Investigation finds miscommunication, policy failures led to suicide of 12-year-old girl at Sacred Heart

Editor’s note: This story includes details of a child’s self-harm and suicide attempts.

It took the staff at Providence Sacred Heart Medical Center 11 minutes after they discovered a suicidal girl was missing from her monitored room last April to trigger a hospital-wide alarm.

In that span, on April 13, Sarah Niyimbona, age 12, had reached the top of a hospital parking garage where she jumped to her death as security guards raced to find her.

A state Department of Health investigation found staff miscommunication led to those minutes of inaction that could have stopped the outcome.

Obtained through records requests by The Spokesman-Review, the full DOH investigation found Providence failed to follow its own policies, which put patients such as Sarah at risk.

Because of ongoing litigation initiated by Sarah’s family, Sacred Heart officials declined to answer specific questions about the investigation’s findings but insisted that any concerns brought forth by the state had been corrected.

“We are heartbroken about the tragedy that occurred at Sacred Heart Medical Center. Safe, compassionate care is always our top priority,” Providence spokeswoman Allie Hyams wrote in a statement.

“Following the incident, we launched an internal investigation and self-reported to health authorities, prompting the external investigation which resulted in an immediate jeopardy. The immediate jeopardy was lifted within 24 hours, and we have successfully addressed each concern in the investigation to the satisfaction of health authorities,” she wrote.

The family’s attorney, Matt Conner, said his clients are “encouraged by efforts at the state and federal level to review the tragic death of Sarah” as they “continue to seek justice.”

Timeline of Sarah’s death

The last time Sarah was admitted to Sacred Heart hospital, she had just been discharged two hours earlier. In that short time, she swallowed a whole bottle of her anti-depression medication in an attempt at suicide.

At re-admittance, she was rated to be at high risk of suicide using the Columbia Suicide Severity Rating Scale and was provided with a “sitter” who constantly observes a patient to ensure they do not harm themselves. After going through the emergency department, Sarah was assigned to one of two dedicated behavioral health rooms in a unit with 36 beds. These rooms are stripped of cords and other items that could be used for self-harm and don’t have a patient call light. It isn’t clear why there is no call light. The doors require a badge for entry but not one for exit.

Sarah remained in this room for months earlier this year as her care team tried to find space for her in long-term residential care. Even while under constant observation, Sarah made frequent suicide attempts at the hospital. One day she cut at the veins on her arms and neck with a thumb tack. On another, she attempted to stab her eyes with the end of a power plug.

She also made several attempts at escape. Her room was located approximately 25 feet from the doors of the unit. Elevators were located directly outside those doors. Staff on the unit had stopped Sarah several times when she bolted to the elevators.

At some point, both remote visual monitoring of Sarah and the use of constant observation by a sitter were discontinued. In both cases, investigators found no evidence or documentation that her mental health providers assessed Sarah to be at lower risk of suicide or had recommended reduced monitoring.

After these precautions were removed, providers within the unit placed an alarm on her door that would sound if she tried to leave. According to notes from an interview with a charge nurse on the unit, there was no procedure in place on what to do if the alarm sounded.

On the night of her death. Sarah left her room at 5:30 p.m. and slipped into the elevator. According to the interviewed charge nurse, Sarah’s door alarm did not sound.

Sarah’s absence from her room was discovered at 5:34 p.m., but staff did not initiate a “missing child” alert across the hospital until about 11 minutes later at 5:44 p.m.

At 5:46 p.m., security footage shows Sarah on the fourth level of the hospital’s westernmost parking garage. At 6:03 p.m., security officers located her at the top of the parking structure but were unable to reach her before she jumped off the four-story building and landed on the concrete entrance below. She was rushed to Sacred Heart’s emergency room and died from her injuries two hours later.

Why the 11-minute delay?

If Sacred Heart staff had immediately sounded the “missing child” alert, security guards may have intercepted Sarah before she reached the parking garage. The investigation reported that hospital policy required staff to call the security dispatch number and identify if there is a missing child after discovering their absence.

When the alarm is sounded, staff across the hospital are trained to immediately check all adjacent main hallways and exit areas of their department or unit. Staff are required to remain at these exits and observe anyone who is accompanied by a child or attempts to leave the building with a child.

