BRATTLEBORO — Samantha Siano was last seen on Sept. 2. Two days later, her body, which had begun to decompose, was found in a residence hall bathroom at the Brattleboro Retreat, the state's largest psychiatric hospital.
Siano died of a drug overdose. The Vermont medical examiner and local police determined last week that the 36-year-old former social worker from Exeter, N.H., had committed suicide.
After six days of intensive inpatient care at the Retreat for mental health and addiction treatment, Siano was released to the Birches Treatment Center, a Retreat outpatient care program, on Aug. 28. On Labor Day weekend, Siano, who had a history of substance abuse, brought more than a dozen prescription drugs back to her room at the Ripley residence hall after a short stay at a local motel, according to a recently released Brattleboro Police Department investigation. She was last seen on the evening of Sept. 2.
Siano was absent for two days of intensive outpatient treatment classes before Retreat staff found her body on Sept. 4, according to police. Rigor mortis had begun to set in and her face showed signs of decomposition, the police reported.
The first day she missed treatment, a Retreat employee went to Siano's room to see if she was OK, but did not knock on a closed bathroom door. The next day personnel found Siano's body in the bathroom.
Police photographed the scene: More than two dozen empty and partially emptied pill bottles littered the room. An iPhone was playing the Rihanna song “Stay,” on a continuous repeat, police reported. A suicide note dated Sept. 2 was found at the scene.
The death certificate shows that Siano consumed six drugs. She was pronounced dead on the evening of Sept. 4. No estimated time of death was recorded.
An unidentified family member told police that Siano had significant alcohol and prescription drug addiction problems and had been in and out of hospitals in New Hampshire. On a visit to New York City, she stole money and jewelry from her sister to buy drugs.
Konstantin von Krusenstiern, the Retreat's vice president of strategy and development, said in a statement: “This death reminds us that mental illness and addiction can take a human life. We are saddened by this and wish to express our condolences to the family and loved ones of this individual.”
Siano's death is the second fatal drug overdose at the Brattleboro Retreat since 2012. In January of that year, Jared Fitzpatrick, 29, died of a methadone overdose. His death led to an investigation from Centers for Medicaid and Medicare Services.
After Fitpatrick's death, the Retreat lost its “deemed status” as a federally funded facility. Since then the Retreat has struggled to maintain compliance with federal standards of care, and CMS has twice threatened to terminate funding for the facility.
This May, the Retreat was investigated for a series of violations including the forced restraint and medication of a patient and inadequate documentation of patient treatment (patient charts were based on templates and did not include individualized recommendations for therapy and medical care).
The intensive regulatory review of the Retreat comes at a time when the psychiatric hospital has been under an increased level of public scrutiny. The Shumlin administration and lawmakers made the Brattleboro Retreat, a private psychiatric hospital, a hub of Vermont's decentralized system of care in 2012 after the Vermont State Hospital was damaged by Tropical Storm Irene.
The Retreat is now approved to take patients under state care as part of a long-term contract with the Vermont Department of Mental Health. The Retreat serves 14 to 28 state patients at any given time.
On Wednesday, after nearly two years of intensive regulatory review, the Retreat announced that CMS would continue funding the Retreat after regulators determined that the psychiatric hospital had met federal standards of patient care.
The stakes are high: Federal funding pays for a third of the Retreat's patients, including those who are under state care.
Suicide raises questions about Ripley
Ripley, the building where Siano died, is a residence hall for outpatients. Though Ripley is owned and staffed by the Retreat, the hospital does not provide clinical supervision for the dormitory. For that reason, Retreat officials say, Ripley does not fall under stringent state and federal regulations.
Von Krusenstiern characterizes Ripley as a separate facility that is not technically a part of the hospital. Patients must pay for stays at Ripley a week in advance, by check or credit card, as insurance companies will not pay for outpatient housing.
The Retreat's website describes Ripley as “partial hospital” that serves 30 patients with a dormitory option. The hospital is expanding that option: up to 50 rooms in all will be available once renovations are complete.
In a September email statement about Siano's suicide, von Krusenstiern characterized Ripley as a lodging service “available to clients who choose not travel for their care.”
Centers for Medicare and Medicaid Services officials initially said they had no regulatory authority over Ripley because the facility is not part of the Retreat's clinical care programs.
Later, the Vermont Division of Licensing and Protection, which regulates mental health facilities for CMS, inspected Ripley after Siano's suicide and determined that the Retreat had violated no federal regulations.
The Retreat did not formally report the suicide to the Vermont Department of Mental Health, according to a log of incidents obtained by Rep. Anne Donahue, a Republican from Northfield who has long advocated for quality services for Vermont psychiatric patients. Retreat officials verbally notified several lawmakers and the department, but didn't report on the incident until later.
Frank Reed, deputy commissioner of the department, said he thought the Retreat reported the suicide at the time. He recalled, however, that they “questioned whether it was a reportable event because it occurred in an outpatient treatment program.”
“In our discussions with them, we advised that with the scrutiny placed on the facility, and interest in multiple outside entities, it was better to be conservative and report it, which they did,” Reed said in an interview.
Reed said any facility funded by the state is required to report incidents that occur at other programs they operate, regardless of who pays for the services.
Donahue questions more broadly whether Ripley can be considered a residence hall under state statute, which defines a private psychiatric hospital as a “domicile” occupied by two or more mentally ill persons.
Like its other buildings on campus, the Retreat requires patients who enter Ripley abide by a strict set of rules. They are not, for example, allowed to bring guests into their rooms; drugs, alcohol and cigarettes are prohibited.
In an email, Donahue told VTDigger that she is “very disappointed in the ongoing issues with the Brattleboro Retreat about transparency on key issues reflecting on the ability to provide good patient care.”
“This tragic suicide was essentially dismissed by the Retreat as unrelated to clinical oversight or programs, and the Retreat told the Department of Mental Health it was not a reportable event,” Donahue wrote.
She added: “The failure to investigate her absence from the day program for two days while staying at a Retreat-run and -staffed residence is very disturbing. I hope that now that the facts are out, the Department of Mental Health will be closely reviewing this death within its oversight responsibilities for hospitals providing psychiatric care in Vermont.”
In an email to lawmakers, Donahue wrote that “this entire episode exposes further misleading information (misleading through omission) by the Retreat.”
Donahue told her colleagues on the Mental Health Care Oversight Committee that the “reliability” of the Retreat as a long-term facility for patients under the care and custody of the state, especially in light of Fitzpatrick's death in 2012 from a drug overdose, “needs to remain an issue of concern for us, whether or not [the Retreat] is found by CMS to have come back into compliance in the recurring back-and-forth status of violations and threats of termination that has marked the past two years.”