Norwalk State Hospital Reports Detail Lapses in Patient’s Case: Broken neck went unnoticed
Diane Rodrigues sang, prayed and bounced on her bed during the night at Metropolitan State Hospital. A nurse assigned to keep her under constant watch sat by, occasionally dozing.
By 7 a.m., the 52-year-old psychiatric patient was lying motionless on the floor, her neck broken.
It took at least an hour for caregivers at the Norwalk mental hospital to glean the extent of her injuries. It took four more hours to send her to a trauma center for treatment. Rodrigues, a former kindergarten teacher, was left paralyzed after the November 2009 accident and died six months later from related respiratory complications.
Internal investigative reports in the Rodrigues case, recently obtained by The Times, detail serious lapses in medical treatment at the height of a massive court-supervised effort to improve care in the state’s psychiatric hospitals. Among the findings: Staffers slept on the job, failed to conduct regular patient checks, moved Rodrigues despite what turned out to be a serious cervical injury, failed to summon timely help and lied to protect themselves and one another.
In the end, hospital investigators refused to sign the final draft because the recommendations were diluted by Metropolitan administrators, according to two sources familiar with the investigation who asked not to be identified because the process was confidential. Deleted from the report, for instance, was a proposal for mandatory staff training on head injuries. The factual findings were unaltered.