The late Caulette Julien fell in the isolation cell of Mental Health Foundation in Cay Hill, likely due to side effects of the medication she received, and died in the absence of a doctor and proper emergency response.
PHILIPSBURG--The Medical Disciplinary Court concluded in a case brought by the family of a mental health patient who died in solitary confinement that psychiatrist Dr. Kitty Pelswijk did not adequately monitor her patient’s health and safety.
The doctor’s “seriously reprehensible” actions are evident from the verdict handed down on Wednesday.
The Medical Disciplinary Court handles complaints from citizens about a doctor, dentist, pharmacist or midwife. Every complaint received at the courthouse in Philipsburg is handled by a judge and two medical specialists. They are supported by a secretary who is a legal expert.
During a hearing, the complainant is given the opportunity to explain the complaint and the accused medical professional is given the opportunity to defend him- or herself. Parties are generally assisted by lawyers. The process takes place behind closed doors; the public is not allowed in the courtroom.
The oral hearing of the complaint from the mother and sister of the late Caulette Julien took place on October 3, 2023. The victim was found dead in the solitary confinement of Mental Health Foundation in Cay Hill on August 25, 2020. She was 43 years old.
The Julien family's complaint, filed by attorney Geert Hatzmann, consisted of five parts: 1) Excessively long confinement in a solitary cell (the victim had been locked up for almost three weeks when she was found dead); 2) The psychiatrist failed to make daily notes of coercive measures used; 3) The psychiatrist failed to take daily notes of the patient's condition; 4) The audio and surveillance system of the solitary cell did not work and the walls of the solitary cell had protruding parts that could cause injury to the patient; 5) Julien's death was not reported to the Public Health Inspectorate.
The Medical Disciplinary Board declared the complaint well-founded on all five counts.
Caulette Julien had bipolar disorder, also known as manic depression, a mental disorder characterised by periods of depression and manic (uninhibited) periods. Although she had no health insurance, Julien was on and off medication from MHF for years. The institution keeps a black stock of medication for patients without insurance.
Julien rang the MHF clinic in Cay Hill at 11:30pm on August 9, 2020. She asked for a place to sleep. Nursing staff took her to the isolation cell. Because she was manic, she was given 15mg Olanzapine and 20mg Diazepam.
The next day, psychiatrist Dr. Kitty Pelswijk visited her in the solitary cell. According to the verdict, Julien was given depot Haloperidol, which is an intramuscular injection with an antipsychotic used in the treatment of schizophrenia. Among the side effects are muscle stiffness, inability to move the eyes, unusual drowsiness, tremor, possibly leaving a patient in a “zombie”-like state. Dr. Pelswijk decided that Julien would remain in isolation and gave her additional medication.
Dr. Pelswijk did not measure Julien's blood pressure, check her heart or take a blood sample prior to administering medication. Pelswijk's attorney Dana Kweekel of BZSE lawyers stated in the doctor’s defence that “it is not mandatory to make daily notes of medical findings.”
The lawyer pointed out that there was a COVID pandemic at the time and that the psychiatrist had to be quarantined at home. She was therefore unable to physically examine Julien or take blood for laboratory testing for two weeks. The psychiatrist kept an eye on Julien's condition from her home, according to attorney Kweekel.
The nurse reportedly stated that Julien was apparently asleep on her bed in the early morning of August 25, 2020. A check at 3:30am showed that she was unresponsive, the attorney told the Medical Disciplinary Court. “The ambulance was called and chest compressions were started.”
The attorney further stated that psychiatrist Pelswijk subsequently “came out of her quarantine and went to the clinic and diagnosed the death of her patient.” Dr. Pelswijk not only completed form A, as a testament to the death of her patient, but also signed form B on which she described the passing of Julien as a natural death.
According to her attorney, there was no objection to the doctor completing Form B herself. However, physicians are not allowed to attribute the cause of death to their own patients if it has not been conclusively established that the death occurred from natural causes. To date, Julien’s exact cause of death is not known.
Inspector General Dr. Earl Best of the Ministry of Public Health, Social Affairs and Labor VSA Inspectorate learned through the media that Julien had died in the MHF isolation cell and criticised the fact that the psychiatrist had not informed him of this. Pelswijk's attorney told the Medical Disciplinary Court that her client "was not obliged" to report her patient's death as a disaster to the VSA Inspectorate.
