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Troy Geske's Colorado Mental Health Institute death due to "malfeasance," grand jury reports

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A grand jury has concluded that a lethal combination of bad calls, poor training and inadequate supervision led to the death of a patient in restraints at the Colorado Mental Health Institute at Pueblo last year. But the probe found no criminal misconduct by employees in the incident -- one of a string of suicides and fatal accidents at the state mental hospital in recent years.

Patient Troy Geske, 41, died of asphyxiation last August shortly after he was bound and left face-down on a padded table. Two other patients have committed suicide in the past two years at CMHIP, which houses hundreds of patients deemed in "acute psychiatric distress" or criminally insane. The family of a fourth fatality, Joshua Garcia, reached a $223,000 settlement with the state after an investigation indicated that he'd been over-medicated.

A report by a team of independent investigators issued last fall linked the deaths to budget cuts and understaffing at the hospital, as well as low morale and dysfunctional policies. The grand jury report, though, says that the hospital's budget troubles had little or nothing to do with the pile-on of errors and "systematic failure" that contributed to Geske's death.

The face-down restraint procedure used on the schizophrenic patient, who was obese and had a history of respiratory problems, had been prohibited by the Colorado Department of Human Services years ago, but there's no evidence anyone at CMHIP knew that. Staff failed to monitor the restrained patient; vital information wasn't shared; Geske's removal from the restraints took longer than it should have; and an oxygen tank used to try to revive him turned out to be empty. A subsequent investigation into the death by the hospital was also inadequate, the Pueblo grand jury decided.

While the panel didn't think there was sufficient evidence for criminal charges, the report does assert that employees "committed malfeasance" and "abused their authority." But the Colorado Attorney General's Office has disputed the report, claiming that employees acted withing the framework of policies in effect at the time and that many changes have been implemented as a result of Geske's death; see this account in the Pueblo Chieftain for additional details.

More from our Colorado Crimes archive: "Grim details emerge in prison death of sex offender."

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