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Investigation Concludes Nurse Disobeyed Doctor’s Order

MADISON, WI – The family of a former Winnebago Mental Health Institute resident has filed a wrongful death lawsuit against the State of Wisconsin after their 15-year-old developmentally disabled daughter choked to death while in the care of the state run facility.

The untimely and avoidable death of Myriah Peronto garnered media attention approximately a year ago when a Journal Sentinel Watchdog report exposed numerous negligent practices at the facility including federal rules violations for poor medical care, lax supervision and short staffing. Over a two-year period, 3 deaths, 1 rape and three dozen acts of violence or sexual aggression occurred at the facility.

Myriah was admitted to the facility in September of 2003 with a seizure disorder along with a well documented history of swallowing problems and rapid eating. After a preliminary evaluation of Myriah’s eating and swallowing abilities, the facility’s Registered Dietician and Speech Language Pathologist placed Myriah on a special diet that consisted of soft foods.

According to medical records, Myriah was to be closely supervised during her meals, her food was to be cut into small, finger-sized pieces and only half of her meal was to be given to her at a time. After every few bites the staff was to ensure that Myriah drank liquids to help with swallowing.

In November 2005, a nurse requested that Myriah be taken off the diet because she felt Myriah could eat regular food if closely supervised. A pediatrician requested an order for a dietary evaluation by the Speech Language Pathologist. Despite the doctor’s order, the nurse chose not to consult with the Speech Language Therapist and changed Myriah’s diet.

Shortly after the change in diet, Myriah’s records indicated that she had two choking episodes in December 2005, however nothing in her records indicates appropriate measures were taken to prevent a future occurrence.

On January 11, 2006, Myriah was in the facility’s dining room eating a beef sandwich on a French roll when she began to cough and subsequently choked to death.

A state investigation concluded that the nurse failed to keep Myriah’s care plans up-to-date and that her decision to disobey the physician’s order led to Myriah’s death.

The lawsuit contends that the State failed to properly care and supervise Myriah and its staff, and in failing to do so, violated federal and state regulations, the policies and procedures of the facility, and Myriah’s constitutionally protected rights by allowing her to choke to death on her food.

“Myriah’s death was completely avoidable and was caused by choices that disregarded Myriah’s health, safety and constitutional rights,” said the family’s attorney Jeffrey Pitman. “This lawsuit was necessary because the State chose not to accept responsibility for its employee’s choices and conduct. The State chose not to respond to the family’s attempt to settle this case without the need for a lawsuit and putting the family through the horror of what happened.”