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Questions surround patient's unexpected death in psychiatric hospital

Effects of medications led to death, medical examiner ruled
Posted at 5:05 PM, Mar 12, 2020
and last updated 2020-03-12 21:05:27-04

WARREN, Mich. (WXYZ) — Pauline Klug walked into a Warren psychiatric hospital on a Saturday. She would leave eight days later in a body bag.

“They said your daughter’s dead,” recalled her mother Patricia Peterson. “And I just started screaming and kicking my feet.”

Pauline’s death was not expected. While she had a host of health problems—from obesity to diabetes to high blood pressure—her family said she seemed fine when they visited her.

“She was walking around, she seemed to be herself,” said her husband Larry, “and she told us she’s going to be home next week.”

Whether Pauline’s death could have been prevented is a question that has yet to be answered. She struggled with bipolar disorder and depression and came to Warren's Behavioral Center of Michigan last March after suffering a manic episode.

RELATED: When psychiatric patients suddenly died, state didn't ask why

“She gets real edgy,” said her husband. “She doesn’t get violent, but she gets edgy.”

According to hospital records, Pauline was given a whole host of medications from sedatives to antipsychotics to antidepressants on top of medicines that treated her other health issues.

On her eighth day at the hospital, Pauline’s family went to visit, but was turned away.

“They wouldn’t let us see her,” her mother said. “They said that she was too riled up…nobody could see her. “

Pauline was having another manic episode, and hospital records show staff was struggling to control it.

Medications increased

She’d been receiving an anti-depressant called Nortriptyline, according to medical records. While the recommended maximum dose is 150 mg/day, Pauline was prescribed 225 mg. It triggered a “high dose alert,” telling nurses to “monitor patient closely.” But on the day Pauline died, records show doctors upped her dose even more to 300 mg. It is unclear how much she received.

They also repeatedly increased her dose of Haldol—a powerful antipsychotic—and Benadryl too. Each of the drugs comes with potential cardiovascular side effects, according to Macomb County Deputy Medical Examiner Mary Pietrangelo. About 90 minutes after Pauline’s last dose, she was dead.

“They said they didn’t know why she had died,” Patricia said.

The medical examiner did, concluding it was the “combined effects of multiple oral and injectable medication.” Pauline’s autopsy found that the level of Nortriptyline in her blood was at toxic levels.

Pauline’s family turned to a lawyer who hired Birmingham psychiatrist Dr. Gerald Schiener to review her medical records.

“There was an unusually high number of different medications that were used, and they were piled one on top of another on top of another,” Schiener said.

“When I see that doses are escalated or doubled, that’s even more troubling. Because for some of these medicines, doubling the dose doesn’t make them work any faster," he said, “and in the early stage, doesn’t make them work any better.”

Reached by e-mail, deputy medical examiner Mary Pietrangelo said that the high levels of Nortriptyline in Pauline’s blood may or may not have been raised by what’s called “postmortem redistribution,” which can lead to higher levels than would be found at the time of death.

A Metro Detroit pathologist told 7 Action News that the toxic levels could also have been the result of Pauline’s liver struggling to metabolize some of the drugs that were given to her.

Unanswered questions

With no answers from the hospital about Pauline's medications, the family's next best hope was state regulators. The Behavioral Center of Michigan is licensed by Michigan’s Department of Licensing and Regulatory Affairs or LARA. While they were alerted to Pauline’s death, they did not investigate the medications she was given.

Spokesman David Harns said that’s because the “efficacy of a treatment is outside the scope and authority” of the Bureau of Community and Health Systems, a division of LARA. “That would be a practice of medicine question.”

Mark Reinstein, an advocate with the Mental Health Association in Michigan, says the state’s response is akin to burying its head in the sand.

“The lack of state interest and oversight and monitoring and enforcement is atrocious,” Reinstein said, especially in light of the medical examiner’s conclusions.

“My God,” he said, “how can you not have an independent review of the entire mix of all the medication interactions from day one until the very end?”

In December, the Centers for Medicare and Medicaid Services received a complaint about how the hospital reported Pauline's death to state officials.

Michigan Protection and Advocacy Service, an agency designated by the governor to protect those with disabilities, reviewed records related to her death. According to a police report from the Warren Police Department, staff reported that Klug was placed in a "seclusion room."

They also told police that she was given Haldol and Benadryl "to calm her down." For those reasons, MPAS believed Klug died under chemical restraints and in seclusion, conflicting with what hospital staff reported to the state.

The Centers for Medicare and Medicaid Services designated LARA to investigate the claims.

While hospital staff acknowledged placing Klug in a room that can be used for seclusion, they said she was not actually secluded. Calling it a "quiet room," they said that the doors were left open, allowing Klug to come and go as she pleased. The hospital also said it does not chemically restrain patients, and that the medications used on Pauline were only intended to calm her.

Ultimately, LARA could not substantiate that Klug died in seclusion or in chemical restraints.

The Behavioral Center of Michigan declined an on-camera interview, but released a statement:

“Behavioral Center of Michigan has a long history of providing exceptional care to our patients. Our policies and procedures are designed to promote a compassionate and therapeutic treatment environment while meeting and exceeding the state’s licensing standards. If an incident occurs, we investigate fully and partner with state agencies to ensure its appropriately addressed. We have a continuous improvement mindset and work diligently to advance patient and staff education, pursue clinical and operational excellence and implement best-in-class procedures with integrity.”

Citing privacy laws, the hospital said it could not comment on Pauline’s case, but offered “heartfelt sympathies” to her family.

More than sympathy, Pauline’s family says they want answers.

“It’s because they don’t care. It’s not their family. Not their daughter,” Patricia Peterson said. “It’s just another person to them.”

Pauline Klug’s family is preparing to file a lawsuit against the Behavioral Center of Michigan. It could be filed as soon as this week, according to their attorney.

Contact 7 Investigator Ross Jones at or at (248) 827-9466.