Jim Brieske’s final hours before his suicide were a mystery to his family for two years.
May 23, 2016, was a Monday. The high temperature was 83 degrees. Skies were clear.
At 11:52 a.m., Brieske checked into Mercyhealth Hospital and Trauma Center, Janesville, according to his medical records.
At about 10:30 p.m., Brieske jumped off the south side of the Centerway Bridge into the Rock River, according to police reports.
Three days later, his body was retrieved downstream near the Center Avenue bridge in downtown Janesville.
Brieske’s family didn’t know he had visited the hospital the day he died until fall 2018 when his brother Brian Brieske was contacted by reporters from WebMD and Georgia Health News who were reporting on emergency room violations across the country.
The Brieske family wonders if Jim’s death could have been prevented had his hospital visit gone differently, Brian said.
A complaint made to the U.S. Centers for Medicare and Medicaid Services shortly after Jim’s death prompted the agency to launch an investigation into Mercyhealth’s compliance with the Emergency Medical Treatment and Labor Act.
Investigators found the hospital had violated multiple requirements and put emergency department patients in “immediate jeopardy,” according to a letter from Gregg Brandush of the Centers for Medicare and Medicaid Services to Mercyhealth.
The federal agency threatened to terminate Mercyhealth’s Medicare participation as a result, according to the letter.
The Gazette obtained documents detailing the investigation from the Center for Medicare and Medicaid Services and from journalists with WebMD and Georgia Health News.
A Mercyhealth official said Friday the hospital disputed and still disputes multiple findings from the Centers for Medicare and Medicaid Service’s investigation.
May 23, 2016
Medical records provided to The Gazette detail Jim’s hospital visit.
Jim, 53, told hospital staff he had a “desire to end his life” but did not have a plan in place for suicide. He had experienced suicidal ideations about six months earlier, which landed him at Mercyhealth the week of Thanksgiving 2015, Brian said.
Jim was diagnosed with bipolar disorder in 2006. The disorder caused Jim to experience chaotic episodes. He struggled to maintain stable living situations but never was deemed a danger to himself or others, Brian said.
In November 2015, Jim self-committed at Mercyhealth and was transported to Mendota Mental Health Institute in Madison for a three-day hold, Brian said.
But Jim’s hospital visit in May 2016 went differently, according to his medical records, which detail the following:
Jim was placed under suicide watch at Mercyhealth and was cleared for behavioral health evaluation. While waiting for doctors, Jim walked out of his exam room, removed his underwear and attempted to walk around naked.
Jim struggled to keep his eyes open and mumbled incoherent statements as a social worker tried discussing treatment options with him.
Jim did not respond to the social workers’ questions about his conditions.
The social worker directed staff to call the Rock County Crisis Intervention team to assess Jim for involuntary treatment.
The social worker left the room to consult with the psychiatrist on call. When the social worker returned, Jim had been discharged.
The Centers for Medicare and Medicaid investigation indicates the doctor who discharged Jim did not discuss Jim’s condition with his case manager, the social worker or the crisis team. The doctor believed Jim was stable enough to be discharged and instructed Jim to contact his case manager from Rock County Human Services immediately after leaving the hospital.
Brian has contacted Rock County Human Services to learn if Jim ever visited or called his case manager that day.
A representative from the county told Brian his brother’s records are sealed and the county could not discuss Jim’s history with Brian, he said.
Director of Human Services Kate Luster said she was unaware of Brian’s request and recommended he talk to the county’s HIPAA privacy officer.
A lawyer told Brian he could petition to become Jim’s special administrator to get the records, but Brian suspects that would be costly and take time, he said.
The July 20, 2016, report on the investigation at Mercyhealth indicates problems with Jim’s case and others. According to the report, the hospital failed to:
- Complete an appropriate medical screening exam for one of six patients with suicidal ideations.
- Document time of medical screening exam for three of 20 patients.
- Continuously monitor four of six patients with suicidal ideations.
- Ensure all patients in the emergency department received stabilizing treatment before being discharged.
- Post Emergency Medical Treatment and Labor Act signs in five of nine areas likely to be noticed by all individuals entering the emergency department.
Mercyhealth disputes the finding that the hospital did not complete an appropriate medical screening exam for one of six patients with suicidal ideations, said Paul Van Den Heuvel, vice president of legal affairs for the health system.
