Connecticut Department of Children and Families Commissioner Joette Katz said on Thursday she is seeking an independent review of the state-run psychiatric facility for children where a pregnant teenager hanged herself last month.
Katz said she is bringing in a group of experts that will include a psychiatrist and nursing supervisor, among others, to evaluate the safety of children at the facility and make recommendations for change.
“This is going to be people who actually aren’t going to cherry pick through files, who aren’t going to be looking for something specifically wrong,” Katz said. “They are going to be looking at everything with a complete open lens and canvas.”
The 16-year-old girl died just one day before she was supposed to be discharged from the South Campus of the Albert J. Solnit Children’s Center in Middletown and sent to a foster home, according to DCF officials. That facility takes in children from other DCF centers, hospitals, private providers, and directly from the community.
Michelle Sarofin, the facility’s superintendent, said Thursday that the teenager received a regular staff check at 8:30 p.m. on July 29, but was found 15 minutes later in her bedroom where she had “affixed herself to her closet door.”
Sarofin said the teenager did not show any previous signs of an intent to harm herself or warnings indicating she would take her own life.
The 16-year-old’s progress in her treatment meant she would have been discharged from a transitional program known as the Psychiatric Treatment Residential Facility (PRTF) and sent to a foster home one day later. She began treatment at the facility in February, 2018.
“She was very forward thinking around her discharge, had saved money to help care for her baby, passes had gone without incident,” Sarofin said.
Katz said that Connecticut Department of Mental Health and Addiction Services (DMHAS) police seized the teenager’s last journal.
“We have not seen it, but … they were able to confirm for me that there was no foul play and she acted alone,” Katz said.
The department has said it is taking steps to improve how it responds to and prevents suicide attempts, including placing medical equipment like oxygen tanks and suction devices directly on each unit at the hospital and the PRTF. Sarofin said staff at PRTF have locked or removed all of the closet doors in the unit’s bedrooms.
Sarofin said the unit increased staffing after the teenager’s death to “mitigate copycat suicide, to support the other kids and the other staff.” Sarofin said there are a number of vacant direct care and registered nurse positions at both the hospital and PRTF, but DCF is currently interviewing applicants to fill those slots.
Improving safety at the facility will also involve addressing current physical risks at PRTF like ligature points—objects that could be used to support a noose or other strangulation devices.
The Joint Commission, which accredits and certifies health care organizations in the U.S., found ligature risks and points in eight out of eight checked bathrooms at the hospital in 2016.
Sarofin said the Joint Commission didn’t review ligature risks or points at PRTF during that review, but the department said it has been working on mitigating physical risks at the unit since 2015.
DCF changed its procedure after the 16-year-old’s suicide to include a random check of all youth in addition to its 15-minute observation schedule. Katz said plans to place cameras in the halls of the hospital and PRTF are underway but haven’t yet been implemented.
Katz said the baby was buried with its mother, but she would not comment on how many months pregnant the teen was when she died.
Katz also said the teenager’s mother had retained her parental rights. Without specifying, the DCF commissioner said the teenager was involved with the department for a significant period, adding that the mother asked for her daughter’s DCF worker to give a eulogy at her funeral.