Greystone patient was stabbed to death after hospital stopped his one-on-one supervision, court record shows – NJ.com

Shamir Shawn Segura needed protection.

His psychiatrist at Greystone Park Psychiatric Hospital left orders that Segura required one-on-one supervision. The 25-year-old man diagnosed with a cognitive disability and bipolar disorder had a history of putting himself in harm’s way.

But on the morning of Dec. 31, 2019, the psychiatric director overruled the order without explanation, according to a court record obtained by NJ Advance Media.

Hours later, Segura was dead, stabbed to death by Rashid Davis, another Greystone patient who had killed before, according to the Morris County Prosecutor’s Office.

The state Office of the Public Defender says it doesn’t see Davis as solely responsible for Segura’s death.

Rather, the events that day are the latest proof an independent monitor is needed to run the state hospital, where violence, mismanagement and despair have become “normalized,” according to an ongoing federal lawsuit the Public Defender and a private law firm filed against the Murphy administration.

Segura’s murder is “the most recent — and most horrific — example of the preventable violence and gross mismanagement,” according to a January letter by David J. DiSabato of the Wolf Law Firm in North Brunswick to U.S. District Court Judge Esther Salas.

Hospital employees found Segura bleeding from multiple stab wounds to his neck inside Davis’ room. Davis used an X-Acto knife, police said.

“General hospital staffing was so low that no one had initially realized there was a stabbing until blood was observed on another patient’s hand,” the letter said.

That patient was likely Davis himself. According to the arrest warrant from the Morris County Prosecutor’s Office, Davis walked up to staff and told them to call police, saying, “you’ll find him,” according to court documents. One of his hands “was covered in blood,” the warrant said. He told police officers arriving at the scene that he “did something bad” and threw something in the trash, the document said.

Murphy administration officials have declined requests for comment on the lawsuit since it was filed nearly two years ago. The state Health Department, which operates Greystone, would not answer questions about Segura’s treatment and the events that transpired the day he died.

The details of Segura’s final hours came as a shock to his parents, who despite being his guardians did not know he had been assigned one-to-one supervision, his mother Carolyn Segura said.

What Carolyn and Jorge Segura knew was what their oldest son had told them: he had been deemed medically stable enough for discharge and would hopefully leave in a few weeks.

“He was supposed to be going out to the group home in January. To my understanding there was a group home lined up and they were waiting on different papers and a bed — someone was supposed to be moving out,” Segura said.

Greystone called and left a message with the Seguras late afternoon on New Year’s Eve, she said.

The doctor she spoke to told her cryptically, “‘Shamir is no longer with us.’ I figured he eloped, or he was moved to another unit. ’Ok, where is he? Where did he go?’”

Segura said she recalls distinctly the doctor telling her, “There’s been an accident.”

Hours later at the hospital, the Seguras learned the truth — their son was stabbed to death, and with a weapon that should not have been allowed in the building.

“The hospital made it sound like it was a homemade shank,” she said.

The Seguras have retained an attorney, Demetrios Stratis, and are weighing their legal options.

“The family hopes and prays that Shamir’s death was not in vain. It was senseless and preventable. Shamir was at Greystone to get help, not be killed,” Stratis said.

“I want the man who killed him to go to jail, not a psychiatric hospital,” Segura said. “I want justice for my son. I don’t know what I want from Greystone.”

“Where were the people who were supposed to be watching?” she said. “You wouldn’t think these things would occur in a place that is supposed to keep him safe.”

The Seguras of Hopatcong adopted Shamir from foster care at age 5. When he arrived at their home a year earlier, he had already lived in four other foster homes.

Born with fetal alcohol syndrome, Shamir was a sweet and upbeat child, his mother said. But the instability of his earliest years left him feeling unsettled and insecure.

“He always felt pushed aside. When it got to be too much, they would cast him off,” his mother said, describing his time in foster care. “He was a very loving person. He just wanted to feel like he was part of something.”

The Seguras adopted another son, then had four biological children, including a daughter who died at birth, she said. Mourning the death of her newborn, Segura said Shamir wiped the tears from her face.

He played baseball and loved music, she said. “He was one of these people where if he was your friend, he would go all out to make you comfortable. He had an infectious laugh.”

Behavioral issues emerged at age 13 that the family could no longer handle on their own, she said. He swallowed inedible objects, an eating disorder known as Pica. He made verbal threats to harm others. He moved to a residential school and a group home, but frequently ran away. After police picked him up one too many times, he was taken to a nearby hospital emergency room.

Greystone was supposed to be a two-week stint to get his medication straight before he returned to a group home, his mother said. He was involuntarily committed at Greystone for seven years, she said.

Shamir was close to leaving Greystone a few times but his behavior would backslide. He told her some of the staff would “needle him,” she said. “I had spoken to another (patient) and he said the same thing. Anytime he would get close (to leaving), they would do something to egg him on.”

Segura said she was often frustrated that her son’s doctors weren’t more forthcoming with information about Shamir’s progress and setbacks. She wanted to verify the information her son shared with her but she could verify very little.

