Kaiser Permanente faces renewed criticism over mental health services after Santa Rosa suicide

Before she jumped to her death from the top of the parking lot at Santa Rosa’s Kaiser Permanente Medical Center over Fourth of July weekend, Barbara Ragan, 83, wrote a note to her children and her husband saying she “couldn’t stand the pain.”

Her medication routine had become a nightmare, upended by numerous prescription changes after the Prozac she’d used to treat her depression for years stopped working, her family said.

On July 5, dressed in a housecoat, nightgown, socks and slippers, Barbara Ragan drove the 10 miles from her home in Oakmont to the Kaiser medical center on Bicentennial Way. She went to the third level of the parking garage and stood on the edge. Santa Rosa police said witnesses below tried to talk her down, but she said nothing and let herself fall.

Denny Ragan said he believes his wife, who retired from Kaiser in South San Francisco more than two decades ago, was trying to make a statement. The only identification she had with her was her Kaiser medical card and her driver’s license, her family said.

“She drove right over to Kaiser … 16 years working there … she was very upset about them. She went right up to the parking area near the emergency room,” he said. “To me, that’s a statement of what they’re doing out there, how they treat people.”

Kaiser said this week that it extended its condolences to the Ragan family, but after thoroughly reviewing the case found that Barbara Ragan had received a “tremendous amount of care” in the weeks before her death. Officials said Kaiser mental health providers were in frequent contact with Ragan regarding her condition and the medications she was taking.

“We extend our deepest sympathies to the family,” said Dr. Mason Turner, Kaiser Permanente Northern California’s director of outpatient services for regional mental health.

“The care Ms. Ragan was receiving was exceptional care,” Turner said, adding that Kaiser was willing to work with the family to address their concerns.

But Ragan’s suicide has once again raised questions about what critics say are serious gaps in the company’s mental health services.

Specifically, critics say Kaiser fails to provide timely individual appointments to see a mental health therapist or psychiatrist. In recent years, Kaiser has been penalized by the state Department of Managed Health Care for serious “deficiencies” in its mental health care offerings.

Kaiser this week rejected such claims. Turner said the health plan has made great strides in expanding its network by hiring more mental health providers and contracting with an outside network to supplement its staff. The health plan said it hopes to become a national model for mental health care.

Worsening condition

For more than two decades, Barbara Ragan had been taking Prozac. But Denny Ragan said that his wife only recently began feeling like it was wasn’t working for her.

“You could always tell something was always there, but it was livable,” Ragan said, adding that about a month ago his wife’s condition was worsening.

On June 15, the couple were at the Trader Joe’s on Cleveland Avenue when Barbara Ragan said she didn’t think she could continue shopping. She got extremely quiet, her mood worsened and she asked her husband to take her to the “emergency hospital,” Denny Ragan said. He said he didn’t know exactly what his wife was going through; her condition changed so rapidly.

“They’re the only ones that can explain what they’re going through,” he said. “I said, ‘Gee, you’re feeling that bad?’ She said, ‘Yes, can you please take me to the emergency room?’?”

Denny Ragan said emergency department staff told them the only thing they could do was give his wife a sedative and try to get her an appointment to see a psychiatrist.

Turner, the Kaiser mental health care director, said emergency department staff determined Ragan was not a danger to herself, and therefore they could not admit her. But they sought immediate help for her, he said.

Medical center staff were able to get her an appointment at Kaiser’s adult psychiatric services building on Round Barn Boulevard in 15 minutes, Denny Ragan said.

After seeing a psychiatrist there, Barbara was given prescriptions for Ativan and Lexapro. Denny Ragan said that since May 28, his wife’s medications were modified several times and that she was having an extremely difficult time with such repeated changes. Prior to the emergency room visit, Barbara Ragan had been prescribed Zoloft and Xanax, the family said.

Turner said such switches are not unusual when doctors are trying to find the right medications to meet a patient’s needs.

Denny Ragan said that after the emergency department visit, his wife called Kaiser’s advice nurse two or three times from June 15 until July 3 seeking guidance with her medications. That should have raised red flags among her providers, he said. Days before her death, when she learned that she was prescribed Prozac - the original drug that had stopped working - Barbara Ragan became desperate, her husband said.

“Why would they put her back on Prozac when they said it wasn’t doing any good?” Denny Ragan said. “She said, ‘Denny, I’m just not getting help.’?”