“Given privacy laws, we cannot comment on specifics as to the patient’s treatment, however, to the extent that any patient consents, generally all patients receive a medical screening exam,” Van Den Heuvel said.
Many suicidal patients receive comprehensive treatment in the emergency department and then are treated in the hospital’s in-patient psychiatric department.
The hospital cannot commit a patient without consent or government intervention, such as from law enforcement or county social services, Van Den Heuvel said.
“What I will tell you is Rock County is very reluctant in circumstances to proceed with a process to admit a patient against his or her will,” Van Den Heuvel said. “It does not have the staffing or resources to staff a night shift relative to crisis intervention.
“It is unfortunate that there are other counties that are more aggressive in their approach to save the patient from themselves and perhaps put other people in harm. There is an apparent philosophy with Rock County is they are kind of reticent in that circumstance.”
A social worker, in Jim’s case, requested Rock County Human Services be called, but Jim was discharged before the call was made, according to investigation records.
The health system also disputes the finding that four of six patients with suicidal ideations were not continually monitored, Van Den Heuvel said.
The patients’ medical records might not have properly identified the environment the patients were in, Van Den Heuvel said.
Patient rooms in the emergency department are glass-fronted and situated in an ovular shape around a large work station where nurses, doctors and staff had a view of patients, Van Den Heuvel said.
The finding that Mercyhealth failed to document actual time of medical screenings for three of 20 patients was correct but should be viewed in context, Van Den Heuvel said.
Mercyhealth’s emergency department is often busy. Physicians had been allowed to document care at a time when it was most convenient to them, which might have been an hour or so after care was given. After the investigation, the health care system changed its policy to require more real-time documentation, Van Den Heuvel said.
The health system provided additional training to emergency staff and reviewed policy as a result of the investigation, Van Den Heuvel said.
A follow-up survey Sept. 7, 2016, by the Centers for Medicare and Medicaid Services found Mercyhealth made corrective action to be in compliance and was no longer at risk of losing its Medicare participation, according to a letter from Tamra Swistowicz of the centers to Mercyhealth.
Van Den Heuvel said incidents with unfortunate results in the emergency department should not diminish the incredible work emergency workers do every day.
The hospital cares for more than 2,000 behavioral health patients in emergency rooms every year. More than 600 of those patients receive inpatient psychiatric care, Van Den Heuvel said.
“Our physicians, our nurses, our other support staff, they’re heroes in the work that they do,” Van Den Heuvel said. “A lot of people can shy away from this work and many do.”
Would Jim be alive if Mercyhealth had called his family to tell them Jim was in the hospital?
Brian thinks so, but there is no way of knowing now.
Van Den Heuvel said he believes the process for calling emergency contacts was the same for physical emergencies, such as injuries sustained in a car accident, and behavioral health emergencies, but he is unfamiliar with the exact policy.
“But I know from interacting with our team in multiple environments, they will search for emergency contacts not even just in your medical records, they will search for if anyone knows if they have a husband, wife, sister, brother,” Van Den Heuvel said.
Brian said none of his family members received a call that day.
Brian and his family wish they knew more about what drove Jim to jump that day. They speculate the death of Jim’s father, death of Jim’s stepfather and the recent loss of his apartment contributed to him being suicidal, but they will never know for sure.
The question of whether Jim saw his Rock County case manager that day nags at Brian, he said.
Is there something they can do now?
Some of Brian’s family members want to take legal action against Mercyhealth, Brian said.
Brian has been told conflicting opinions from lawyers on whether a sibling or parent could sue for wrongful death. Some have said a spouse or child would have to do so, but Jim had neither.
“It is not about money, but we are trying to find out what happened, what led up to this,” Brian said. “He had all day to think about this.”
Before Jim jumped off the bridge, he stopped and asked a nearby fisherman for a cigarette.
Jim walked around for a while and then returned the cigarette to the fisherman, saying he no longer wanted it, according to police records.
Brian thinks his brother was stalling, hoping to find someone to talk to on the bridge to talk him out of jumping.
But that didn’t happen.
“I am guilty like other people,” Brian said. “When we see people on the street, what do we do? We turn the other way. I am probably just as guilty as the other people, but I am trying.”