At least one Department of Mental Health employee who was involved in the suffocation of a longtime patient earlier this year was fired, and a contract employee left his job the day of the incident, according to records obtained by The State.
But at the end of a three-month internal investigation into the death of 35-year-old William Avant, Mental Health allowed the four other employees involved in the death to return to work, retroactively suspended them for just 30 work days and offered to pay them for the remaining seven weeks of work they missed while the investigation was ongoing, according to Department of Administration records.
Mental Health’s investigation found those four employees violated the agency’s safety practices and written policies in handling Avant, who died after he was restrained face down by staffers who dogpiled on top of him in violation of agency policy. But the investigation also concluded that “the allegation of abuse could not be substantiated,” according to letters hand-delivered to each employee.
The investigation’s findings on the two departed employees — and any other staffers who might have been involved — remain secret, as the Administration Department does not have them and Mental Health refused to release them this week at The State’s request.
The employment records, which The State obtained after learning the names of six suspects in a closed criminal investigation into Avant’s death, offer new insight into how Mental Health responded to the Jan. 22 death of a patient.
Mental Health has refused to answer questions related to Avant’s death or how it disciplined the employees involved, citing patient privacy laws.
First reported by The State last month, Avant’s death was ruled a homicide because Mental Health hospital staffers pinned him face down in a hallway and lay on top of him, preventing his ability to breathe. The staffers restrained Avant after he tried to push his way into a nearby medicine room. Unable to breathe under their weight for four minutes, Avant suffocated and could not be revived.
Avant, who had been a patient for 12 years at Columbia’s Bryan Psychiatric Hospital, had Klinefelter syndrome, a chromosomal disorder linked with anxiety, depression, learning disabilities and behavioral problems, such as impulsivity.
The employees’ actions were explicitly prohibited in their training, which instructs employees to verbally de-escalate such confrontations, never pin patients face down, never lie across their back or torso, and always ensure that patient being restrained is breathing.
Records obtained from a February investigation by state health regulators show three of the 13 employees involved in the incident had not completed their required training.
The State Law Enforcement Division declined to press criminal charges.
Mental Health’s response
Now, employment records obtained by The State confirm for the first time that at least one staffer involved lost his job after Avant’s death, while others were disciplined.
Edward Lee Freely Jr., who started as a registered nurse at Mental Health in November 2018, was fired on April 24, a day after the agency’s internal investigation concluded. Mental Health would provide no records explaining why Freely was fired, and the Administration Department had none in their possession, a spokeswoman said.
The State has sent the agency a Freedom of Information Act request for the records.
The State called a Buffalo, New York, phone number listed on a healthcare provider registry for a registered nurse specializing in adult mental health named Edward L. Freely Jr. A man answered but hung up shortly after a reporter identified himself.
Another suspect in SLED’s investigation, Joshua Canales, was a contract employee whose work for Mental Health ended on Jan. 22, the day of Avant’s death and the start of the internal investigation, records show. The agency would not say why Canales left.
Four other employees were suspended without pay from Jan. 22 until the end of the three-month investigation. They are human services coordinator Vivian Ward and behavioral health assistants Shytia Goodson, Donald Beard and Dorien Bailey.
On April 23, they each received a letter from Mental Health Assistant Director of Nursing Trinita Floyd informing them that the internal investigation determined they failed to follow the department’s training, “which led to a sentinel event.”
A “sentinel event” is an unexpected incident that involves a serious injury or death, or the risk of them, according to the Joint Commission, which accredits hospitals.
Violating safety practices doesn’t necessarily constitute physical abuse of a patient, a Mental Health spokeswoman said, citing a state law that defines physical abuse as “intentionally inflicting or allowing to be inflicted physical injury on a vulnerable adult by an act or failure to act.”
The employees were each given 30-day suspensions that had already been served in the three months of work they missed. As a result, Mental Health offered them nearly seven weeks in back pay for the extra time they missed during the investigation.
Mental Health employees are generally suspended without pay when they become the subject of an internal investigation.
The employees were ordered to return to work the next day and attend mandatory training at 8 a.m.
Three of those four employees remain at Mental Health, records show. But Bailey left his job two weeks later on May 9 for reasons that the agency won’t explain. Bailey did not respond to a request for comment.
Efforts to reach the other employees were unsuccessful. A Mental Health spokeswoman said the employees had been informed of an upcoming news article that would mention their suspensions.
Mental Health employees were sent an email on Monday, July 15, a day after The State’s initial story on Avant’s death, reminding them not to speak with reporters and to direct any inquiries to the department’s communications office.
“In light of events that have taken place at Bryan, there may be efforts to contact staff for statements,” Mental Health Director of Social Work Shannon Shuler wrote in the memo. “DO NOT under any circumstances discuss any hospital-related information with the media. They must be directed to the Director of Public Affairs.”
Avant’s family declined to comment through an attorney.
State agencies keep case secret
Exactly what role each of the six staffers played in Avant’s death is unclear, since Mental Health and SLED won’t answer questions about the incident, employees were not named by state health regulators in their investigation into the death, and the employees’ identities were not clear in The State’s review of video footage of the incident.
The State was able to request their employment records after seeing their names listed as suspects in Avant’s death in an April 4 letter to SLED from the 5th Circuit Solicitor’s Office.
The solicitor’s office advised SLED that it didn’t think probable cause existed to charge the suspects with a crime in Avant’s death, based on a review of SLED’s investigation.
SLED has refused to publicly release that investigation, citing privacy laws that seal the records of vulnerable adults, even after a patient’s death at the hands of government employees.
The State was unable to identify any other employees potentially involved in Avant’s death or whether they were disciplined by the agency.
Since The State’s July 14 report, the Joint Commission that accredits hospitals has opened a review into Avant’s death, and the S.C. House Oversight Committee has begun to investigate what went wrong.