In late June, she received an “appointment confirmation” from Kaiser. The card, which was dated June 27, was for an Aug. 25 appointment to see her psychiatrist.

“That really threw her off. She said, ‘Denny, I can’t wait that long,’?” Denny Ragan said. “I said, ‘Barbara, if you just last the weekend.’ I said, ‘Just hang in and on Monday morning, we’ll go over there and I’ll make sure you get some treatment.’

“She didn’t wait. She just got fed up.”

He said his wife “was disgusted with the pills she was taking and the appointments she wasn’t getting.”

Kaiser defends treatment

Kaiser says mental health staff were attentive to Barbara Ragan’s needs in the weeks leading up to her death. Turner said that shortly after the emergency department visit, Ragan was offered both individual or group therapy but she declined.

He said that even though she was given an Aug. 25 appointment to see her psychiatrist, she could have seen a mental health provider at any time before that if the need was urgent. He said that just a few days before her suicide, she was evaluated over the phone by a psychiatrist.

“If she actually did call and in any way was urgent or needed to be seen, she would have been accommodated,” Turner said.

Denny Ragan said that wasn’t enough.

“The point is, they gave her a two-month appointment and all that medicine in a two-week period,” he said. “If that didn’t call their attention to something …”

Tragic outcome

On the evening of the Fourth of July, Denny Ragan said his wife’s condition reached an unprecedented low. The next morning, a Sunday, he said his wife went into the porch room where she usually has a cup of coffee and a cigarette.

“She was mumbling to herself, shaking,” he said. “She could hardly get the cigarette up to her mouth … just shaking and mumbling.”

Denny Ragan said he asked his wife to come read the newspaper with him in the bedroom, their usual Sunday morning routine. She asked him for a few minutes. A half-hour later, he came back and asked again that she come in. She agreed.

On the way to the bedroom, she asked if she could go into the den and sit in the leather armchair. He went into the bedroom and soon took a call from his daughter Denise. He said he called out to his wife to let her know that their daughter was on the phone, thinking that might cheer her up, but there was no answer.

He went into the den, but there was no sign of his wife. Her purse was still in the house.

Denny Ragan said his wife left a note in her desk, but it wasn’t found until two days after her death. He believes she wrote it just hours before she drove to Kaiser.

The note is simple and begins, “My children, I love you all so much, Mom. Denny, I love you, Barbara.”

He reported his wife missing at about 12:30 p.m.

At 1:53 p.m., an emergency dispatcher reported someone on the third level of the Kaiser parking garage threatening to jump. Police said there were witnesses below who tried to talk her down. At 1:55 p.m., a dispatcher reported, “CPR in progress. … She jumped.”

Family members have requested a copy of the police report, the coroner’s report, medical records and any video surveillance of the parking structure and emergency department area. They said they don’t know if she tried to seek help in the emergency room before she died.

“Video does not lie; people can,” her son Patrick Ragan said.

Patrick Ragan said his mother never showed signs of being “suicidal.”

“In her right mind, that is not my mom,” said Patrick Ragan, who rejected Kaiser’s claim that his mother received proper care.

“In my opinion, Kaiser failed to notice her cry for help,” he said. “With a deadly mix of drugs, you are not in your right mind.”

Supervisor’s criticism

Last week, the family reached out to Sonoma County Supervisor Shirlee Zane, a vocal critic of Kaiser mental health services. Zane said the death of Barbara Ragan was the latest example of Kaiser’s troubled mental health network.

She criticized Kaiser’s repeated claims that the health plan has taken the necessary corrective steps to alleviate problems identified by the state in 2013.

Those problems led to a $4 million fine by the Department of Managed Health Care, which is charged with protecting the rights of health plan patients. Kaiser at first challenged the penalty but last fall opted to pay the fine, though it did not concede the state’s findings of wrongdoing.

Zane disputes assertions that Kaiser has since greatly improved its mental health services.

“Clearly that was not Barbara Ragan’s experience,” Zane said. “She didn’t get what she was seeking; neither did her husband or her children.”

Zane has publicly stated that Kaiser’s lack of mental health services played a role in her husband’s 2011 suicide. She said the HMO’s ongoing problems with access to therapists continue to endanger the lives of those suffering severe mental health issues.

Kaiser, she said, is bound by the state’s Mental Health Parity Law, which mandates that if a health plan offers mental health benefits, they must be offered at the same level as physical health services.

