Family looks for answers after son’s suicide
The message on the answering machine filled them with dread. It was about 10 p.m., a few days before Thanksgiving a year ago. Bill Gottesman and Debra Lopez had been at a holiday party near their home in Vermont — a brief distraction from their monthslong nightmare. While they were out, someone from The Menninger Clinic had called. It was about their son.
Bill fumbled for the phone, then dialed.
“What do you mean he’s missing?” he said to the nurse in Houston. Debra started sobbing.
They hadn’t wanted to send Alan 1,600 miles away. But he’d been talking about killing himself, had even taken a couple of practice runs. His best hope, doctors had said, was at a 50-acre campus near the Texas Medical Center.
Three weeks after dropping him off, Bill and Debra pressed their ears to separate phone receivers:
Alan had been on a group outing to a restaurant, the nurse said “If these kinds of safety lapses are happening at the much-celebrated Menninger Clinic, can you imagine what’s happening out of the public eye at facilities that operate on a fraction of their budget?” Skip Simpson, Dallas attorney
… had asked to use the bathroom … went by himself … didn’t come back …
They hung up and immediately chartered a plane, flying out the next morning. They landed in Houston around 1 p.m., rented a car and began searching.
At a hospital across town, an emergency room doctor would soon make the official declaration:
Alan Gottesman was dead.
Months later, a state investigator concluded that Menninger staff had made mistakes. They shouldn’t have let Alan go off by himself. Should have done more to protect him. The clinic was slapped with
As Menninger Clinic stands by its practices, Texas laws prevent parents from knowing what mistakes were made
three fines totaling $75,000 for violating state code governing safety at psychiatric hospitals, according to a notice of violation sent to the clinic and obtained by the Houston Chronicle.
That investigation — like Alan’s death — has never been publicized. But that’s not surprising. Although it’s considered one of the nation’s best psychiatric facilities, The Menninger Clinic’s safety record has been protected by Texas laws that shield the public from learning about lapses at hospitals, a Chronicle investigation has found.
Other incidents at Menninger not reported before now: In 2005, a 22-year-old woman from Minnesota was left alone, giving her time to hang herself with a strip of clothing. Six years later, a patient reeling from a recent divorce checked himself out of the hospital and tried to kill himself after a counselor started having sex with him. In 2013, a 66-yearold Florida businessman hanged himself with his belt in a bathroom. Just two months later, another patient was found hanging from a belt in a bathroom but survived.
Through a spokeswoman, Menninger Clinic officials declined to answer questions for this story, citing privacy laws that prevent providers from talking about individual cases, and wouldn’t agree to a more broad discussion about safety protocols. In an email, spokeswoman Nancy Townbridge noted the clinic’s “profound commitment to safe and effective health care.”
There’s no way of knowing how many patients have harmed themselves at Menninger or any other hospital because no agency tracks that information. The Chronicle called malpractice lawyers, scoured death records and contacted people who had left online reviews to find examples.
Those incidents might have drawn swift headlines in other states. But in Texas, the law that gives the Department of State Health Services authority to investigate hospitals also requires that it keep its findings secret, even from families and their lawyers.
“Bottom line, there’s no way to hold psychiatric hospitals accountable in Texas,” said Tommy Hastings, a malpractice lawyer in The Woodlands who’s familiar with Gottesman’s case. “You have to hope their own conscious takes over and they decide on their own to do a better job caring for patients.”
In response to questions for this story, DSHS spokesman Chris Van Deusen initially said he couldn’t even disclose how many times the state had investigated Menninger. Later, after being pressed with questions about specific cases, Van Deusen revealed the agency had looked into 41 complaints since the clinic moved to Houston from Kansas 13 years ago.
Only three of those investigations resulted in sanctions, according to public records. Any fines levied against psychiatric hospitals are posted on the DSHS website, but it lists violations only from the last 12 months and includes no details about the events that prompted the penalties.
“There’s absolutely no public policy rationale for the state’s investigation to be secret,” said Glenn Cunningham, a San Antonio malpractice lawyer who has fought DSHS to release its investigations. “The policy exists for no other reason than to protect the reputation of hospitals.”
Indeed, the legislator who authored the 1999 law, former Rep. Patricia Gray, D-Galveston, didn’t intend to cloak state investigations in secrecy, she said. The amendment requiring confidentiality was added late in the process at the request of the Texas Hospital Association; she didn’t have a clear understanding of the consequences.
Eighteen years later, the secrecy law remains unchanged.
