LAYTON — Pete Kassel was ready to beat his heroin addiction, his mother says.
They went to Davis Behavioral Health‘s Crisis Recovery Unit, where he was evaluated and admitted.
“I’m thinking he’s in a safe place, a safe environment,” said Nina Kassel.
Four days later, Pete Kassel was dead, found cold to the touch on his bed in the treatment center.
Nina Kassel and Kassel’s wife, Amanda, contend he received inadequate and inappropriate care.
“I believe that they killed him,” Nina Kassel said.
Arpidet “Pete” Kassel, 29, was the father of three and had worked as a welder and laborer at a Clearfield trailer manufacturer.
His death on Nov. 20, 2018, remains an event his mother and wife still cannot accept.
Forty-one people died in Utah rehab centers in 2017, according to a report by the U.S. Substance Abuse and Mental Health Services Administration. That was up from 33 in the previous reporting period, 2015.
Nationwide, 3,788 people died in substance abuse rehab, the federal agency said.
The national average death rate in rehab is 0.02%. Utah’s rate in 2017 was 0.03% — 41 deaths among the 14,506 people discharged from rehab centers during the year.
INJURY, THEN ADDICTION
Kassel’s trouble started with a back injury several years ago, his wife said.
After surgery, he became addicted to painkillers and later the street drug heroin.
In 2018, his problems cascaded. He no longer lived with his wife and children in Clearfield. He was arrested on a misdemeanor drug possession charge and missed some court appearances.
On Nov. 16, Kassel and his mother arrived at the Davis Behavioral Health CRU. He had no insurance, but Davis Behavioral Health, depending upon available beds, serves people who cannot afford to pay.
“I told them he wants detox,” Nina Kassel said. “He wants to get clean now.”
She visited him each evening for the next three days.
“On the 19th, the last day, he was fine,” she said. “He told me he was going to get a Vivitrol shot” in the next few days.
Vivitrol injections deter addicts from using. They often are given to people as they leave rehab.
He died before he could get the shot.
“I was so happy that he was going to get this done,” his mother said. “Next day they called me and told me he’s dead.”
Kassel’s autopsy and toxicology reports, provided to the Standard-Examiner by his wife, found Klonopin, a sleep aid and calming drug, in his system. He also had Ambien, a sedative, and Benadryl, an antihistamine often used to treat insomnia.
According to Davis Behavioral Health patient records provided by Amanda Kassel, doctors had prescribed those medications to Pete Kassel during his stay.
The state autopsy tests showed low levels of the drugs in his body, with no toxicological significance.
Kassel also had no heroin or other opioids in his body, the reports said.
Dr. Satish Chundru, assistant state medical examiner, said in his autopsy report that Kassel had a mildly enlarged heart. He listed the cause of death as natural, due to cardiomyopathy, a type of heart disease that can lead to heart failure.
According to the U.S. National Library of Medicine, heroin addiction can cause cardiovascular damage, including bacterial infections of blood vessel linings and heart valves. Heroin also may contain contaminants that can contribute to cardiovascular problems.
SCOPE OF UTAH REHAB REGULATION LIMITED
No state or local agencies specifically track deaths in Utah rehab centers.
The Utah Department of Human Services logs critical incidents, including deaths, but any investigations are handled individually and no aggregate death count is kept.
“Unfortunately it’s not something we would track as an overall trend,” said Amanda Slater, director of the department’s Office of Licensing.
All centers are audited annually by the division, and any license violations are addressed as needed, she said.
“We really focus on the provider, not trends of all providers,” Slater said.
“Client and staff health and safety is our main purpose and main goal,” Slater said. “We offer technical assistance to the providers” so they can better “serve those clients that are so vulnerable.”
FAMILY CRITICIZES CARE
Amanda Kassel said she believes her husband should have been sent to a hospital-level detoxification center before being accepted as a patient by the Davis Behavioral Health CRU.
“They accepted him to this CRU unit for psychotic people and it’s not even for drug addicts,” she said. “He shouldn’t have even been there.”
Circumstances of his enrollment and the types of facilities that were considered are unclear, because Davis Behavioral Health declined to comment specifically about Kassel’s care, citing federal medical privacy laws.
However, the company’s corporate compliance officer, Shelly Tanner, said the CRU “offers short-term crisis residential treatment for clients with mental health or substance abuse issues.”
Because opioid addiction is an epidemic in Northern Utah, Davis Behavioral Health “has tried to cater our services to the needs of the community,” Tanner said. “We are trying to treat that as best we can.”
Nina Kassel said she and her son ended up at the CRU after several other clinics would not accept him because he lacked insurance.
Amanda Kassel was skeptical of the treatment regimen used for her husband described in the medical records she obtained from Davis Behavioral Health.
“To detoxify him they just gave him Klonopin and Ambien. He was like the guinea pig — ‘Let’s just see if we can treat him here.’ They pumped him full of drugs and failed to detox him properly.”
A National Institute of Drug Abuse study said current front-line medication-assisted opioid detoxification treatment usually consists of one or a combination of the drugs buprenorphine (brand names Suboxone and Subutex), methadone, and naltrexone (brand name Vivitrol).
The study also said less than half of privately funded substance use disorder treatment programs offer the treatments and only a third of patients with opioid dependence at these programs actually receive it. Availability and costs inhibit their wider use, the study said.
“I don’t think they knew or understood how to detox a heroin addict,” Nina Kassel said. “And I felt like they didn’t care because he’s a heroin addict.”
Amanda Kassel said after she obtained her husband’s medical records from Davis Behavioral Health, she learned that company staff members did not fill out incident reports on the death until 10 days later.
Slater said critical incidents are supposed to be reported to the state licensing office within one business day.
Amanda Kassel also questioned the level of monitoring her husband received during the night of his death.
“Client was in bed at all bed checks and appeared to be sleeping at all bed checks,” the CRU shift notes said.
“They say they do bed checks every 30 minutes, but it’s just a head check to make sure he was still in his room,” Amanda Kassel said. “You should go in and see if they’re still breathing.”
The medical examiner could not determine when Kassel died. A CRU staff member found him unresponsive at 8 a.m. when he entered the room to give Kassel his morning medications.
The Kassels are now considering legal action.
“I don’t want this to happen to anybody else, the parents, wife, sister the sibling of a drug addict,” Nina Kassel said.
Amanda Kassel said she doesn’t want to let go of what happened to her husband.
“This was the first time in a long time he had clarity and was very emotional and determined,” she said. “Our family was so proud of him and excited for his soberness and him to be a part of us again.
“Really and truly, it’s wrong,” she said. “We feel lost. Our story needs to be heard by somebody.”