Death at West Oaks Hospital
All the little radios and tightly clamped-on headphones in the world couldn't shut out the voices Mario Vidaurre was hearing. He was off his meds again, but even when he was on them, the hallucinations were there, taunting him, whispering things to him. Immersed in his schizophrenia, he became increasingly aggressive. Left home alone, he put the microwave in the freezer. Another day he shaved off all his hair. He was throwing things.
His older brother Chazz tried to calm him down, and 41-year-old Mario spit at him. Chazz would tell him he loved him but he had to behave, and sometimes Mario would and sometimes he wouldn't. Sometimes he'd be belligerent, and other times he'd curl up in bed like a little boy, with a blanket wrapped around him.
He had been in IntraCare Medical Center Hospital on Fannin a couple of times lately and then St. Joseph Hospital's psychiatric ward for two weeks. From there, his brother wanted him to move into a halfway house, a measure of tough love Chazz says he used periodically to try to get across to Mario that there were rules everywhere. A transport company took Mario to Heavenly Care, a private board-and-care facility in Spring. But his medication did not make the trip. Marilyn Limbrick, the owner/manager of the facility, says the transport driver said someone would come back with Mario's medicine, but no one ever did.
During the time Mario stayed at Heavenly Care, he was quiet and stayed to himself, Limbrick says. But after three days, Mario left Chazz a voicemail message saying he was leaving. Chazz placed a quick call to Limbrick, but it was too late. Mario had disappeared.
Mario called him later from a dentist's office about two miles from Chazz's home and office on Irvington Boulevard. They'd let him use the phone. Chazz came to pick him up and brought him home. But the reunion did not go well, as Mario spun increasingly out of control, his brother says. He tried to convince his brother to go to the hospital, but he didn't want to.
In the end, it was too-loud rock and roll music in Mario's room that led Chazz to a final step he wishes he'd never taken. Around two or three in the morning, he went upstairs after listening to Mario laugh and play the music nonstop for 48 hours.
"I told him to lower the volume. I turned off the radio. He punched me in the eye. I punched him in the head. And then we started wrassling. I said, 'Mario, Mario, stop it.' He stopped."
"He was not well. He needed to be treated, sedated."
Chazz called the Harris County constables. He expected them to take Mario back to St. Joseph, which they did, but St. Joseph didn't have any beds available. Instead, Mario was transferred to Texas West Oaks Psychiatric Hospital in west Houston, where he signed himself in.
Almost immediately, Mario got into trouble. He was shadowboxing in the halls, fighting with other patients, hitting people. Hospital records list employee complaints that he was aggressive and uncooperative. They called Chazz.
"I told them to sedate him, to give him more medicine," Chazz says.
Three days later, on June 14, Mario was dead, beaten to death by the very same psych attendant assigned to keep him safe.
A single door lets out into the hospital's smoking area, where Mario Vidaurre died somewhere near two benches, a sidewalk and a patch of grass. The area is surrounded by 15-foot-high walls, with no video cameras, buzzers or alarm system.
The only person with him in that L-shaped courtyard behind a locked door was Frederick Williams, 33, a staff member assigned to watch Mario and record his actions every 15 minutes as part of the hospital's "one-to-one" program. In its literature, West Oaks Hospital describes one-to-one orders as "the highest level of precaution and...intended to prevent injury to the patient or others."
Staffers on one-to-one duty are required to stay within one arm's length of the patient at all times, even "when the patient is bathing, toileting, having visitors, or seeing their physician." Also, "suspicious or unusual behavior must be investigated immediately." If the staffer is watching someone who is an assault risk, the tech is required to place himself between the patient and other patients and to physically restrain the patient if necessary.
Nowhere does it state whether there are limits to how much force should be used in subduing a patient.
According to the statement Frederick Williams made to police, on June 14 Mario had been agitated and Williams offered to take him out to the smoking area. Williams told police this had worked two days before to calm Mario. As he bent to light a second cigarette for Mario, his patient punched him in the face. Then Mario hit him in the mouth. Williams grabbed Mario's arms, wrapped his arms around him and took him to the ground. He told Mario that he was not his enemy, to calm down and quit fighting.
Instead Mario got loose and Williams thought Mario was going to scratch his eyes. "Everything was happening so fast," Williams told police. Williams said he punched Mario one time in the face and Mario came at him harder. Mario caught Williams and ran his head into the wall. Williams got ahold of Mario and took him down again. He said he was unsure how long they rolled around on the ground before Mario stopped moving.
