This was the complaint I sent to Nursing and Medical boards
STATEMENT TO DENNIS MENARD: SECRETARY OF STATE INVESTIGATOR
I admit that even though it was early in the morning on November 18, 2015 on Unit D at the Vermont Psychiatric Care Hospital’s Unit D, I was slamming doors. The noise was very loud. Yet never before had this triggered anything from the unbelievably patient and forbearing staff on Unit D, except perhaps some bemused bewilderment at what set me off. After all, with only 3 patients on the unit at any time and the other two either still awake, or highly medicated and dead to the world, it usually did not matter to anyone if I raised a ruckus. But this time, because Annette Brennan was the nurse on duty, it mattered a great deal more than it should have.
Instead of letting me slam my door a few times and cool off, as I had so often before, Nurse Brennan came barreling through the doorway and into my bathroom, where I had been sleeping on a mattress since shortly after my admission, two weeks before. I backed away. Brennan pushed up closer, yelling at me, “You will not slam any more doors tonight, do you understand?!”
To explain what preceded this, you should know a little of the “backstory.” I had gone to the med window about a half hour earlier, asking for an extra Ativan for “anxiety”. But really I needed it because I had been unable to speak since Nov 15. On November 19, people were coming to evaluate me from Meadowview Recovery Residence in Brattleboro, and I needed to be able to have a voice to speak with them.
Now, you should be aware that for many years catatonia and long episodes of mutism have been a problem for me. In 2003, a Connecticut doctor discovered that Ativan by
IV was effective for my catatonia. When mutism was the bigger problem, my outpatient doctor at the time decided to try Ativan orally, seeing mutism as a feature of catatonia, and she used it with good result.
However, at VPCH the on-call doctor, Dr. Lasek, had not been told about my relapsing mutism, nor my need for Ativan. He only knew about my complaints of sleeplessness and anxiety. So when called around 1:30 AM he refused me a second tiny dose and ordered me to try to relax on my own and sleep for two hours, before he would order another.
This is what occasioned, at nearly 2:00 AM, my panicked outburst of door slamming. But the real trigger for what followed was that Nurse Brennan did something she should not have. My advance directive explicitly warns against it. She grabbed me by
the wrists. Yes, feeling threatened by her being up in my face, I had thrown a notebook at the wall. But I had not thrown it at her, as Nurse Mansukhani who was watching all this, explicitly states in both the chart and her APS interview. Maybe having cornered me in the bathroom, Nurse Brennan saw my mute shaking my fists as threatening. Even so, she ought to have backed away. Just backed away not provoked trouble.
Instead, she approached closer and, here is the thing, she reached out and she grabbed both my wrists. Immediately, the other nurse, Jennifer Mansukhani, watching from the door, said to her, “We don’t go hands on here at VPCH.” I want to repeat this because it is vitally important, even though it was never mentioned in the chart. Nurse Mansukhani cautioned Annette Brennan, even as she grabbed me: “WE DON’T GO HANDS ON HERE AT VPCH.”
But no one, not Jennifer Mansukhani, not anyone, came to my aid. I pulled and I struggled to get loose from her grip but Nurse Brennan only held on tighter. So reflexively, and in terror, I bent my head to bite her fingers with my teeth, desperate to get her to release me. And the chart says as much when it reports, “Patient tried to bite staff times 3.” Well, of course I did not just up and bite staff for no reason. The reason, the only reason, I bit staff, that is, bit nurse Brennan, is because she had me by the wrists and restrained me, without just cause. And because being mute i could not simply tell her to let go!
Of course all hell broke loose. The nurse yelled for help and help arrived in seconds with staff now officially going “hands on” to stop me from biting and to restrain me completely .
As they bodily hoisted me off the floor, screaming but wordlessly, one man asked, “What now? Brennan answered promptly, “Bring her to seclusion!” and so following her directive, without trying any other intervention, they carried me there, even though there was a large armchair right in the empty day room they could have placed me in to calm down…
So there I was, in seclusion largely because Nurse Brennan had backed me into my own bathroom and grabbed my wrists in a moment of inappropriate anger, telling me I was not going to slam doors on her watch.
After staff dashed from the seclusion room, I ran after them but they closed the door, locking me in alone. Dazed and sad, and frightened, I sat back down on the mattress, not moving, my back to the door. I heard them talking. Scarcely listening, I tried to calm myself and wondered how long they planned to keep me locked in that room. Then I heard someone say, “She has her glasses and watch. We have to take them away from her!” (So what? I thought. What is the problem?)
