Ailing Patient at St. Elizabeths Poorly Monitored, Agency Says

Man With Stomach Pains Later Died

A mental patient who complained of stomach pains was not properly examined or monitored in the hours before his dead body was discovered at St. Elizabeths Hospital, according to an investigation by the city's mental health agency.

The 55-year-old patient died at the District's public mental hospital in April, less than four months after another unusual death at the facility.

In its investigation of the most recent death, the city's Department of Mental Health found many of the same problems that have affected St. Elizabeths for years, such as employees regularly working double shifts and patient records being poorly maintained.

Mayor Adrian M. Fenty (D) appeared at St. Elizabeths a few weeks ago to announce a plan to address the hospital's chronic failings and to settle a Justice Department civil rights investigation that found the facility lacking in its basic care.

The agreement with the Justice Department, which had threatened to sue the District, calls for adding staff, increasing training, improving treatment and cleaning up unsafe and unsanitary conditions.

Investigators said they were unable to conclude whether better care would have prevented the man's death April 22 from a twisted bowel that apparently went undetected. But they said a nurse failed to thoroughly examine him and the staff did not follow up with regular bed checks.

Their report, which was released pursuant to the Freedom of Information Act, makes clear that the problems at St. Elizabeths go well beyond one patient's care.

The events surrounding the patient's death "reflect serious concerns about the overall system of medical processes and treatment coordination at the Hospital. . . . It is clear that there is a significant gap in both nursing and physician leadership at St. Elizabeths," the investigators wrote.

Patrick Canavan, the psychologist who has been in charge of St. Elizabeths since January, said he is taking steps to correct the problems highlighted by the investigation. The hospital has changed the bed-checks practice, and a physician consultant is being brought in to examine medical and nursing practices in light of the death, Canavan said.

Elmer Randolph Jr., who was found not guilty by reason of insanity in 1979 in an assault and weapons case, had been at St. Elizabeths ever since and had come to see it as his home, his father said in a phone interview from North Carolina.

"He's been there so long, he got used to it," said Elmer Randolph Sr. He said he drove to the Southeast Washington hospital almost every week to visit his son.

To comply with privacy laws, the younger Randolph's name was redacted from the copy of the report provided by the Department of Mental Health to The Washington Post. Randolph's father identified him in an interview about his son and what happened to him.