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Lawsuit claims woman's mental health ignored prior to suicide at Buzzards Bay jail
Cape Cod Times - 2/8/2021
Feb. 8—BARNSTABLE — The estate of a Centerville woman who hung herself in the Barnstable County Correctional Facility has filed a lawsuit against the sheriff's office and the third-party vendor that handles mental health cases at the jail.
In the suit, the estate says the warning signs of Jessica DiCesare's mental health issues were ignored.
DiCesare, a mother of two, died by suicide in 2017 at the Buzzards Bay jail while awaiting a hearing on charges of receiving stolen property, driving uninsured and without a license and possession of class C and E drugs out of Falmouth District Court.
Her estate filed a wrongful death and negligence claim against Correctional Psychiatric Services, which was hired by the jail in 2014 to conduct mental health services. A medical malpractice tribunal was held last week to see if there is enough evidence to have a trial against the company and some of its employees.
According to the lawsuit, DiCesare was undergoing detoxification after two years of using opioids when she arrived at the jail in June 2017.
She was screened by Correctional Psychiatric Services, which noted her past opioid use and her required detoxification.
The company also documented that she had been diagnosed as bipolar, had PTSD and had panic attacks, and that she was hospitalized in a Westfield psychiatric unit in 2015.
DiCesare had been taking suboxone, clonazepam, gabapentin, Prozac and Adderall to deal with her psychiatric conditions, a fact that was also on her medical entrance exam report, according to the lawsuit.
DiCesare, who had been dealing with high levels of stress as a result of her first time being incarcerated, had been identified by jail officers and Correctional Psychiatric Services employees as "high priority" in the mental health category.
Two of her medications for her anxiety, insomnia, bipolar disorder and seizures were discontinued without explanation in June 2017. Neither was replaced and later that month, she appeared pale, dehydrated and said she was dizzy, nauseous and kept hitting her head when she got up.
She was admitted to Falmouth Hospital for abdominal pain and was discharged the next day. During her admission, it was documented that she had thoughts of killing herself.
She had a couple of more visits with health clinicians and on July 7, she gave a written note to a Correctional Psychiatric Services mental health clinician asking for urgent mental health care.
The clinician tried to respond immediately to the note but was told by a supervisor that "mental health will not see her today, she will go on the list," according to the lawsuit.
"Witnesses reported that Jessica was pleading for help and submitted an urgent written request for immediate mental health intervention," the suit read.
But none was provided, she was found hanging in her cell the next morning, according to the suit. She was brought to Falmouth Hospital and later to an off-Cape hospital, where she succumbed to her injuries.
Despite her being at risk for suicide, at some point, DiCesare had been placed in solitary confinement and remained there until her suicide attempt. It was one of two deaths by suicide at the jail in three weeks.
DiCesare's estate asked for her complete medical records but was told that due to a computer failure, documents that had been scanned in prior to Jan. 2018 were now lost, including DiCesare's urgent plea for help.
In June 2020, DiCesare's estate filed a lawsuit in Barnstable Superior Court against Jorge Veliz, the president and owner of Correctional Psychiatric Services; Kiri Jarvis, a mental health counselor; Irene McCormack, a registered nurse; Karla Gagnon, a registered nurse; and Terri Lynn Ferreira, a practical nurse, saying they were all involved in her wrongful death by failing to identify and prevent her suicide.
Sheriff James Cummings, the Barnstable County Commissioners, and the state were also named as defendants in the suit.
The charges against the commissioners, Gagon and Ferreira, have all been dismissed.
Cummings declined to comment, citing the pending litigation.
On Dec. 23, a Barnstable Superior Court judge ordered that Correctional Psychiatric Services, Veliz, Jarvis and McCormack go before a medical malpractice tribunal.
Tribunals, which are composed of a doctor, an attorney and a judge, decide whether there is enough evidence to bring malpractice cases to trial.
Dr. Suzanne Bird, attorney John Manoog and judge Gregg Pasquale listened to the case over Zoom on Feb. 3, peppering both the attorneys for Correctional Psychiatric Services and the estate with questions about why there should or shouldn't be a trial.
An affidavit from an expert found that Veliz, Jarvis and McCormack each "breached the standard of care," in the handling of DiCesare's case, and that "it is more probable than not that their failure to provide appropriate medical care was a direct and proximate cause of Jessica DiCesare's death."
Veliz had an obligation to provide appropriate training, guidelines, policies and protocols for implementing and providing psychiatric services, and Dr. Mary Tarail, who reviewed the documents and penned the affidavit in the case, felt that there were not appropriate protocols for identifying DiCesare's needs.
"Although Jessica's psychiatric history of bipolar disorder, PTSD and panic attacks was identified at her intake screening, no follow-up consultation with psychiatry was ordered, psychiatric medications that were identified as needed were discontinued without explanation and without consideration of the deleterious effects of discontinuing the medication," Tarail wrote.
Jarvis should have referred DiCesare for a psychiatric evaluation to determine and prescribe appropriate medication after learning of the absence of her prescribed medications, according to Tarail, who is the interim chief of psychiatry at Mercy Medical Center in Springfield.
McCormack should have noted DiCesare's suicidal ideation displayed at the hospital on her chart to identify her higher risk and need for closer monitoring. She also failed to refer her to a psychiatrist for medication after complaints of shakiness, irregular pulse, heart palpitations and mouth twitching, the expert wrote.
Caroline Smith, who was representing the company, Veliz, Jarvis and McCormack, argued in Wednesday's tribunal that it was speculative to find that different guidelines would have prevented DiCesare's death and felt that portions of the letter offered insufficient evidence to get to causation.
"There's no causation link provided at all," Smith said of McCormack's case. "It simply says she failed to note history, address symptoms and refer her to psychiatric treatment."
Michael Malkovich, the attorney for the DiCesare's estate, contended that Veliz, as the owner and president of the company, had a responsibility to oversee his employees' treatment of DiCesare.
"She was just not treated appropriately," he said. "She fell through the cracks."
The tribunal took the case under advisement.
Contact Ethan Genter at email@example.com. Follow him on Twitter: @EthanGenterCCT.
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