But they piled in again, all of them pushing on top of me at once, knocking me in the face and severely bruising my nose and breaking my eyeglasses in their zeal to take away my glasses and watch and my medical band. Then they proceeded to fondle my body, looking for pockets, of which I had none. All this time I was screaming, without verbalizing a word…and fighting them in protest at their violation of my person. They tried to dash out of the room and lock me alone inside again, but I followed them and escaped, wedging myself in-between their ranks. So someone said. “Back inside!” and we all moved as one, back in towards the mattress.
Instead of trying anything to calm me or disentangle themselves and leave again, or better yet trying to follow the instructions on my detailed Advanced Directive and the one plea I had made from the moment I arrived at VPCH, which was never to leave me alone in a seclusion room, imagine my dismay when I heard nurse Brennan shout, “Get the Bed!”
The bed? The restraints bed? For what? What had I done to deserve The Bed? All I had done was try to get out of their terrifying seclusion room, a seclusion room I never deserved to be dragged to in the first place!
But the bed was gotten and as they clamped restraints on my body, Ms Brennan was the person who held my head between her hands as she commanded me — I was howling in terror beyond words, without any words – “YOU WILL CALM DOWN RIGHT THIS MINUTE!” Again and again, gripping my face between her hands, she ordered me to calm down.
You should be aware that my advanced directive EXPLICITLY states and always has, and they were aware of this, that I have been deeply traumatized by the use of restraints and seclusion and that their use should be avoided at ALL costs.
Holding me down as I screamed, they fastened an extra restraint, a fifth restraint, a thick plate of velcro across my chest so I could not sit up nor do more than bend my neck slightly, before I lost strength and had to put my head flat on the narrow gurney.
Then what I can only term “the goon squad” trooped out, with Annette Brennan and Dr Joseph Lasek leaving last, saying, and I want to emphasize this because of its sheer brutality: “You will tell us out loud when you are safe enough to be released, or you will remain in restraints.” Then they departed too.
Although two monitors were posted in the adjoining room, I could not see them because of the chest restraint, nor were they permitted to say a word to me. I screamed in despair and terror but it made no difference. Yes, I once heard Chelsea’s voice from somewhere, a sweet, female staff member who had remembered my Advance Directive. She took a risk and told me from her position across the other room, “Pam, try to take a deep breath, try to calm yourself, I am here, you are not alone…” I tried to be grateful, indeed I was grateful. But as soon as I heard that Chelsea was there for me, they replaced her with someone who was told in no uncertain terms not to speak to me again.
I remained very still and so was rewarded with an assessment at every fifteen-minute interval to see whether I was “safe enough” to be released from restraints. Time and again they said I was “non-responsive” or non-compliant because I could not answer them in spoken words. Nurse Brennan made a point of checking my restraints and touching my body, without asking permission. You can read this in the chart if you do not believe me. She expected me to accept her touching me, and not flinch or kick in reaction. But no one would frame Yes or No questions to allow me to communicate! Yes, I became increasingly frustrated and upset. I was not unwilling to answer their questions, I was simply unable to. And they would leave me in restraints, again and again, hour after hour, writing in their chart notes that because I “refused to speak” I would stay that way.
First one hour passed, then two, then three. Finally the nurse Jennifer Mansukhani, relented and allowed as how I might answer the “safety” questions with a shake or nod of my head.
“Will you remain safe and not hurt anyone?” she asked me, standing above me.
I nodded my head.
“Will you remain safe and not attempt to harm yourself?”
I nodded again.
Will you get up go back to the unit to and to your room and continue to behave safely if we let you out of restraints?” (I am writing these questions from memory so they won’t be exact, but you get the gist of them.)
Nod, nod, nod.
Ms. Mansukhani seemed pleased with my responses but also at a loss as to what to do with them. She paused. “Okay, Pam. I have to go back and confer with Nurse Brennan and the doctor.”
She left, turning her back, promising to be back shortly.
Instead, it took an hour, and when she did come back, she arrived with Nurse Brennan and a plan. “We have decided that we want to free up a hand so you can write a safety plan. Then if we approve it and if it is adequate we will see about taking you out of restraints.”
I frowned. Annette Brennan had in the meantime moved to the end of the gurney where my stocking feet were exposed. Her groin pushed against my toes and the soles of my feet. I felt an immediate revulsion, feeling molested by someone who knew I was vulnerable. Helpless to resist, I kicked out mightily. If I could have spoken in words I would have yelled too, but I could say nothing, only scream wordlessly and kick. This got her to swiftly move away. Someone else present suggested that she pass me at the head of the bed next time.
But writing up a safety plan was just upping the ante. I shook my head emphatically. They trooped out, leaving me alone again, still in restraints at 5:00 o’clock in the morning.
