Investigation Into The Death Of D.M.

December 2010

The Disabilities Rights Center investigated the untimely death of a 43 year old man who died of an acute diabetic crisis. Mr. M, who was a client of Riverbend and had been repeatedly hospitalized at New Hampshire Hospital , took psychotropic medications which had contributed to his substantial weight gain, metabolic syndrome, and adult onset diabetes.  He had not seen a primary care physician for the two years prior to his death despite his serious medical conditions. Just prior to his death, a neighbor had called Riverbend emergency services to try to get help for him due to changes in his mental state and complaints of excessive thirst, but Riverbend had not responded other than to tell the neighbor to keep an eye on him.

Changes in policies and procedures, both within the mental health center and within the Bureau of Behavioral Health, are recommended to avert similar tragedies. A more comprehensive, integrated and coordinated model for the delivery of both mental and physical healthcare is recommended, including the areas of informed consent, systems for measuring and monitoring medical risk, prevention strategies, integration of medical care, information transfer, assertiveness as to medical risk, and crisis response.

Read the Redacted report here: Review of the Circumstances Surrounding the Death of D.M., Former Client of NH’s Community Mental Health System