State cites multiple deficiencies in Rock Co. crisis plan for suicidal teen

The state Department of Health Services has found Rock County’s Crisis Intervention Unit failed in four areas when handling the case of a suicidal teenager.

Cole Fuller killed himself April 4. His dad, Jeff, has since pushed for new programming in schools to help with students’ mental health. He also filed a formal complaint with the state, claiming the team assigned to Cole’s care failed to help him while he was under Rock County’s supervision. At the time, Cole’s treatment for a Chapter 51 mental health commitment was being transferred from Walworth County to Rock County.

According to documents summarizing the state’s investigation, surveyors found four deficiencies for Rock County’s Crisis Intervention Unit:

Failure to link and coordinate services while Cole was at risk of experiencing a crisis
Failure to complete a crisis plan that was in line with state and county policies that would be helpful at a time of crisis
Failure to give the family formal or informal procedures for resolving complaints and disagreements with the county
Failure to provide prompt and adequate treatment, support and services to Cole
State cites multiple deficiencies in Rock Co. crisis plan for suicidal teen

According to the investigation, a crisis worker took Cole’s health insurance information, but never found a community provider to treat him. That employee documented having six months to find Cole a new psychiatrist, but the investigation found that six-month time span did not meet Cole’s needs during his transfer of care.

Additionally, the report shows the crisis plan developed for Cole in Rock County showed no history of suicidal ideation and no new patterns of risk. According to that report, his trauma history and medical problems were identified as “unknown at this time.” Investigators also found that there was no information in that plan about Cole’s transfer or his previous crisis provider when it came to documenting previous emergency mental health services provided, and that his history of hospitalizations was incomplete.

Cole’s most recent exam identified him as being at high risk of crisis. According to the report, that included “suicidal and violent behavior, if current treatment did not continue.”

A Rock County crisis worker rescheduled two meetings with Cole within the same week, according to the report, further delaying his treatment.

State cites multiple deficiencies in Rock Co. crisis plan for suicidal teen

The state’s investigation goes on to say an unidentified family member called one of the case managers the day before Cole died by suicide to report he had an episode at school and that there was fear for Cole’s safety and the safety of his family. The following afternoon, the crisis manager met with Cole and told him it was recommended he undergo another six-month commitment at a mental health facility. Cole’s family member reports that suggestion made him “go nuts” before he calmed down about 30 minutes later. The crisis worker documented Cole was “highly upset” about the extension.

According to the state’s report, the crisis manager who met with Cole did not inquire about any weapons because it was assumed Cole was educated about that during his prior mental health commitments. That manager also told investigators Cole had “future thinking” and “plans for the weekend” at the end of their meeting on April 4, the day Cole took his own life.

Months later, the report states Cole’s family tried to meet with the county to discuss their concerns with his care. According to the findings, they were not given the choice filing formal or informal grievances.

When asked about the lack of complaints filed against Rock County in connection with Cole’s treatment, an unnamed director said, “You know, I never really thought of it that way. We were trying to listen to and be there for the family but as it progressed I didn’t think to determine whether or not this had escalated to a formal complaint.”

The Rock County’s Crisis Intervention Unit is responsible for submitting a plan of correction within the next month.

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