During an interview with inspectors, Calderon’s emergency room physician said he had attributed Calderon’s “depressed affect” to his living in the Bronx. “When I wrote that the patient had a very depressed affect I meant that he seemed like most people who live here in the Bronx … you know life is hard and it’s not easy for people who get older and have health issues to live here,” the physician said. “I didn’t refer him for a psychiatric consult because he didn’t say the words ‘I want to harm or kill myself.'”

The report also revealed that Calderon’s nurses failed to complete their hourly rounds, leaving him alone in his room for hours. It identified numerous “gaps and inconsistencies in the hourly nursing documentation,” where nurses claimed they’d checked on Calderon around the clock. Yet video tape of the hallway outside his room showed that his nurse did not enter his room during a few crucial hourly check-ups. The next time they entered at 4:32 a.m., he was found hanging in the bathroom.

After investigating Calderon’s death, government inspectors also concluded that in eight of 12 medical records they reviewed, Montefiore “failed to ensure that potentially suicidal patients were appropriately screened, assessed, and /or monitored.” Three of those patients were not screened for suicide risk, according to nursing triage documentation. The Director of Nursing for Professional Practice told inspectors that nurses were not trained on suicide and depression risk screenings when they transitioned to EPIC, the new electronic medical records provider.

Hopkins, the Montefiore doctor, said that the health system’s rollout of the new software provider was “very, very fast.” “Basically we went live at three major campuses over the space of a year and a half,” he said. “Every time you go live with new software, you have to implement new stuff. You can never anticipate every single thing.”

He added that the entire health system uses standard depression screening tools. “We screen pretty much every patient,” he said. “We’re trying not to miss the folks who are depressed, who are gonna go home and hurt themselves.”

A March 2017 report also determined Montefiore had “failed to provide a safe environment in the Emergency Department for patients with Mental Health Disorders.”

Eventually, the problems and deaths culminated in an “immediate jeopardy” warning from the government, and the hospital’s fourth overall. According to a report obtained through a Freedom of Information Act request, in April 2017, CMS declared that Montefiore had placed patients in immediate jeopardy of harm or death for failing to adequately care for potentially suicidal patients in its medical units.

Later that month, Montefiore submitted documents detailing promised changes. Its corrective action plan included revisions to its suicide screening and behavioral management policy for suicidal patients in non-psychiatric units, and training all staff on the new policies. After a brief delay, federal inspectors accepted that plan. There is no evidence of any subsequent threat to Montefiore’s federal funding.

After hearing Montefiore’s track record, Knoll, the SUNY suicide risk and prevention specialist, said its issues and “rash of deaths by suicide” were concerning.

“It’s simply never acceptable for the person to die by suicide in the hospital. That’s what they came there for,” said Knoll. “Does it happen? Yes, and it usually happens due to human or institutional error.”

‘I still don’t understand’

Bryant is still angry over what happened with Montefiore, and says they never apologized to her.

“If he had the proper care and treatment, this could have been avoided,” she said.

Her father’s death also reverberated across his community. He was a lifelong New Yorker and longtime Bronx resident. He was also a drug counselor who had been sober for about 30 years when he died.

“I remember him as caring. He was thoughtful, and he tried really hard to make up for not being around when I was younger,” said Bryant.

In February, a month before he died, he was also in love. He and his fiancé were planning their wedding. In April, his fiancé was planning his funeral arrangements.

The service was held at a funeral home on Morris Park Avenue in the Bronx, where people he had treated spoke about how he helped them change their lives. Members of the church he regularly attended, St. Helena on Olmstead Avenue, remember him as soft-spoken and friendly.

“To this day, I still get phone calls from people telling me ‘I still don’t understand, I can’t put it together,'” said Bryant. “He was a force in his community.”

Montefiore, in its emailed statement (read it in full here), said that it had more than 50 multidisciplinary quality committees and a system-wide quality performance group that aims to “continuously improve quality and ensure safety.”

“We practice a ‘Just Culture’ environment predicated on learning, and flagging potential or actual errors,” the statement continued, “This model supports a balanced, rigorous multidisciplinary approach that looks for root causes of problems within the system and addresses them.”

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