In July, a Harris County Grand Jury no-billed Williams in Mario's death. Muhammad "Mo" Aziz, Chazz Vidaurre's civil attorney, says he believes it was because the grand jurors thought it was self-defense.
Chazz Vidaurre, unable to accept the decision, asked for an investigation by Advocacy, Inc., a nonprofit that advocates for people with disabilities, and he is pursuing a civil case as well. Advocacy, Inc. will be making a determination to see if the hospital followed policy on the use of restraints for patients, says Sarah Guidry, the organization's regional managing attorney. "We are leaning toward finding that there were some policy violations," she says, adding that their investigation is not complete.
She says the fact that the two men were alone could be a policy violation. "It appears that proper restraints were not used, from talking to people." Once they have assembled their information, they will present it to the Texas Department of State Health Services, which has licensing and oversight authority on private mental hospitals in Texas.
Lucinda DeBruce, who had just been in her new position as West Oaks's chief executive officer for two weeks when Mario died, told the family "she was very sorry it happened," Chazz says. DeBruce declined to talk to the Houston Press, but issued a press release through her attorney which said in part: "The events surrounding the patient's death were fully investigated by the authorities and none of our employees were found to have committed any wrongdoing. Our thoughts and prayers are with the families of the individuals involved in this tragic event."
But that's not what DSHS investigators found. The Press obtained copies of the state's investigation after filing an Open Records Request with the department's Facility Licensing Group. In direct and clear language, the state found that "the facility staff failed to protect the patient's rights to a safe environment and therefore resulted in the patient's death."
The state found that West Oaks should have switched to a two-to-one ratio after Mario demonstrated that he was repeatedly violent and difficult to control.
"2:1 observation may be considered if the risk of harm to self or others is considered so significant that 1:1 observation is insufficient to assure the safety of the patient and/or others. These documented episodes of aggression...were an indication that 1:1 observation was insufficient to assure the safety of patient #1 and/or others. However 2:1 observation was not implemented."
Also, according to the state, as a 1:1 patient, Mario never should have been in the smoking enclosure without special permission from a physician — something he did not have. (In some accompanying investigations about this time, the state also found general laxness in West Oak's admitting and oversight procedures for other patients, including one episode of a suicidal patient being allowed to bring in a phone charger cord, a patient with a pocket knife, a diabetic patient who was never weighed and didn't have doctor-ordered blood drawn, a patient caught smoking what was believed to be marijuana, and two patients having sex after one crawled into the other one's room. In the last incident there were no written, signed or dated statements from any of the staff to whom the incident was first reported.)
Crucial to any civil case is the statement of Edmond Smith, a part-time tech at the hospital who is employed full-time as a correctional officer with a state agency. His recollections do not match those of Williams.
Working a double shift that day, Smith told police it was about 4 p.m. when the charge nurse told him that "Fred needs some help in the back smoking area."
"I noticed Fred was kind of standing over the patient and the patient was leaning down kind of slumped over on his side. Fred made a statement that the guy had punched him in the head. Fred looked like he'd been in a fight," Smith is heard saying in an audiotape made by police.
"Fred turned and kind of kicked the guy and immediately after that he stomped him," Smith says. "I rushed over and separated them and got between him and the patient. He wasn't moving. I rolled him over and his eyes were glazed over."
Asked to be more specific about the kick, Smith answers that the kick was "in the side," and that Williams "jumped on him with both feet."
Smith says he went to get the nurse, and together they tried to revive Mario by giving him CPR. During this time there was never any response or sound from Mario, Smith says.
Asked for an assessment of both men, Smith describes Williams as a soft-spoken man with dreadlocks who works the night shift. "Fred's a good person."
He says that Mario spent the short time he was in the West Oaks facility "constantly throwing punches" as he walked around and telling both staff and other patients, "I can kick your ass."
Asked by police if he thought the fight was over before Williams kicked and stomped Mario, Smith says he doesn't know. At the same time, he says he couldn't see any attempt by Mario to start the fight up again.
Mario was rushed to Memorial Hermann Southwest's emergency room, where they were unable to revive him. His death certificate and autopsy report say that he died as a result of "multiple blunt force injuries" and that his death was a homicide.
At death, Mario was 5'11" tall and 143 pounds. The drugs Cyclobenzaprine, Haloperidol and Olanzapine were detected in his system. The pathologist reported multiple rib fractures; laceration of the heart; and injuries to his intestines, back, abdomen, chest, wrist, face, neck, buttocks, shoulders, both forearms and both knees.