Kweekel, who served as advisor to VSA Minister Omar Ottley prior to joining BZSE lawyers, is co-author of the VSA Inspectorate’s Calamity Guidelines, a comprehensive 52-page document describing the steps medical professionals need to take after something goes wrong during the care of their patients and how this should be reported for investigation by the Inspectorate.
However, attorney Kweekel stated to the Medical Disciplinary Court that “such a legal obligation for individual physicians does not exist in St. Maarten. There is also no protocol for such a report.”
Former Inspector General Dr. Earl Best started an investigation on his own initiative and concluded that Julien had fallen with her head against a protrusion from the wall of the solitary cell, causing serious head trauma, and that the nurses on duty had waited far too long to enter the isolation cell and call the ambulance. According to Dr. Best, the nurses tried in an "amateurish and wrong way" to resuscitate Julien.
Dr. Best also reported that the audio portion of the video and audio surveillance system had been down at the time of the fatal incident, preventing staff from hearing Julien.
The Inspector General indicated to Julien's family that there are two possible causes of death: a heart attack or a cerebral haemorrhage.
However, the verdict of the Medical Disciplinary Court reveals another possible cause of death: carbamazepine poisoning.
The Court stated: “No ECG [electrocardiogram – Ed.] was made, while Pelswijk knew or should have known that serious heart rhythm abnormalities can occur with the medication used by Caulette. This applies mutatis mutandis that orthostatic hypotension (blood pressure) was not sought, while a drop in blood pressure, as well as cardiac arrhythmias, is a known side effect of the medication administered to Caulette.
“Orthostatic blood pressure drop can be an important cause of falls. According to Pelswijk, this may have been the cause of the fall, the head trauma and Caulette's death.”
The Court found that no laboratory testing was done after the patient's intake on August 9, 2020, and that one such test was scheduled for August 26, 2020. “Much too late,” the Court concluded. “Carbamazepine was increased [by Pelswijk] from twice to three times a day. Since there was a sub-maximal level of 10.2 in February – with a target value of 12 to avoid a toxic concentration of 15 mcg/ml – there was a good chance that the concentration would rise too much.”
In addition, the court concluded, “liver enzymes, renal function and electrolytes should be determined when using carbamazepine.” Pelswijk did not provide the court with an explanation as to why a laboratory test had not been carried out earlier. “It is unlikely that this would not have been possible given Caulette’s condition. Pelswijk also remained Caulette’s main practitioner during her quarantine and was in that capacity responsible for Caulette’s safety and health.”
All in all, the Court stated, the bottom line is that “the medication used – especially in high doses and through interaction with the various medications used, as was the case with Caulette – is notorious with regard to the occurrence of cardiac arrhythmias, dizziness, balance disorders and drops in blood pressure.”
Furthermore, the court stated that placement in an isolation cell is “at most a management measure, but never a treatment intervention.” No treatment plan was drawn up by Dr. Pelswijk, the Court concluded. “And she wrote virtually no notes.”
At the hearing on October 3, 2023, Dr. Pelswijk admitted that the death of her patient was to be considered a calamity. “It is incomprehensible that Pelswijk almost immediately completed a declaration of natural death and did not order an investigation into the cause of death,” the court stated. “By noting natural death in the death certificate, Pelswijk has blocked any investigation into the cause of death.”
Although the psychiatrist’s actions result in “serious disciplinary reproaches,” the court attaches no consequences to this other than a reprimand. The psychiatrist has acted culpably and is reprimanded for this by the court, but remains fully authorised to practice the profession.
The late Caulette Julien is one of six patients of Dr. Pelswijk who died of unnatural causes in her care over the past three years.
Two of these patients committed suicide; a taxi driver took his own life after the psychiatrist ended his medication abruptly and gave him other pills; whereas a schoolteacher lost all hope after almost five months of begging the psychiatrist in vain to help her. The youngest victim, who had not reached the age of 30, remained unresponsive after receiving antipsychotics prescribed by Dr. Pelswijk. Shortly after the MHF nurse left the family home, the young man’s mother found him deceased.
VSA Minister Omar Ottley granted Dr. Pelswijk, whose licence to practice medicine on St. Maarten expired on November 30, 2021, an extension for two years.