My muscles and veins hurt because I had remained still for so many hours. Afraid I would develop a blood clot, I carefully circled each leg ten times, restraints clanking as I did so. Then I bent each knee a few inches up and down, up and down. Ditto with my arms, until I was satisfied that I had done enough and could relax into the absolute stillness required for an assessment. I later learned my self-administered range-of- motion exercises was described as “patient flailing in restraints.”
Jennifer returned around 6:30. Making motions of desperation, I offered to write a safety plan. But the night shift was leaving. “First shift will have to take you out of restraints. It is too late for us to do it now.”
When I heard this, I let out a despairing howl and suddenly urine poured into my clothing. That meant little to the third shift; they left doing nothing about it. Only when first shift came on and found me, soaked in urine, and still in five-point restraints at 7:00 am did they relent and give me both Ativan and my morning meds. Even so, I wasn’t actually released until 7:30 am.
A patient has the right to be free of unnecessary restraint, and to have the least restrictive environment possible. The fact is, I DID NOT POSE AN
IMMINENT THREAT OF HARM TO SELF OR OTHERS when this incident occurred. I only fought when assaulted by people restraining or secluding me!… I should never have been placed in restraints. Any possible danger – kicking when Annette’s groin pressed against my bare feet? or merely grimacing? — that I may have seemed to pose was wholly induced by the situation.
It is repeatedly on record that Annette Brennan, RN, with the doctor’s complicity ordered that I was not to be released from 5-point restraints until I spoke aloud, stated multiple times in multiple ways. This led to many instances of grotesque abuse, including when Nurse Brennan pushed her groin against my bare feet and then accused me of kicking her.
Please understand what happened: I was immobilized in 5-point restraints, including a large chest restraint. She herself noted that I was lying quietly at the time. So why and how did Ms. Brennan’s groin make contact with my bare feet? I could not “lunge” at anyone, despite the notation later made in my chart. I could not even see Nurse Brennan unless she was right at my side. She pressed her groin against my feet while I was in a helpless and vulnerable state. So I protested by kicking out to the very extent that my restraints allowed. Her behavior violated every professional standard and code there is. It was indeed abuse of everything a nurse stands for.
Abuse was intrinsic to the situation that Brennan (with Dr. Joseph Lasek’s complicity) set up. I should have been released very quickly, except that the staff involved repeatedly refused to ask me their “safety questions” in a manner to which I could respond. Since they had decided I “refused to speak,” they would not permit me to communicate in any other fashion. They acknowledged this was deliberate both verbally and in writing. Several times, the chart says, I was lying quietly in 5-point restraints on the bed, but as I “refused to speak” I would not be released.
Even when Nurse Mansukhani relented enough to ask me the requisite “safety questions” in a yes/no fashion, I had not met their conditions for release so they left me there. This was punishment, and it was abuse, pure and simple.
Finally, I want to show you just one example of what these illegal conditions of release led to, the supposed violence I exhibited and their claims that “patient still needs restraints.” The chart states that they offered me “patient’s own blanket,” when they discovered that I was cold. My response is described as “violent.” What they don’t say is that this was the hospital’s extremely heavy weighted blanket, filled with shot pellets. When Nurse Mansukhani had a male tech bring this and try to drop it on top of me, a patient shackled in 5-point restraints, I was terrified for my life and I responded from that fear: I could not understand why anyone would do such a thing unless they were trying to suffocate me.
(Why in god’s name didn’t they just release me from restraints at that point? I was obviously not trying to harm anyone or myself. I was shivering from the cold that was all…Why? Because they were intent on punishment, not in fact on safety.)
But you see how interpretations written in my chart became inaccurate in the extreme? Because Nurse Brennan insisted on my speaking aloud rather than finding some way for me to communicate, she deliberately rejected any attempt to understand what was going on.
Nevertheless, the fact remains that whether I refused to speak, as she claimed, or whether I could not speak, which was reality, it does not matter. I had the right not to be restrained as punishment or for coercion. I also have always had the right not to speak and to communicate however I so choose, whether VPCH staff, or you, or anyone else likes it or not.
I believe that because she got angry Nurse Brennan grabbed my wrists, restraining me inappropriately, initiating a chain of events that eventuated in my torture.
Instead of stopping the chain reaction at any point along the way, Brennan kept it going, wanting to force me to speak. She chose to further punish me with seclusion and 5-point restraints. She did this for four and a half hours with deliberation and full knowledge of the possible consequences for me, consequences she checked off in boxes (“trauma to patient”) each time she had the doctor renew the order for restraints. I live with those consequences now and have had to live with them every day of my life since that night.
This is the truth of what happened, and I have told the truth on every occasion about this terrible incident at VPCH on the night of November 18, 2015, even when it was unpleasant and did not make me look good. I hope you will see that.