Spokane hospital where 12-year-old died endangered other suicidal patients, investigators find

A 12-year-old girl who died by suicide at Providence Sacred Heart Medical Center in April was one of four suicidal patients the Spokane hospital put at risk this year, the Washington Department of Health found last month.

Department investigators, who reviewed patient records, security footage and interviewed Sacred Heart staff, found that the hospital had repeatedly violated statewide safety standards by failing to follow its own policies around screening and supervision of patients with suicidal ideation. In the case of Sarah Niyimbona, whose suicide spurred the state’s investigation and a malpractice lawsuit by her family, investigators also raised alarms over Sacred Heart’s delayed response to her escape from the pediatrics floor. On April 13, Sarah managed to walk out of the unit where she had been staying as a psychiatric patient, walk to a hospital parking garage and jump from the fourth floor. She died in the emergency room from her injuries two hours later.

The state’s findings, which InvestigateWest obtained through a public records request, expose a broader pattern of missteps where Sacred Heart staff failed to administer required twice-daily suicide screenings and left at-risk patients unmonitored. One patient had one missed screening, another had 18, and Sarah missed 64 out of 92 screenings she should have received. Another patient hospitalized after a suicide attempt wasn’t screened once in 46 days spent at Sacred Heart. Hospital staff ordered one-on-one supervision of that patient and Sarah to prevent them from harming themselves, but later eliminated that supervision with “no documentation explaining why,” health department investigators found.

“Failure to implement policies and procedures, monitor patients with suicidal ideation, and activate emergency responses without delays puts patients at risk for physical and psychological harm, potential adverse outcomes or death,” investigators said in a notice of “immediate jeopardy” issued to the hospital on April 30.

State regulators place hospitals in immediate jeopardy to notify them of severe deficiencies that can threaten patients’ lives. Hospitals risk losing Medicare certification if they don’t correct the issues promptly. The Department of Health began its investigation after reading InvestigateWest’s first report about Sarah’s death.

The agency lifted Sacred Heart’s immediate jeopardy designation after Providence submitted a corrective action plan, which primarily involves reminding staff of existing policies and confirming their compliance. But health department spokesperson Frank Ameduri said the investigation will continue.

Hospital spokesperson Allie Hyams wrote in an emailed statement Friday, "Providence implemented improved protocols and trainings, which included screening all patients for potential suicide risk and responding to situations when patients go missing while hospitalized." Providence has declined several requests for an interview since Sarah's death, which came six months after the hospital closed its children's psychiatric unit against objections from staff and community members.

“The DOH investigation shows that the systems issues at Sacred Heart have already led to the tragic death of one young patient and endangered others,” said David Keepnews, executive director of the Washington State Nurses Association, who reviewed the immediate jeopardy notice. “The hospital’s response — committing to follow their own policies — should just be an initial step. We hope Sacred Heart will focus on identifying and resolving the systems problems that have led to these dangerous conditions, and avoid pinning blame on individual care team members.”

After reviewing the Department of Health findings, Disability Rights Washington Attorney Chloe Merino said "it's all very concerning." The report, she said, raised many questions including where the "sitter" assigned to watch Sarah around the clock was during repeated attempts on her life inside the hospital.

Sarah’s sister, Asha Joseph, said the question of why her sitter was removed amid Sarah's turmoil is one that has tortured her family the most. The hospital has not provided an answer, she told InvestigateWest after hearing the findings.

"I didn't know. My mom didn't know. We had no clue that they were even taking away the sitter," Joseph said, "and no one could tell us why but I guess that's because there wasn't a reason. No one had one. It's crazy to hear that. And it's unfortunate. She clearly needed it."

Since last summer, Sarah had received intermittent care for self-harm and suicidal thoughts at an outpatient center, psychiatric hospital, group home and at Providence Sacred Heart, where she spent her final weeks.

Sarah was discharged in February — but returned to Providence's emergency room just two hours later, after overdosing on depression medication, Department of Health records show. A suicide assessment determined she was at high risk for self-harm, which means she "must not be left alone," according to hospital policies. Sarah was assigned a sitter to monitor her around the clock and moved to the general pediatric unit, where two rooms were renovated to care for patients with acute psychiatric needs following the closure of its children's psychiatric unit. Pediatrics staff, who asked for anonymity for fear of losing their jobs, told InvestigateWest they repeatedly raised concerns to hospital managers about the need for additional training and safety measures in the rooms but were ignored.

Washington law requires hospitals to develop and follow policies that enable staff to keep patients safe. Sacred Heart’s policy requires patients who are screened as a suicide risk to be assessed twice a day. But Sacred Heart failed to give Sarah and three additional patients suicide screenings as required by the policy, investigators found.

Sarah’s self-harm was continuous throughout March and into April. Her care team documented five self-harm attempts in just six days, including an instance where she ran past her sitter and made it to an elevator before staff stopped her. A camera was installed to add remote monitoring in her room.

On March 17, St. Patrick’s Day, Sarah tried again to leave her room and threatened to harm herself multiple times. Two days later, she was caught trying to swallow a shower cap while taking a shower. The next week, Sarah wrote “a suicide plan that stated they would make everyone think they were okay and not depressed," the health department record said, and she listed multiple ways she could end her own life, including "jump off a high building.”

Even so, on April 4, the camera was removed from Sarah's room without an assessment or recommendation from a mental health provider, Department of Health documents show. And four days later, the sitter was also removed without an assessment or documented reason, leaving Sarah without constant supervision for the first time in more than five weeks.

Sacred Heart also faltered in its supervision of another patient, who was admitted to the intensive care unit after a suicide attempt, the Department of Health found. That patient had no sitter for the first three days. The next morning, their sitter “was pulled for other duties” and didn’t return until 11 hours later. When constant monitoring of the patient was canceled less than a week later, no reason was documented, investigators found.

The day after Sarah's sitter was removed, she told staff that she was feeling isolated and lonely. “The patient remained shut in the room with no call light, television remote, and few belongings,” the report said.

Four days later, at 5:30 p.m. Sarah left her room and the unit. She was gone for four minutes before staff noted she was missing, according to investigators' findings. It was another 11 minutes before security issued a missing child alert. A voice blasted Sarah's description over intercoms hospital-wide at 5:45 p.m.: "a 12-year-old female, African American with braided hair wearing a teal top and purple pants." One minute later, Sarah walked onto the fourth floor of a nearby parking garage where she lingered until 6:03 p.m. when security officers spotted her and she jumped.

Staff members’ delayed notification to security that Sarah was missing also put the hospital in violation of state health and safety requirements, investigators determined.

In a plan of correction responding to investigators’ findings, Neil Apeles, chief nursing officer for Providence Sacred Heart, said the hospital would make renewed efforts to educate workers on their missing child policy, which requires immediate notification to security dispatch. Staff are also required to check all hallways and exits within their own departments.

To address deficiencies in the care of suicidal patients, Apeles said, all nurses and behavioral health providers would be required to confirm that they reviewed existing policies around suicide screenings and monitoring requirements. Additionally, department leaders and charge nurses were tasked with daily checks to ensure suicide screenings are completed and that patients are being monitored at “appropriate levels.”