Report: 2 patients who died at Massachusetts psychiatric hospitals were improperly medicated — 9 findings

Two patients who died overnight in their beds at psychiatric hospitals owned by Pembroke, Mass.-based Arbour Health System were improperly medicated with numerous powerful drugs, according to a report from the Disability Law Center in Boston obtained by the Boston Globe.

Here are nine things to know.

1. A 48-page report sheds light on the care lapses that may have contributed to the death of Michael Bakios and Amber Mace, who both died of "probable cardiac dysrhythmia" in 2015. Mr. Bakios died at Westwood (Mass.) Lodge and Ms. Mace died at Pembroke Hospital.

2. While the Massachusetts Department of Mental Health faulted staff at the two psychiatric facilities in 2015 for not closely monitoring its patients, the new report focuses on the issue of improper prescribing. Disability Law Center officials said the state DMH never looked into whether the drugs the two patients were prescribed were appropriate.

3. The Disability Law Center report says both Mr. Bakios and Ms. Mace were each prescribed 12 psychiatric drugs. Life-threatening heart conditions, such as cardiac dysrhythmia, are a risk of certain psychiatric drugs.

4. Mr. Bakios was medicated with strong drugs to "the point of insensibility" and argues Westwood Lodge "relied solely upon the use of powerful medications to suppress symptoms" instead of "developing an effective treatment plan," according to The Globe.

5. In Ms. Mace's case, the law center report claims that while her medical record said she consented to taking six new medications on top of the six she already took, she was mentally impaired when she arrived at Pembroke Hospital, which suggests she couldn't have made an informed decision. Further, during her stay at the hospital, nurses raised concerns about the combination of drugs she was taking.

6. "I don't think anyone said loudly enough: 'This is wrong,'" Christine Griffin, the law center's executive director told The Globe.  In addition, Ms. Griffin argues the state mental health department did not require enough improvements. 

7. State mental health officials disagreed with Ms. Griffin's comments, claiming the deaths lead to a cascade of unannounced inspections that demanded improvements at the hospital.

8. A spokesperson for the state's mental health department told The Globe, "It is not DMH's role or authority to investigate the specific clinical decisions (including medication decisions) made in individual cases by physicians employed at licensed facilities."

9. Arbour Health System officials declined to comment on the Disability Law Center's report.

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