Improving Patient Care at Mental Healthcare Facilities

A Father's Experience: Tragedy and a Call for Change at Mental Health and Psychiatric Centers

As a father who lost his child to suicide, while under the care of professionals trained in mental health care and suicide precautions, I am sharing my deeply personal and heart wrenching story as a call to action. The competence, training and passion of mental health care providers across the country must be elevated to match the needs of our most vulnerable population. I am committed to being an advocate and a voice for change within our mental healthcare systems in order to prevent another family from losing their child in the way I did.

My daughter Avah was admitted to a mental health facility on December 4, 2023 under observation for suicide. On December 6, 2023 at approximately 3:00 am, Avah was pronounced dead. I am sharing details of Avah’s inpatient admission and the events leading to her death in hopes that other facilities and healthcare providers will seriously consider their practice patterns, culture of their team and adherence to and understanding of regulatory requirements that are intended to reinforce practices for safe patient care.

Points of Failure

Communication and collaboration amongst the multi-disciplinary team. After Avah’s death, her chart review revealed a complete disconnect amongst her care providers, which underscored a culture lacking accountability and coordination.
Lack of including myself, as Avah’s father, in her plan of care led to very important medical and social history being absent from her medical record. This information was a critical component that should have been included in her care. Despite multiple attempts to reach the physicians assigned to Avah to share this information, I was unable to provide that information.
Explicit negligence – Avah’s plan of care included every 15-minute direct observation checks, a common observation level for patients at risk for suicide. During the investigation after Avah’s death, it was revealed that Avah was left unattended and un-observed for approximately 2 ½ hours.
Failure to provide a ligature-free environment. Avah had access to a standard bed sheet that was pulled through the top of the door frame.

Call to Action

The above points of failure highlight several concerning gaps in care. As an RN for 20 years—and a nursing director employed by Sutter Health—my partner Lisa is committed to being an advocate of the changes needed to improve care for patients and to prioritize the promotion of a positive working culture among healthcare employees. Together, through the AVAH (A Vision At Hope) Foundation we will continue to challenge the acceptance of mediocrity in mental healthcare facilities, and advocate for those who find themselves in a similar situation as Avah.

Since this horrific tragedy, Sutter and the facility involved have taken several actions to learn and put in place the training, processes and the technology needed to prevent this from happening again. The organization has made significant investments in electronic monitoring and protocols to ensure enhanced oversight at the facility where this occurred and other mental health facilities, and Lisa is working with Sutter on additional training for all healthcare professionals—to further address the communications breakdowns that occurred in my daughter’s situation by focusing on what happened to Avah, what was learned, and how every patient interaction matters.

I am grateful to Sutter Health for their willingness to accept responsibility, and their engagement and dedication to prioritizing Mental Health services and the needs in our community and beyond.

The AVAH foundation, with a founding grant and support from Sutter Health, is dedicated to inspiring healthcare providers to prioritize patients who so desperately need the greatest levels of support, while also focusing on programs and resources that build education, skills and resilience among high school students. We want to be a catalyst for change inside and outside the walls of mental health facilities, supporting providers caring for patients and teenagers to better support one another.

We invite you to connect with us, as we believe through shared learnings, we will make steps towards positive change.