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An investigation into the death of a 39-year-old retarded patient at St. Elizabeths Hospital revealed a chain of failures that contributed to the Jan. 9 death of Mark Harris from a heart attack. Mental-health counselor Calvin Green, who restrained Harris on the floor, also may face criminal charges after the D.C. Medical Examiner’s Office ruled Harris’ death a homicide because of the restraint. The report by the D.C. Department of Mental Health’s Office of Accountability was released last week to Legal Times. The psychiatric hospital in Southeast D.C. has been plagued by problems and is under investigation by the Justice Department for substandard medical care and lax staff supervision, which already has contributed to the deaths of at least two other patients. Before his death, Harris became violent in the hospital’s Treatment Mall, where he slapped another patient and began “banging his head against a concrete wall, throwing chairs, and pulling the fire alarm,” the report states. The incident occurred during a 3 p.m. shift change, so few staff were present when Green took Harris to the floor and laid on top of him. Green sent an emergency alert, but no staff responded, and two female employees who were present didn’t offer to help, the report states. After a second call, some medical staff arrived, but no one had a key for the nearest closet containing oxygen. Another oxygen tank didn’t work, and a nursing assistant told investigators there wasn’t a defibrillator at the scene. Green, who is on administrative leave, told investigators “the process was taking too long . . . . That can become a life-threatening situation.” Green couldn’t be reached for comment last week. Mental Health Department Director Stephen Baron says Harris’ death was “a terribly tragic situation for everybody” and represented “a convergence of a lot of bad things all at the same time.” Baron admits the hospital’s restraint policy “probably wasn’t followed as it should have been.” Patrick Canavan, who was appointed chief of St. Elizabeths in January, says changes have been made to ensure proper medical equipment is available and employees are trained on the proper use of restraints. Baron says the department is close to a settlement with the Justice Department, including benchmarks for needed improvements, to avoid a civil-rights lawsuit filed on behalf of patients.
Brendan Smith can be contacted at [email protected].

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