New lawsuit reveals chilling allegations of teen death in SLO County mental health facility
The Paso Robles teen who died in May while being treated at the San Luis Obispo County Crisis Stabilization Unit in May was dead for hours despite being checked on by employees multiple times, a new federal lawsuit alleges.
Elina Branco, 19, was found dead at the county’s Crisis Stabilization Unit in San Luis Obispo on the morning of May 16, after her mother Linda Cooper brought her to the facility to be closely monitored following an overdose the previous day.
The lawsuit, filed Monday, claims that staff falsified records and lied to Cooper after an autopsy showed Branco had died at least eight hours before the Crisis Stabilization Unit called for medical help, despite the fact that records showed she had been checked on at least five times overnight and found to be alive and well.
To make matters worse, the lawsuit said, Cooper spoke with a stabilization unit employee that morning who told her “’everyone is sleeping,’ implying her daughter was breathing, sound and alive” — well after she had already died, according to the autopsy findings.
San Luis Obispo County Health Agency spokesperson Tom Cuddy told the Tribune in a statement that the county is aware of the lawsuit but could not comment on pending litigation. He told The Tribune in June that the agency had been “deeply saddened” by Branco’s death.
“Our thoughts and condolences are with the individual’s loved ones during this difficult time,” Cuddy said at the time. “No priority is more important to us than the safety and well-being of our clients and staff.”
The lawsuit covers nine counts, including wrongful death, failure to provide safe conditions, that the state created danger, and neglect of a dependent adult. It also requests for injunctive relief, meaning a temporary or permanent closure of the Crisis Stabilization Unit, mandatory training for staff and creation of an independent entity to ensure the facility is in compliance with state heath and safety regulations.
The Crisis Stabilization Unit is a 24-hour voluntary short-term care facility within county Behavioral Health that provides immediate support and treatment services. It’s meant for patients who require urgent care beyond what an outpatient clinic service can provide but are not a danger to themselves or others — which is the criteria to be placed in a 5150 involuntary 72-hour hold.
How did Elina Branco end up in the Crisis Stabilization Unit?
May 15 was not the first time Branco had been admitted to the Crisis Stabilization Unit.
According to the lawsuit, Branco, who suffered from substance use disorder co-occurring with anxiety and borderline personality disorder, had previously been admitted to the Crisis Stabilization Unit on Feb. 26, when she was placed on a 5150 involuntary hold because she was found to be gravely disabled and a danger to herself.
About three months later, on May 13, the lawsuit said, Cooper and Branco talked about how Branco had been clean for 12 days and wanted to receive treatment at a drug rehabilitation facility. So Branco filled out the forms and packed her bags that day.
But by the following afternoon, Cooper found her daughter had relapsed. Branco was conscious, and Cooper stayed with her daughter until the next morning.
Then, around 8 a.m. on May 15, Cooper found Branco unconscious after overdosing on fentanyl. She called paramedics, who administered Narcan, a drug that can reverse the effects of opiate overdoses, and transported Branco from their Paso Robles home to Twin Cities Community Hospital in Templeton.
Branco was given additional Narcan doses while in the emergency room and ultimately recovered, the lawsuit said.
According to the lawsuit, Cooper wanted her daughter to be kept under close observation at the emergency room or another facility until Cooper could safely bring Branco to a rehab facility.
Cooper contacted the Crisis Stabilization Unit around 1 p.m. to see if her daughter could be admitted. She told stabilization unit staff that Branco had recently overdosed and would be in the ER for the rest of the day, but “needed a safe place where she could be admitted, keeping her alive.”
The stabilization unit then sent a staff member to give Branco a mental health evaluation while she was in the ER at Twin Cities.
By this time, the lawsuit said, Cooper had already set up placement for Branco to begin drug rehabilitation treatment on May 16. Staff at the stabilization unit told Cooper they could facilitate a transfer application from the CSU to the detox facility in Tarzana so that paperwork could be easily faxed between the two facilities.
The lawsuit said Cooper made it clear to stabilization unit staff that her daughter must be closely monitored overnight. One staff member reassured Cooper that the stabilization unit was a more appropriate facility for Branco than a psychiatric hospital, the lawsuit said.
Branco was then placed on a 5150 hold “as an additional layer of reassurance, and (staff) indicated Branco couldn’t leave the facility until the following morning when she would be off to her treatment center,” the lawsuit said.
