Suicidal Patient Jumps to Death at Crozier

By Walter F. Roche Jr.

A shoeless psychiatric patient who had acknowledged having suicidal thoughts including plans to jump in front of an Amtrak train, was discharged unattended from an area hospital then climbed to an unsecured roof top access and jumped.
The fatal Nov. 16 incident at the Crozer Chester Medical Center was detailed in a recent 9-page report from the state Health Department.
"The facility failed to assist a patient at risk of suicide and failed to implement a plan to deal with withdrawal from alcohol," the report states.
The unnamed patient had been transported to the Upland hospital by an emergency medical team. He was rated as high risk for suicide after admitting to a plan to walk into a passing Amtrak train.
Asked if he had ever wished he was dead, the patient said, "Yes."
After being informed he was being discharged, the patient asked for shoes, but was told all of his belongings, including a wallet, had disappeared. When the hospital workers discovered they had no shoes that would fit him, he was given a second pair of socks.
Efforts to find a place in area shelter were unsuccesful.
When health department staffers reviewed the records they discovered a series of tests that should have been performed, but never were.
The facility failed to provide "a safe and detailed discharge," the report states.
The health department team also viewed surveillance videos shot during the discharge. "The last video shows the patient falling on the ground," the report states.
Crozer filed a plan of correction including new security measures to monitor the areas near the roof access point.
The plan also calls for the reassesment of patients for suicide risks and education of staffers, along with audits to ensure compliance.
The hospital did not respond to a series of questions about the incident and the state report.
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