05/15/2024
From: ###xx ###xx
Email: ######@###xx.com; Tel: ###-###-###x
###x #########x
###xx, xx ###xx
To: Chair ###XX, Vice ###### and Members of the Board of Trustees
University of Pennsylvania
1 College Hall, Room 211
Philadelphia, PA 19104-6380
Email: [email protected]
Phone: 215-898-7005
Cc: Interim President J. Larry Jameson
Email: [email protected]
Phone: 215-898-7221
By Email
Date: 03/12/2023
Dear Chair ###XX, Vice Chair ###XX, and
Members of the Board of Trustees:
I am writing to you about my shocking experiences with your affiliated hospital, Penn Medicine Princeton Health. The issues I found are very serious in the sense that the practices at the hospital can endanger the lives of underprivileged patients.
Let me begin with a real story. A mentally ill patient escaped from the security gate of a mental hospital in my hometown #########, and then the patient was tragically shot by a policeman on the street. A similar event occurred at your hospital, Penn Medicine Princeton Health, on the evening of March 9, 2023, the only difference being that the patient was chased by your staff and got badly wounded by falling on an obstacle in the ambulance area and then got caught by your staff instead of being shot by a policeman. The heartbreaking part is that the mentally ill patient was forcefully released by your staff hours afterward, with the wound bleeding and uncovered, at around midnight, less than 10 hours after the patient was sent to your hospital by Princeton police for psychiatric treatment. Your staff refused to treat the patient’s psychosis at the hospital and refused to transfer the patient to a true psychiatric hospital. I have strong reason to believe that your doctor intentionally failed to cover the patient’s wound before releasing her. I will explain my reasoning later.
It should be noted that the police emphasized to me that your hospital was partly a psychiatric hospital, when they took the patient to your hospital. In a way, I was completely helpless when all this happened to the patient.
On March 10, 2023 (the very next day), the patient was taken by me to an urgent care clinic in New York City to treat the wound, wherein the doctor called New York police, who forcefully took the patient to the psychiatric division of Bellevue Hospital. The patient was then treated at Bellevue Hospital for more than 2 months and then transferred to and treated at McLean Hospital (a psychiatric hospital) until about August 2023. The duration of treatment at these two psychiatric hospitals shows the severity of the illness of the patient. The history of her treatment at all these hospitals, including yours, is known to her psychiatrist, Dr. G###x. Please let me know if you need the patient to authorize Dr. G###x to discuss this with you.
I am not sure about the State of New Jersey, but the mental hospitals in N######xx and many other states are legally required to have strict security measures as to not let the patients in severe psychosis escape, and to have a referral system for outpatient care after treatment to ensure the safety of the treated patients. Your hospital clearly lacks such safeguards.
On March 13, 2023, I wrote to the “Patient Advocate” at the hospital requesting an investigation. After the patient signed three different variants of “Power of Attorney” that were sent to “Patient Advocate” in the course of a few weeks, I had finally received a report (Appendix C) from the “Patient Advocate.”
The report claimed that the hospital “was unable to connect with” me prior to releasing the patient. In latter communications, your staff stated that they had to release the patient since the patient wanted out. The story was untrue and may be easily refuted by my ATT telephone record (see Appendix H). The phone records shows 10 phone calls to or from the hospital’s phone number (609-853-7700) in that evening/night; there was no missed call. The story also contradicts my earlier letter of March 13, 2023 that detailed the phone conversations between your staff and me in the hours before and after the releasing of the patient.
The report further lied that the patient was “provided the option to be admitted locally, which you [i.e., the patient] declined.” This contradicts my earlier letter stating that I had requested your staff to transfer the patient to a psychiatric hospital but your staff refused.
Why would some of your staff manufacture such lies in an official report, if not to cover a deeper issue? I have been puzzled for some time before arriving at a reasonable answer; see below. I really want to find out the truth there. Another shocking part is that the CEO stood by the lies even after the phone record was sent to him as solid refuting evidence.
The report stated that “Dr. Cridge and Mr. Lucariello determined that based on the clinicians assessment and collateral information they obtained from your outpatient providers it was appropriate to discharge you home.” The very fact that the patient was subsequently treated for over 4 months in Bellevue Hospital and McLean Hospital is a strongest evidence that your doctor lacks the experience to even diagnose a patient in severe psychosis, with incredible hallucinations and timidity. I have video of the patient on that day that shows her severe mental condition. In fact, your doctor was told of the following by me: a) the patient had run away from her own home to avoid any family member; b) the father of the patient flew from Florida a few days ago specifically to locate her after noticing her hallucinations; c) the patient had been previously treated 4 times in psychiatric hospitals: one time in #########xx, twice in #########, one time in a hospital in ############; d) the patient had previously jumped from a low railing in hallucination and then went upstairs and attempted to jump from a railing on the upper floor to the basement but was fortunately grabbed by her Dad. She could have killed herself. By the way, Dr. G###x was in routine conversation with me during these days and was extremely anxious about the patient during his calls to me.
