Woman’s Suicide Prompts State to Review Mental Health Care

From The Oregonian, June 1, 1997 – not available online

The Crisis Triage Center opened four months ago at Providence Portland Medical Center with a primary goal: Corral a fragmented county mental health system to make getting help easier.

Although the triage center has made progress, a tragic incident in April underscores the need for even better systemwide coordination and more respect for clients’ input into their care, a state investigation into the incident has found.

On April 12, Emily Comeaux, 37, pulled a gun from her purse and shot herself to death in the lobby of the center at 5228 N.E. Hoyt St.

An advocate for the mentally ill and mother of a teen-age daughter, Comeaux struggled with multiple personality disorder. Letters she wrote the day she died described her anger and panic at her loss of control of her treatment.

In 1995, Comeaux crafted a plan with staff members at Providence St. Vincent Medical Center. When her illness prompted her to harm herself, she would be placed in physical restraints to keep her safe while she calmed her internal demons. She would not be medicated and would be released when she felt ready.

But several times this spring, doctors instead placed her on an involuntary hold and injected drugs, hampering her ability to do her internal work.

On April 7, Comeaux slit her throat at the Crisis Triage Center while waiting in an examination room to see a psychiatrist. Her concealed razor blade went undetected by the center’s metal detector. Comeaux was hospitalized until April 11, and Providence staff members met to discuss her care.

The state’s preliminary investigative report, issued Friday by the Mental Health and Developmental Disability Services Division, showed that many of the doctors and nurses who cared for Comeaux at various sites were not aware of her history or treatment plan.

The state’s recommendations for the Crisis Triage Center include:

    * Have one person coordinate the care of people with complex mental health problems and reassess its internal communication regarding clients.

    * Seek a second opinion, preferably from a provider familiar to and suggested by the client, when a client requests a questionable or unorthodox treatment.

    * Review its security and policies for greeting clients, including the capacity for continuous visual monitoring of clients receiving or waiting for services.

Providence Health System officials said the report provided valuable insights and highlighted the challenge of coordinating care in a 24-hour system.

Providence is addressing or has addressed each of the state’s recommendations, said Magnus Lakovics, regional executive director of mental health and chemical dependency services at Providence. Providence, for example, is going forward with a previously planned network computer system that would allow the center to access a client’s history immediately.

Although the triage center provides a single place for people in crisis to go, the larger system still includes about 17 inpatient and outpatient programs.

The triage center was founded on the concept of involving clients in their treatment. But when clients endanger themselves or others, the mental health professional must be able to make treatment decisions if necessary, Lakovics said.

He said the mental health profession has conflicting views about using restraints but said it is rare for a client to request them.

“I don’t think we would ever pre-guarantee a certain (treatment) approach, particularly when it involves restraints, because we have to evaluate the patient each time,” Lakovics said.

A consultant reviewed the triage center’s security policies after the suicide and made minor recommendations. Lakovics said patients who arrive highly agitated are asked to put on a hospital robe, lessening their ability to be left alone with undetected weapons.

The state will publish a final report after looking into several additional aspects of the suicide, including how someone with Comeaux’s history of mental illness could buy a gun.

Meanwhile, friends and family of Comeaux said the report encouraged them.

“I feel like they’re trying to get to the bottom of everything and figure out what went wrong with the treatment she got,” said Mariah Young, Comeaux’s 19-year-old daughter.

“But it sounds like they were just making recommendations, not enforcing anything. I think some of those things need to be enforced.”