After delay in reporting alleged assault on patient, VA chief taking disciplinary action, reminding all staff about responsibility to report



Last modified: Tuesday, April 28, 2015

NORTHAMPTON — The head of the medical center that treats veterans in Leeds said he is disciplining staff members who reportedly misled police and delayed reporting the alleged assault of a psychiatric patient by one of their co-workers in January.

John P. Collins, medical center director at the Veterans Affairs Central Western Massachusetts Healthcare System, also said he is working to spread an important message around the Leeds campus.

“If there is anything an employee sees that they don’t think is right, they should immediately notify their supervisor,” Collins said.

In an interview in his office Wednesday, Collins said he learned about the alleged abuse near the end of February, about a month after the incident that led to the arrest of a nursing assistant who worked in a locked psychiatric ward in the hospital.

Garrett C. Crehan, 42, pleaded not guilty in Northampton District Court on April 16 to a charge of assault and battery on a person over 60 or disabled. According to witness statements collected as part of a federal investigation, Crehan allegedly threw a 61-year-old patient to the floor, held him down on his bed by twisting his arm behind his back, kneed him several times in the ribs, and threatened to kill him.

Collins said the reported assault itself was a serious cause for concern, but he learned more distressing information when Special Agent Matthew Kidd from the Department of Veterans Affairs Office of Inspector General briefed him on his investigation April 8. “He concluded that they witnessed the event, but delayed reporting it,” Collins said of three staff members. That violates Veterans Affairs policy, he said.

“Is it acceptable? Absolutely not,” Collins said. “We’re taking action. We’re going to make sure we have in place the right people and the right processes.”

Kidd said in his report that Nancy Chapman, a registered nurse who was in charge of the shift, also provided “misleading information” to Veterans Affairs police after the incident, causing the officers to write an inaccurate report of the event. Chapman, of Williamsburg, declined to speak to the Gazette.

Reporting required

Collins said the allegations have prompted him to do three things. First, VA leaders will review the policies and training programs that deal with physical restraint of patients and reporting suspected abuse, to see whether any changes could prevent similar situations in the future. “We need to make sure people understand it’s not correct,” he said.

Collins added that he is also taking “appropriate disciplinary action” against staff who failed to report, although he said he cannot be specific about the punishment because it is a personnel matter.

Collins’ third goal is to ensure that staff understand that they are required to report any abuse.

“I’ve asked all the supervisors all the way down the chain of command to talk to their staff, to reinforce the VA’s core values,” he said. “To remind people that this type of behavior is not tolerated and to remind people about their obligation to report it — at any level.”

Asked whether the Leeds campus is an environment where staff feel comfortable reporting when something is not right, Collins said he believes it is. “We have people reporting all the time. We’ve looked into several things,” he said. For example, he said, staff might report their concerns that a patient is getting an inappropriate dose of medication.

Crehan is still technically employed by the Veterans Affairs Central Western Massachusetts Healthcare System. Collins said the VA is taking disciplinary action against him, but he could not provide details.

Crehan has been incarcerated since Feb. 3, according to Northampton District Court records. He was arrested and ordered held without the right to bail in Greenfield District Court on charges of strangulation or suffocation and assault and battery on a family or household member after he allegedly strangled and punched a woman with whom he lived on Feb. 3.

Crehan declined to speak to the Veterans Affairs investigators who tried to interview him at the jail, according to court documents. His attorney in the Northampton case, Lisa S. Lippiello, said in an email that it is “peculiar and suspicious” that the allegations against her client were not made in a timely manner. She did not elaborate.

Outside review

Collins said that while his administration could have investigated the reported assault internally, he decided to contact the Veterans Affairs Office of Inspector General to investigate due to the seriousness of the alleged abuse and the failure by staff to report it immediately.

“When it gets to this level, my thought is to call in a third party, an experienced criminal investigator,” he said.

A report compiled by Kidd of the Office of Inspector General was included in Northampton District Court documents. It includes the accounts of staff members who said they witnessed the assault: Chapman, nursing assistant Kaleena Burke and nursing assistant Derek Richardson.

The Gazette’s attempts to speak with the nursing staff were unsuccessful. Chapman and Burke declined to comment, and Richardson could not be reached for comment.

