KALAMAZOO, MI — The death in March of a woman in the Kalamazoo Psychiatric Hospital set into motion events that turned the hospital on its ear — not because she died, but because of how details of her death were reported to the state.

Privacy laws prevent the hospital’s release of Majel Joyce Youdell’s name and many of the medical details of her case, but friends, family and other public documents, including her obituary, death certificate and hospital reports, confirm her death at KPH on March 6.

According to the documents, this is what happened:

Youdell, 68, had spent eight days being treated for pneumonia at Bronson Methodist Hospital before being returned March 5 to KPH, where she was a patient. She died at the Oakland Drive psychiatric hospital the next morning.

In May, an investigation was launched by the state’s Office of Recipient Rights, the arm of the Michigan Department of Community Health charged with protecting the rights of recipients of public mental health services.

According to the ORR report, obtained by the Kalamazoo Gazette through the Freedom of Information Act, the KPH associate director of nursing’s initial review of the death indicated that “based upon video surveillance at 8:18 a.m. (Youdell) removed her oxygen tubing and goes to the bathroom independently; at 8:20 exits the bathroom, bends over and picks up her oxygen tubing, sits down in a chair, begins to raise her oxygen tubing to her nose, and plops both arms (while holding the oxygen tubing) onto her abdominal area, apparently to rest; at 8:23 a.m. staff notice that (Youdell) is cyanotic, pull back her chair and apply oxygen. No PO2 reading was ever obtained after Youdell removed her oxygen tubing at 8:18 a.m.

“Page 13 of this report indicated that at 9:13 a.m. on 3/6/14 (Youdell) was pronounced deceased …”

The ORR report goes on to note at least four documented reports were given to the registered nurse supervisor March 5 regarding Youdell’s shortness of breath. But the inter-shift report that nurse wrote made no mention of any decrease in the woman’s pulse oxygen or episodes of shortness of breath.

The associate director of nursing’s concludes: “The oncoming shifts, without the benefit of of the patient’s condition sufficiently communicated to them, were unaware of the patient’s fragile condition and were thus inadequately informed of the need to to take the supportive interventions necessary to ensure adequate oxygenation while she was up to the bathroom, or to closely monitor her PO2 level and more closely attend to the re-administering of her oxygen. (Youdell) was noted to sit in her chair for three critical minutes without oxygenation while staff sat close by, unaware and thus inattentive to the ensuing crisis.”

That nurse’s belief that the RN supervisor’s inaction contributed to Youdell’s death was not reported to ORR. Whether her death was partly the result of inaction or negligence by hospital personnel or the natural progression of her illness was a matter of dissension among staff and administrators at KPH.

The certificate of death, signed by Medical Examiner Anil Patel, calls the death “natural” with causes listed as pneumonia, diabetes mellitus-2, hypothyroidism and hypertension. No autopsy was ordered.

Kalamazoo Department of Public Safety Chief Jeffrey Hadley said his department’s report shows that on March 6, the department responded to KPH “on a ‘found dead,’ report.” A public safety officer assisted in CPR on 68-year-old woman. 

“The patient had extensive medical problems and had just been released from Bronson (Methodist) Hospital,” Hadley said. “The patient was pronounced dead at the scene by a physician; it does not appear an autopsy was completed on the patient and the M.E. (medical examiner) released her body to the county morgue immediately.”

Police investigated no further. “There are no criminal charges being sought in this case as it appears to be a natural death,” Hadley said.

The Morbidity and Mortality Committee, made up of the hospital’s nursing supervisor, clinical director, medical director and the risk manager, filed a Final Death Report March 18, according the ORR’s investigative report. Approved by Coleman, the committee’s report terms Youdell’s death as “expected,” not “sentinel.” The Joint Commission, the nonprofit group that accredits health care organizations, defines a “sentinel event” as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof” that signals “the need for immediate investigation and response.” 

There was nothing in the Final Death Report that suggested any potential issues with patient care or staff failure to follow policy, the ORR report noted. Nor was the timeline established by the video surveillance included in that report or an April Sentinel Event Report filed with the Joint Commission.

“The omission of this information,” the ORR report said, “left an inaccurate and skewed picture of how the events of that morning occurred and how they were related to (the RN supervisor’s) failure to communicate between shifts as required.”

Coleman told investigators he did not notify ORR of apparent or suspected neglect in connection with Youdell’s death because: “At no time was I given information by the Morbidity and Mortality Committee, (the director of nursing) or the Sentinel Event Review Committee that there were concerns. Also, there were no concerns from the Joint Commission Reviewer.”

In his letter of resignation, Coleman notes: “My senior staff and I made a judgment that the problems identified in the ORR investigation were a result of employee performance issues, not neglect, and the ORR investigation fails to set forth any facts showing our judgment was wrong.”

The Kalamazoo Psychiatric Hospital on Oakland Drive.Kalamazoo Gazette file

Since Youdell’s death Coleman has resigned; the director of nursing and the RN supervisor have been fired; another associate director of nursing was disciplined, and another administrator has resigned.

According to her obituary from Redmond Funeral Home in Kalamazoo, Majel Joyce Youdell of Kalamazoo was born October 9, 1945 in Allegan County, the daughter of Charles and Mary (Jones) Lamb. She graduated from South Haven High School and received a degree in organ and music performance, and was a member of the Second Reformed Church. A member there recalled her active participation in senior activities and weekly Bible study before her hospitalization at KPH.

Youdell was preceded in death by her husband, James O. Youdell, in 2007.

Her niece, Gretchen Van Ness, of Boston, said the family learned of her aunt’s death a few days afterwards.

“She had been ill for some time, and had been in and out of the hospital, ” Van Ness said of Youdell. “She had a difficult time keeping her diabetes under control.”

“She’s the youngest of a large family — the only brother passed away last year,” said Van Ness, adding that Youdell is survived by a daughter, several sisters and nieces and nephews.

“Everyone deeply loved and tried to care for her. We were shocked by her death, but given her health problems it wasn’t a total surprise,” Van Ness said.  Youdell’s sisters did not know she was that ill, Van Ness said.  “Pneumonia is something people recover from these days,” she said, “so it was a surprise.”

As for events leading up to her aunt’s death, or the changes at KPH in its aftermath, “this is all news to us,” Van Ness said this week. “The family is devastated.”

“My mother understood she died in the hospital,” she said, “but by the time they found out, her body was already at the morgue.”

Her mother, Judith Van Ness, of Rochester, N.Y. said: “This is such a hard time because we have lost the bookends of our family.”

“In one short year, this family lost the oldest, David, and the youngest, Majel,” she said.