Death at West Oaks Hospital

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.

In July, a Harris County Grand Jury no-billed Williams in Mario's death. Muhammad "Mo" Aziz, Chazz Vidaurre's civil attorney, says he believes it was because the grand jurors thought it was self-defense­.

Chazz Vidaurre, unable to accept the decision, asked for an investigation by Advocacy, Inc., a nonprofit that advocates for people with disabilities, and he is pursuing a civil case as well. Advocacy, Inc. will be making a determination to see if the hospital followed policy on the use of restraints for patients, says Sarah Guidry, the organization's regional managing attorney. "We are leaning toward finding that there were some policy violations," she says, adding that their investigation is not complete.

She says the fact that the two men were alone could be a policy violation. "It appears that proper restraints were not used, from talking to people." Once they have assembled their information, they will present it to the Texas Department of State Health Services, which has licensing and oversight authority on private mental hospitals in Texas.

Lucinda DeBruce, who had just been in her new position as West Oaks's chief executive officer for two weeks when Mario died, told the family "she was very sorry it happened," Chazz says. DeBruce declined to talk to the Houston Press, but issued a press release through her attorney which said in part: "The events surrounding the patient's death were fully investigated by the authorities and none of our employees were found to have committed any wrongdoing. Our thoughts and prayers are with the families of the individuals involved in this tragic event."

But that's not what DSHS investigators found. The Press obtained copies of the state's investigation after filing an Open Records Request with the department's Facility Licensing Group. In direct and clear language, the state found that "the facility staff failed to protect the patient's rights to a safe environment and therefore resulted in the patient's death."

The state found that West Oaks should have switched to a two-to-one ratio after Mario demonstrated that he was repeatedly violent and difficult to control.

"2:1 observation may be considered if the risk of harm to self or others is considered so significant that 1:1 observation is insufficient to assure the safety of the patient and/or others. These documented episodes of aggression...were an indication that 1:1 observation was insufficient to assure the safety of patient #1 and/or others. However 2:1 observation was not implemented."

Also, according to the state, as a 1:1 patient, Mario never should have been in the smoking enclosure without special permission from a physician — something he did not have. (In some accompanying investigations about this time, the state also found general laxness in West Oak's admitting and oversight procedures for other patients, including one episode of a suicidal patient being allowed to bring in a phone charger cord, a patient with a pocket knife, a diabetic patient who was never weighed and didn't have doctor-ordered blood drawn, a patient caught smoking what was believed to be marijuana, and two patients having sex after one crawled into the other one's room. In the last incident there were no written, signed or dated statements from any of the staff to whom the incident was first reported.)

Crucial to any civil case is the statement of Edmond Smith, a part-time tech at the hospital who is employed full-time as a correctional officer with a state agency. His recollections do not match those of Williams.

Working a double shift that day, Smith told police it was about 4 p.m. when the charge nurse told him that "Fred needs some help in the back smoking area."

"I noticed Fred was kind of standing over the patient and the patient was leaning down kind of slumped over on his side. Fred made a statement that the guy had punched him in the head. Fred looked like he'd been in a fight," Smith is heard saying in an audiotape made by police.

"Fred turned and kind of kicked the guy and immediately after that he stomped him," Smith says. "I rushed over and separated them and got between him and the patient. He wasn't moving. I rolled him over and his eyes were glazed over."

Asked to be more specific about the kick, Smith answers that the kick was "in the side," and that Williams "jumped on him with both feet."

Smith says he went to get the nurse, and together they tried to revive Mario by giving him CPR. During this time there was never any response or sound from Mario, Smith says.