WINNEBAGO COUNTY, Wis. (WBAY) - The Winnebago County District Attorney's Office will not file criminal charges against a doctor who was subject of an investigation into the death of a Winnebago Mental Health patient.
The District Attorney's Office released a decision Wednesday saying the "incident is a horrible tragedy, but this tragedy cannot be criminally attributed to the doctor."
Target 2 Investigates broke the story this week after learning Oshkosh Police were investigating the death
Open records requests uncovered at least two cases of patient care
called into question by state regulators. One of those cases involves
a patient who hit his head, and it took nearly 14 hours before he was
transferred to a hospital for treatment. He required surgery for
bleeding on the brain.
On Oct. 14, 2017, the 58-year-old Racine County man was admitted to Winnebago Mental Health Institute. Witnesses told investigators that the patient was "defiant" with staff and intentionally falling out of bed and on to the floor. Intentional falls were part of the man's history as an attempt to self harm, the investigation found.
The next day, the patient stood up and fell backwards, hitting his head on the floor. That was about 10 a.m.
A nursing report says the man "slept all shift after [the] fall ... without responding to verbal stimuli."
The doctor in question made two checks on the patient for assessment, but they were not documented. The first assessment was four hours after the fall. On each check, the doctor said the patient didn't need outside medical help, and that his issues were behavioral in nature. This was attributed to the fact that the patient was on sleeping medications. The doctor said he found no bumps, bruises, or swelling.
Some staff members said the patient had been vomiting, but reports he received indicated it wasn't "true vomiting."
"Many of the observable signs did not make it clear that the patient had a significant medical issue: he appeared at most times to be sleeping peacefully, there was a lack of physical evidence of injury, and the patient's condition was to some degree consistent with his prior behavior," reads the conclusion from the prosecutor.
One nurse suggested the patient be taken to the emergency room. The nurse said the doctor lectured her about "wasting taxpayer money."
Several nurses said the patient had wet himself, which was not a normal behavioral issue.
Night shift nurses became concerned because there was no documentation that neurochecks were completed during first or second shifts. The doctor in question said later that he had done the checks but didn't document them because they were normal.
The night shift nurses did the neurochecks. The first two came back normal. The third raised concerns because the patient's pupils were not equal in size.
Another doctor made the decision to bring the patient to the emergency room.
The man was taken to the emergency department of a local hospital on
Oct. 16. He was admitted to the intensive care unit and never regained consciousness. He died at 6:42 a.m. on Nov. 1, 2017, 17 days after the fall.
The doctor in the investigation said he told nurses that the patient should be sent to the ER if he didn't wake up by 8 p.m., but the nurses say they don't remember him saying this. Nevertheless, the man did not wake up at 8 p.m., and he was not taken to the hospital at that time.
A psychiatric care technician (PCT) told investigators about an interaction with the patient at 4:30 p.m. on Oct. 15. The PCT said the man had been unresponsive in the day room for a long period of time and that he had wet himself. The PCT reported asking the man if he wanted to eat, and the patient responding that he did not.
The PCT reported helping change the patient's clothes at about 10 p.m. and the man being "physically cooperative by moving his arms in and out of shirts."
No other staffers reported the man being responsive during this time period.
The prosecutor's decision not to file charges says it is possible the patient's prior history of "acting out" may have "clouded the judgment" of the doctor tasked with the man's care.
"It is possible that sending the patient to the emergency room at a much earlier point may have saved this patient's life. We cannot prove, beyond a reasonable doubt, precisely what impact that decision would have made."
The prosecutor's office says the doctor's failure to document interactions with the patient did not "create a risk of death or bodily harm."
The prosecutor notes that there is uncertainty whether or not neurochecks were performed during the day. However, because the first two night shift checks came back normal, it "raises doubt about whether earlier checks would have resulted in a different course of treatment for the patient."
The decision continues, "The issue here is not whether one agrees with the doctor's decision making. The issue is not even whether the doctor came to the wrong conclusion based on the information he had available. The issue is whether the doctor displayed criminal negligence or neglect. He did not."
Target 2 found an email from the new acting director of Winnebago Mental Health saying, "two [nurses] were referred to the Licensing Board as a result of the matter involving the death."
Target 2 has not found any disciplinary actions taken against the nurses or the doctor.
State regulators have ordered Winnebago Mental Health to have more
training to deal with staffing issues and patient falls.
Regulators say the facility's Medicare contract will be terminated in July if the problems are not fixed.
A consulting firm spent 12 weeks interviewing staff and analyzing
their daily duties. They found workers are very focused on helping
patients. However, when it comes to the work environment, some
staffers reported feeling, "demoralized, discouraged and disengaged."
"The current state is not sustainable and will impact the ability of Winnebago Mental Health to meet its mission, vision, guiding
principles and values," reads the report.