Suicide report faults hospital — (The Rutland Herald)

SSRI Ed note: Man in psychiatric hospital has Zoloft added to meds, dies by suicide 2 days later. Hospital tries to reduce opportunities for suicide, but not cause (meds).

Original article no longer available

The Rutland Herald

November 19, 2008

By Susan Smallheer Herald Staff

BRATTLEBORO ­ A report into the suicide of a patient at the Brattleboro Retreat faulted the private psychiatric hospital for its treatment of the 42-year-old New Hampshire man last year and praised it for changes it made after his death.

The investigative report by Vermont Protection and Advocacy, a federally funded program, looked into the death of James Biggar of Keene, N.H., after Biggar hanged himself with a bed sheet in his room on Dec. 10, 2007.

It is at least the second suicide of Retreat patients in the past year: In June, a Claremont, N.H., optometrist left the hospital where he was a patient and jumped from the Interstate 91 bridge over the West River to his death.

The changes implemented by Retreat Healthcare range from fixing a closet hole in Biggar’s room, which allowed him to tie a bed sheet and hang himself, to removing all curtain rods from rooms and fixing the beds to the floor.

The Retreat also implemented an improved system of safety checks and suicide assessments, according to a letter from Robert Simpson, the chief executive officer of the Retreat.

“Although we are not in full agreement with some of the conclusions drawn from the data, we do very much appreciate the spirit within which the report was developed and as such the report was used as one of the cornerstones of our efforts to respond to this tragedy and to take steps to improve the care we provide,” Simpson wrote to Ed Paquin, the executive director of Vermont Protection and Advocacy. Paquin couldn’t be reached for comment Tuesday.

“Mr. Biggar and his family sought treatment at the Brattleboro Retreat precisely because they feared that Mr. Biggar’s mental illness would prompt him to harm himself severely or commit suicide. Despite reasonable efforts, this tragedy was not avoided, leaving everyone involved and who cared about Mr. Biggar very sad and discouraged,” the report concluded.

“Throughout our investigation we were impressed by the efforts made by Retreat staff to analyze the circumstances of Mr. Biggar’s death, their willingness to share information with us about the death, and their efforts to put in place changes to policies and practices that may help to avoid another similar tragedy in the future,” the report stated.

“VP&A hopes that some good can come from Mr. Biggar’s experience and untimely death,” it added.

Biggar’s family cooperated with the investigation, which concluded that the Retreat didn’t do enough to protect Biggar from himself and didn’t respond appropriately to Biggar’s increasing depression and anxiety and statements to staff that he wanted to die.

In particular, the report stated that Biggar’s psychiatrist had added Zoloft to Biggar’s list of medications two days before his suicide, which may have contributed to his increasing suicidal wish.

It was Biggar’s unnamed psychiatrist who discovered him hanging in his room, and started resuscitation. Biggar was taken to Brattleboro Memorial Hospital, where he was pronounced dead.

Biggar, who worked in the food service department at Keene State College, had a long history of mental illness and had been hospitalized at Cheshire Medical Center in Keene before he was admitted to the Retreat on Nov. 26, “very ill and suicidal.”

The report noted that Biggar was treated in a program called Tyler 1, which Biggar wanted to be transferred out of, since the program’s focus is on detoxification and alcohol and substance abuse, from which Biggar did not suffer. Biggar wanted to be transferred to Tyler 2, which focused on people with psychiatric illnesses.

Contact Susan Smallheer at