“If there’s a way to fix this, I will come back from the grave and testify in favor of it,” said Gray, whose later attempts to repeal the bill failed. “That is not the way it was supposed to be.”
In some cases, the public can learn about problems at hospitals by requesting U.S. Department of Health and Human Service investigative reports, which are public. But private hospitals like Menninger that don’t accept Medicare or Medicaid aren’t subject to federal oversight.
Each of the families whose loved ones killed themselves at Menninger told the Chronicle they considered suing the hospital. But due to the state’s lowest-in-the-nation cap on malpractice lawsuits — and because of a 2008 state Supreme Court ruling that seemed to suggest hospitals can’t be held responsible for suicide — none could find a lawyer in Texas willing to take the case.
In that context, any problems at Menninger raise bigger questions, said Skip Simpson, a Dallas attorney who advocates for better oversight of hospitals nationally. Texas has 10 state-run psychiatric hospitals, but the vast majority of mentally ill patients receive care at one of about 60 private psych hospitals, including 10 in Harris County.
“If these kinds of safety lapses are happening at the muchcelebrated Menninger Clinic,” Simpson said, “can you imagine what’s happening out of the public eye at facilities that operate on a fraction of their budget?”
Alan’s parents had spent days vetting the clinic. They read the national rankings. Talked to experts. Browsed online testimonials.
Debra, a psychiatrist herself, was well aware of Menninger’s reputation.
“I had heard good things from a colleague of mine. Some of the people on their staff are well known in the psychiatry world. They are really well-respected.”
She and her husband could find no reason not to send Alan.
For most of eight decades, Topeka, Kan., and the famed Menninger Clinic were at the center of the psychiatric universe. People traveled from around the globe to check themselves in to the clinic’s sprawling campus, some staying for years of treatment from the world’s foremost mental health experts. Generations of counselors trained in its classrooms.
Over time, though, psychiatry changed. Gone was the era of months-long stays at remote facilities. And gone was the business model that had made Menninger so successful.
By 2003, clinic leaders had concluded that, in order to survive, they needed to move to a bigger market and find a prestigious academic partner. The staff loaded their remaining 29 patients onto a chartered jet in May of that year and headed south.
In Houston, Menninger joined forces with Baylor College of Medicine, where its esteemed clinicians serve as faculty members. Baylor deferred questions for this story to the clinic. Patients pay up to $2,200 a day for care at the upscale South Main Street facility, in part because the clinic still offers longer stays and more intensive treatment than most hospitals.
Two years after the move, Diane Roforth-Smith brought her 22-year-old daughter, Laura Kliebenstein. She sent Laura to an eight-week program for young adults struggling to transition to adulthood — the same program Alan Gottesman would attend a decade later.
Twice a day, Roforth-Smith called to check in. One day, about three weeks after dropping her off, Kliebenstein told her not to call for a couple of days. She said she needed space. Roforth-Smith phoned her daughter’s social worker at the clinic to tell her she was worried, but the staffer never returned the call, she said.
A day later, a different clinic employee called: Her daughter had hanged herself in a conference room with a piece of clothing.
“I thought I had her in the safest place in the world,” said Roforth-Smith, who still chokes up every time she discusses it. “The betrayal I felt was nearly as bad as the pain from losing her. I trusted these people to take care of her.”
Afterward, Roforth-Smith hired a mental health expert to review her daughter’s records in preparation for a lawsuit she never filed. The expert, the late Houston psychiatrist Joel Hochman, concluded that because Kliebenstein had recently expressed suicidal thoughts — and because she’d made previous attempts — she shouldn’t have been left alone. He faulted a “breach in the standard of care” at Menninger.
Roforth-Smith didn’t know that DSHS had done its own investigation. The Texas agency found no evidence of violations by the clinic, spokesman Van Deusen said in an email to the Chronicle. Since the state’s investigation is secret, there’s no way to compare it with Hochman’s review.
The state agency also investigated in 2013 after Kevin Hill’s father hanged himself with a belt in a Menninger bathroom. Hill, who spoke with the Chronicle on the condition that his father not be named, said he was furious his dad was left alone.
His father had been a successful small business owner in Florida. When he became depressed, Hill and his siblings decided to send him to the best facility they could find, regardless of cost. Menninger offers a specialized six-week program for professionals in crisis.
“We took a tour and were really impressed,” he said. “Everything was shiny and new. There was good food, not the depressing cafeteria food you’d get at other clinics. It seemed like a great environment for him.”
He, too, was surprised and upset to learn from a Chronicle reporter that the state had investigated his father’s suicide without ever notifying him. Van Deusen said DSHS found “deficiencies” in care, but the state took no action against the clinic. He said state law barred him from detailing the deficiencies or the decision.
