Williams v. United States

• Decision Date: 05 May 1978
• Docket Number: No. CIV76-5017.,CIV76-5017.
• Citation: 450 F. Supp. 1040
• Parties: Mary E. WILLIAMS, Special Administratrix v. UNITED STATES of America.
• Court: U.S. District Court — District of South Dakota

450 F. Supp. 1040

Mary E. WILLIAMS, Special Administratrix v. UNITED STATES of America.

No. CIV76-5017.

United States District Court, D. South Dakota.

May 5, 1978.

Joseph Butler and Allen G. Nelson, Robert E. LaFleur, Rapid City, S. D., for plaintiff.

David V. Vrooman, U. S. Atty., Sioux Falls, S. D., for defendant.

MEMORANDUM OPINION

BOGUE, District Judge.

This suit under the Federal Tort Claims Act is brought to recover for the wrongful death of Robert Williams. Mr. Williams was shot and killed by Alonzo Bush on May 3, 1975, the day following Bush's release from the Fort Meade, South Dakota Veterans Administration Hospital. Under all of the circumstances, examined in detail below, we find that failure of the hospital to notify Meade County authorities of the discharge and release of Alonzo Bush was negligent and that such negligence was the proximate cause of Mr. Williams' death.

FACTS

In June of 1973, while on parole in California, Alonzo Bush suffered a severe head injury. Following brain surgery, he received permission from the California Parole Board to come to South Dakota. He was first admitted to the Veterans Administration Hospital at Hot Springs, South Dakota on September 17, 1973. The admitting doctor's impressions on that date were that Alonzo Bush evidenced organic brain syndrome and a psychotic disorder. The doctor noted that Bush was disoriented and had "psychiatric disturbance."

In the two and one-half years following this initial contact Bush was in and out of VA hospitals a total of twenty-three times. The voluminous VA medical records show a consistent pattern of diagnoses of chronic brain syndrome, chronic alcoholism, and severe personality disturbance. During his stay at various VA facilities Bush was diagnosed again and again as "paranoid", "psychotic" and "schizophrenic." The records are filled with references to Bush's hostility, his defensiveness, his disorientation and his potential for violence. On several occasions, the records show, Bush had to be placed in the locked wards of VA hospitals because of violent behavior and threatened violence. At various times, VA officials discussed the possibility of having Bush committed.¹

In January of 1975, while a patient at the VA hospital in Hot Springs, Bush wandered into the ward's television room and, without any provocation, attacked another patient. Bush was rough and abusive and force had to be used to restrain him. He was placed in the locked ward and his parole officer was called. His parole officer, in turn, contacted the Fall River Sheriff who apprehended Bush at the hospital and jailed him. All of the above information became part of Bush's VA records.

By the end of January, Bush had been transferred to the alcohol treatment ward at the Human Services Center in Yankton, South Dakota. Counselors there found him hostile and noted his difficulty in getting along with other patients. Alonzo Bush was released from the hospital in Yankton on March 6, 1975. Five days later he appeared at the Fort Meade VA hospital. The Fort Meade medical records show that he was intoxicated. On the following day, March 12, Bush insisted on leaving the hospital. He was allowed to leave AMA (against medical advice) but on the following night, March 13, he returned. The Fort Meade records show that he was drunk and, according to the nurse on duty at admissions, he was loud and abusive. He accused various staff members of hating Indians. When the nurse asked his name and if he were a veteran he replied, "I am a boy scout." Then, without provocation, he attacked a staff member, wrestling him to the ground. Bush was told that if he did not settle down he would be placed in restraints. He continued to make verbal threats and was subsequently escorted out of the hospital by three members of the hospital's Protective Service.

On the following day, March 14th, Alonzo Bush was returned to Fort Meade by the police. The medical records reveal that "Instructions from this officer were to keep him in this hospital and if we are unable to do that . . . to notify the Police Department of this patient's departure." A later notation made that same day states, "Dr. Wells further instructed us to contain this patient even if he wrote an AMA letter —to accept it but not to honor it until the chief attorney notifies us."

Between March 14th and March 18th VA officials were much concerned about what to do with Alonzo Bush. A report signed by Wayne Christenson, the Administrative Assistant to the Chief of Staff of the hospital details these concerns; Bush was insisting that he be allowed to leave. At the same time, VA officials considered him to be "fairly dangerous." The District Counsel for the VA had advised that Bush had been "bouncing around the country hitting people." Yet, there was uncertainty about whether Bush would qualify for involuntary commitment under South Dakota law. The report concludes: "We will contact the doctor and if he decides to let the patient go, we will notify local authorities. We should document this."

