Signature Healthcare: Family Sues Aurora San Diego Psychiatric Facility for Failure to Prevent Patient Death

January 5, 2023

SAN DIEGO — On July 4, 2022, a San Diego grandmother and her two daughters got the call they feared would come.

Their nephew, 22-year-old Tyler Thatcher-Cox was dead. 

Thatcher-Cox, they learned, hung himself with a noose he made from a bed sheet while he was on suicide watch at Aurora Behavioral Health.

Now, the family wants answers. They are suing the hospital after they say staff failed to provide adequate care and did not conduct the 15-minute checks on Thatcher-Cox required by law. And, after finding the 22-year-old San Diego native dead, staff allegedly made changes to his medical chart to make it seem as if they had conducted those checks.

Thatcher-Cox's Aunt Alix Nolin who is filing the lawsuit says, “There was not even understanding of why he was feeling the way he was feeling and acting. No understanding of he'd lost his mother. He's lost his uncle. He lost his grandfather. He's lost his best friend. It was a nightmare. Nobody even knew his story. He was just a number that was on their ledger that they could check off.. so they could get paid. That’s what it was about so they could get paid. Not about him. Not about getting him help. It was so they could get paid and have the least amount of staff to do that.”

Hospitalization of Tyler Thatcher-Cox

On June 19, 2022, paramedics transported Thatcher-Cox to the behavioral health unit at the UC San Diego Medical Center after Thatcher-Cox had tried to poison himself with Carbon Monoxide. 

It was the latest in a string of prior attempts and mental health issues in the months following the death of Thatcher-Cox's mother from breast cancer in 2020.

"He didn't want her to die. And it broke his heart. They went everywhere together," said Debbie Thatcher, Tyler's godmother, and aunt.

But the months after his mom's death, Debbie Thatcher says she and her sister, Alix Nolin saw Tyler's mood decline and his depression intensify.

After the attempt at carbon monoxide poisoning, doctors at UC San Diego Hospital placed Thatcher-Cox on a 5150 in-patient hold to ensure his safety and arranged for him to be transferred from UCSD Hospital to Aurora Behavioral Hospital in San Diego's Carmel Mountain neighborhood in the following days.

Thatcher and Nolin tell CBS 8 that Thatcher-Cox was transferred despite their objections.

"I read the reviews," said Debbie Thatcher. "And it was horrible. I told them, not to put him there. Please do not put them in there."

Despite Debbie Thatcher's objections, on June 21, Thatcher-Cox was admitted to Aurora Hospital. According to the lawsuit filed by his family, intake staff noted that Thatcher-Cox had "suicidal ideation" of hanging himself.

During the next week, the family says staff noted that Thatcher-Cox mental health worsened, he failed to show up for group meetings, his depression worsened as did his behavioral problems. Staff responded by increasing his medications, says the lawsuit.

Staff also placed Thatcher-Cox on a 15-minute "line of sight observations," meaning nurses and others were required to make physical contact with Thatcher-Cox every 15 minutes and then log each interaction in Thatcher-Cox medical chart. 

"Tyler called me almost every day and he said, 'Auntie, I want to come home. This place is horrible. I want to come home. And sometimes he was so drugged up. And I couldn't even like talk to him. That breaks my heart. I wanted to go in and drag him out," said Debbie Thatcher.

Tyler Thatcher-Cox is Seen Making a Noose

On July 4, 2022, the family says Thatcher-Cox was seen making what appeared to be a noose from his bed sheets.

Minutes later, the family's lawsuit, as well as a police report viewed by CBS 8, states that at 4:11 pm Thatcher-Cox left his bed inside the facility's "quiet room" and went into the connecting restroom. Inside, reads the lawsuit, he "anchored" the noose to the top of the bathroom door. A minute later, the police report and lawsuit says the bathroom light could be seen flickering. 

By 4:13 pm, no more movements were seen through the small 1x1 bathroom window.

At 6:10 pm, more than two hours after staff saw Thatcher-Cox making a noose, nurses returned to check on him and found that the bathroom door was locked. After finally getting inside, nurses saw the 22-year-old unresponsive on the floor. 

Paramedics pronounced Thatcher-Cox dead at 6:53 pm.

Attorney D.L. Rencher represents the family. Rencher tells CBS 8 that staff at Aurora signed off on the 15-minute checks after Thatcher-Cox was already dead and despite hospital video reveals that no checks were conducted during that time.

Reads the lawsuit, "While the staff at Aurora signed the 15-minute line-of-sight observations log, the video record shows these medical records are fraudulent as they report that [Thatcher-Cox] was checked after his time of death of 6:15 p.m. While the staff signed the Patient Observation Record on the lines for the 15- minute intervals of 1530, 1545, 1600, 1615, 1630, 1645, 1700, 1715, 1730, 1745, 1800, 1815, 1830, and 1845 hours on July 4, 2022, the video shows that no staff completed 15-minute line-of-sight observations on Cox after 1525 hours on July 4, 2022.

CBS 8 asked Rencher how they knew staff had not done the checks. He says, “The investigating officer used his body worn camera to review the video. And in a very shrewd investigating technique described the video sequence by sequence.”

Alix added, “There is very serious evidence. This is a tragedy, an unavoidable tragedy. The lack of the services. The lack of their facility. Their lack of common decency, just common decency. And the callousness and then on top of that, you compound it with the things that are going to be called out in the lawsuit that are just staggering for a family to even deal with, that adds to our frustration and our anger and our grief.”

QUOTE FROM RENCHER ABOUT HOW WE KNOW ABOUT VIDEO:

Staffing Shortages and Disappearing Beds and Facilities

Rencher blames staffing shortages and a search for boosting profits as the main reasons for Thatcher-Cox's death.

Aurora, reads the lawsuit, had a practice of "obtaining profit through understaffing...diminishing the quality of nursing care given to such suicidal patients and leaving such patients unobserved and within potential reach of harmful or deadly implements placed these patients at an increased risk of self-harm or suicide..."

According to a report from CalMatters, staffing shortages and fewer beds for those experiencing severe mental health issues is not just a regional issue. 

CalMatters found that California has 30 percent fewer acute-care psychiatric beds than it had in 1995, this despite a growing mental health crisis that has only been exacerbated by the pandemic.

In addition, the number of psychiatrists and psychologists who treat the mentally ill is dropping, according to CalMatters, with nearly one-half of all psychiatrists in the state are expected to retire in the coming years. 

But for Alix Nolin and Debbie Thatcher, recognizing the challenges in addressing the mental health crisis will not bring their nephew back. 

"They did worse than not help them," said Debbie Thatcher. "They let them die. It feels to us that they killed him like they shot him right in the head. It's ugly, ugly what they did, and he's not alone."

Added Nolin about the two hours when she says nurses had failed to check on her nephew, "I think about every conversation we ever had. You think about somebody you love in that position for two hours, with no one coming. Imagine your loved one in that position. Imagine what it feels like to know he was in that position and nobody gave a crap. How would anybody feel? They'd feel horrible, just like we feel."

Source: Dorian Hargrove, Anna Laurel, “Family says staff at San Diego psychiatric hospital failed to stop suicide of loved one,” Dec. 16, 2022, URL: https://www.cbs8.com/article/news/investigations/nurses-at-san-diego-psychiatric-hospital-failed-to-stop-suicide-of-loved-one/509-42ecf9d5-be11-45fd-901d-62199df8187b