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Mental Anguish at Texas West Oaks Hospital

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Later that same day, in the afternoon, Greg came to see his brother, but Alan was in a bad mood and they talked for only ten to 15 minutes in the TV room before Greg thought it best to go. The next day, Alan's parents came to see him about 4:30 p.m. Alan still had on his bloody work shirt and became upset when his mother tried to persuade him to change it, Greg says. Greg's wife had brought over clothes for Alan earlier. Instead, Alan asked his mother to get him out of there, and when she told him she thought he should stay, he went in his room and slammed the door, Greg says.

By the time Greg and his wife got there, at about 5:15 p.m., their parents were gone. He asked to see his brother, but was stopped at the nursing desk and told his brother might not want to see them. While they waited, an orderly went to Alan's room to check on him, opened the door, hesitated a moment and then said, "He hung himself."

A nurse went in the room, and Greg and his wife were close behind. Alan had looped his makeshift rope over a closet door. They pushed the beds back, and Greg and a nurse began alternating CPR. Greg remembers that his twin's hands were still warm.

As he stayed in the room with his brother, Greg, an engineer with training in emergency trauma at offshore rigs, says the scene was chaotic. One or two of the staff members appeared to know what they were doing, but the rest, he says, didn't. An ambulance finally arrived and took Alan to Memorial Hermann Southwest. Over the next several days his family, including Alan's wife, remained at his side, optimistic that their vigil would have a positive outcome.

That night, as Greg tried to compose himself in the wake of trying to save his brother, he and his wife were pulled into a room with a West Oaks director and another person. "They were saying if people are suicidal, they're going to do it anyway. I couldn't believe they were telling me they have no control."

"What is particularly tragic about this is that he was still in the bloody clothes that he'd appeared in," Pickett says. "They had not changed him into any hospital gowns. Somebody's in a hospital in which they're there for over 24 hours in bloody clothes. Who's paying attention?

"They just absolutely ignored him."

At the time of his hanging on March 22, 2007, Alan Chambers had been at West Oaks for about 38 hours. He died about five days later at Memorial Hermann Southwest, three hours after the family took him off life support.
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At least every 15 days for more than two years now, Loretta Lilley has carefully saved the same message on her cell phone. It is her one bit of proof that West Oaks administrators knew her daughter had not been cared for correctly.

In the message, Kelly Turner, program director for youth services at West Oaks, says she's talked with Janet Codamo, director of performance improvement, and chief nursing officer Joyce Winters about what happened to Amanda.

"I'm doing a thorough investigation, and training and disciplinary action is needed. I'm so sorry, and I'm appalled at what happened to Amanda, and I want to know how she's doing, and if you have any questions, anything at all, please, please call me."

Later, Turner goes on to say: "I want you to know that we are definitely taking this with a heavy heart and very, very firm measures. This is not acceptable, and I am truly so very sorry."

Loretta says right after she found out Amanda's arm was broken, she called the hospital and spoke with Codamo, who told Loretta that her daughter did not get the proper attention and should have had an X-ray; Loretta also spoke with Winters, who told her that "the staff doesn't keep good records."

From all of this, Lilley was encouraged to believe that West Oaks would set about changing some of its policies. She did think it was strange that Turner called her from her cell phone rather than one of the West Oaks phones. Now, Lilley says, she thinks that was done so there would be no official record at West Oaks that a call with such an admission was ever made.

She filed a complaint with the Texas Department of State Health Services. The agency issued a finding of "inconclusive for abuse." Loretta wonders if they would have substantiated an allegation of neglect — as she understood it, children are not supposed to be behind closed doors at the facility, even for time-out. "You do not put an autistic, mentally retarded child with a seizure disorder in her room unsupervised by herself. That to me is neglect."

Former employee Hudson confirmed the policy is to keep the doors open for children because there's too great an opportunity they'll get into trouble if left unsupervised in their rooms.

Loretta says her husband made the rounds of attorneys, but no one would take Amanda's case, saying it wasn't provable or there wasn't enough money in it. She appealed to her congressman, Kevin Brady, for help, and she says he told her the best thing she could do was to move out of Texas if she wanted to get help with Amanda's problems.

Amanda is eight years old now, living at home with good days and bad. She went through a period where she ripped out her own teeth. She scratched her ears repeatedly till they bled. When sensations overcome her, she hides in a box in the front room closet. She loves purses and changing clothes and cats. But she's strangled a kitten — it scratched her — and has tried to drown and has hit other kittens until someone intervened.

Her accounts of how her arm broke vary and sometimes differ from the hospital's version that she was slamming her door and then hit it with her hand. Sometimes she says she was being bad, other times that a "black man pushed" her. The truth will probably never be known. There's no record that a doctor looked at it, despite what Loretta was told by phone. On March 1 a note on the nursing chart says there was no pain in that location, which Loretta finds darkly humorous now.

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