Failed patient checks linked to suicide at Wyoming State Hospital


EVANSTON — “On the nightstand located between the two beds … was a note which read: ‘Tell my family I love them. Keep my Baby Kermie with my body at all times,’” states a police incident report recently obtained by the Herald.

It was going on 8 p.m. on Monday, June 18 — the day after Father’s Day, and the 39-year-old man’s body had already been transferred to Evanston Regional Hospital, where he was pronounced dead. Moments later, the coroner took possession of the body.

But back in room 321 of Evergreen Hall, one of the lower security units at the Wyoming State Hospital, Evanston Police Detective Scott Faddis found the suicide note and several hand-written messages he referred to as “love notes.”

There were medical supplies strewn across the room’s two beds and on the floor, the patient’s mattress was pulled partially off the plastic molded bed — that’s where WSH employees and local first responders performed CPR on the victim. A black sweatshirt had been cut off and laid on the floor near the shower door, so staff could administer an AED (automated electronic defibrillator), albeit without success.

And just inside the shower door, against a wall, was the bedsheet the 39-year-old man had tied to the top hinge of the shower door and then around his neck, taking his own life.

Faddis noted the sheet was saturated with vomit and phlegm.

It shouldn’t have happened — at least not if WSH staff had stuck to protocol. But Dante Sinche, the employee charged with visually checking on the victim and other patients every 15 minutes, was less than diligent on that fateful day, according to detectives who viewed security footage after the incident.

According to the police report, two security guards — Jeremy Carlsen and James “Brady” Purcell — responded to the victim’s request to take a shower sometime between 5-5:50 p.m. on June 18. Carlsen took the shower key, turned on the water and checked the temperature. After the patient also checked the temperature, he thanked Carlsen, who then left the room.

According to the police report, a written observation sheet filled out by Sinche, indicated the employee checked on the victim at 5:45 p.m., 6 p.m. and 6:15 p.m., each time noting that the patient was in the shower and his behavior was calm. At 6:30 p.m. (the last entry), Sinche wrote on the observation sheet that the victim was in his room and his behavior was calm.

Police had to execute a search warrant in order to obtain surveillance video from the Wyoming State Hospital. And what detectives saw reveals a much different story than what Sinche allegedly wrote on the observation sheet.

The footage does show Carlsen and Purcell turning on the shower at 5:30 p.m., and the victim entering the room at the same time. But at 5:36 p.m., video footage shows the victim leaving his room and walking to the kitchen area before returning to his room one minute later. That was the last time he was seen alive.

At 5:45 p.m., Sinche, who was supposed to make 15-minute checks, “is seen walking to the end of the hall to the area where [the victim’s] room is located. The door … is closed, and it is apparent that Dante (Sinche) does not open the door to check on [the victim],” states the police report. The door to the room across the hall was also closed, and Sinche failed to check inside that room as well.

At 5:59 p.m., Sinche “is seen conducting his 15-minute checks again,” the report states. “Once again he walks up to [the victim’s] closed door and fails to look inside the room to see if [the victim] is all right. At 6 p.m., the [victim’s] roommate is seen knocking on the door to [the victim’s] room. [The roommate] then walks away from the room.”

At 6:17 p.m., according to the police report, Sinche once again walks to the victim’s room and fails to check inside. Again, Sinche also failed to check the room across the hall, the report states.

At 6:30 p.m., nearly one hour after the victim was last seen alive, “Ligia Biggs can be seen conducting 15-minute checks, and at 6:36 p.m., she finds [the victim’s] body hanging,” the police report states. Two minutes later, the video shows a crash cart full of medical supplies taken to the victim’s room.

Sinche no longer works at the Wyoming State Hospital, but Kim Deti, spokersperson for the Wyoming Department of Health, which oversees the WSH, said she can’t say whether that has to do with the June 18 incident or not because it’s a personnel issue. She also declined to say whether then-administrator Rich Dunkley’s sudden retirement had anything to do with the June 18 incident.

Deti said, however, that visual contact when performing the 15-minute checks is the standard and expectation.

“The special observation policy at the Wyoming State Hospital includes patient observations every 15 minutes,” Deti said. “This policy has been updated to require verbal interaction with patients during hygiene and toileting activities. Training requirements on the updated policy and processes for employee supervision have been strengthened.”

On June 19, an autopsy confirmed the cause of death was asphyxiation by hanging, and the manner of death as suicide.

Deti said, “There were a few bathrooms with tubs that patients could use on a very limited basis. … These bathrooms had doors with hinges. … These bathrooms are now unavailable to patients.”

She said safety concerns are being further addressed as the state builds on to the newest building, where staff and remaining patients will be moved.

“For the new facility,” Deti said, “planning for patient safety has been a primary consideration. Choices made will reflect what’s been learned over time with existing and past facilities.”

That leaves another question about the June 18 suicide — a question survivors always ask, but is seldom answered: Why?

According to the police report, hospital staff said the man was involuntarily admitted to the State Hospital about a month prior to his death. “He had quite a bit of trouble in his life,” the report states. “He lived in Seattle, Washington, then moved to Salt Lake City, Utah, where he got into trouble.”

He served a prison sentence in Idaho, then made his way to Cheyenne, where he allegedly threatened to kill people. He was sent to the Wyoming Behavioral Institute in Casper, where he was diagnosed with schizophrenia and depression.

He’d twice tried to end his life before — once by overdosing on pills and another time by hanging himself. At one homeless shelter, someone gave him a stuffed Kermit the Frog, which he kept in his pocket at all times. According to the police report, the victim believed the holy spirit would speak to him through Kermit.

The report details how the victim was homeless for most of his adult life, how he was beat up by other homeless people and forced to take meth. While he was in prison, a homeless man murdered his girlfriend. Two of his four children have passed away, along with his mother.

Before June 17, Father’s Day, and the day before he took his own life, he hadn’t spoken to his father in six years. But his dad was happy to hear from him, and happy that his son was getting help.

Then there were the “love notes” that Faddis found stacked underneath the victim’s suicide note next to his bed.

They detail a brief but intense romance between a female patient and the victim. They spanned from June 6 through June 17. They talk about love, having children, dreaming of a life together outside the hospital. They talk about their mutual love of God, meeting family and cuddling while watching movies.

Two letters dated June 15 show signs of trouble in the relationship, as the female patient appears to pull back, saying, “I’m scared about things between us.” A letter to the victim on June 17 states, “… you are overbearing a lot. That scares me. We can maybe be friends, but this has to go slow.”

A WSH staff member told police the female patient had told the suicide victim that she needed more boundaries, and that the victim wanted to have sex with the patient.

Deti said romantic relationships are discouraged at the State Hospital and that “physical expressions of love are not allowed.”

Detectives found the victim’s journal, which details some of the pain he was experiencing leading up to his death.

“Life once again is very difficult but I brought it all on myself,” a June 17 journal entry states. “I usually live by the rule not to date anyone while at the psycho ward, etc. … I’m hurting so bad. I don’t know why I’m so hated by others no matter where I go. Well I must say my prayer at the moment, I really need the holy spirit.”

(Editor’s Note) The Herald doesn’t generally report on suicides, but we chose to report on this given the public nature and the state’s role in this particular incident. Anyone experiencing suicidal thoughts is asked to call the 24-Hour National Suicide Prevention Hotline, 1-800-273-TALK (8255).

Advertisement


Video News
More In Homepage