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Despite mother’s pleas, UNC discharged a young man in crisis. He died 74 minutes later.

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Editor’s note: This article refers explicitly to suicide, which may disturb some readers.

Less than six hours after he arrived by airlift, 29-year-old Troy Simoncelli walked out the front doors of UNC Medical Center’s emergency room into the fading late April daylight alone, still wearing his hospital gown.

After he crashed his vehicle into a tree at high speed earlier that day, a doctor suspected he might have a concussion. And although Simoncelli denied thoughts of suicide, he disclosed he had been hearing voices for days.

Almost as soon as he was admitted, Simoncelli’s mother started calling the hospital, pleading for them to keep her son there. Susan Vaill said he had been on his way to a local hospital for mental health evaluation before the crash. She wanted to talk to his doctor directly.

None of that information was shared with Simoncelli’s doctor, who cleared him for discharge late in the afternoon of April 21.

Vaill called the hospital again, confused about why he had been released. She had just been on the phone with her son when the line went dead.

Minutes later, EMS responded to a 911 call after the man leapt from a two-story-high pedestrian bridge at the medical center. Simoncelli died in the emergency room, where medical staff had just released him about an hour before.

The case is one of several detailed in a 53-page report authored by state regulators, obtained by The News & Observer. The report details why federal regulators in late June threatened to cancel the hospital’s Medicare contract if the facility failed to fix major problems.

UNC Medical Center’s failure to “communicate, escalate and resolve issues” while the patient was in the emergency room — and its failure to quickly fix the mistakes that preceded the man’s death — presented an “immediate jeopardy” to the health and safety of patients, the report said.

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That finding is the least common and most serious result of inspections by health officials — and it carries the potential for the most severe sanctions.

The state-owned hospital declined to make any of its leadership available for an interview.

But UNC Medical Center leaders submitted a corrective action plan to federal regulators in early July. And state inspectors were satisfied with the hospital’s fixes, finding the facility was now in compliance with Medicare regulations, spokesperson Alan Wolf said in a statement Tuesday.

Corye Dunn, director of public policy at Disability Rights North Carolina, said the report revealed incidents where people with disabilities were “significantly harmed by the inappropriate reaction or inaction by the hospital.”

“Underneath every convoluted, procedural, bureaucratic failure is a real human loss,” Dunn said.

Patients in ‘immediate jeopardy’

Prompted by a complaint, a survey team from the state Department of Health and Human Services spent two weeks inspecting issues at UNC Medical Center in mid-June.

Much of their report details the team’s investigation into the death of Simoncelli, identified as an anonymous patient who was transported to the facility’s emergency department by air ambulance after a high-speed wreck.

An attorney for Simoncelli’s family confirmed the man’s identity Wednesday after the N&O shared a copy of the report.

Simoncelli was conscious, although somewhat confused, complaining of back and stomach pain. He denied to a doctor he had thoughts of killing himself, although he said he had been hearing voices. The doctor told him he would likely need a psychiatry referral.

But the report also revealed Simoncelli’s mother, who lives in Connecticut, called the emergency room at least six times that afternoon with information about his mental health status.

The survey team’s interviews with the doctor show he was never told Simoncelli was headed to another hospital for a mental health check, or that his mother had called and asked to speak with him.

“MD #17 stated if he had been notified of the family’s request to speak with him, he would have called them,” the report said.

View note

A seventh and final call from Simoncelli’s mother noted in the report occurred less than an hour after he was released.

“Patient #11’s mother called back and did not understand why Patient #11 was out front of the hospital, that she was on the phone with him and lost connection,” the report said.

Simoncelli died about 8:30 p.m. from injuries sustained during the fall.

The hospital did take some action that night, the report said, calling in medical center leaders and interviewing staff. Over the next few weeks, staff also held meetings and worked to develop new systems for sharing information about patients.

But just days into the state survey team’s two-week-long inspection, regulators found “no written processes had been sent to staff or providers,” prompting them to declare immediate jeopardy, a designation that “was recommended to be ongoing” when they finished their survey on June 17.

Through her lawyer, Vaill declined to comment on her son’s case at this time. She’s represented by Pinehurst attorney Tom Van Camp, who said they’re continuing to examine the circumstances surrounding Simoncelli’s death.

‘Shouldn’t be happening anywhere’

Issues with the care and treatment of a half-dozen other patients were also noted in the report, including documentation errors, a failure to notify family members about the use of sedatives and cases where patients with mental health issues wandered out of the emergency room.

Dunn, who reviewed the report at the N&O’s request, said she’s especially concerned about several “troubling incidents” involving people with disabilities — including those experiencing mental health crises.

“Yes, these are violations of the law,” Dunn, with Disability Rights North Carolina, said. “They are also just violations of common sense.”

To Peg Morrison, assistant executive director of the National Alliance on Mental Illness North Carolina, the report highlights why families should have a stronger voice in the treatment of patients with mental health issues. Loved ones can provide crucial data on a person’s life that can lead to better outcomes.

“It was disheartening to see a mother try so hard to reach the clinical team and have such a tragic outcome nonetheless,” Morrison said.

The flagship campus of UNC Health, UNC Medical Center in Chapel Hill is licensed for nearly 1,000 beds, making it one of the largest hospitals in the state. It currently rates four of five stars on Medicare’s quality rating site as of Wednesday, up from a previous three-star rating.

Dunn, whose organization serves both as a legal advocacy agency and also investigates allegations of abuse and discrimination at facilities across the state, said issues with the treatment of people with disabilities — particularly in the emergency room — aren’t unique to UNC Medical Center. But she said that doesn’t make fixing the problems any less important.

“That it’s happening at one of our state’s most prestigious and best resourced hospitals is especially troubling,” Dunn said. “But it shouldn’t be happening anywhere.”

UNC Medical Center is the second North Carolina hospital in recent weeks to receive an immediate jeopardy designation — and a similar threat to its Medicare contract — from federal regulators. The N&O reported earlier this month that patient deaths at Wilson Medical Center, about an hour east of Raleigh, led to a finding of immediate jeopardy there.

As the N&O previously reported, issues involving immediate jeopardy are relatively uncommon nationwide, making up less than 3% of deficiencies identified at facilities across the country from 2007 to 2017, according to one study.

Although the issues identified in the UNC Medical Center report are now effectively resolved from the regulatory standpoint, the hospital could face additional scrutiny going forward — either from government surveyors or the Joint Commission, a nonprofit health care accreditation agency.

“We are grateful for all of our teammates for their efforts during this process, and their commitment to providing excellent care for all of our patients,” Wolf, the UNC Health spokesperson, said in a statement. “Working closely with state and federal regulators is one important way we are able to continuously improve the quality of care.”

After reviewing the hospital’s corrective action plan, Morrison said the hospital appears to have responded appropriately in its focus on new technology, procedures and additional accountability.

But she notes that hospitals — particularly emergency departments — are often forced to bear the brunt of larger issues with mental health treatment, in addition to dealing with the stress, trauma and burnout in health care more generally.

“There’s a huge capacity problem with mental health,” Morrison said. “We don’t have the number of clinicians to meet demand.”

Dunn said she’s also heartened by regulators’ actions to protect North Carolina residents. But she said that doesn’t amount to a “full-throated endorsement” of the fixes now in place.

“I’m pleased to see the willingness to take decisive action in order to get facilities to make change in an urgent fashion — that’s important,” Dunn said. “I don’t think that means everything’s good.”

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