A third patient in 13 months has died while in treatment at the Sierra Tucson center north of Tucson, an autopsy report says.

The report from the Pinal County Medical Examiner’s Office released last week says a 55-year-old Pennsylvania man hanged himself with a belt in his room at Sierra Tucson on Jan. 23.

According to the report, the man had been on suicide watch and he left a suicide note inside a tote bag next to his bed. Witnesses told investigators that he was discovered in his room, “unconscious but still breathing,” two hours after staff began looking for him, the report says.

The suicide is the third patient death at Sierra Tucson since January 2014 and the fourth since August 2011.

Autopsies determined two of the patient deaths to be suicides and two as undetermined. The deceased patients, all male, ranged in age from 20 to 71.

“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 officials said in a statement emailed by director Philip Herschman.

“We are also cooperating with a review by appropriate agencies, which is still in a preliminary stage. Out of respect for the privacy of this patient and his family, we are limited in what else we can say.”

patient checked in Jan. 4

The upscale, nationally known Sierra Tucson facility is situated on a 160-acre site at 39580 S. Lago del Oro Parkway along the Pinal/Pima County border. It has 124 beds, plus 15 acute level beds.

In the latest case a married father of two, who had checked into Sierra Tucson on Jan. 4 for severe depression and chronic pain due to neuropathy, was found dead in his room at 12:41 p.m. Jan. 23.

The report says the man went to his exercise class at Sierra Tucson at 7:30 a.m. but did not show up to two subsequent classes.

According to the autopsy report, staff began looking for the man at about 10:30 a.m.

“He was on suicide watch and per protocol if the patient misses any classes that he is assigned to, they are supposed to immediately search for the patient,” says the autopsy report, which was signed by medical examiner Dr. John Hu.

911 call

When a staff member called 911 at 12:41 p.m., the man was reportedly “unconscious but still breathing.” Staff then began CPR but the Golder Ranch Fire Department arrived and took over and pronounced the patient dead at 1:13 p.m., the report says.

The patient’s family does not want the man’s name to be published, Tucson attorney Dev Sethi said. The patient was an engineer and business analyst who had recently been on short-term disability due to chronic pain that left him depressed. He went to Sierra Tucson at the urging of family members.

“The circumstances surrounding this death raise many questions,” Sethi said. “The family has requested a meeting with Dr. Herschman and the treatment team to get some answers.”

The facility has programs to help patients with addictions, mood disorders, chronic pain, eating disorders and trauma through its “Sierra Model” of integrating therapies such as massage, yoga and acupuncture with traditional psychiatry. Most patients are in their late 30s and early 40s. A majority of patients self-pay at a cost of about $1,300 per day.

“Like other treatment centers that care for patients with very difficult issues, suicide prevention is a key focus at Sierra Tucson,” the Sierra Tucson statement says. “We are committed to providing quality treatment and the safest care possible.”

Prior problems

State officials with the Arizona Department of Health Services, which licenses Sierra Tucson, on Thursday declined to comment on the most recent suicide and would not confirm whether they are investigating.

The state has reprimanded Sierra Tucson numerous times since 2009 for failing to follow its own policies on patient care:

  • The facility agreed to pay a $250 state fine for failing to follow its policies and procedures in its treatment of a 20-year-old man who died April 15.

The 20-year-old East Coast man had been in Sierra Tucson for drug rehabilitation and died of acute drug toxicity. An autopsy said it was unclear whether the lethal drug mix was intentional or accidental and listed the cause of death as undetermined.

Sierra Tucson officials in October filed a plan of correction in that case that said the facility had begun a random patient-chart monitoring program. Compliance with its suicide risk assessment and management policy would be monitored on a monthly basis by a random selection of at least 30 charts, the plan said. Staff training sessions on the facility’s suicide-prevention protocol also were conducted in May and June, documents show.

Before signing an enforcement in that case, state officials discussed two concerns with Sierra Tucson officials, documents show: practices relating to the assessment of patients’ vital signs; and also concerns about documentation of suicide risk assessment and management.

  • In June the state fined Sierra Tucson $2,000 for violating four rules and regulations related to patient care and safety connected to the Jan. 2, 2014, suicide of a 59-year-old patient. The fine was $500 per violation, and the infractions included not ensuring that a resident’s assessment information is reviewed and updated when additional information is identified.

The patient, who had a history of depression and anxiety, hanged himself with a shoelace from a shower head, according to a Pima County autopsy report. He died three days later at Oro Valley Hospital.

State records show that on Jan. 1, the patient had told his wife over the phone that he wanted to kill himself, and that she called the facility to tell them. But less than 24 hours later, the woman’s husband was dead.

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. While Sierra Tucson paid the state fine, it made no admission of wrongdoing.

  • 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 determine how he died.

After Litwack’s death, the state fined Sierra Tucson $9,250 for 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 was settled out of court in September.

  • In 2009 Sierra Tucson paid $3,500 to the state related to two incidents involving patients leaving the grounds. One patient with a history of psychosis left without permission, a state investigation said. In the second incident, documents show that a patient with suicidal thoughts, who had threatened to rape another patient, was discharged and left in his private car without documentation that he was safe to leave by himself.

Contact reporter Stephanie Innes at sinnes@tucson.com