May 8, 2023

Tatum A. Pritchard
Director of Litigation
Disability Law Center

Disability Law Center Investigation Finds Neglect in Cancer-Related Death of an Individual Involuntarily Committed to Lemuel Shattuck Hospital

Boston, MA – The Disability Law Center (DLC) issued a public report today outlining findings of neglect and recommendations concerning the death from cancer of an individual with mental health disabilities who was involuntarily committed to the Metro Boston Mental Health Units at the Lemuel Shattuck Hospital (LSH). As the designated Protection and Advocacy agency for Massachusetts, DLC is authorized under federal law to investigate incidents of abuse, neglect, and death of individuals with disabilities throughout the Commonwealth.

The report discusses the experience of Mr. Harris (a pseudonym), a Black man from Boston diagnosed with schizoaffective disorder, who developed a cancerous lesion on his nose that was not properly diagnosed or treated for more than a year and a half while he was inpatient at LSH. As part of the investigation, DLC’s medical expert concluded that Mr. Harris would have had a high chance of survival had his cancer been treated promptly at or soon after his initial presentation. Unfortunately, LSH provided Mr. Harris medical treatment that failed to comport with the standard of care in a several ways, including by failing to diagnose through biopsy and appropriately treat his lesion; failing to ensure that Mr. Harris received a timely surgical referral to remove the lesion; and failing to obtain informed consent for Mr. Harris’ treatments from his legal guardian, despite medical records indicating that Mr. Harris did not have the ability to provide such consent.

DLC provided LSH, the Department of Public Health, and the Department of Mental Health its initial findings and recommendations for corrective action in 2022. DLC also gave these entities an advance copy of the public report prior to its release. In response to DLC’s findings, LSH conducted a thorough review and ultimately implemented key changes aimed at improving care for LSH patients, including: requiring LSH dermatology staff to photograph skin lesions and wounds for the medical record; requiring biopsies on “all conditions identified as ‘lesion,’ ‘growth’ [or] ‘suspicion of skin malignancy’ prior to initiating treatment; and developing new formal processes and practices to ensure better communication between LSH providers.

DLC recognizes the importance of the corrective action LSH has taken and the many changes in LSH administration since the time of Mr. Harris’ death but believes that more must be done to address the lack of or unequal access to quality medical care that people with mental health disabilities experience every day in our Commonwealth. ”Mr. Harris’ death is a tragic example of what can happen when a health care system fails to be attentive and accommodate the medical needs of a vulnerable individual – an example made worse by the fact that he was institutionalized at LSH to protect him from harm based on to the severity of his mental health disability,” stated Barbara L’Italien, Executive Director of the Disability Law Center.  As discussed in the report, it is well-established that many individuals with mental health disabilities experience poor health outcomes and unequal access to health care. Compounding these experiences are the institutional racism in U.S. health care delivery systems and pervasive health disparities for communities of color, women, people who identify as LGBTQIA+, people with Limited English Proficiency, people with low incomes, and people with other disabilities. While the Commonwealth continues to make efforts to improve health equity, barriers persist and must be dismantled, especially in public hospitals like LSH.

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Disability Law Center Investigation Finds Neglect in Cancer-Related Death of an Individual Involuntarily Committed to Lemuel Shattuck Hospital

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