Death at West Oaks Hospital

All the little radios and tightly clamped-on headphones in the world couldn't shut out the voices Mario Vidaurre was hearing. He was off his meds again, but even when he was on them, the hallucinations were there, taunting him, whispering things to him. Immersed in his schizophrenia, he became increasingly aggressive. Left home alone, he put the microwave in the freezer. Another day he shaved off all his hair. He was throwing things.

His older brother Chazz tried to calm him down, and 41-year-old Mario spit at him. Chazz would tell him he loved him but he had to behave, and sometimes Mario would and sometimes he wouldn't. Sometimes he'd be belligerent, and other times he'd curl up in bed like a little boy, with a blanket wrapped around him.

He had been in IntraCare Medical Center Hospital on Fannin a couple of times lately and then St. Joseph Hospital's psychiatric ward for two weeks. From there, his brother wanted him to move into a halfway house, a measure of tough love Chazz says he used periodically to try to get across to Mario that there were rules everywhere. A transport company took Mario to Heavenly Care, a private board-and-care facility in Spring. But his medication did not make the trip. Marilyn Limbrick, the owner/manager of the facility, says the transport driver said someone would come back with Mario's medicine, but no one ever did.

During the time Mario stayed at Heavenly Care, he was quiet and stayed to himself, Limbrick says. But after three days, Mario left Chazz a voicemail message saying he was leaving. Chazz placed a quick call to Limbrick, but it was too late. Mario had disappeared.

Mario called him later from a dentist's office about two miles from Chazz's home and office on Irvington Boulevard. They'd let him use the phone. Chazz came to pick him up and brought him home. But the reunion did not go well, as Mario spun increasingly out of control, his brother says. He tried to convince his brother to go to the hospital, but he didn't want to.

In the end, it was too-loud rock and roll music in Mario's room that led Chazz to a final step he wishes he'd never taken. Around two or three in the morning, he went upstairs after listening to Mario laugh and play the music nonstop for 48 hours.

"I told him to lower the volume. I turned off the radio. He punched me in the eye. I punched him in the head. And then we started wrassling. I said, 'Mario, Mario, stop it.' He stopped."

"He was not well. He needed to be treated, sedated."

Chazz called the Harris County constables. He expected them to take Mario back to St. Joseph, which they did, but St. Joseph didn't have any beds available. Instead, Mario was transferred to Texas West Oaks Psychiatric Hospital in west Houston, where he signed himself in.

Almost immediately, Mario got into trouble. He was shadowboxing in the halls, fighting with other patients, hitting people. Hospital records list employee complaints that he was aggressive and uncooperative. They called Chazz.

"I told them to sedate him, to give him more medicine," Chazz says.

Three days later, on June 14, Mario was dead, beaten to death by the very same psych attendant assigned to keep him safe.
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A single door lets out into the hospital's smoking area, where Mario Vidaurre died somewhere near two benches, a sidewalk and a patch of grass. The area is surrounded by 15-foot-high walls, with no video cameras, buzzers or alarm system.

The only person with him in that L-shaped courtyard behind a locked door was Frederick Williams, 33, a staff member assigned to watch Mario and record his actions every 15 minutes as part of the hospital's "one-to-one" program. In its literature, West Oaks Hospital describes one-to-one orders as "the highest level of precaution and...intended to prevent injury to the patient or others."

Staffers on one-to-one duty are required to stay within one arm's length of the patient at all times, even "when the patient is bathing, toileting, having visitors, or seeing their physician." Also, "suspicious or unusual behavior must be investigated immediately." If the staffer is watching someone who is an assault risk, the tech is required to place himself between the patient and other patients and to physically restrain the patient if necessary.

Nowhere does it state whether there are limits to how much force should be used in subduing a patient.

According to the statement Frederick Williams made to police, on June 14 Mario had been agitated and Williams offered to take him out to the smoking area. Williams told police this had worked two days before to calm Mario. As he bent to light a second cigarette for Mario, his patient punched him in the face. Then Mario hit him in the mouth. Williams grabbed Mario's arms, wrapped his arms around him and took him to the ground. He told Mario that he was not his enemy, to calm down and quit fighting.

Instead Mario got loose and Williams thought Mario was going to scratch his eyes. "Everything was happening so fast," Williams told police. Williams said he punched Mario one time in the face and Mario came at him harder. Mario caught Williams and ran his head into the wall. Williams got ahold of Mario and took him down again. He said he was unsure how long they rolled around on the ground before Mario stopped moving.