HARTFORD, CT — Following the suicide of a pregnant teen and seven other suicide attempts at a state Department of Children and Families psychiatric facility, Child Advocate Sarah Eagan asked state lawmakers to require all state-run treatment programs for children to be licensed and subject to routine inspections.
Eagan told the Children’s Committee Wednesday that in her investigation of the teen’s suicide she found that the state currently doesn’t have “an adequate or transparent system for ensuring safe and high-quality care for children in treatment facilities.”
However, she said the legislature has the power to change that.
Sen. Len Suzio, R-Meriden, said he hopes this will lead to legislative action next year because “it’s very apparent from the Child Advocate’s report that some legislative response is warranted.”
Eagan said there was a “dearth of public information” regarding the “immediate jeopardy” faced by the children housed at the Solnit South treatment facility despite the involvement of three state agencies. Aside from DCF, the Department of Public Health and the Department of Social Services have some oversight of the facility in Middletown, but not on a regular basis.
In fact, three months before the 16-year-old took her own life and the life of her unborn child, a Department of Public Health investigation found that the center had failed to properly supervise two suicidal patients and was generally placing the residents in “immediate jeopardy.”
The “immediate jeopardy” finding occurred three times in a period of eight months and is the most serious finding the Department of Health can report.
However those findings were never published or shared widely with stakeholders. Eagan urged the committee to publish or share those reports in the future.
Eagan said the existence of that health department report, which included the “immediate jeopardy” finding in the months before the 16-year-olds death, was first unearthed by the Hartford Courant.
In terms of what regulatory authority is already in place at the facility, the Department of Public Health, on behalf of the Department of Social Services, is tasked with ensuring compliance with the Medicaid contract. Medicaid provides some of the funding for the facility and as such Solnit operates under conditions stipulated by the contract.
But neither agency conducts any routine audits or inspections of Solnit and the facility is not subject to licensure under Connecticut’s system. If it was licensed by the Public Health Department, then it would be inspected on a regular basis where there would be a framework the disclosure and investigation of significant events.
Barbara Cass, chief of healthcare quality and safety at the Public Health Department, said their involvement at the moment is restricted to restraint and seclusion, so they are limited to what they can look at in these facilities. If a suicide attempt isn’t related to restraint and seclusion, it would technically fall outside the bounds for the agency.
She admitted they probably pushed the boundaries in investigating some of the suicide attempts at the facility.
“Our federal authority is limited to restraint and seclusion,” Cass said.
She said they’ve expressed their frustration with the Centers for Medicare and Medicaid Services about the restrictions, but their authority is currently limited.
In total, there were six suicide attempts at Solnit South by children between Nov. 14, 2017 and March 22, 2018. In June, the 16-year-old teen died by suicide, and on July 15, 2018, another youth attempted suicide in the facility.
Department of Children and Families Commissioner Joette Katz said the suicide was “a horrible blow — especially to those who knew the young woman — but also to anyone who learned of it.”
It costs $2,957 per day, or $1.079 million a year, to treat one child at the Solnit South center. Last year, the 24-bed South unit, which is for adolescent girls, served 86 patients. The one suicide that occurred and the seven attempted suicides all occurred at that facility.
“We at the Department are deeply saddened by the tragedy, and because she was in our care at the time, it is a devastating event for our staff at Solnit South, many of whom are here today,” Katz said. “The profound impact that Destiny’s death has and continues to have on staff cannot, however, allow us to be overwhelmed as we also are responsible for examining what happened and doing everything in our power to prevent such a tragedy in the future as we continue to serve Connecticut’s most vulnerable youth.”
Michelle Sarofin, superintendent of the Solnit South unit, said there are new safeguards in place at the facility, including an assessment of all youth by a nurse on each shift.
It has also restricted what items youth can have in their rooms, and the rooms are checked weekly by the staff.
Sarofin said they are also working with two consultants on how they can improve safety at the facility, and told the committee that she and her team will do anything and everything to prevent another tragedy from occurring.