Suicide victim had been hospitalized for 49 days

Sept. 04--When Joy Silva leapt to her death from the third floor of her downtown apartment building on July 27, it wasn't the first time she had done so.

Public safety personnel had responded to the same location, 237 Main St., less than two years earlier. Silva had jumped from the same window; it was one of at least five suicide attempts in the past three years.

The fact that the 63-year-old woman was released from the state psychiatric hospital on July 27, after talking about a plan to commit suicide by jumping off a building, shocked some of the professional staff who had become acquainted with Silva over several short-term stays at New Hampshire Hospital in the months leading up to her death, according to a hospital administrator who spoke only on the condition of anonymity.

Whether Silva's death was the consequence of poor judgment by medical professionals who had plenty of warning signs, or a tragic but unpredictable event, will be the focus of an independent investigation. Publicly available documents obtained by the New Hampshire Union Leader reveal just how many warning signs there were.

Nashua police, acting on a Right-to-Know request, released all records pertaining to Silva, with several redactions, going back to 2010.

Officers were called to assist in at least four unsuccessful suicide attempts involving drug overdoses, on Nov. 23 and Nov. 30, 2013; and on April 7 and April 17, 2015, in addition to the first time she jumped from her apartment window on Aug. 11, 2014.

She spent 49 days in a Nashua hospital just two months before her suicide, as doctors prepared a plan for involuntary emergency admission to New Hampshire Hospital, and police considered her a missing person.

Mental health professionals agree that such cases are rarely black and white. Strong measures are in place to protect people suffering with mental illness from involuntary hospitalization, and for good reason. Yet those same protections set the stage for someone who can be lucid at times or suicidal at times to fall through the cracks.

"A lot of this has to do with the laws regarding mental illness," said Victoria Cronin, a psychiatric nurse practitioner who previously worked at New Hampshire Hospital and now works at the Veteran's Administration Medical Center in Manchester. "Many people don't understand that people have a right, under federal and state law, to refuse medical and psychiatric treatment. The only time we can intervene is if they are an imminent danger to themselves or others."

Well-intentioned patient privacy laws, like the Health Insurance Portability and Accountability Act, or HIPPA, can prevent health care professionals from notifying other practitioners and family members of a patient's discharge, Cronin said, creating more holes in the mental health safety net.

Long history

Nashua Patrolman John Hannigan was working second shift at the intersection of East Hollis and Main streets in August of 2014 when he heard glass break in the area of 237 Main St.

"When I looked up at the building, I observed a female, later identified as Joy Silva, hanging outside of a third-story window," Hannigan wrote in his Aug. 12, 2014, report. "Silva was holding onto the ledge with both hands and hanging in the air."

As Hannigan rushed to the third floor of the building in the hope of rescuing Silva, she fell to the ground, although she remained conscious and was transported to the hospital.

According to the police report, as she fell through the air, her feet broke the window on the second story and she fell to the pavement parallel to the ground, hitting the right side of her body and shattering her right arm. She was transported from Nashua to a Massachusetts hospital for treatment.

From March 21 to May 4 of this year, Nashua police considered Silva a missing person, because unbeknownst to them, she had been admitted to Southern New Hampshire Medical Center's west campus.

Concerned neighbor

A concerned neighbor called police on March 21 to check on Silva's apartment, telling officers she had not been seen for several days. Police checked with local hospitals, and came up empty. "Negative at both hospitals," states the report.

Police issued a BOLO (be on the lookout) for Silva and listed her as a missing person in a national database.

"Due to Joy's long mental health history, including several suicide attempts via prescription medication and jumping out of a window, it was determined that she would be entered into the NCIC (National Crime Information Center) as a missing person," wrote Officer Steve Hallam.

On May 4, Nashua police were able to confirm that Silva had been treated as an in-patient at the SNHMC west campus for the past 49 days.

Doctors there "were apparently in the process of completing an IEA (involuntary emergency admission) for Silva," according to the police report. That set the stage for one of several visits to New Hampshire Hospital in the ensuing weeks, including the brief stay on July 27.

Plan not implemented

Doctors at SNHMC kept Silva under supervision for almost two months, and appear to have developed a plan that could have resulted in long-term care at the state hospital. Why that plan was never implemented, and why newly appointed doctors at New Hampshire Hospital released her to an unsupervised apartment on July 27 remains to be determined.

North Country Executive Councilor Joe Kenney pressed Health and Human Services Commissioner Jeffrey Meyers on the process by which Silva was discharged at the council meeting on Aug. 25, when councilors refused to approve a new, $36.5 million staffing contract for the state hospital with Dartmouth-Hitchcock clinic.

"What I can say is the patient was discharged as a result of a clinical determination made by two board-certified psychiatrists, both of whom had substantial experience," said Meyers. "I can tell the governor, the council and the public, that the staffing of the hospital, the issue of bed availability, in my judgment, were not factors at all."

Meyers also reported that no disciplinary action has been taken and no personnel changes made at the hospital as a result of the discharge decision. He told councilors an independent team was being assembled to investigate the case, and on Friday, he announced its members.

They include retired state Supreme Court Justice James Duggan; former Assistant Commissioner of the Department of Safety Kevin O'Brien; former Commissioner of the Vermont Department of Disabilities, Aging and Independent Living Susan Wehry, a psychiatrist; state Circuit Court Judge James J. Leary, who organized and presided over the state's first mental health court; and Jill A. Desrochers, assistant attorney general.

Confidential review

The group will conduct its review and report its finding to Meyers behind closed doors, and issue a public report on recommendations when the review is complete.

A key question that remains unanswered is whether Silva asked to be discharged on July 27, or whether she was released at the initiative of doctors.

The police record is full of documents recounting interviews with Silva in which she was lucid and articulate.

Her family members, who recalled her in her obituary as a woman with early dreams of becoming a dancer, made clear to the Union Leader that they do not want to discuss her case.

"After being in this business for so long, I can say most patients who have persistent and chronic mental illness have a course like this," said Cronin, "in and out of treatment over long periods of time."

dsolomon@unionleader.com

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