The S.C. Department of Mental Health is being sued by the brother of a 35-year-old patient who suffocated earlier this year under a dogpile of hospital staffers who were violating their own training.
The 16-page lawsuit, filed this week, accuses the agency, Bryan Psychiatric Hospital and a pair of its contract employees of negligence and medical malpractice in the Jan. 22 death of William Avant, a Georgetown native who had lived at Bryan since 2007 and was actively suing to be released at the time of his death.
The State first reported on Avant’s death in July, drawing details from a video of the incident and records that showed at least three of the employees involved had not been trained properly on how to restrain agitated patients.
Paired with testimony from a psychiatrist who reviewed records of the incident, Avant’s brother’s lawsuit paints a more detailed picture of incompetence, from the hospital’s failure to prevent a physical altercation with Avant to the crowded and dysfunctional effort to resuscitate him.
It alleges Avant suffered “emotional distress, anxiety, fear and hopelessness” in his final minutes as he struggled for air under a mass of bodies on the hallway floor. The lawsuit requests unspecified compensation for Avant’s distress and his family’s loss.
In a written statement, a Mental Health spokeswoman said the agency does not comment on pending litigation.
Avant was born with Klinefelter Syndrome, a condition associated with shyness, but also aggression and impulsiveness. He had an IQ of 65 and was first hospitalized for psychiatric care at age nine, according to the lawsuit.
His death was ruled a homicide by the Richland County coroner, but the State Law Enforcement Division declined to press charges against anyone involved.
According to the lawsuit, the incident began with an agitated Avant kicking a plexiglass wall — something he regularly did when upset — because Bryan’s staff had denied him a pass to go home for his grandmother’s birthday as punishment for being involved in “an altercation with another patient the night before,” which the lawsuit says he hadn’t initiated. Charles Whetstone, a Columbia attorney representing Avant’s family, said the altercation became physical but wasn’t serious.
Several Mental Health staffers spoke with Avant briefly, but the scene became more chaotic when he attempted to follow another staffer into a medicine room nearby. Staffers then grabbed Avant from behind, threw him onto the floor face down and piled on top of him for the next four minutes, according to the lawsuit and video reviewed by The State.
When they got up, Avant was no longer breathing and his face had turned blue. Hospital staff and, later, first responders failed to resuscitate him, and he was pronounced dead at the hospital later that morning.
The lawsuit alleges hospital employees violated department training by restraining a patient face down and failing to monitor his breathing. The lawsuit charges two contract employees it says were in supervisory positions — psychiatrist Brittany Peters and licensed family practice nurse practitioner Rosalyn Saunders — with observing the improper dogpile and failing to intervene.
Neither is still working at Mental Health, though the agency won’t say why, adding it “does not discuss individual personnel matters.”
Peters worked at the agency from Dec. 3, 2018, until Aug. 15, 2019, according to employee records provided by the agency. Saunders’ contract with Mental Health began in October 2014 and ended a day after Avant’s death.
Records show both are licensed and remain in good standing with South Carolina licensing boards.
Reached over the phone Wednesday, Peters said she could not comment. Efforts to reach Saunders Wednesday were unsuccessful.
In a sworn statement supporting the lawsuit, Charlotte-based psychiatrist Patricia Boyer wrote that Bryan staffers spent less than two minutes trying to calm Avant down before the incident turned physical and did not take “adequate and appropriate steps” to verbally de-escalate the situation.
After reviewing case records, Boyer also concluded the facility failed to remove patients and nonessential staff from the scene as hospital staff and first responders attempted CPR.
About 27 people were in the area, she said, cited Mental Health agency records that found problems in the code response, improperly conducted CPR and unacceptable “overall staff performance.”
“According to EMT records, Mr. Avant had to be removed to the ambulance because EMTs were hindered by the excessive number of SC DMH staff milling about the scene,” Boyer wrote.
All told, the lawsuit makes 27 allegations of negligence or substandard care against staff and administration at Bryan Hospital, including failing to appropriately train employees, properly supervise staff and have policies and procedures in place to ensure security staff and first responders can quickly respond to emergencies.
At the time of his death, Avant was a key figure in a lawsuit that accused the department of unnecessarily institutionalizing patients, including Avant, who could live in their own communities with local treatment and services.
In response to The State’s reporting, the Joint Commission, which accredits Bryan and nearly 80% of U.S. hospitals, opened a review into Avant’s death. The agency has not released any results of that review.