[S]erenity Bolt had just put her son to bed on his first birthday and was relaxing in her parents’ basement when she heard two cars drive up. She thought someone might be there to deliver a special birthday present.
She walked upstairs and saw two police cars outside. Serenity thought maybe someone had called the police to complain the family’s golden retrievers were running around the neighborhood again.
She didn’t know the police were there to tell the family that her younger sister, Darshana, who had gone missing several days earlier was found dead the day before, her face significantly decomposed, hanging from a tree in Burlington.
Serenity remembers seeing her father walk inside, with a ghostlike expression on his face, asking him what the police were there for, and hearing him finally blurt out the news. Then, she went outside, where her mother and her older sister had just pulled into the driveway.
“What is it? What is it? What is it?” her mother screamed.
“Is it Darshana? Is it Darshana? Is it Darshana?” the mother kept screaming.
Serenity couldn’t speak.
“Is she alive?” her mother screamed again.
Serenity’s older sister asked her to nod her head if Darshana was still alive.
Serenity couldn’t move her head.
Her mother collapsed in the driveway screaming.
Darshana Bolt
Darshana, 31, had been diagnosed with dissociative disorder, which means her memories were often separated from reality. She also had a type of post-traumatic stress disorder after suffering sexual assault and domestic violence multiple times as an adult.
At the time of her death, she was living on Social Security disability benefits as a result of her psychiatric diagnoses, according to Serenity.
Darshana had changed psychologists and psychiatrists several times, and officials did not contact the family when she first went missing. Serenity says that because of the Darshana’s disassociation from reality, she told medical professionals about false memories of being abused before the age of 2, and they were reluctant to call the family.
In the months before she died, Darshana was regularly taking Adderall, and an antidepressant called Effexor, which has been shown to put patients at high risk for suicide if they stop taking it abruptly. She admitted to being addicted to Adderall and often called it “legal speed,” according to Serenity.
Her boyfriend complained about Adderall use, Serenity said, and broke up with Darshana a few days before she died. In an effort to win him back, she flushed all her pills, including her antidepressants, down the toilet, according to Serenity.
Serenity thinks that’s when her sister’s psychiatric crisis started.
As first reported in Seven Days, early in the morning on July 12, a friend called the police when Darshana made suicidal threats, police reports say. The police arrived at Darshana’s residence to find her acting erratically. She hadn’t slept in days, according to the police report.
Police convinced Darshana to go to the University of Vermont Medical Center’s emergency room, according to the report, and she was admitted for “suicidal ideations.” The hospital discharged her on July 13 to Howard Center’s Assist.
A report filed by a state regulatory agency shows that Assist did not properly supervise Darshana. She left the facility and took her own life. Her body was found four days later.
The hospital declined to comment for this story, citing patient confidentiality.
Bob Bick, the chief executive officer of Howard Center, said regulations prohibit him from discussing whether a person has received care from the nonprofit company’s facilities.
“Obviously it’s a terrible loss when you lose a family member unexpectedly in that way, and certainly my and the staff’s condolences go out to the family,” Bick said.
The website for Assist says it offers a “respite from a stressful situation” that allows people to stay “in a safe place with professional support” and “address the issues in their lives and set goals so they can get their life back on track.”
Howard Center regulatory citations
State and federal officials did not investigate the UVM Medical Center for how it handled Darshana’s case before they referred her to the Howard Center, according to a spokesperson for the U.S. Centers for Medicare and Medicaid Services.
But the Vermont Department of Disabilities, Aging and Independent Living’s Division of Licensing and Protection cited Howard Center 10 times for violating federal regulations in the time period surrounding Darshana’s death.
Specifically, Howard Center did not tell Darshana and another patient how much they would be charged, provide appropriate documentation for advance directives, give them information on advocacy organizations they could call if they had problems, inform them of the grievance process, develop a clear treatment plan, keep notes to inform a worker on the next shift about the patient’s needs, or record information on patients’ next of kin, according to the Division of Licensing and Protection report.
Bick says the Division of Licensing and Protection has a responsibility to ensure “that there are consistent protocols in place for therapeutic community residences, and we certainly respect their professionalism in looking at how our program and other programs operate.”
The most consequential violation happened when Howard Center allegedly failed to supervise Darshana, according to the report. Staff at Assist did not perform adequate safety checks, which should have been conducted hourly for a patient threatening suicide, regulators said. She was not monitored for a full 24-hour period.
Darshana asked to go outside alone, and the staff said no. A friend then called the police, saying that Darshana was threatening to hurt herself. The police, like staff at Assist, noticed Darshana’s mood was constantly fluctuating.
Later, when Darsahana’s boyfriend visited she told him she wanted to hang herself.
