OSHKOSH, Wis. — Wisconsin prosecutors decided Wednesday they won't file charges against a mental hospital doctor in connection with a patient's death.
State inspectors say the Winnebago Mental Health Institution patient fell at 10 a.m. on Oct. 15 and became unresponsive, but it wasn't until after midnight that he was taken to an emergency room. He was diagnosed with a brain bleed and died weeks later. A nurse told inspectors investigating the death that a doctor seemed unconcerned and said they "needed to wake the patient up."
Winnebago County Assistant District Attorney Eric Sparr released a memo late Wednesday afternoon saying the office focused on whether to charge the WMHI doctor who examined the patient. He wrote the doctor's actions didn't rise to the level of criminal negligence or abuse. The memo doesn't identify the doctor.
"This incident is a horrible tragedy, but this tragedy cannot be criminally attributed to the doctor," Sparr concluded.
Sparr wrote that the patient, a 58-year-old man from Racine County who also isn't identified in the memo, arrived at the institution the day before the fall. Staff members said the man was defiant, had a history of hurting himself and purposefully fell out of bed onto the floor.
On the morning of Oct. 15 the patient stood straight up and let himself fall backward, hitting his head on the floor. For the rest of the day he was unresponsive.
The doctor in question examined the patient twice but wasn't called in until four hours after the fall. The doctor found no bruises, bumps or swelling and staff told him the patient was taking sleeping medications. The doctor concluded the patient didn't need outside medical attention.
A nurse reported that she suggested the patient go to the emergency room but the doctor said he didn't want to waste taxpayer money. The doctor said he didn't remember that conversation. He told a nurse that if the patient didn't wake by 8 p.m. he should be sent to the emergency room, although no nurses recalled that directive.
Another doctor ultimately decided to have the patient sent to the emergency room.
Sparr wrote that the doctor in question had no motive to keep the patient at the institution, that he was told the patient was on sleeping medication and staff accounts of what happened were inconsistent. Sparr added that it's not clear sending the patient to the emergency room any earlier would have saved his life.
The Oshkosh Northwestern reports the investigation comes at a time when the Winnebago Mental Health Institute is at risk of losing federal funds because of safety concerns raised by state and federal investigators.
In February, the Centers for Medicare and Medicaid Services ordered a safety review of the facility and found staffing shortages and that the hospital could not "ensure a safe environment for the patients."
The hospital is working to correct the shortcomings CMS found and the federal agency will conduct an announced survey before July to review their progress. The threat of losing federal funds will be lifted if the hospital is complying with all standards of care.