Mental Health Patient Who Died in Car Accident “Not Properly Secured By Seatbelt”


Guam – The deaths of two Department of Mental Health and Substance Abuse patients in May could have been prevented, according to papers filed in District Court by Federal Manager Dr. James Kiffer.


Dr. Kiffer submitted a 3rd Quarter Status Report to the District Court of Guam detailing the events that led up to the deaths of the two patients which occurred just weeks apart.

One patient died in a car accident. After an internal investigation, it was determined that the patient “was not properly secured by seatbelt” in the vehicle that was being driven by a DMHSA vendor. Kiffer notes that although the driver of the vehicle that struck the Mental Health van was speeding, the area in which the Mental Health patients lived was in one of Guam’s busiest highways.

“Vendor’s homes should be in community settings where clients have the opportunity to interact with neighbors within a community in order to gain appropriate independent living skills,” wrote Kiffer, adding that he has requested that future Request For Proposals include this requirement in order to qualify for program selection.

In August, Kiffer told District Court Judge Consuelo Marshall that the DMHSA van with six mental health clients was making a left turn when another car coming from the opposite lane struck the van, forcing the patient to be ejected out of the vehicle. The other occupants of the vehicle suffered minor injuries, he added.

In the second incident, a patient suffered a fatal heart attack after he choked on a piece of watermelon. According to Kiffer, there was a notation in the patient’s chart that he had difficulty swallowing.

“It did not appear that program precautions were taken in the home as they may not have been aware of reported swallowing difficulties,” wrote Kiffer. “The primary action to taken to reduce the likelihood of this event is for the Department to assume responsibility of professional service and treatment to clients in the homes rather than shift that responsibility to vendors.”

The patient, Kiffer says, was being cared for in a residential placement home and by the vendor providing the services. He adds that DMHSA will begin providing its own staff to each vendor to assure “quality of service” and that “information in the mental health chart is acted upon within the residential settings by the vendor staff.”