Policy changes at Alameda Co. hospital after high-profile murder: 2 Investigates

The California Department of Public Health has agreed with part of an Oakland mother’s complaint that Alameda Health System (AHS) could have done more to treat her mentally ill son, who later followed through on threats to kill his own brother.

Days after Demetrius Sells was discharged from Highland Hospital -- an AHS-run facility -- in May 2015, he stabbed and killed his brother Kevin McGhee.

Before being discharged, medical records obtained by 2 Investigates show Sells had attempted suicide, overdosing on the prescription drug Abilify. He also threatened to kill McGhee for calling 911. Documents show staff knew Sells made threats and had a history of bipolar disorder, drugs and violence. Sells spent less than nine hours in treatment before his mandatory hold was canceled by a John George mental hospital psychiatrist working in the hospital's Emergency Department.

“Kevin for a fact would’ve still been living May 15 because Demetrius should have been still detained,” Diston told 2 Investigates.

Diston filed a complaint against AHS, and this month, investigators with the California Department of Public Health (CDPH) responded. According to its deficiency report, the state found that Highland Hospital failed to assure that the emergency room psychiatrist made “reasonable efforts to communicate the threat” Sells made against his brother.

Also, AHS emergency room staff failed to make a follow-up appointment with Sells to ensure he didn’t “attempt suicide or harm others.” 2 Investigates also learned the discharge papers’ signature lines for the patient and witness were left blank.

“They need to be held accountable. I want a public apology. I want them to address [CDPH’s] findings. Anybody that sees those papers and sees where my son is at, nobody is being held accountable. How can anyone trust Alameda Health System? How can anyone trust the state?” said Diston.

After failing to submit an acceptable response by its initial deadline, Alameda Health System has since submitted a Plan of Correction to the state to address the issues that were highlighted. The plan includes requiring patients to sign discharge papers and requiring staff to provide a list of community resources if patients need follow-up care. AHS’ response does not address the issue that nobody made a reasonable effort to warn McGhee or other family members about the possibility of Sells posing a threat to safety.

Both Alameda Health System and the California Department of Public Health declined on-camera interviews with 2 Investigates.

In a statement AHS wrote, in part, “We offer our sincerest condolences to Ms. Diston for the loss of her son…Following a thorough review of this incident, it was determined that the adherence to some administrative procedures should be strengthened.”

“This is sweeping under the rug. This is something to appease. This is nothing,” said Diston after 2 Investigates showed her the statement.

When asked why CDPH accepted AHS’ Plan of Correction even though it did not respond to the lack of warning issue, the State wrote in an e-mail that the failure is "not enforceable by the California Department of Public Health. The Medical Board has jurisdiction over psychiatrists.” 2 Investigates reached out to the Medical Board which responded, “[it too] does not have any authority to take any action against the hospital.”

Diston sad she is still going to continue her fight in hopes of holding AHS accountable. She has started a foundation in honor of her sons called the Kevi-Dems Straighter Path Foundation, combining both their first names. She said it’s a program designed to reduce recidivism for people coming from jails and prisons by focusing on embracing mental wellness.

 “I expect someone to look at this and know I’m hurting. Not because I’m a mother, but because I’m looking at laws and regulations that broke and nobody is being held accountable,” said Diston. 

Statement by Alameda Health System for KTVU

"Providing the highest quality care for those we serve is a priority for Alameda Health System – Highland Hospital. We offer our sincerest condolences to Ms. Diston for the loss of her son. Because of patient privacy rights under HIPAA, we are restricted from providing details related to any patient’s care.

We are committed to delivering the best possible care and reviewing our processes to optimize the care, safety and privacy of our patients.  Following a thorough internal review of this incident, it was determined that the adherence to some administrative procedures should be strengthened. 

 

To that end, we have created mechanisms to ensure that staff consistently record a patient’s signature indicating the patient understands the discharge instructions, or document if the patient refuses to sign the discharge form. We will also continue to provide community resource information for follow-up care, particularly for individuals presenting with mental health problems."

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