Muhammad Aziz, who is representing Chazz in the possible civil case, is in the process of assembling his evidence now. Both he and Wes Tribble, the civil attorney representing West Oaks, say that under Texas law, this would play out as a medical malpractice case.
"If Mr. Williams acted in self-defense, he went a bit far," says attorney Aziz. "There is no doubt that this is a violation of policy, even their policy, whatever it was."
On the afternoon of June 11, there was a seclusion/restraint order placed on Mario. He was apparently put in a locked room, and emergency medication was dispensed after he refused to follow directions and hit a staff member. He was given another emergency injection after he attacked a patient from behind later in the day.
Dr. Steven Schnee, executive director of the Mental Health and Mental Retardation Authority of Harris County, who is not acquainted with Mario's case, spoke to the Press hypothetically about mental health care procedures. Schnee says seclusion/restraint is part of a commonly used training method called "Prevention and Management of Aggressive Behavior." PMAB, as it is usually referred to, is used by most public mental health facilities in the Houston area in training staff to deal with patients who are going out of control, he says.
"Staff are trained to use verbal interventions to try to talk down an individual, decompress a situation. Try to find a way of calming the individual who might be in a kind of more critical, agitated state," Schnee says.
If that doesn't work, then there's a physical intervention process that is supposed to minimize the risk of the patient or staff being injured in the process, Schnee says. Depending on how that goes, the treating doctor may be brought in and asked for an order for an emergency injection, Schnee explains.
"Each hospital is expected to have its own policies and procedures," Schnee says. "So what you would look for is: Do they have those, and do they offer their staff training, and was that implemented, and do they have a process for reviewing where there would be multiple instances with the same patient?"
Alex Azzo, the attorney who represented Frederick Williams in his appearance before the grand jury, says, "It's just unfortunate that Mr. Vidaurre died. My client feels horrible about that. He feels horrible that he wasn't able to control Mr. Vidaurre in some way after he, my client, was attacked. He tried the methods that he was taught to use and it just didn't work."
"Does the same thing work with all patients all the time? No, the answer is no," Schnee says. A patient being placed on one-to-one — as Mario was — shows a level of caution, but Schnee says he can't comment on whether that was sufficient because he doesn't know the case.
West Oaks, a private hospital, is accredited with the Joint Commission on Accreditation of Health Care Organizations. All facilities have some training programs, but Schnee says he can only speak about the public ones using the PMAB process.
"Physical intervention, my recollection is that it involves two people, not one, because you're trying to avoid being in a scuffle," Schnee says. "My recollection is that there is a single-person PMAB takedown, but wherever possible you would want to use two people because it's just a safer environment for everybody."
The image Chazz Vidaurre holds of his brother is at odds with Mario's chaotic end days. Chazz remembers his brother as a beautiful person and a talented jewelry maker, and the younger Mario as someone who liked to fight but always legally, in the ring. "At 17 he was featherweight champion of the Southwest," Chazz says. He refers to him frequently as "a skinny, good-looking guy." He says the doctors and personnel at IntraCare always liked Mario.
But his fond memories don't always hold up under closer scrutiny.
He doesn't like to think of the times that Mario drank too much or smoked pot, laughed without reason or refused to take his medication. He doesn't like to think of the more than 40 times Mario was hospitalized, the trouble he got in for fighting or the criminal assault charges filed against him and then dropped in February 2006 when Mario was found incompetent to stand trial. Chazz prefers to think of the days when his immigrant family was all together in Louisiana and Mario was perfectly normal.
Tragedy changed that when Mario was 14, Chazz says. Mario was walking with a friend and as they went to cross Interstate 10 in New Orleans, a car struck and killed Mario's buddy. Mario was distraught, and he didn't get over it.
"He started crying and going in the closet. He wouldn't talk," Chazz remembers.
Their parents, immigrants from Costa Rica and Honduras with six children, "were trying to survive," Chazz says. They took Mario to a doctor and got an initial diagnosis of bipolar. Given hefty doses of Thorazine, Mario became virtually comatose.
Mario, who spoke Spanish and English, tried to stay in school but ended up dropping out. He got his GED later on. The family moved around a lot. Their father died in 1988, and it was left to their mother to take care of Mario, with help from Chazz. Just before her death in 1996, she entrusted Mario to Chazz.
As Mario's illness got the best of him, he became odd; his strange manner made him a ready target for bullies.