According to the report, VA nursing staff members had called for a police “intervention” around 11 p.m. Jan. 25 because a male patient was yelling and acting aggressively toward a staff member in a common area. Richardson was able to talk him into calming down and going to his room, a technique Collins said is called verbal de-escalation.

Witnesses said the patient was still yelling and agitated but was going to his room when Crehan grabbed his arm and took him down to the floor. Once they got the patient to his room, Crehan twisted his arm behind his back, swearing at and threatening the man, according to an account Burke eventually provided. Burke said she told Crehan to stop, but he kneed the man in the ribs before eventually releasing him.

Collins said all nursing assistants have their backgrounds checked before being hired, and new hires go through significant training, including a program called Prevention and Management of Disruptive Behaviors. The program teaches caregivers how to verbally de-escalate a situation and, if that fails, to use specific physical restraint techniques “when there is an imminent risk of the person physically harming themselves or others,” according to the policy included in court documents.

Crehan’s techniques were “outside the way VA staff is trained to therapeutically contain patients,” Kidd wrote.

‘Reports of contact’

After Crehan released the patient, according to the report, two Veterans Affairs police officers arrived and the patient took medication and remained calm. Officer Corey Loranger told Kidd that he prepared a report of the incident, as usual, based on what Chapman told him had happened. The report stated that the patient threw himself on the floor and was picked up by staff and taken to his room.

But at some point over the next three weeks — for reasons that are, at this point, unclear — the nursing staff began communicating with Daniel Del Caro, a nurse manager, about what they had seen. Starting around Feb. 12, according to court records, Del Caro began collecting “reports of contact” from staff in which Chapman, Burke and Richardson described the alleged assault.

On Feb. 24, Associate Nursing Executive Angela Taylor informed Veterans Affairs police that she and Del Caro had information indicating that Crehan had assaulted a patient. Police contacted the Office of Inspector General that day, and Kidd began investigating Feb. 25. He presented his findings to leaders at the Veterans Affairs Central Western Massachusetts Healthcare System April 8, and Crehan was charged the next day.

(Del Caro, who did not witness the alleged abuse but began investigating it when it was reported to him, no longer works at the medical center. Collins said that fact is unrelated to the incident involving Crehan. “It wasn’t related to this specific case,” he said. “It was something else.” He declined to elaborate and Del Caro chose not to comment for this article.)

Threats

In his report, Kidd said that staff members he interviewed described Crehan’s actions as “unprovoked,” “too forceful,” “wrong” and “an assault.”

Richardson said he did not report it because Chapman was present and “did not interject,” Kidd wrote. The investigator did not include in his report whether Chapman gave a reason for misleading police about what happened or for not reporting the incident to a supervisor. “When asked why she didn’t seek justification from Crehan regarding his actions, Chapman said she never thought to,” Kidd wrote.

He did not include in his report whether he asked Burke why she did not immediately report what she saw, but she did tell Del Caro and Kidd that Crehan had threatened her. Burke wrote in an email to Del Caro that immediately after the alleged assault, Crehan said, “We’re good, right?” and “I guess I got a little out of control there” before laughing.

She told Kidd that the next night, Crehan said, “You tell anyone, I’ll f---ing kill you,” but then laughed and said, “I’m just kidding.” Burke told Del Caro she feared for her life after the incident.

When contacted by Kidd, the patient reported that as a result of the assault Jan. 25, he has become more distrustful of the VA. Collins said the statement is very concerning. “We want to have the best treatment of our veterans,” he said. “In this case, that wasn’t the situation.”

He said that in the future, he and other VA leaders will review policies and training, take any necessary disciplinary actions, and continue to work hard to earn veterans’ trust.

“When a situation like this occurs, it’s a step back, but our job is to move forward,” he said. “Every day we take great care across the system and the VA.”

Rebecca Everett can be reached at reverett@gazettenet.com.


 


Daily Hampshire Gazette Office

115 Conz Street
Northampton, MA 01061
413-584-5000

 

Copyright © 2021 by H.S. Gere & Sons, Inc.
Terms & Conditions - Privacy Policy