Dr. G###x had told your doctor that the patient was taking clozapine. Unfortunately, not every psychiatrist (M.D. or not) is certified to prescribe clozapine. However, according to Dr. G###x, clozapine is the most effective anti-psychotic medicine based on his decades’ experience working as a psychiatrist and as the head of psychiatric division at a large hospital in #########x. McLean Hospital also likes clozapine, as I learned from talking to its doctors. I doubt if any of your doctors has the certification to prescribe clozapine (although the certification is not technically hard to obtain). That emphasizes my belief that your hospital should not pretend to have a psychiatric division.
The following list of key requests, demands, and reasoning were mailed to the CEO of the hospital (see Appendix F) who could not give me any specific response. I am therefore requesting a proper review by you and a response on each specific item.
Mentally ill patients in severe psychosis need proper protection and extra security in a hospital otherwise they may run away from the hospital and/or hurt themselves in the hospital. Every other mental hospital I have seen has these protections. However, your hospital lacks these yet Princeton Police sent the patient to your hospital telling me that your hospital is a psychiatric hospital. I am not sure about New Jersey State law on the legal requirement of these protections, but many other State laws require such protections. If indeed New Jersey State does not have such laws, I invite you to join me to lobby the New Jersey State legislature for a reasonable change in laws. These laws are very important for the protection of mentally ill patients. I would be extremely willing to contribute to the change.
Your (only) psychiatrist lacks experience. She may be able to treat a normal patient but not those in an acute mental condition. Even if a mentally ill patient is released in the daytime, tragedy can still happen. Releasing a mentally ill patient around midnight, with or without family members, is a highly unprofessional and highly unethical decision. Think about releasing your own son or daughter with severe mental stress (not to mention severe psychosis with hallucination) to the street? In fact, I had told your doctor that the patient had run away from all family members and hid in a hotel at Princeton for more than two days. It took me a lot of stress and effort to finally locate her at a Princeton hotel.
Because of the above, at this time, I ask you to seriously and urgently consider my request that your hospital should work with the local police so that the police shall send a mentally ill patient to a true psychiatric hospital that has proper protections and adequate security.
Your doctor’s refusal to cover the patient’s wound on her leg was both shocking and inexplicable in a normal situation. I can’t think of any motive except an attempt to cover up the fact that she fell in your property and thus your hospital could be liable, especially if we take into consideration of the fact that your staff lied in Mr. Karpiscak’s first report to the patient (copied to me). The report stated that your staff were unable to contact me and thus had to release the patient since she wanted out. That was a lie since your psychiatrist talked to me over the phone before the release and I told her not to release the patient; and after she told me the patient wanted out, I talked to the patient and the patient said she was ok to stay in your hospital. By the way, the patient didn’t even spend 12 hours in your hospital before being forcefully released by your hospital. That is against New Jersey law I think (although I am not a legal expert). Even if your staff’s statement were true (it is not!), then, your staff basically admitted they released a mentally ill patient in severe psychosis (without any family member around) to the outside. Such an action could easily lead to loss of the patient’s life, no matter whether it was midnight or daytime. That would be a greater risk to the patient than forcing me to take her to New York City. Why could your staff not tell the truth? I have been thinking about that. My conclusion is as follows.
The decision to release the patient at midnight was motivated by your staff’s fear that the patient could fall again and create liability for you. There is no other rationale that I can think of. If there is one, then please let me know. Of course, your staff knows their rationale. Indeed, the patient ran away after waking up because she had a severe psychosis and feared any new environment. She was having hallucinations. A reasonable psychiatrist should know this phenomenon and that the patient would fear even more in the darkness outside, without any person next her (assuming your staff were right that they were unable to contact me). Releasing her to me is also very risky. I am not a professional and I don’t have the facility to protect her. In fact, I had asked your hospital to transfer her to a psychiatric hospital but your staff also refused for inexplicable reasons (except the cover up of her wound for fear of liability, or the competition for business from a specialized psychiatric hospital). In fact, when we were arguing about the patient’s release on the phone with your psychiatrist, I sensed hesitation in her voice but a gentleman seemed to have forced her not to say anything more to me. A direct inquiry to the psychiatrist should reveal the truth.
