Suicide Mission

On May 22, 1996, John Sheron put on his softball uniform and told his wife he was going to a game. He played for a while, then drove up to the Wal-Mart in Evergreen, where he bought a shotgun.

He took the gun out to his car, got in and blew his brains out.
It wasn't hard for the Jefferson County Coroner's Office to determine that John Sheron had committed suicide. But even if he was the one who pulled the trigger, others had put him in a position to do so.

John and Mary Lee Sheron were living in Peoria, Illinois, when John's employer of twenty years, Canteen International, decided to transfer him to Denver. The new position as regional vice president would be a challenge, different from servicing one major customer, as John had been doing in Peoria, but he was game. He and his wife packed up and moved into a house in Genesee. Mary found work at the University of Colorado Health Sciences Center, and John started his new job.

It didn't work out. After a year, Canteen let John Sheron go.
He started looking for another job, but the search didn't go well. Every day, John seemed a little more down. One day in particular, he was acting so oddly that Mary kept calling to check on him. He kept assuring her that he was fine, but she felt so uneasy she decided to go home.

When she pulled into the garage, she saw that John's car radio and electric system were on. She walked into the kitchen and found a loaded .22 by the back door and an open bottle of pills on the counter. John was asleep on the living room couch. When she had difficulty waking him, she called her family doctor. He told her to call 911.

On May 21, 1996, an ambulance transported John Sheron to Lutheran Medical Center. In the emergency room, they cleaned him out and got him stabilized. Then, following ER procedure, the attending doctor called West Pines, Lutheran's closely held subsidiary psychiatric hospital. West Pines sent a staffer--an assessment and referral technician, West Pines calls them--to see Sheron.

In her initial evaluation, West Pines ART Janice Vernon spent less than half an hour with John, then decided he could go home.

John Sheron was dead the next day.
Experts will tell you that John Sheron was at the top of the charts for serious suicide risk: white, middle-aged, out-of-work and childless. Experts will tell you that even if Sheron wasn't kept in the hospital overnight (although hospitalization was reasonable), he should have been given a serious, lengthy evaluation by a qualified professional. If he had been, he might still be alive. At least he would have lived through the next morning.

And in fact, that's what a few experts will be telling a Jefferson County jury next week, when Mary Lee Sheron's wrongful-death case against Lutheran Medical Center, West Pines and Janice Vernon goes to trial. The defendants have experts, too, who will argue that John Sheron was responsible for his own death.

But jurors may never get to hear the most interesting opinion, which is buried deep in the thick court file that contains all the documentation on this case. The defendants' lawyers are arguing against its admission, claiming that while the Jeffco coroner's official report is a legitimate part of the case, the letter that Chief Deputy Coroner Triena Harper decided to write Julie Chicoine of Lutheran Medical Center's risk-management department was confidential and should remain so.

Here's what Harper wrote: "Enclosed is a copy of the Jefferson County Coroner's Office report on the death of Mr. John Sheron. I wanted to let you know a couple of my personal observations gained from reviewing the Lutheran Hospital ER record of 5/21/96, and from the interview you and I had with counselor Janice Vernon and her supervisors at West Pines. I realize that mental health issues and care are at times controversial and often vague. I also feel that when a middle-aged executive who has recently lost his job presents with an overdose of medication that was acknowledged as a suicide attempt, there is nothing vague or controversial.

"During our interview with the West Pines staff, I got the feeling that they did not see this suicide attempt as anything close to serious. Although Janice Vernon has the ability to call a psychiatrist for consult when evaluating patients, she apparently felt this was not necessary in John Sheron's case. Her evaluation it seemed from the beginning was that Mr. Sheron was not really suicidal. Ms. Vernon spent more time telling us what a 'nice guy' Mr. Sheron was, and little reference how she made the decision that he was not suicidal.

"I also noted that Ms. Vernon provided an aftercare instruction sheet for Mr. Sheron when he was discharged from LMC 5/21/96. The instructions were to 1. 'follow-up with Mental Health provider' (with the responsibility of doing this placed on a suicidal party), 2. 'Don't have that margarita with your burrito!!' (a rather unprofessional way of saying don't drink. This instruction is so cutesy it makes me feel that a real indepth evaluation of this man's mental status was not done.) The number three instruction was 'Remove the guns!!' Does this mean he really is suicidal?

"My responsibility is to determine cause and manner of death when a case falls under the jurisdiction of the Coroner's Office but I did feel uncomfortable about the evaluation process in this case and wanted to share some of my thoughts with you."

Eighteen hours after John Sheron was judged not to be a suicide risk, released and sent home with the wife who'd told staffers she was "overwhelmed," he succeeded in killing himself. He was dead before Mary Lee Sheron could even get him the counseling appointment Vernon had suggested.

The rest of Vernon's jovial instructions were so inappropriate, given Sheron's condition, that Harper took the highly unusual step of writing Lutheran. Now Lutheran's lawyers would like to keep that letter out of the record. Harper is an expert on dead bodies, not live ones, they say, and so she's "not qualified to render an opinion."

The plaintiff's main argument, of course, is that Vernon was not qualified to render an opinion on John Sheron, either, and that West Pines and Lutheran, for whatever reason--convenience, the economics of health care in the Nineties--didn't call in anyone who was. In the process, the suit claims, the defendants violated the Colorado Psychiatric Technicians Act, which requires individuals to attend "an accredited psychiatric technician educational program" and be licensed by the Colorado Board of Nursing before they can conduct the type of evaluation Vernon was called on to provide for John Sheron.

Vernon is not a licensed psychiatric technician. Although she has years of experience working at mental-health facilities, she has just a bachelor's degree. And while West Pines had a psychiatrist on call, Vernon did not contact her or any other clinical psychologist, psychiatric nurse or qualified individual, "in contravention of the defendants' own internal hospital protocol," the plaintiff argues. Instead, she assessed John Sheron not to be a suicide risk and let him go home.

"If you believe there is such a thing as mental health or psychiatry or psychiatric illness or depression," Dr. Steven Dubovsky, vice chairman of the Department of Psychiatry at the University of Colorado School of Medicine and one of the plaintiff's experts, testified in a deposition, "then you would say this man did not kill himself. He did not make a valid, competent decision to kill himself. He was driven to suicide by untreated depression, and by unrecognized risk in the emergency room where they let him go. I think if anybody made the decision for him to kill himself it was Janice Vernon and the Lutheran ER staff by not recognizing that he had an acute illness...by not recognizing and acting on that, they are the ones who let him die."

This would not play in Peoria, and it should not play here.

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