“How many more wake-up calls do they need?” she said. “They have completely and utterly made these public statements that they have improved their services.”

Zane said Kaiser is “exactly where they were two-and-a-half years ago” when the DMHC issued a scathing report criticizing the health plan’s mental health services.

Timely appointments

That report, which came out of a routine survey of Kaiser medical services, found among other things that Kaiser was not providing timely appointments to its mental health patients.

Earlier this year, in a follow-up to the survey, the department found that while Kaiser had corrected two of four troubling deficiencies found in previous evaluation of the plan’s medical services, Kaiser still was not providing timely appointments for a significant portion of the HMO’s patients in Northern California.

The DMHC reported in its follow-up that appointments for mental health services did not occur within the required regulatory time frame in 22 percent of the medical records it reviewed in Kaiser’s Northern Region, which includes Santa Rosa facilities. In Kaiser’s Southern Region, timely appointments did not occur in 9 percent of the medical records that regulators reviewed.

Struggling with demand

Rosemary Milbrath, who until recently was the executive director of the Sonoma County chapter of the National Alliance on Mental Illness, said many health plans are struggling to meet patient demand for services.

“All the health plans are facing the same challenges of how to provide effective mental health services in a cost-effective way under the new guidelines of health parity,” Milbrath said. “I hear the same frustration that people express from those individuals who are insured by BlueShield, by UnitedHealthcare - all of them.”

Milbrath said patients often report limitations on the number of individual therapy visits and also trouble getting emergency mental health care.

“Kaiser has been singled out, I guess, because they have so many patients,” she said. The HMO has just over 200,000 patients in Sonoma County, a Kaiser official said.

Kaiser said this week it had made more progress since the follow-up survey was conducted and that staff is working closely with DMHC. That survey was based on site visits to Kaiser facilities in October 2013, March 2014 and April 2014.

Turner, the Kaiser mental health care director, said mental health care staffing has increased by 25 percent across the state and that the health plan has also contracted with a “high-quality” third-party mental health care network of 4,500 clinicians. The health plan also has incorporated other initiatives, such as establishing more flexible extended hours to accommodate patients.

Turner said that Kaiser has taken to heart lessons learned in the couple of years since the DMHC report was issued.

Union’s position

Sal Rosselli, president of the National Union of Healthcare Workers, said Ragan’s death was the result of Kaiser’s failure to hire more behavioral health staff. The union, which represents about 1,600 mental health clinicians (including psychologists, therapists and psychiatric social workers) in Northern California, has said the provider lacks enough staff to handle its mental health patients, particularly after President Barack Obama’s Affordable Care Act brought in more members.

“This tragic situation is the inevitable cost of a system run by accountants rather than caregivers,” Rosselli said. “How many people have to die before Kaiser listens to the clinicians they hired to fix the problem?”

Kaiser has dismissed such criticism as a labor bargaining ploy.

Loss and grief

For Denny Ragan, the loss of his lifelong partner has been devastating.

The couple, who would have celebrated their 63rd wedding anniversary July 13, met at a birthday party in San Francisco, where they both grew up.

“She was nice and quiet and sweet. She was considerate, she was beautiful … made a lot of friends easily. She just listened to everybody,” he said. “She just fit the bill.”

Denny Ragan owned a number of businesses in the Bay Area, including a gas stations, a furniture store and a carpet cleaning business, mostly down in Millbrae, he said. After raising five children, his wife went to college for a degree and got a job at Kaiser Permanente South San Francisco Medical.

She worked for about 16 years as a medical records transcriber, transcribing doctors’ notes. She retired in her early 60s. Shortly after that, the couple moved to Oakmont to a home they had built with a beautiful view of Annadel State Park.

In the note she left, Barbara Ragan’s writing is strained, the product of a shaky hand, her husband said. Some of the words are hard to make out - the last word in the note, “pain,” was at first difficult to make out, he said.

Denny Ragan struggled to understand the kind of pain that would drive someone to take her life. He said he understood physical pain but couldn’t grasp the kind of mental and emotional pain his wife was going through.

“What’s the pain? It’s not physical, it’s mental,” he said. “What was the pain? It must have been horrible.”

Staff Writer Mary Callahan contributed to this report. You can reach Staff Writer Martin Espinoza at 521-5213 or On Twitter @renofish.

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