When CaSonya King was admitted to her third psychiatric hospital in a year in 2018, her family thought she was going to get the help she needed.
But after spending 19 days at the now-closed High Point Hospital in Middleborough, King was still disoriented and severely ill. Yet, she was discharged from the private psychiatric hospital and taken to Boston, where it appears she was expected to go to a homeless shelter. She never checked in.
Thirty hours later, 44-year-old King was dead.
Her family has since filed suit over King's death, and the Disability Law Center has this week completed a report after investigating her death. The DLC report says King's death raises questions about so-called "patient dumping," where patients are suddenly discharged from treatment without support.
"There hasn't been an account of her death publicly, and there hasn't been accountability for her death," said Rick Glassman, director of advocacy for the Disability Law Center. "This is a woman who — later in life — began experiencing mental health issues. Prior to that, she was a very successful professional and a homeowner. This woman died needlessly."
After living in Georgia for years, King returned to live with her family in Massachusetts in 2016 when she began experiencing mental health issues, the report said. Her mother, Angela King, says her daughter planned to start a business similar to the one she owned in Georgia, according to a lawyer for King's mother and the report.
Reports from King's family and medical records in the DLC report, say that King was delusional and repeatedly described as "exhibiting auditory hallucinations" and engaging "in self-dialogue." King remained in this condition during her more than two weeks at High Point Hospital. The report says the hospital did not "provide treatment that was effective in substantially improving her condition."
Yet, the hospital determined that King could be discharged. Medical Records from the DLC report say that although hospital staff described King as "disheveled" and "yelling and self-dialoguing," her doctor informed the treatment team that King "no longer requires inpatient level of care."
The report says it appears the hospital transported King to a Boston homeless shelter, even though she could have been placed in a Department of Mental Health facility instead. Her mother, who was appointed her legal guardian, was not told about King's discharge, according to the report.
King never checked in at the shelter. She was found at a CVS Pharmacy six miles away in Brighton when a pharmacy worker notified police that King was behaving erratically and ingesting large amounts of over-the-counter pain and cold medicines. King later died at Carney Hospital in Boston.
"The tragedy of CaSonya King’s unnecessary death appears attributable to, an all-too-common practice called patient dumping," the DLC report says. "Patient dumping occurs when a hospital denies emergency medical care or inappropriately discharges a current patient, either upon learning that the individual is unable to pay for treatment, or for another reason."
The report also cites a 1992 study, which estimates that close to a quarter million patients are inappropriately discharged from treatment every year in the United States.
High Point Hospital closed in 2019 shortly after losing its accreditation. High Point still runs addiction treatment facilities in Massachusetts that are licensed by the Department of Public Health.
"High Point Hospital closed almost two years ago in August 2019," said Kathy Norris, director of community relations for High Point. "In fact, the property was just sold to another provider. The staff involved in the daily operation of the hospital are no longer with the organization."
Norris said High Point would not comment further.
The DLC report also criticized DMH for not doing more to hold the hospital accountable. Although the department investigated and found that hospital staff acted "in a manner that was dangerous," the report says DMH did not take strong enough action and force the hospital to fully answer several questions, including why King was taken to a homeless shelter, or why her mother was never notified about her discharge.
"This lack of rigorous oversight devalues the lost life of CaSonya King and undermines the Department’s core mission: to provide access to quality treatment and supports to meet the needs of individuals with mental health challenges, enabling them to live, work and participate in their communities," the DLC report says. "DMH's measures fell far short of the strong enforcement action against HPH (High Point Hospital) that was warranted."
DMH points out that it did investigate and ordered the hospital to take corrective actions. The department says High Point Hospital in response created a policy on discharge to homeless shelters that it did not have before.
"The Department of Mental Health is deeply saddened by Ms. King’s death, and immediately investigated the actions taken by the provider," a DMH spokesperson said in an emailed statement. "DMH identified serious issues with the hospital's discharge actions, conducted unannounced inspections of the facility and required corrective action in policy and training from High Point Hospital. DMH strongly opposes the practice of patient dumping in any facility.”
The Disability Law Center report makes several recommendations, including asking DMH to take stronger action when there are serious incidents at hospitals and to collect data on the number of people discharged from psychiatric hospitals to homeless shelters or the streets. The report says current discharge practices disproportionately affect people from communities of color.
"It shouldn't go unnoticed that this was a 44-year-old Black woman when we're having a national conversation about race equity and health disparities," Glassman said. "This report points out that some people's lives are dismissed — especially people with disabilities, and particularly people of color with disabilities."
The lawsuit seeking monetary damages because of King's death was filed in Worcester Superior Court and names High Point, two clinicians and CVS. The lawsuit argues the drug store "failed to safely sell the medications."