My experiences (as explained in my letters and emails) led me to believe that there’s too much lying in your system to cover up the responsibilities and to resist substantial changes. I demand your hospital again find out the truth with a formal, responsible investigation. Your employees had lied in the report. I am 100% sure! At a minimum, they should be stopped from lying in the future. Stopping lying is important in the medical profession because your staff are trusted with human lives.
I believe that the lying could be a systematic issue within the hospital. Lying by your doctors is a very serious ethical issue, and the CEO ignores the evidence and insists on the same lies, apparently due to a need to side with the doctors, sacrificing the interest of the patient. The issue is, because doctors are given a greenlight by the CEO to lie, they will lie conveniently anytime in the future.
I had the privilege to work at several Universities in my career and I believe that many of the Universities have higher ethical standards than for-profit corporations. That is the reason I am writing this letter to you for your help. I had told the CEO of the hospital that I shall pursue this issue to the bottom but the CEO doesn’t seem to care at all. The CEO may gamble that we would not go public since most people do not wish to discuss their mental illness history in the open. However, the CEO’s inaction will not deter us. I trust that most people, such as the leadership of University of Pennsylvania, are kind and passionate to the under-privileged groups that are struggling in our land.
The “Patient Advocate” was apparently indifferent to the issues, talked like an attorney representing the hospital, and made the complaint process inconvenient. The name “Patient Advocate” is truly a joke since she has shown no compassion.
The patient is my beloved daughter, D###x. My daughter and I are not seeking any monetary compensation from the non-profit organization, even though I believe my daughter was harmed by the delay in the treatment of her psychosis in addition to suffering from the scars on her leg due to the fall on your facility. We have enough money for our needs. We are just trying to expose the lying by some of your staff and advocate for the unprivileged few, the mentally ill people. They badly need your kind help! Indeed, any significant, concrete changes in your institution’s mistreatment of the underprivileged people are worth a lot of millions to us.
I look forward to a prompt and comprehensive response and attach some of the main correspondence with your staff since the incident on March 9, 2023, as well as supporting evidence, to aid your understanding of this matter.
Last but not least, on December 19, 2023, I wrote a letter to Interim President Jameson. My letter to the President is almost identical to the content of the present letter. On March 8, 2024, I received an emailed copy of a letter from the Office of Patient Affairs, Penn Medicine dated December 28, 2023, in response to my letter to the President. See Appendix I. The letter from the Office of Patient Affairs did not address any of the specific requests and issues raised in my letter to the President. Instead, the letter only printed some standardized general remarks:
We have investigated this matter on your behalf and believe your concerns have been fully escalated through the proper channels and they have been thoroughly evaluated by the appropriate individuals.
Concerns such as yours …. provide us with an opportunity to identify potential problems and improve the services we provide to our patients and their families.”
In a subsequent phone call, Ms. F######, of the Office of Patient Affairs, was unable to give me any details of how things were improved, or of who was in charge of making the improvement. Ms. F###### hesitantly said that President Jameson read my letter but when asked, she did not know what the President had said or done in response. In my emails before the phone call, I had also expressed the following thoughts to the Office of Patient Affairs:
As the father of a grossly mistreated patient, I had been very angry at your institutions for quite some time. Now, a year after my daughter was forcefully released by your affiliated hospital, I am still angry at your institution’s ignoring of the basic facts and maintaining the faulty report filled with lies. You need to take a serious look at the evidence provided to you!! However, my anger has never motivated me to financially punish any individual (after all we are all humans and we make mistakes) and my focus has been to make a meaningful change at your institution. The first step is for you to admit the truth and have the liars directly apologize for lying.
I believe that University of Pennsylvania has a lot of political influence on various government agencies. U Penn’s alumni have extensive connections while we have none. If I complain at a government agency, I don’t think that it will be a fair forum for us. That is why I think it is better for me to go directly to the public. Even so I am disadvantaged as I have much less resource than your institution, but I have the facts that you can’t deny.
It should be clear to me that the office of the President or the President himself has made little effort if any at all to investigate the incident or to resolve the requests or issues in my letter. This has led me to write this letter to the Board so as to not miss any hope before I publicize my letter.
Thank you so much in advance for your time and effort.
Yours Sincerely, /###xx ###xx/###xx ###xx
