The Sierra Tucson treatment center north of Tucson did not follow its own policies when a patient committed suicide there earlier this year, a state report says.

The latest case is the third time since 2009 that Sierra Tucson, owned by California-based CRC Health Group, has had problems with supervising patients, including a death in 2011.

A Sierra Tucson patient with a history of anxiety and depression was found unconscious in a shower on Jan. 2, the recently released report from the Arizona Department of Health Services says. The patient hanged himself with a shoelace from a shower head, an autopsy report says. He died three days later at Oro Valley Hospital.

The patient was at a “very high” risk for self-harm when he arrived at Sierra Tucson, 39580 S. Lago del Oro Parkway, the state records say. On Jan. 1, the patient had told his wife over the phone that he wanted to kill himself, state investigators found.

The phone call was witnessed by a Sierra Tucson residential therapist, the report says.

Bob Boatman, a lawyer for the patient’s family, says the facility subsequently had contact with his wife, who was extremely worried and wanted reassurance that her husband was okay.

Less than 24 hours later, her husband was dead.

“We are taking this situation extremely seriously and are reviewing what happened to see if we can make improvements that might enhance the quality of patient care,” Sierra Tucson’s Executive Director Stephen P. Fahey wrote in an emailed statement.

The facility is cooperating with the state probe and is providing state health officials with additional information, Fahey said.

“Out of respect for the privacy of this patient and his family, we are limited in what else we can say,” he wrote.

The state’s report found no evidence of documentation in the patient’s medical record that he was reassessed after he told his wife he wanted to kill himself.

 At Boatman’s request, the Star is not identifying the patient or his family. “This was a case of flat-out dropping the ball,” he said. “It was the grossest negligence you can imagine.”

State health officials stressed that the 16-page report is not a final determination and that Sierra Tucson still has the right to challenge the findings. The state, which licenses Sierra Tucson, has not sanctioned the facility related to the report, though that could still happen.

Sierra Tucson has had prior problems with following its own policies on supervision.

In 2009, it paid $3,500 to the Arizona Department of Health Services related to two incidents involving patients leaving the grounds. One patient with a history of psychosis left without permission. In the second incident, a patient with suicidal thoughts, who had also threatened to rape another patient, was discharged and left in his private car without any documentation that he was safe to leave by himself.

In 2011, Dr. Kenneth Litwack, a 71-year-old Orange County physician with anxiety and depression, disappeared from Sierra Tucson. Two weeks later he was found dead near Sierra Tucson’s stable, about a quarter-mile from the main building, in an area off the facility’s footpaths and trails. His body was so decomposed that an autopsy report could not determined how he died.

After Litwack’s death, the state fined Sierra Tucson $9,250 for multiple violations, including failing to appropriately allocate staff to supervise patients. The state also placed the facility on a probationary license.

Litwack’s family filed a lawsuit against Sierra Tucson in 2012, accusing it of improperly supervising patients. The lawsuit is scheduled to go to trial in Pinal County Superior Court in August.

The 31-year-old Sierra Tucson has been owned by CRC Health Group, a subsidiary of Boston-based Bain Capital financial services company, since 2006. CRC Health Group bills itself as the largest specialized behavioral health-care service provider in the U.S., seeing more than 30,000 patients per day at 115 locations.

Contact reporter Stephanie Innes at or 573-4134.