Family: San Diego hospital staff failed to stop suicide

Tyler Thatcher-Cox was on suicide watch at Aurora Hospital. The family says that the nurses saw him making a noose but were unable to control him for more than 3 hours.

SAN DIEGO — On July 4, 2022, a San Diego grandmother and her two daughters received the call they feared would come.

His nephew, Tyler Thatcher-Cox, 22, was dead.

Thatcher-Cox, they learned, hanged herself with a noose she made from a sheet while on suicide watch at Aurora Behavioral Health.

Now, the family wants answers. They are suing the hospital after they say staff failed to provide adequate care and fail to perform the 15-minute Thatcher-Cox checks required by law. And, after the 22-year-old San Diego native was found dead, staff allegedly made changes to his medical records to make it appear they had performed those checks.

Thatcher-Cox’s aunt, Alix Nolin, who brought the suit, says: “She didn’t even understand why she felt and acted the way she felt. Not understanding that she had lost her mother. She has lost her uncle. She lost her grandfather. She has lost her best friend. It was a nightmare. No one even knew the story of her. It was just a number that was in her ledger that they could dial… to get paid. That was what it was about to get paid. Not about him. It’s not about getting him help. It was so they could get paid and have the least amount of staff to do that.”

Tyler Thatcher-Cox Hospitalization

On June 19, 2022, paramedics transported Thatcher-Cox to the behavioral health unit at UC San Diego Medical Center after Thatcher-Cox attempted carbon monoxide poisoning.

It was the latest in a series of previous attempts and mental health problems in the months after Thatcher-Cox’s mother died from breast cancer in 2020.

“He didn’t want her to die. And that broke his heart. They went everywhere together,” said Debbie Thatcher, Tyler’s godmother and aunt.

But in the months after their mother’s death, Debbie Thatcher says she and her sister, Alix Nolin, watched Tyler’s mood drop and his depression deepen.

After the attempted carbon monoxide poisoning, doctors at UC San Diego Hospital placed Thatcher-Cox on 5150 inpatient hold to ensure her safety and arranged for her transfer from UCSD Hospital to Aurora Behavioral Hospital in the Carmel Mountain neighborhood of San Diego in the following days.

Thatcher and Nolin tell CBS 8 that Thatcher-Cox was transferred despite her objections.

“I read the reviews,” said Debbie Thatcher. “And it was horrible. I told them not to put it there. Please don’t put it there.”

Despite Debbie Thatcher’s objections, Thatcher-Cox was admitted to Aurora Hospital on June 21. According to the lawsuit filed by her family, intake staff said Thatcher-Cox had “suicidal ideas” about hanging herself.

Over the next week, the family says staff noted Thatcher-Cox’s mental health worsened, she did not show up for group meetings, her depression worsened as did her behavioral problems. The staff responded by increasing her medication, the lawsuit says.

Staff also placed Thatcher-Cox on a 15-minute “line of sight observation,” meaning nurses and others were required to make physical contact with Thatcher-Cox every 15 minutes and then record each interaction in the medical record. Thatcher-Cox.

“Tyler would call me almost every day and say, ‘Man, I want to come home. This place is horrible. I want to come home. And sometimes he was so high. And I didn’t even like talking to him. It breaks my heart. heart. I wanted to go in there and drag him out,” Debbie Thatcher said.

Tyler Thatcher-Cox is seen making a noose

On July 4, 2022, the family says Thatcher-Cox was seen making what appeared to be a noose out of her bed sheets.

Minutes later, the family’s lawsuit, as well as a police report seen by CBS 8, states that at 4:11 p.m. Thatcher-Cox left her bed inside the facility’s “quiet room” and went to the connected bathroom. Inside, the lawsuit says, she “anchored” the noose to the top of the bathroom door. A minute later, the police report and lawsuit say the bathroom light could be seen flickering.

At 16:13 no more movement was seen through the small window of the 1×1 bathroom.

At 6:10 p.m., more than two hours after staff saw Thatcher-Cox making a noose, nurses returned to check on her to find that the bathroom door was locked. After finally going inside, nurses saw the 22-year-old unconscious on the floor.

Paramedics pronounced Thatcher-Cox dead at 6:53 p.m.

Attorney DL Rencher represents the family. Rencher tells CBS 8 that Aurora staff signed checks 15 minutes after Thatcher-Cox was already dead, and despite video from the hospital revealing no checks were performed during that time.

The lawsuit says: “While Aurora staff signed the 15-minute line-of-sight observation record, the video record shows that these medical records are fraudulent, as they report that [Thatcher-Cox] was verified after the time of death of 6:15 p.m. At 6:00 p.m., 6:15 p.m., 6:30 p.m., and 6:45 p.m. on July 4, 2022, video shows no staff completed 15-minute line-of-sight observations on Cox after 3:25 p.m. hours of July 4, 2022.

CBS 8 asked Rencher how they knew the staff hadn’t done the checks. He says: “The investigating officer used his body camera to review the video. And in a very astute investigative technique he described the video sequence by sequence”.

Alix added: “There is very serious evidence. This is a tragedy, an inevitable tragedy. The lack of services. The lack of its facilities. His lack of common decency, just common decency. And the callousness and on top of that, compounding it with the things that are going to be called in the lawsuit that are staggering for a family to even face, that adds to our frustration, our anger, and our pain. ”


Shortage of staff and disappearance of beds and facilities

Rencher blames understaffing and the quest to increase profits as the main reasons for Thatcher-Cox’s death.

Aurora, the lawsuit read, had a practice of “making profit through understaffing…decreasing the quality of nursing care provided to such suicidal patients and leaving such patients unobserved and within potential reach.” of harmful or deadly implements placed these patients at increased risk of self-harm or suicide…”

According to one CalMatters reportStaff shortages and fewer beds for those experiencing serious mental health problems is not just a regional problem.

CalMatters found that California has 30 percent fewer psychiatric intensive care beds than it did in 1995, despite a growing mental health crisis that has only been exacerbated by the pandemic.

Additionally, the number of psychiatrists and psychologists treating the mentally ill is declining, according to CalMatters, and nearly half of all psychiatrists in the state are expected to retire in the next few years.

But for Alix Nolin and Debbie Thatcher, acknowledging the challenges in tackling the mental health crisis won’t bring their nephew back.

“They did worse than not help them,” said Debbie Thatcher. “They were left to die. It seems to us that they killed him as if he had been shot in the head. He is ugly, ugly what they did, and he is not alone.”

Adding about the two hours in which she says the nurses had been unable to control her nephew, Nolin added: “I think about all the conversations we had. You think about someone you love in that position for two hours, with no one coming. Imagine your loved one in that position. Imagine what it would feel like to know that he was in that position and no one gave a shit. How would someone feel? They would feel horrible, just like we do.”

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