Lawsuit: Teen was already dead when staff reported she was alive
According to the lawsuit, Branco’s intake forms for the stabilization unit indicated her chronic substance use, “grave risk to personal safety” and history of suicidal ideation that met the criteria for her to be deemed gravely disabled.
“Client requires close monitoring, support and supervision to prevent recurrence of what likely would have been her death without her mother finding her and the subsequent administration of Narcan,” the intake form said, according to the lawsuit. “Parent indicates that she believes client would use again if she were not directly transferred/admitted and fears client will overdose.”
Cooper continued to express concern for her daughter’s safety despite reassurances from employees, the lawsuit said, to which an employee told her that Branco “would be monitored around the clock until the next morning.”
Branco was transferred from the ER to the Crisis Stabilization Unit on Johnson Avenue in San Luis Obispo at 5:10 p.m., when her vital signs were stable enough for her to be transferred under the 5150 hold, the lawsuit said.
According to the lawsuit, stabilization unit staff were all advised of Branco’s situation, her need for close supervision and her impending transfer to drug treatment. Branco’s charts also indicated she needed two-hour monitoring checks starting at 7:30 p.m
Branco’s chart notes indicated identical statements with each check: that Branco was “engaged in therapeutic rest without incident. Breathing is even and unlabored. Will continue to monitor for changes.”
During the 11:30 p.m., 1:30 a.m., 3:30 a.m., 5:30 a.m. and 7:30 a.m. checks, her chart notes read, “the client is lying in bed with eyes closed, breathing evenly and without labored breathing,” the lawsuit said.
But, according to the lawsuit, sometime between 8 and 8:30 a.m. — 30 minutes after the most recent check — staff called 911 reporting Branco was in an “unresponsive state.”
A mobile crisis team responded and determined Branco had died 8 to 10 hours earlier because her body had begun to show signs of livor mortis, or physical signs of death in which the blood pools in the lower parts of the body, turning the skin purplish-red.
The lawsuit said a coroner’s investigation later determined Branco’s actual time of death to be between 10 p.m. and midnight — meaning Branco was deceased during at least four of the five noted checks.
Lawsuit alleges medical staff lied to mother about daughter’s death
None of this was known by Cooper, according to the lawsuit.
She called the stabilization unit at 8:06 a.m. to coordinate her daughter’s transfer, the lawsuit said, but was told the staff member who was helping her was not available. Then, when Cooper asked to speak with her daughter, she was told, “Everyone is still sleeping,” which seemed odd to Cooper because her daughter was supposed to be preparing to leave the facility, the lawsuit said.
Cooper called again at 8:43 a.m., the lawsuit said, and again was told her daughter was still sleeping, despite the fact that medical aid had been called.
Then, not even 20 minutes later at 9:01 a.m., a first responder called Cooper and told her Branco was dead.
“Then, everything went dark,” the lawsuit said.
The lawsuit alleges stabilization unit staff falsified Branco’s medical records “because had the 2-hour checks been conducted, Branco’s medical distress would have been noticed hours much earlier that 9:30 a.m., 10-12 earlier than when she was found dead the next morning.”
It alleges the unit’s staff failed to monitor and observe Branco despite being advised that she was a vulnerable client with a high risk of relapse and medical distress. That failure was “a serious dereliction of their duties and the one responsibility they had toward their client: to monitor for signs of distress.”
The lawsuit alleges that the county and Sierra Wellness Mental Group, which runs the stabilization center, were aware that staff regularly failed to monitor clients, given a 2021-22 grand jury report that noted staff playing video games, covering their computer screens and tampering with the video surveillance system.
“It is unimaginable how defendants who supposedly were stationed within the CSU staffing monitoring area, in the same open living area as clients such as Branco, with only four beds to monitor and unobstructed visual sight, would fail to notice that Branco was not in fact engaged in a therapeutic rest, that she stopped breathing, that her chest was not rising up and down,” the lawsuit said.
The lawsuit alleges staff “cowardly pushed off the devastating news” of Branco’s death to be shared by a first responder, rather than the employees Cooper had called at least twice earlier that morning, and lied about her daughter’s well-being during those two calls.
The lawsuit also notes that an “independent source” said the facility’s automated external defibrillator, or AED, that can assist in providing lifesaving care to someone in cardiac arrest, was not working at the time of Branco’s death and that staff and supervisors knew that it was not working.
The county has 30 days from the lawsuit’s filing to respond in court.
This story was originally published September 28, 2024 at 5:00 AM.
