A state-operated addiction treatment center failed to take basic precautions that could have prevented the suicide of a 24-year-old former high school basketball star with a history of previous attempts, according to a state maltreatment investigation.

The Minnesota Department of Human Services found that Ater Manyang, a refugee from Sudan and basketball record holder at Century High School in Rochester, had attempted suicide four times within the seven months before his admission in March to the Community Addiction Recovery Enterprise (CARE) facility in St. Peter.

And while each of these suicide attempts was described in Manyang’s medical records, staff who admitted him to CARE were largely unaware of them and failed to increase supervision, according to an investigative report released last week.

Citing “systemic failures,” the state agency found the 16-bed CARE facility was responsible for neglect in the death of Manyang, who suffered from depression, post-traumatic stress disorder and alcohol dependency, among other diagnoses. “Staff persons’ lack of awareness about [Manyang’s] history and current needs presented a risk that endangered [his] physical and mental health and safety,” said the investigative report.

The findings come amid a recent increase in suicides at state-operated facilities that treat people with mental illnesses and substance abuse disorders. There have been four suicides at such facilities since 2015, including two suicides at the CARE treatment center in St. Peter.

Manyang’s suicide attempts were chronicled in medical records provided to the CARE facility before Manyang’s admission. They showed that in November of last year he attempted to jump off a bridge before police intervened and brought him to a hospital.

A month later, he was seen in an emergency room for acute alcohol intoxication with suicidal ideation; while in the hospital, he asked physicians to “end his life” and had one-to-one supervision due to the risk of self harm.

Then, on March 10, just seven days before being admitted to CARE, he consumed 40 ounces of alcohol within half an hour, in what was believed to be a suicide attempt, according to the state investigative report. In addition, Manyang was civilly committed due to mental illness and chemical dependency; and these commitment records, also sent to CARE, said he displayed “numerous suicidal thoughts, ideations and attempts that have led to lengthy hospitalizations.”

In a statement, Human Services Commissioner Emily Johnson Piper said her agency, which oversees CARE, last August completed a review of incidents of self-injury at state facilities and has since made changes to improve the assessment of suicide risks of new patients to state hospitals and how those risks are communicated to staff.

The agency has also worked to standardize admissions paperwork, though Piper said the state needs to make further investments in electronic medical records.

“In this case, there were a number of red flags in the medical record accompanying this newly admitted individual that should have alerted staff to potential risks and would likely have caused us to approach this case differently had all staff been aware,” Piper said.

Despite these warning signs, details of Manyang’s suicidal behavior were not relayed to staff members at CARE responsible for his care, according to the state report. Several staff members said they were only aware of “one incident” of the patient drinking too much.

Had details about the suicide attempts been known, Manyang likely would have received a psychological exam and been placed under increased supervision, including 15-minute checks, staff members told investigators.

“Apparently [Manyang] had been suicidal recently and apparently no staff here knew that [he] was, and [he] had jumped off a bridge,” according to a CARE staff member quoted in the state report.

High turnover at the facility appeared partly to blame. At the time of Manyang’s admission, the CARE facility was in “flux” and a new staff person who had responsibility for summarizing a patient’s preadmission information was not fully trained, investigators found.

In the brief time Manyang was at the CARE facility, he participated in all the scheduled programming, appeared positive and “displayed no signs” that he intended to kill himself, staff members told investigators.

On March 18, the day of his death, a CARE staff member saw him talking to peers about basketball at 3:30 p.m. Forty minutes later, a staff member checking rooms found Manyang hanging by his belt. Paramedics were unable to revive him, and he was pronounced dead at 4:52 p.m.

The CARE facility was fined $1,000 and ordered to implement a correction plan, which includes enhanced procedures for assessing the risk of suicide and self harm for each patient.

Manyang’s death was the second suicide in a little over a year at the facility in St. Peter, which union officials say is chronically understaffed.

In March 2015, Logan Brodal, a 28-year-old patient, was found hanging in the facility’s exercise room. Brodal had a history of suicide attempts and reported hearing voices telling him to kill himself; even so, the facility ceased regular, 30-minute checks of Brodal within two weeks of his admission, according to a DHS investigation of his death.


Twitter: @chrisserres