Two VA doctors, Dr. Herman and Dr. Garlisi consulted on the matter. Dr. Garlisi subsequently conceded that at the time he attempted to convince Dr. Herman that Bush was not dangerous he was not aware of the unprovoked assault Bush had committed on a staff member a few days before although a report of the incident was part of the medical records and the records, in their entirety, were available to Dr. Garlisi. Nonetheless, it was determined that Bush did not qualify for commitment. On March 18th, Alonzo Bush left the locked ward of the Fort Meade VA Hospital.

The following evening Bush was arrested by the Meade County sheriff and jailed. That night, Bush attempted to set fire to the jail. A jailer was able to put out the fire and Bush was subsequently charged with criminal damage to property. Jail officials, however, could not control Bush and on March 25, 1975 they received permission from the VA to return him to the hospital at Fort Meade. The report of contact signed by Salvatore Valadez, Medical Administrative Specialist, states:

"This veteran is presently in jail there for assault and battery, disturbing the peace, and criminal damage to property. He has been having some `fits' or something and they feel he needs care. He has been brought here with the understanding that if he is hospitalized he will be returned to the Meade County authorities when need for hospitalization is terminated."

At trial, Mr. Valadez clarified the meaning of this statement:

Mr. Valadez: Well this was the understanding —I want to clarify the return to the authorities. What I meant was that we would notify them. We are not permitted to release or turn patients back to the authorities . . . but we are permitted to notify them of his (sic) release.

* * * * * *

The Court: You intended to notify them and then turn him over to the sheriff when he got there?

Mr. Valadez: Right.

It was with this express understanding that Alonzo Bush was admitted to the hospital at Fort Meade. A notation to that effect was attached to the outside of his current file and Alonzo Bush was placed in the hospital's locked ward.

Several days later Bush requested that he be transferred from the locked ward to the alcohol treatment ward and, on the joint decision of Dr. Thomas Marvin and Dr. William Trumpe, the transfer was effected. Dr. Trumpe had not reviewed any of Alonzo Bush's medical records. He did not know about the March 13th attack on a staff member, about Bush's previous history of violent behavior or about prior diagnoses indicating that Bush was psychotic, paranoid or schizophrenic. Dr. Marvin was designated the treating physician. Dr. Marvin had consulted only Bush's current medical records and did know about the recent attack on a staff member. On the April 4, 1975 intake note Dr. Marvin stated:

About two weeks ago the patient appeared in the front lobby of the hospital intoxicated. Employees attempted to help him, however, Bush refused and became quite violent and struck one of the hospital personnel."

Observing Bush throughout the month of April, Dr. Marvin noted "Bush shows no genuine motivation regarding permanent sobriety."

Alonzo Bush went through the regular four week treatment program as would any patient who had come to Fort Meade for alcohol treatment. Near the end of that period, on April 28, 1975, a routine discharge staff meeting was held. Although Dr. Marvin was the treating physician and aware of at least some of Alonzo Bush's prior medical history, he was not present at the discharge staff meeting and he testified that he could not remember what, if anything, about Bush he told the staff members who handled the discharge. Dr. William Trumpe was the doctor in charge of the discharge staff meeting and it was he who authorized Alonzo Bush's release.

Dr. Trumpe testified that he had no knowledge of why Alonzo Bush had been placed on the hospital's locked ward and had never seen any medical records regarding Bush prior to discharging him with the exception of the records relating to the current admission of March 25, 1975. He testified that, at the time he authorized Bush's discharge, he did not know of the attack on a staff member which had taken place on March 13th. Dr. Trumpe testified that he had no knowledge of discussions conducted the month before regarding the possibility of seeking involuntary commitment of Alonzo Bush. He was not aware, at the time he authorized the discharge, of the report, available in Bush's files, which was prepared by Wayne Christenson, Administrative Assistant to the Chief of Staff, and which indicated that Bush was "fairly dangerous." He was not aware of that portion of the report indicating that the District Counsel for the VA had advised Mr. Christenson that Bush had been "bouncing around the country hitting people."

Dr. Trumpe testified that on April 28, 1975 when he authorized the discharge of Alonzo Bush he had...