PEMBROKE, Mass. - The mother of a 20-year-old Lynn woman who died suddenly at a South Shore psychiatric hospital believes her daughter’s death could have been prevented.
Amber Mace had suffered for seven years from mental illness, an eating disorder and multiple suicide attempts. Last August, she entered Pembroke Hospital, a 120-bed psychiatric facility owned by Arbour Health System.
Her mother, Tammy Mace, visited her and told a nurse that her daughter didn't seem herself.
“She was just like, kind of drugged, in a way,” Mace said. “I talked to her that night on the phone. She said she didn’t feel good; she was going to bed. She never woke up.”
State reports obtained by FOX25 show the Department of Mental Health did not blame the hospital for Amber’s death, because the medical examiner determined her death was natural, caused by heart failure due to inflammation of the heart muscle.
But the state criticized Pembroke for “dangerous and inhumane" conditions, including failing in its 15-minute nighttime wellbeing checks and “concerns related to documentation of the patient’s status.”
The state cited nurse’s notes referring to Amber’s vital signs as stable, when her pulse rate was actually “not considered to be stable vital signs for a young woman of 20 years old.”
Amber’s headache and nausea were attributed to her history of migraines, but migraines were not documented by the hospital, the report states, nor was the “important observation of a mother that, ‘This is not my daughter. She seems like a zombie.’”
“She’s my only daughter, and just the neglect of her being there so long, it’s just unbearable,” Mace said. “It would be one thing if they said, 'Well, she passed and we did everything we could,' you know? It’s another thing that she was there neglected.”
When Amber was discovered unresponsive, some Pembroke staff members described her as still warm to the touch, “lying on her side” and “making gurgling type sounds,” the report says.
But paramedics described finding her minutes later with “rigor mortis noted to all extremities and jaw,” leading them to believe, "it looks like rigor mortis for two hours.”
The hospital physician described Amber as “pale, bluish and cool,” with her teeth clenched.
Although rigor mortis rarely sets in earlier, former forensic anthropologist for the Chief Medical Examiner’s Office, Anne Marie Mires, says, under certain circumstances, the process can begin in less than two hours. The timeline for rigor mortis, she said, is difficult to pinpoint.
“Literature says that normally it sets in in two to four hours,” Mires said. “But in fact, there are certain variables that are going to trigger it, and it may be within minutes.”
Last month, DMH threatened to shut down admissions if Arbour did not fix safety violations, including inadequate staffing and issues with quality of care, found at Pembroke Hospital and three other Arbour facilities, in 16 unannounced inspections.
Arbour Health System declined to comment specifically about Amber's death, citing patient confidentiality laws, but sent a statement to FOX25.
“Pembroke Hospital serves a critical role in the Commonwealth by accepting and treating patients with acute psychiatric and co-occurring substance use disorders. The hospital accepts over a thousand patients each year from area emergency departments and other settings who are at risk of harm to themselves or others. The hospital admits patients who are in acute psychiatric distress including many who have aggressive and/or assaultive tendencies. Our dedicated staff receive extensive orientation and training to actively manage patient’s issues as well as to monitor their safety and well-being. Pembroke has been successful in caring for adolescents and adults over the past several decades and we remain committed to serving those who need access to acute mental health treatment.
All Arbour Health System (AHS) hospitals including Pembroke Hospital are licensed in good standing with the Massachusetts Department of Mental Health (DMH) and fully accredited by The Joint Commission. In fact, within the past year, all AHS facilities including Pembroke successfully passed their licensure renewal inspections conducted by DMH. DMH regularly completes unannounced inspections at all of their licensed facilities. AHS and DMH share the common goal of ensuring the best possible care and treatment for our patients and we appreciate our collaborative relationship to achieve that goal. Notwithstanding any findings from their recent surveys, none of the AHS facilities have had their licenses impacted nor admissions affected. Pembroke Hospital and other AHS facilities received reports from DMH identifying issues for remediation. We have responded with action plans which have or are in process of being implemented and monitored for completion. Pembroke Hospital’s action plan was accepted by DMH and all corrective items have been implemented. We continue to work collaboratively and cooperatively with DMH to ensure we are meeting the highest standards of care.
Patient confidentiality laws prevent us from discussing specific details of the unfortunate incident which occurred last August where a patient died. As indicated in the report from DMH, the patient died of natural causes. The matter was fully investigated by DMH last year. While we disputed the conclusions of the report, Pembroke Hospital took appropriate actions based upon issues identified from this incident.”
The office of Thomas Hickey, Chief Executive Officer of Pembroke Hospital, declined to comment when reached by phone.
State Representative Shaunna O’Connell, of Taunton, a mental health advocate, believes Arbour needs new management.
“I’m not sure why they don’t seem as appalled as everyone else about what’s happening at their facilities,” O’Connell said. “We need to hit them where it hurts in the pocketbook and maybe with some fines.”
Meanwhile, Amber’s death has taken an emotional toll on her grieving mother, who has been depressed, angry and confused since her daughter’s death.
“I’ve never lost someone like this. Losing a child is the worst thing you could ever lose,” Mace said. “So I don’t know how to go through this process.”
She vows to keep Amber’s memory alive – her love for writing and helping people, her dreams of going to college, getting married and having children.
Mace has since hired an attorney to help her get answers about Amber’s death.
“We didn’t win,” Mace said. “No one’s gonna win. We’re never gonna win. Even if we win a law settlement, we lost our child.”
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