The state Department of Health Services identified four deficiencies in services by Rock County’s Crisis Intervention Unit following an investigation into how the county handled a suicidal teen.
The county has to provide a plan of correction to the state as a result of the July 31 investigation, according to records obtained by The Gazette.
Family members of Cole Fuller, who died by suicide April 4, believe Rock County officials failed to help Cole during the 45 days he was under county supervision for a Chapter 51 mental health commitment.
Cole’s father, Jeff, filed a complaint with the state, hoping the county would be held accountable for failing his son.
The investigation found Rock County:
- Failed to coordinate for or link Cole and his family with services while Cole was at risk of a crisis.
- Did not complete an adequate crisis plan for Cole in accordance with state statutes and county policies.
- Did not give Cole’s family the option to use formal or informal procedures for resolving complaints and disagreements.
- Failed to provide prompt and adequate treatment, supports and community services.
Cole had been seeing mental health professionals in Walworth County before being transferred to Rock County early this year. Mental health services halted after Cole landed in Rock County.
State statutes require providers offer “linkage and coordination services” to clients at risk of crisis.
Rock County officials, according to the report, took Cole’s health insurance information and told the family they would find a provider that accepted his insurance, but Cole never received treatment.
A crisis intervention worker involved with Cole’s case noted in his reports he had six months to find Cole a psychiatrist. The state investigator determined a six-month timeline did not meet Cole’s needs, according to the report.
Rock County adapted a crisis plan for Cole based on the plan he had in Walworth County. Investigators found Rock County’s crisis plan “was not completed ... in a manner that would thoroughly inform crisis staff and family with information found to be helpful in a time of crisis.”
The crisis plan:
- Did not include Cole’s history of suicidal ideation or new patterns of risk.
- Stated “unknown at this time” under categories of trauma history and medical problems.
- Did not include information on Cole’s previous crisis provider.
- Gave incomplete history of Cole’s hospitalizations.
- Failed to include a specific plan for crisis response as required by county policy.
Investigators found prompt and adequate services were not provided to Cole “as evidenced by delayed case management appointments, a lack of referrals, and under-assigned risk potential.”
The most recent examination of Cole before his death determined Cole was at “high-risk of crisis, including suicidal and violent behavior” and had a history of losing progress when not receiving constant treatment, according to the report.
Cole’s family feels crisis workers did not take the result of Cole’s examination seriously, according to the report.
A crisis worker rescheduled meetings with Cole twice because of health problems, delaying Cole’s access to treatment.
Crisis workers told investigators it is the responsibility of individual crisis workers to reschedule and make appointments with clients and that there is no policy for monitoring of canceled or rescheduled appointments with clients receiving crisis services.
A crisis case manager told investigators the manager conducted a Columbia Suicide Scale screening with Cole. When asked if the worker inquired on access to weapons in the home, the crisis manager told the investigator it was assumed Cole was educated on weapons access because of Cole’s commitment, according to the report.
The crisis manager said Cole reported having “future thinking” and “plans for the weekend” at the end of the assessment meeting, which took place hours before Cole’s death, according to the report.
Cole’s family July 18 met with representatives from the county to discuss concerns they had about Cole’s care and were not given the opportunity to file a complaint or grievance with the county, according to the investigation.
“You know, I never really thought of it that way,” a crisis worker told an investigator about why a complaint with the county was not filed.
“We were trying to listen to and be there for the family but as it progressed I didn’t think to determine whether or not this had escalated to a formal complaint. I didn’t have that procedure in mind.”