People would pick on him after seeing Mario flail his arms around or contort his face. Boxing became street fighting, and while Mario may have been a champion in the ring, he was a loser outside those boundaries. "He'd come out of jail all black and blue," Chazz says. Several of his teeth were knocked out in fights over the years.
He would get into fights with strangers, imagining that they had something to do with the death of his mother. In the 2006 criminal case, Mario, who'd been drinking, mistook a Hindu man for a Muslim and went up to him, demanding an answer to the question "Why did you bomb New York?" "He did punch the guy and he ran. He ran and he hid," Chazz says.
Around his family, though, Mario was calmer. "He never hit me or my mother. Never," Chazz says. But he amends that statement later. When Mario went off his medicine, things didn't go so well. And, of course, hitting his brother is exactly what got him taken to West Oaks just before he died.
By the time the police officers made it to West Oaks on June 14, Mario had already been transported to Memorial Hermann Southwest. The police report notes the condition of Frederick Williams, who had clearly been in a fight.
"He had a deep abrasion to the right side of his forehead...a swelling above his right eyebrow...a small cut on his left cheek and another small cut near the inside corner of his left eye. He also appeared to have an abrasion on the underside of his top lip. There was swelling to the thumb palm area of his right hand."
Also noted: Williams's blood, hair and tissue on the stucco wall and a bloodstain on the sidewalk. Mario's black T-shirt was on the sidewalk, his green socks in the grass.
According to attorney Azzo, Williams was justified in what he did. "It's clear that my client was the one who was attacked and was trying to defend himself, calling for help as soon as he could." He described his client as a "soft-spoken, very nice man in his early thirties" who was beaten badly by Mario. Because of the attack, Williams had to have an operation on his hand, Azzo says.
Williams was never arrested, but was detained for questioning for about two hours after police arrived at West Oaks. Azzo says he's aware of the witness who said that Williams had kicked and stomped Mario, but that obviously made no difference to the grand jury who heard his testimony.
"I don't know how much effort was needed to control Mr. Vidaurre, as far as should they have had two or three people on him watching him at all times, should they have had him in restraints to protect my client and others? I don't know what goes into the considerations by psychiatrists in determining the type of restraints are required on a person."
Azzo says he thought it was amazing that they had a person totally dedicated to no one else but Mario at all times. "I think that speaks volumes to what they thought of his violent nature, with, as you know, the expense that that involves."
Still, the around-the-clock personal attendant strategy ultimately didn't work. "It certainly wasn't enough to keep my client from being hurt, but realistically I suppose if you had three people and Mr. Vidaurre lashed out against one, that one would have still been injured before he could be controlled," Azzo says.
"My client is not a big man — no more than 5'8", and he's not fat or muscular," Azzo says. "He doesn't have weight to him where you could put pressure with your own weight vs. like a 350-pound person who could just sit on someone."
The thing Mario Vidaurre wanted above everything else was to have a job. But Chazz says that time after time that didn't work out. "He worked when he was about 24 at Veteran's Hospital, but he got nervous. He worked at 31 Flavors, but he couldn't remember the flavors. He was going to try welding."
In fact, Mario did take some basic academic courses at the University of Houston, but that didn't lead to anything because he'd get just as nervous before going to class as he would with a job.
"I even let him have an apartment by himself. He didn't eat. God forbid, there was no picking up," Chazz says.
He often got in trouble because he was gullible. A woman paid him with a fake $100 bill once and the police came to their house after Mario, Chazz says. "I said, 'Please, he's counterfeiting?'" They arrested him anyway. He ended up spending about three months in jail. Why so long? "Basically, the reason they were keeping him there was the judge didn't know what to do with him."
On the day he was admitted to West Oaks, the nurse assessing his condition wrote that he was experiencing "auditory hallucinations telling him to hurt someone."
On the second day his brother was at West Oaks, hospital personnel called Chazz complaining of Mario's behavior. A counselor told Chazz that if Mario hit her, she'd call the police, he says. Hospital records show that he was talking fast, nonstop and that he spoke of "beating up people." He was listed as "actively psychotic."
The third day, Chazz brought cigarettes to Mario, who asked him to let him come home. He says his brother was weak that day, saying the people there didn't like him. Chazz told him he had to calm down, kissed him goodbye and said he'd be back soon.
That was also Mario's best behavior day. Records repeatedly state that he was "compliant with staff."