Hill had pressed clinic officials to refund the $87,000 his family paid for his father’s care, but all he got, he said, was a promise that staff would make changes to prevent future patients from hanging themselves from belts in bathrooms.
Yet it happened again two months later, according to documents obtained by the Chronicle. That patient suffered serious injuries, including memory loss. The state investigated again, according to records, and this time issued a $25,000 fine.
Hill sat at a computer a couple of years later, frustrated that no lawyer would take his case, and typed an anonymous Yelp review, warning others not to send loved ones.
“We took my dad to Menninger because our health care provider told us it was top three in the country,” Hill told the Chronicle. “We had other options that were less money, that were local. But we wanted to get him the best care we could.
“Taking him there was the worst mistake I’ve ever made.”
After a couple of weeks at Menninger, Alan Gottesman wasn’t doing better. In calls home, he sounded more hopeless than ever, his parents said.
They were so worried, they scheduled a phone call with the doctor in charge of his care. “Are you aware of how bad he is?” Debra remembers saying.
Alan’s psychiatrist assured them the staff knew he was continuing to struggle after switching his medication, she said. That they were doing everything possible to help him.
The next afternoon, Alan called to tell Mom and Dad that he’d been cleared to go on an outing with other patients to a restaurant. That was a surprise. “But we thought, ‘Well, he’s safe,’ ” Debra said.
That night, Alan stood up
“If there’s a way to fix this, I will come back from the grave and testify in favor of it. That is not the way it was supposed to be.” Patricia Gray, former legislator who authored the law that requires state investigations into hospitals be kept secret
from the table and asked to use the bathroom. No one knows what he did after walking out the back door of Houston’s restaurant on Westheimer Road, only where he ended up 17 hours later.
About a quarter past noon on Nov. 21, 2015, he climbed to the top of a four-story parking deck in the Galleria area. Light rain fell from a gray sky. A witness told emergency responders later that he’d glimpsed a man standing at the edge. Another said she saw him fall.
Two police officers found Bill and Debra at their hotel late that night and confirmed their fears.
The year that’s followed has been a frustrating fight for answers.
“There are so many layers of protection that keep us from learning about what happened at Menninger, from learning about what changes were made afterward, from learning what consequences they had with the state, because the state protects their records,” said Bill, a retired family physician.
They felt they owed it to their son to fight. They submitted a formal complaint to DSHS. Filed records requests for past sanctions against the hospital. Tried to find other families whose loved ones had committed suicide at Menninger.
They reported their son’s suicide to the Joint Commission, a nonprofit that accredits hospitals nationwide, but discovered the commission helps facilities improve care after suicides rather than taking punitive action.
This summer, they got a call from the DSHS employee sent to investigate their complaint.
“He called us and said, ‘Listen, I have findings in my report, but you will never see my report, because it’s protected by state law, and it won’t be discoverable by you,’ ” Debra said. “You had the feeling that he felt sorry for us.”
They continued to harass DSHS for answers, eventually learning that Menninger had appealed the state’s $75,000 fine. At an informal, closed-door meeting last month, clinic leaders were allowed to present evidence to the state defending their staff’s actions.
The clinic also appealed in 2012, according to DSHS records, when it was cited and fined $40,000 for three violations. Records give no indication what prompted the sanctions.
Menninger ultimately paid just $8,000 in exchange for agreeing to a corrective action plan.
“I’m surprised they paid anything at all,” said Cunningham, the San Antonio malpractice lawyer. It’s not uncommon, he said, for psychiatric hospitals to avoid sanctions through legal maneuvering:
“The system in Texas is designed to protect the profits of hospitals. It’s all about money, not about patients.”
A week after Alan’s death, his obituary appeared in the Burlington Free Press, detailing highlights from a life cut short.
His Little League teammates had nicknamed him “Wheelz,” a nod to his speed on the base paths.
He’d been a member of his high school drama club and is remembered for his hilarious portrayal of Gaston in “Beauty and the Beast.”
He’d graduated with honors from Dartmouth College. Had given private saxophone lessons. Had volunteered to teach children chess at the library.
“Alan was kind, gentle, and deeply loved.”
The morning of the funeral, an envelope from Menninger arrived in the mail. Bill and Debra opened it before leaving for the synagogue.
It was an invoice, refunding them the money they’d sent in advance for weeks of care that Alan would no longer need.
And it was a bill, they said, for about $12.
The cost of the last meal their son ever ate.