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The video released Tuesday shows employees playing cards, watching
television and goofing off as Sabock sat ailing and dazed a few feet away, his
clothes soaked with his urine.
Though the footage was described in an August investigative report, the
recordings were not made public until The News & Observer and other media
outlets worked with Sabock's widow to force their release.
The visual record of Sabock's last day shows that at least 16 staff members
responsible for his care over four work shifts failed to recognize that he was
in distress until it was too late.
The state's internal review, released to The N&O in the last week, says
employees lied to investigators and falsified Sabock's medical records to show
that they had provided him care that the video proves they did not.
An autopsy would later conclude that Sabock, who had bipolar disorder, died
of a heart condition. But records show the medical examiner was provided false
information about the patient's condition in his final hours, including
fabricated measurements of his vital signs. The hospital's report of the death
also omits any mention of his choking or falling.
Requests for interviews with Cherry Hospital Director Jack St. Clair and
Nursing Director Bonnie Gray, who prepared the report to the medical examiner,
were declined.
Tom Lawrence, spokesman for the state Department of Health and Human
Services, said there would be no response Tuesday to questions submitted
earlier by phone and e-mail.
Dr. John Butts, the state's chief medical examiner, said Tuesday he doubted
that having access to the video or internal investigative report would have
changed his office's conclusion that Sabock died of natural causes related to
heart problems. The autopsy report shows no evidence of head trauma, he said.
Started with a fall
Sabock's ordeal began April 28, when shortly after 8 p.m. he went to a room
where he took his evening medication. The tape shows him starting to choke on
the pills, with health care technician Lucretia Houston patting him on the
back. He then falls, his head bouncing off the floor.
As Sabock turns purple while he's on his back, Houston thrusts on his
abdomen with her hands in an attempt to help him breathe. She then quickly
pulls him up off the floor, without checking to see whether he was injured by
the fall, which the report notes is a violation of the hospital's emergency
procedures. A nurse, Susan Watson, stands by and does little to help.
Watson later told investigators she "freaked out" when Sabock choked and
fell.
"I just stood there and froze is what I did," Watson is quoted as saying in
the investigative report.
Sabock was guided back to the day room on his ward and deposited in a
chair. Nearly two hours passed before he was taken to a nurses' station to be
checked out by a physician assistant. She ordered the staff to take Sabock's
vital signs every six hours to ensure that he was OK.
The patient was returned to the chair in the day room at 10:22 p.m., where
Houston took his vital signs. While doing so, she can be seen dancing and
joking with employees.
The employees appear to largely ignore Sabock until they finish their card
game about hour later, when a worker turns out the lights and leaves the
patient sitting in the dark.
In a chair for 22 hours
All told, Sabock remained in the chair for 22 hours and 34 minutes. His
medical records indicate that during that time workers followed instructions
to check his vital signs regularly and provide him food and fluids.
The video footage shows those records were falsified.
Though not all the entries are signed by an employee, investigators
concluded that health care technician William Mathis fabricated entries
indicating he had taken Sabock's vital signs and given him juice.
The report also says Mathis lied to investigators, as did nurses Latasha
Lewis and Catherine Carraway, about care the video shows was never given.
A list of Cherry Hospital employees provided by the state last month shows
Lewis was no longer at the hospital. Mathis, Carraway, Houston and Watson were
still on the payroll.
As people crowded into the day room the next morning, the video shows other
patients appearing to check on Sabock. Employees try to rouse him occasionally
and change his T-shirt. At mealtimes, his food is set aside or eaten by
others.
Not until 8:59 p.m. on April 29, about 25 hours after he choked and fell,
did two employees lift Sabock and slide him into his bedroom, out of the
camera's view.
Moments later, employees rush through the day room with a crash cart,
indicating a Code Blue had been called. Sabock is seen being wheeled out on a
stretcher by paramedics at 9:27 p.m.
Rights group shocked
Attorneys for Disability Rights North Carolina reviewed the video and
investigative report. Vicki Smith, the advocacy group's executive director,
said the lack of adequate response when Sabock choked and fell was especially
indicative of the poor care at Cherry Hospital.
"Almost immediately, they're pulling on his arms and trying to get him to
stand up and walk him away," Smith said.
"I mean, if you were at the mall or on a street corner and you saw someone
fall and hit their head like that, the first response would be to care for
them, to check their head, to get ice, to tell them to be still. There was
none of that."
Smith said that changes made at the hospital in the wake of Sabock's death
amount to little more than window dressing.
"We have a lot of concern about whether or not the hospital's current
management will be able to turn this facility around," she said. "I don't
think Dr. St. Clair has the will to do all that needs to be done."
Gene Riddle, a Goldsboro lawyer representing the patient's family, said
Sabock's wife and children are still trying to cope with his loss.
"They were heartbroken when he died and they are heartbroken at what they
are now learning," Riddle said Tuesday. "We need to remember that this was
somebody's son, somebody's husband, somebody's father."
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EMPLOYEES' STATUS
In a report completed in June but not released until last week, state
investigators named 16 Cherry employees as being derelict in their duties in
the events leading up to Steven Sabock's death. Until the case became public
in August, no punishment stronger than a 5-day-suspension had been given to
any of them. Others received only counseling. One nurse resigned during the
investigation.
DHHS Secretary Dempsey Benton later ordered that those decisions be
reviewed. However, on a list of Cherry Hospital employees provided by the
state Office of Personnel last month, the names of at least a dozen of the
employees involved in the Sabock case are still listed as employed, including
workers cited in the investigative report as falsifying medical records and
lying.
Though neglecting a patient in a state institution is a crime under state
law, none of the employees has been charged.
Sabock sits alone in the darkened day room, left. After being lifted by
employees and taken to his room, he is shortly thereafter wheeled out on a
stretcher, right photo. He died after sitting in the chair for more than 22
hours and getting no food or drink.^
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