On Thursday morning, Mario called Chazz. "He called me; he always called me. I said, 'I love you.' I told him I would try to come see him."
Instead, later that afternoon, Chazz got a call from the hospital. There had been a confrontation. They had tried to do everything they could. Chazz was desperate. How was his brother; was he dead? The tech who called him handed the phone over to a nurse, who told Chazz to get over to Memorial Hermann. "She tells me he's fine. I go there. He was dead."
"How did it go from smoking a cigarette to being dead?" Chazz says.
The hospital's records chart a number of drugs administered to Mario. Chazz doesn't understand it. "If he'd had that many drugs in him, he'd be sleeping, not walking around. Medicated, my brother falls to the ground."
He didn't think his brother was getting better at West Oaks. He asked Mario's psychiatrist, Dr. Eileen Starbranch — who'd diagnosed Mario as a schizophrenic with aggressive tendencies years before — to send his brother to the state mental hospital at Rusk. But she said that was not a choice, Chazz says. It is also noted on Mario's chart on June 13 that one of the nurses on duty said she was going to ask the attending physician to send Mario to Rusk. Starbranch did not return phone calls from the Press for this story.
According to MHMRA executive director Schnee, Rusk is available for civil admissions if a patient demonstrates he "exceeds the capacities of the acute care hospital to treat him appropriately." Part of that commitment, done by a judge, is the so-called "dangerousness" test, in which it must be demonstrated that a patient is a threat to himself or others. It is not enough to be merely really crazy.
Chazz believes that if they had just left Mario alone, if the tech had just backed off from him or gotten help in subduing him, everything would have been all right. Some of that is wishful thinking, for, as attorney Aziz puts it, when Mario was left alone at West Oaks, he would get into fights.
Chazz says West Oaks should have taken better care of his brother. "They don't see a life."
He blames himself for turning off the radio, knowing that would further set off his brother. He blames himself again for not getting his brother out of West Oaks. "He told me they were being mean to him. He asked me to take him out on Wednesday. And I didn't do it. But I didn't know."
Leonca Soliz, a niece of Mario, told police her uncle was violent if not taking his medication. Another brother, Victor Vidaurre of Walker, Louisiana, said the same thing.
Teresa Kennedy, the nursing program director for West Oaks, told police Mario "had been expelled from several other facilities due to violent behavior and prior assaults of patients and staff," the investigators wrote.
"I suspect he was too much for anybody to handle unless you were willing to tie him up and keep him restrained at all times, which I don't think too many people would have stood for," criminal attorney Azzo says.
But even he doesn't blame Mario for all of what happened.
"You had a person who was mentally ill, had exhibited violence before and again, you know, when you're mentally ill you're not in control of yourself. It's not like being a bad person and deciding to do bad things. You're just out of control. That's what happened here," Azzo says.
Just before he left St. Joseph, Mario enrolled in Houston STRIDES (Steps Toward Recovery, Independence, Dignity, Empowerment and Success) through Telecare, a private company that provides support services for mental patients. Unfortunately, they lost track of Mario until the day of his death.
In "client progress notes" dated June 14, the STRIDES nurse, Lee Villarruel, writes that she called West Oaks to say she planned to visit Mario that afternoon. She was told by a West Oaks nurse that Mario "was extremely violent," and that he put a staff member in a headlock; the employee was only able to break free when his T-shirt ripped. Mario spent the rest of his day doing kickbox moves.
After hearing this and consulting with coworkers, Villarruel postponed her trip. "We decided I would visit when the member's behavior was less violent." The next day STRIDES was notified of Mario's death.
It is clear that West Oaks would prefer to file this under the heading of "unfortunate and unforeseeable." But as the state investigation makes clear, that was not the case. Mario demonstrated repeatedly that he was violent. The staff members demonstrated just as often that they were unable to control him. One employee told investigators Mario "had superhuman strength." But there are 2:1 procedures designed for the most violent patients, and there were supposed to be restrictions on where Mario went. Neither was employed.
Brother Chazz's attorney, Aziz, says it is clear the hospital knew what they were dealing with in Mario and just as clearly failed to take the right precautions. "If Mario was acting violent, he should have been sedated or restrained. At the end of the day, you can't really blame him because he was mentally disturbed. The reason he was there was that they were supposed to take care of him.
"Yes, he was violent. His brain was not functioning like a normal human being would. Just the level of violence that was used against him was pretty extreme. When you have someone aggressive like that, you need a system to take care of it. The whole thing should never have occurred."