Arbour Health Systems
BOSTON, February 13, 2018 – The Disability Law Center (DLC) issues a Report today announcing the results of its abuse and neglect investigation into patient deaths that occurred in psychiatric hospitals operated by Arbour Health Hospitals, Westwood Lodge (currently closed) and Pembroke Hospital. Westwood Lodge was an 89 bed facility serving children, adolescents and adults. Pembroke Hospital is a 120 bed facility serving adults, adolescents and older adults. The Department of Mental Health licenses inpatient psychiatric facilities operated by Arbour Health Systems.

Dan Smith (a pseudonym), a 32 year old man, died on April 25, 2015, after being at Westwood Lodge for a period of 16 days. Mary Jones (a pseudonym), a 20 year old woman, died on August 30, 2015, after being at Pembroke Hospital for a period of 2 days. DLC analyzed whether these individuals were subject to abuse or neglect in connection with their hospital stays or their deaths. Based upon an extensive review and analysis of relevant documents and primary investigations, DLC finds that both of these individuals had been subject to neglect while each of them had been a patient at their respective facilities. In addition, Westwood Lodge abused Mr. Smith when it administered a medication restraint in violation of state regulations

In conducting these investigations DLC’s found disturbing similarities between both the presentation and needs of the individual victims, and the presence of the same failures that resulted or may have resulted in the deaths of these individuals. These common concerns may evidence a broader systemic problem at Arbour Heath Systems. For example:

  • Arbour Health Systems failed to ensure that observation rounds are conducted in a manner consistent with the hospitals’ own policy; and
  • Arbour Health Systems failed to ensure that timely and effective communication between the direct care, nursing, and psychiatric staff occurred and that information was incorporated into the patients’ individualized treatment plan.

Other problems found by DLC in its investigation include the following:

  • Arbour Health Systems failed to ensure that prior to starting a new medication regimen, all risks and benefits associated with both the proposed medication, including all potential drug-drug interactions, and all medications taken on or before admission, are fully discussed with the patient.
  • Arbour Health Systems failed to ensure that upon admission the patient received routine and preventative medical treatment.
  • Arbour Health Systems failed to develop individualized treatment plans that capture all pertinent information and data regarding the patient’s recent history, including, but not limited to, age, medical status, vital signs, recently prescribed medications, current diagnosis, suicidal and homicidal behaviors, self-injurious behaviors, risk assessments, medical history, substance abuse and trauma history.
  • Arbour Heath Systems failed to allow up to 72 hours for the psychiatric and medical staff to assess, diagnose, and develop a written, individualized treatment plan, including the provision of       a “wash out” period to the patient prior to starting that patient on new medication.
  • Arbour Health Systems failed to ensure that the patients were competent and had the capacity to provide Specific and Informed Consent before being administered psychiatric medication.
  • Arbour Health Systems failed to ensure that all life-saving equipment is inspected and serviced on a regular basis to ensure that the equipment is in proper working order and is easily located when needed.

DLC seeks a detailed and effective remedial plan Arbour Health Systems to remedy the problems identified in its Report. Included in such a remedial plan would be changing policies and practices to ensure that the critical lessons learned from these tragic deaths are never repeated in the future.

DLC, as the designated Protection and Advocacy System for Massachusetts, is authorized under federal law to investigate incidents of abuse and neglect of individuals with disabilities. The investigation was conducted and the report was written by Walter Noons, Senior Staff Attorney and Stanley J. Eichner, Litigation Director.

Read the Report

Contact: Stanley J. Eichner, Litigation Director


DLC Issues Report Announcing Results of Its Investigation of Patient Deaths at Arbour Health Systems Hospitals

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