldstein, ASH Independent Oversight Committee chair, said her committee began getting incident reports of so-called "sentinel events" involving patient deaths about two years ago, which she says has helped with transparency.

ASH administration is candid with her committee when deaths happen, she said. Committee minutes include details about two apparent suicides in 2021 and one possibly accidental death in 2022.

The two possible suicides happened in 2021, which was first reported by Amy Silverman of the Center for Investigative Reporting. One patient reportedly slashed himself in a restroom with scissors he got from an art room on Oct. 20, 2021, and another choked to death on Oct. 31, 2021, after forcing a burrito down his throat.

Those two deaths were detailed in minutes and recording from Oct. 21, 2021, and Nov. 18, 2021, ASH Independent Oversight Committee meetings, as well as the committee's annual report for the 2022 fiscal year, which was released in January. The report says the Arizona Health Care Cost Containment System, as well as the state's Adult Protective Services division, investigated both incidents.

In the case of the 2021 choking, the patient had a one-on-one staff monitor, and the monitor called a nurse to say the patient had "shoved a whole burrito down his throat and was choking," the Nov. 18 minutes say. The minutes say staff members attempted the Heimlich maneuver, but the patient stopped breathing. He was taken to a hospital and days later removed from life support, according to the minutes.

Goldstein recalled another patient death in September 2022, when a patient choked on a hot dog and died. The ASH Independent Oversight Committee acknowledged the death, according to an audio recording of the Oct. 20, 2022 meeting.

"I think that one was just a tragic accident," Goldstein said. "They couldn't resuscitate the person. … From the staff I spoke with, they were really upset."

'The patients don't feel they can be totally transparent'

The state health department initially denied The Republic's request for numbers of patient deaths because, officials said, there were fewer than six per year and the state suppresses data when numbers add up to less than six because of "policy and privacy concerns."

Arizona health officials cited the federal Health Insurance Portability Accountability Act of 1996 concerning patient privacy as well as a state law that says the state health department cannot release "personally identifiable medical information or any information from which a patient or the patient's family might be identified." State health officials cited federal and state law when they declined to release incident reports about the two suicides and also said the reports, "could result in re-identifying individuals."

The state did provide incident reports for assaults at ASH and those reports indicate assaults at the facility are a regular occurrence, and typically involve accounts where patients are reported to be hurting themselves, hurting staff and sometimes hurting other patients. Critics have argued that assaults would be happening less often with better-trained staff, more effective treatment programs for patients, and better medication management.

Incidents reviewed by The Republic include several cases of agitated, anxious, delusional and paranoid patients punching staff members in the face, charging at them, biting and spitting on them. In several cases, staff members went to the nearby Valleywise Medical Center for medical care.

There are also incidents where patients have said they've been mistreated by staff, reports show.

The ASH Independent Oversight Committee's most recent report says the law forbidding staff retaliation was a "step in the right direction" but that more action is needed. One problem, the report says, is that ASH has an ombudsman, but the ombudsman reports directly to the ASH administration. Goldstein said an unbiased third party would be better for that job.

"The patients don't feel that they can be totally transparent and that she (the ombudsman) has their interest," Goldstein said. "It's a really awkward position when she reports to the hospital, so how critical can she be? … There's no way someone can be totally critical of their bosses."

Behavioral health technicians at ASH start at $36,463 per year, no degree required

Critics who have been calling for independent oversight of ASH say conditions, staffing levels and transparency at the facility have become a problem. The hospital operates on a "recovery-based" philosophy. The aim is for patients to get stabilized and eventually return to living in the community, but some critics say that's not always happening.

State health officials did fulfill The Republic's request for ASH salary information. The salary range for three levels of behavioral health technicians, a job that does not require a post-secondary degree, ranges from $36,463 to $47,792 per year at ASH and the salary range for a nurse at ASH is $74,104 to $89,704 per year, state officials wrote in their reply.

ASH is permitted to staff 729 full-time employee positions, but as of June 30 only 629 of them were filled, according to an ASH clinical improvement and human resource plan released Sept. 1. The plan says the hospital had been relying on staff working voluntary overtime shifts and on contract registered nurses and behavioral health technicians to make up the difference.

The plan also said that ASH needs to add 117 full-time employee positions at an added cost of $10 million just to meet the community standard of care at ASH.

Staffing shortages are an ongoing problem in health care and particularly in behavioral health care. Goldstein said some of the media coverage of problems at ASH haven't helped in finding permanent staff to work there.

"Right now they are in a Catch-22. The more bad press, the less people want to work there and the less people want to work there, the more staff they get from agencies and the agency staff don't know the patients as well," she said.

Reach health care reporter Stephanie Innes at Stephanie.Innes@gannett.com or at 602-444-8369. Follow her on X, formerly known as Twitter: @stephanieinnes.

This article originally appeared on Arizona Republic: Arizona State Hospital patients have died since 2015