We are doing this for two reasons. The first is to honor her memory. The second is to focus attention on how needless her death was and how easily it could have been prevented.

To explain the second reason, we need to review how and why she died. Nora was about halfway through studying to be a Medical Assistant at Clark University Computer Career Institute. She had earned straight A’s and was very excited about her new career, but was struggling with a long-standing drug problem. She checked into a detox program at Bournewood for help. Between 9:00 P.M. on December 6 and 9:00 P.M. on December 7, her medical record reported that she was given 2 doses of methadone, 4 doses of lorazepam, 2 doses of trazodone, 3 doses of quinine sulfate, 2 doses of depakote, 2 doses of dicyclomine, and 1 dose of trimethobenzamine. She was supposed to be checked for safety every 30 minutes. At approximately 2:00 A.M. she died in her sleep. For the next 6 hours, hospital staff continued to check her off as OK every 30 minutes. By the time a staff member finally realized she was in trouble, at about 8:00 A.M., she was already in rigor mortis.

After a six-month investigation, the Massachusetts Department of Mental Health concluded that the hospital had acted in a “manner that was dangerous.” The DMH Director of Licensing ordered the hospital to revise its safety check policies and improve training. In its corrective action letter Bournewood Hospital stated, “Upon this clinical review and discussion, we have elected not to change our policy regarding safety checks to specify how staff check/assess breathing.” This refusal to correct a clearly inadequate safety policy was rejected by DMH. After several more sets of correspondence between DMH and the hospital, Bournewood finally submitted sufficient information to satisfy DMH on October 27, 2005. Unfortunately, this policy speaks only to checking breathing to determine if a patient is still alive. There is still no plan to provide monitoring to determine if a patient is in trouble in time to save the patient’s life. We are very concerned that patients’ lives continue to be jeopardized by a combination of multiple potentially dangerous medications and minimal monitoring.

Last August there were stories in the Boston Globe, TV Channels 5 and 56 and WBZ radio in reaction to the DMH report. As a result, we heard from another parent whose son died in a similar manner in another hospital. We are determined to do whatever we can to assure that this does not happen to any other family. We are pushing in every way possible that hospitals be required to safeguard the patients under their care. This vigil, in addition to remembering our beloved Nora, is one way to do this. We want to focus attention on these needless deaths.

Please join us from 7-8 P.M. on Friday, December 8th. Bring a candle if you have one or use one of ours.

Bournewood Hospital is located at 300 South Street in Brookline near the VFW Parkway. We will be on a long public sidewalk on the east side of South Street between Intervale Rd. and Clearwater Rd. There is no parking on South Street, and the Brookline Police have asked us to park on side streets. Asheville Road is across from the road that leads into the hospital grounds. You can park on Asheville Rd. or any of the streets off it, Clearwater Rd. or Intervale Rd. Please try to carpool, because parking is limited. We do not want to park or walk on the hospital’s property. Please be careful to avoid blocking driveways and be quiet and courteous so we will not disturb or inconvenience the hospital’s neighbors. If you have space in your car or you need a ride, please contact us and we will try to get you together with someone else for the trip.

Al and Barbara Tosti