Security camera footage shows state mental hospital employees falsified records to cover up negligence in the death of a patient who choked on his medication, hit his head and then was left sitting in a chair for nearly a day without food or water.
Steven Sabock, 50, died April 29 at Cherry Hospital in Goldsboro. An investigation into his death spurred regulators to pull the state facility's federal funding in September, costing N.C. taxpayers millions.
The video, released Tuesday, shows employees playing cards, watching television, talking on their cell phones and goofing off as Sabock sat ailing and dazed a few feet away, his clothes soaked with his urine.
Though the footage was described in an August investigative report, the video was not made public until The News & Observer of Raleigh and other media outlets worked with Sabock's widow to force its release.
The visual record of Sabock's last day shows that at least 16 staff members responsible for his care failed to recognize that he was in distress until it was too late.
Copies of the state's internal review, released in the past week, say employees lied to investigators and falsified Sabock's medical records to show they had given him care that the video shows they did not.
An autopsy would later conclude that Sabock, who had bipolar disorder, died of a heart condition. But hospital records show the medical examiner was given false information about the patient's condition in his final hours. The death report also omits any mention of his choking or falling.
Requests for interviews with Cherry Hospital's director, Jack St. Clair, and nursing director, Bonnie Gray, who prepared the report to the medical examiner, were declined Tuesday.
Tom Lawrence, spokesman for the state Department of Health and Human Services, said there would be no response Tuesday to questions submitted by phone and e-mail.
Dr. John Butts, the state's chief medical examiner, said Tuesday he doubted that having access to the video or investigative report would have changed his office's conclusion that Sabock died of natural causes related to heart problems. The autopsy report shows no evidence of head trauma, he said.
Nurse ‘freaked out'
Sabock's ordeal began shortly after 8 p.m. April 28 when he entered a room to take his medication. The tape shows him coughing on the pills and health care technician Lucretia Houston patting him on the back. He then falls, his head appearing to hit the floor.
As Sabock turns purple while laying on his back, Houston thrusts on his abdomen with her hands in an attempt to help him breathe. She then pulls him up off the floor, without checking to see if he was injured by the fall, which the report notes is a violation of the hospital's emergency procedures. A nurse, Susan Watson, stands by and does little to help.
Watson later told investigators she “freaked out” when Sabock choked and fell.
Sabock was guided back to the day room on his ward and deposited in a chair. Nearly two hours passed before he was taken to a nurses station to be checked by a physician assistant. She ordered the staff to take Sabock's vital signs every six hours.
Sabock was returned to the chair in the day room at 10:22 p.m., where Houston took his vital signs. While doing so, she can be seen on the video dancing and joking with employees playing cards at a nearby table.
The employees appear to largely ignore Sabock until they finish their card game an hour later, when a worker turns out the lights and leaves the patient alone in the dark.
22 hours, 34 minutes
All told, Sabock was in the chair for 22 hours and 34 minutes. His records indicate that during that time workers followed orders to check his vital signs and regularly give him fluids.
The video shows those records were falsified.
Though not all the entries are signed by an employee, investigators concluded health care technician William Mathis fabricated entries indicating he had taken Sabock's vital signs and given him juice. The report also says Mathis lied to investigators about care the patient got, as did nurse Latasha Lewis.
A list of Cherry Hospital employees provided by the state last month shows Lewis was no longer at the hospital, while Mathis and Houston were still on the payroll.
The video shows other patients crowding into the day room the next morning and checking on Sabock. Employees try to rouse him occasionally, changing his T-shirt at one point. At mealtimes, his food was set aside or eaten by others.
Not until 8:59 p.m. April 29, about 25 hours after he choked and fell, did two employees lift Sabock and slide him into his bedroom, out of the camera's range.
Moments later, employees rush through the day room with a crash cart, indicating a Code Blue had been called. Sabock is seen being wheeled out on a stretcher by paramedics at 9:27 p.m.
Still trying to cope
Gene Riddle, a Goldsboro lawyer representing the patient's family, said Sabock's wife and children are still trying to cope with his loss.
“They were heartbroken when he died and they are heartbroken at what they are now learning,” Riddle said Tuesday. “We need to remember that this was somebody's son, somebody's husband, somebody's father.”