The staff later allowed Darshana to go outside for a cigarette with the boyfriend. He came back in 20 minutes later and said he needed to “head out,” according to the report.
“No supervision nor reassessment of self-harm statements was provided at that time,” the report said.
Darshana did not return. Assist contacted the local police department, which searched for her that night and two days later. They found her hanging from a tree on July 17.
“The female appeared to be suspended by a white piece of cloth that was wrapped around her neck,” the police report said. “The female was found in a kneeling position on the ground straddling the tree.”
The police report said Darshana’s body “showed advanced stages of decomposition” and her face “was unrecognizable and appeared mostly decomposed.”
The police positively identified Darshana by her tattoos.
Howard Center underfunded
Howard Center is one of a dozen nonprofit mental health agencies supported by the state through Medicaid funding.
Stakeholders have said for several years that the state is not adequately funding the so-called designated agencies. In January, regulators at the Green Mountain Care Board wrote about how the funding issue specifically affected Howard Center.
“Our analysis revealed that HowardCenter’s current budget does not adequately fund the institution’s desire to accomplish its client service missions, as evidenced by lengthy waiting lists, over 100 staff vacancies, and the closure of valued community services,” the board wrote.
“Medicaid funding, which comprises over 80 percent of HowardCenter’s revenue, has decreased from 2014 to 2016,” the board wrote. “Further, we believe that the underfunding and resulting understaffing of this institution results in substantial unmet needs, which in turn affects many Vermonters.”
In April, the executive director for Washington County Mental Health Services said designated agencies like Howard Center “are at a breaking point.” And in May, a school-based clinician for Howard Center argued that the mental health system was in a full-blown “crisis.”
“For as long as I’ve been involved in following (Vermont’s mental health system), it’s sort of lurched from one crisis to the next,” said Rep. Anne Donahue, R-Northfield. “And that’s in a context where Vermont is probably one of the—if not the leader—in the country. But that doesn’t necessarily say a lot.”
Donahue said: “Sort of the chronic underfunding of the community mental health system has been a big contributor to the inability to have a well-functioning system, but that’s only one piece.”
She said another factor in a dysfunctional mental health treatment is that the traditional health care system is “unfairly discriminatory” because it is separate from the mental health care system.
‘Nobody seems to care’
Five months after Darshana’s death, Howard Center has submitted a corrective action plan to regulators at the Department of Disabilities, Aging, and Independent Living’s Division of Licensing of Protection.
The corrective action plan, dated Sept. 30, says Howard Center will require staff to check on patients hourly. However, Howard Center said it would amend its policy of keeping people on premises for the first 24 hours so that a supervisor can allow people to leave the premises during the first 24 hours on a case-by-case basis.
Additionally, Howard Center disputed the finding that it should have treatment plans for patients because “the vast majority of people admitted to this program are active Howard Center clients who have treatment plans in their electronic health record” and patients stay an average of four days at a time.
The Howard Center also said “in the context of our mission,” it would be “inappropriate” to provide instructions for staff regarding what to do if a patient dies. “We will be requesting a waiver for this item” by Dec. 1, the plan said.
Serenity has taken possession of her sister’s old laptop. Darshana wrote about her experiences with sexual assault and domestic violence, her skepticism of psychologists who made her think she was abused as a child, and other inner thoughts she likely never expected anyone to read.
Serenity is now going to counseling in order to work out feelings of guilt for leaving her sister in the hands of mental health professionals. She sympathizes with the passerby who found her sister hanging from the tree in Burlington, and says that person’s life will never be the same again.
“If ever there was a person who fell through the cracks, it was my sister, and it’s been confirmed that the Assist center screwed up,” Serenity said. She said she doesn’t understand how a person can die and a facility can simply say it will do better next time.
Serenity said she would have acted in a more formal caretaking role if she had any doubts about mental health professionals being able to take care of her sister. But now she has lost her trust in Vermont’s mental health system.
“I think that when somebody is having a psychiatric crisis or exhibiting mental illness that should be taken as seriously as any other health care issue,” she said. “If somebody was having an epileptic seizure, you wouldn’t admit them to the hospital and then put them in a halfway-house type place and just let them wander down the street and wonder if they were taking their medication.”
After her sister died, Serenity learned about how many people fall through the cracks of Vermont’s mental health system, including and Mohamed Said, a Somali native, who overdosed on medication in 2014.
She learned about the closure of the Vermont State Hospital after Tropical Storm Irene. She read about how Cheryl Hanna, a professor at Vermont Law School, was treated at the UVM Medical Center twice and, within days of being discharged, bought a gun to take her own life.
Serenity said she learned that problems with the mental health system date back years, and the situations don’t seem to have changed no matter who falls through the cracks.
“This isn’t some big revelation here,” she added. “It’s just that nobody seems to care.”
