Morton Plant Hospital Failed to Report Suicide of 13-Year-Old in Psych Ward

July 20, 2023

A 13-year-old boy took his own life in May while he was a patient at a clinical, residential mental health treatment facility. Now, his grandmother is speaking to the I-Team about how she believes the facility failed him.

Riddled with pain

Pictures from Jamie Dickerson’s cell phone show her grandson Isaiah Thomas smiling.

“This is supposed to be a fun time in his life. It’s not supposed to be a time riddled with pain,” Dickerson said.

She now sees Isaiah’s smile every time she passes by his framed funeral program in her living room. She tries to forget about his pain.

In the weeks since his death, she has converted his bedroom into an office and gave away his clothing and other personal belongings to his classmates at AMI Kids, where he attended school.

“It’s like the worst thing you ever have to do in your life,” Dickerson responded when asked how hard it was to lose her grandson.

Dickerson said Isaiah was taken from his drug-addicted mother at birth. He lived with a foster mother until he was eight, and she died of natural causes. Dickerson said Isaiah discovered her body on the floor and was traumatized.

“This woman raised him from an infant. And he loved her,” Dickerson said.

Dickerson then became his guardian. She said she provided what she could, from a meager monthly check and an EBT card for groceries.

“He needed deeper, more thorough, regular care”

As Isaiah grew into a teenager, his world grew darker, and Dickerson said she couldn’t afford psychological care.

“I recognized that Isaiah needed some help. He was cutting his arms, both arms, the insides of his legs under his clothes where you couldn’t see them,” she said.

Psychotic breaks eventually led to hospitalizations.

“He’s been in and out of facilities seven times,” Dickerson said.

Dickerson said psychiatrists put Isaiah on lots of medication, but the prescriptions didn’t solve his problems.

“He needed deeper, more thorough, regular care. He wasn’t getting that,” Dickerson said.

Self-harm leads to hospitalization

In April, Isaiah severely cut himself and was rushed to the emergency room at St. Joseph’s Hospital. Dickerson believes the act was a cry for help.

“He said, '[Grandma, I don’t want to die. But I can’t keep living like this.' He told me…he said I’m hearing voices in my head,” Dickerson said.

Isaiah was taken to Morton Plant North Bay Hospital Recovery Center in Lutz, which is owned by BayCare Health. The facility has a 72-bed inpatient psychiatric unit for adults and 25 pediatric beds for children.

It's also accredited by the Joint Commission, which means it has enacted stringent policies aimed at ensuring patient safety and quality care.

“I knew he was gone”

On May 5, Dickerson got a call.

“As soon as I answered the phone, I knew who it was, and I knew something was wrong,” she said.

Dickerson said she later learned that Isaiah hanged himself with a bed sheet.

“He went into his room, threw the knot over the top of the bedroom door, went inside and closed the door, and hung himself on their watch,” Dickerson said.

A staff member found Isaiah several minutes later. He was rushed by helicopter to St. Joseph’s but never recovered.

“I knew he was gone when I first saw him. His eyes were just blank. There was nothing there,” Dickerson said.

Four days later, Dickerson gave permission to cut off life support.

The I-Team asked the Pasco County Sheriff’s Office for the incident report, but all we got was a blacked-out page showing the date, the time, and the address of the incident.

Pasco County denied us the 911 recording, saying the case is still open. An autopsy report confirmed Isaiah died by suicide.

A BayCare Health spokesperson told us in an emailed statement, “BayCare takes patient privacy very seriously, including complying with federal privacy laws that preclude us from commenting on any specific patient’s case.”

“I trusted these people to take care of my little boy,” Dickerson said.

Sentinel Event wasn’t reported to the accrediting agency

Patient suicide is considered a “Sentinel event,” which is among the most serious type of reportable events by the Joint Commission.

“A sentinel event is usually a death, a rape, something of significance,” said Marcie McMaster.

McMaster is an accreditation consultant who previously served as an administrator at mental health care centers.

“I feel sick. I feel nauseous because it’s such a tragedy,” McMaster said when asked about her reaction to hearing about Isaiah’s death.

Last year, accredited hospitals reported 73 suicides nationwide, but only 40% occurred at an in-patient facility. Many instances occurred after a patient had been discharged.

Joint Commission standards say, “For patients considered high risk for suicide, 1-to-1 visual observation shall be implemented.”

“Because he’s in-patient, psychiatric, and 13 years old, I’m going to go with he’s high risk…period,” McMaster said.

“They were supposed to be watching those cameras,” Dickerson said. “I don’t think they were watching.”

A state inspection two weeks after the death found no violations. A Florida Department of Health spokesperson said the situation is currently under review. Accredited agencies are “strongly encouraged” to report sentinel events, but the Joint Commission was unaware of the suicide until we told them.

They have since opened a case.

“I have a feeling it would have never shown up on a report if you did not call them because this is two months ago when the event happened,” McMaster said.

Joint Commission guidelines call for voluntary reporting within a maximum of 45 days of a sentinel event.

Dickerson said her grandson’s death saved others through the donation of his heart, lungs, and liver; But that doesn’t make it easier.

“Our children aren’t supposed to end up like this. My baby wasn’t supposed to hang himself. It wasn’t supposed to happen,” she said.

Source: Adam Walser, “Florida grandmother outraged after 13-year-old dies by suicide inside mental hospital,” ABC Action News, July 10, 2023, URL: https://www.abcactionnews.com/news/local-news/i-team-investigates/lutz-grandmother-outraged-after-13-year-old-commits-suicide-inside-mental-hospital