In Sarah’s case, such measures were unsuccessful because by the time such an alarm happened, she was just two minutes away from reaching a different building through the hospital skybridge. The report did not make any recommendations for the hospital on its skywalks.

According to hospital staff interviewed by investigators, these steps were delayed by 11 minutes because they did not initially believe she was missing.

Treatment for Sarah was split between medical providers within the unit that was not solely designed to treat patients for mental health and a “behavioral health team” that were experts in treating the suicidal ideation of patients like Sarah.

Pediatric nurses within the unit stated multiple caregivers from the behavioral health team would take Sarah for walks or to the hospital gym without informing nurses. This lack of communication between these two groups of caregivers made it more difficult for unit staff to know if Sarah was missing or with another provider.

In an interview with The Spokesman-Review earlier this year, Sarah’s mother, Nasra Gertrude, mentioned Sarah had been taken to the hospital gym by caregivers earlier in the day before her death and had only recently returned to her room when she left on her own and died by suicide.

According to the employees, the delay in activating the “missing child” alert occurred because staff believed the patient was with another staff member, so they checked the unit before activating the alert. It was not until staff confirmed Sarah was not with the behavioral health team that they contacted the security dispatch number.

Why was the sitter removed?

According to Providence policy cited by the investigation, a sitter who remains in place and keeps a constant visual on the patient should be used if the patient is at high risk of suicide, as measured by the suicide rating scale.

“All patients who are identified as high risk must not be left alone and a 1:1 observer will be initiated,” the policy reads.

To decrease monitoring levels, a mental health professional, attending physician or licensed provider must assess and document their recommendation for the reduction in monitoring.

On the last day of documented medical provider assessment, a pediatric hospitalist note showed the plan was to continue suicide and self-harm precautions. But these suicide screenings were not done often enough for the 12-year-old patient. Of the 92 rating scale screenings Sarah should have received while at Sacred Heart, only 28 were documented.

It is unclear if the screenings did not occur or if they were just not properly documented. The Department of Health found similar discrepancies with other suicidal patients in the unit who did not have the proper number of screenings documented. The decision to remove the sitter and video monitoring was also not properly documented.

According to the investigation, there seemed to have been some disagreement between staff in the unit and the behavioral health team over the decision to remove Sarah’s sitter. Nursing staff in the unit told investigators they were “not included in the decision-making process” to discontinue constant observation, and they were “uncomfortable” with the decision to discontinue the sitter. It was in reaction to this decision that unit staff decided to install a door alarm in the room.

According to notes in the investigation, there was a “strong sense” from the behavioral health team that Sarah was improving. Though it was not documented, the removal of Sarah’s sitter was reportedly discussed at a behavioral health team meeting where members expressed a belief that it would be easier to find placement for Sarah in a residential setting if she did not require a sitter.

For much of her stay, Providence had been trying to get Sarah placed within a Children’s Long-Term Inpatient Program, or what is colloquially called a CLIP bed. These intensive inpatient psychiatric facilities often take their pediatric patients for nine months or more. Availability for CLIP beds is extremely limited, with four facilities in Washington totaling 109 beds.

During Sarah’s three-month stay at Sacred Heart, the hospital’s care team found Sarah an open CLIP bed in one of the facilities in the Seattle area. Sarah ultimately did not go because her family could not arrange transportation across the state.

Immediate jeopardy

In the aftermath of Sarah’s death and the Department of Health’s discovery of these varying lapses in protocol, the state placed Sacred Heart under “immediate jeopardy.” Such a designation means the hospital is in severe noncompliance with federal or state health and safety regulations and is placing patients at risk of harm.

Hospitals must correct these deficiencies in a short time frame or face significant civil penalties or even the suspension of licensure.

“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,” wrote investigators in the initial jeopardy notice.

The jeopardy notice for Sacred Heart was placed on April 30. The next day, the hospital provided an abatement plan to investigators that the state approved, resulting in the notice of immediate jeopardy being lifted that evening.

The abatement included plans for daily audits ensuring suicide scale screenings were being conducted and documented at the appropriate frequency. The hospital also created plans and conducted drills to ensure that staff calls security dispatch immediately upon the discovery of a missing child.