“I would ask, ‘How are you preparing for him to go back into society, for the stresses of being in group home with other people?’ “ The reply: ” ‘He hasn’t asked.’ I said, ‘I asked — I am his guardian.’ “

The Health Department “does not comment on specific patient information because of privacy concerns,” spokeswoman Donna Leusner said.

Segura had been assigned to a forensic unit, typically a place for patients with a history of criminal behavior and where supervision is supposed to be tighter.

It is not clear why or when his treating physician recommended one-to-one supervision or why that order was overturned. The Seguras only learned of his doctor’s request for one-on-one supervision from the letter in the Public Defender’s lawsuit, shared with them by NJ Advance Media. “They were supposed to report to me any change in status,” Carolyn Segura said.

It is not unusual for the state to house patients who are dually diagnosed with a mental illness and an intellectual disability in a state psychiatric facility.

In 2014, Gov. Chris Christie’s administration oversaw the closing of the North Jersey Developmental Center in Totowa and the Woodbridge Developmental Center, two public institutions serving people with developmental disabilities. The decision was backed by many disability advocates who said New Jersey relied on institutional care more than any other state besides Texas.

Some people with developmental disabilities and mental illness who could not live safely and independently in a group home wound up at Greystone, making them more vulnerable to harm, according to the public defender’s lawsuit.

“Seemingly overnight, Greystone was the recipient of a huge influx of developmentally disabled patients and geriatric patients,” Yeshuschandra Dhaibar, a clinical psychiatrist at Greystone since 2014, said in an affidavit in support of the lawsuit. “Greystone is not and had never been equipped to treat these two populations.”

Greystone developed a problem with overcrowding, which the Murphy administration addressed by diverting some patients other states-run psychiatric hospitals and to Carrier Clinic, a private psychiatric facility in Montgomery.

The average number of patients at Greystone during the month of July was 349, down from 553 in July 2018, according to state Health Department data.

A smaller Greystone has not translated into a safer hospital, the Public Defender contends in the lawsuit it amended last year to show conditions inside the facility had not improved.

Especially for Segura.

“On the date of the homicide, the deceased patient had been ordered by a psychiatrist to be on one-to-one observation, which requires a mental health technician to closely monitor the patient at all times,” according to the letter to the judge. “Despite this, the Psychiatric Director recklessly ordered the removal of this patient, among others, from one-to-one observation. The covering psychiatrist, without clinically evaluating the patient, ordered the discontinuation.”

Davis was likely on the forensic unit because he had killed before. He pleaded not guilty by reason of insanity in the 2014 stabbing death of an 83-year-old man in Newark and was committed to state psychiatric care.

A video recording taken in the hallway of the unit showed Davis and Segura walking into Davis’ room at 2:38 p.m. Two minutes later, Davis walked out alone, according to the arrest record.

“A doctor with over twenty years of experience in emergency rooms firmly believes that he would have had a realistic opportunity of saving this patient’s life” had Greystone stocked proper emergency equipment, the public defender’s letter said. Since 2017, only basic life savings skills are taught to reduce the state’s medical liability, according to the public defender’s lawsuit.

It took about 30 minutes for an ambulance to arrive at the hospital in Morris Plains, and when it did, the emergency medical technicians were directed to the wrong unit, according to the letter. Segura died at Greystone.

Davis faces with first-degree murder and weapons charges. He is held at the Ann Klein Forensic Center, a state psychiatric facility in Ewing for patients who have committed crimes.

This is the second time legal advocates have sued to change dangerous conditions at Greystone. The first case resulted in a 1977 settlement that installed a court-ordered monitoring panel until 2009 — a year a new Greystone hospital opened to replace crumbling buildings and reduce overcrowding.

Eleven years later, Greystone needs oversight again or tragedy will continue to happen, said Robert Davison, CEO of the Mental Health Association of Essex and Morris County.

“For whatever reason, the state has been unable to run that hospital. I would hope the federal judge would appoint an independent monitor,” he said. “I know there are many wonderful people who work for that hospital, and there are pockets of quality. In the aggregate, they have serious problems.”

“What happened sadly was predictable. (The Public Defender) said if changes weren’t made, people would be hurt and die. Sadly, they were correct,” Davison added.

Other mental health advocates briefed on the matter say Segura’s death is evidence that the unsafe conditions inside the hospital are getting worse and outside intervention is needed.

“We agree with concerns regarding patient safety and the inadequate number of professional staff that has been raised by the Public Defender’s lawsuit. Moreover, the tragic death of a young man who was ready for discharge is evidence of systemic failures related to patient safety and care,” said Gwen Orlowski, executive director for Disability Rights New Jersey, a legal advocacy organization.

The Public Defender’s lawsuit seeks changes in policy as well as awarding plaintiffs — several unnamed patients — “their reasonable costs and attorneys’ fees.”

Just prior to the coronavirus pandemic, the Public Defender’s Office and the state “notified the Court that they had reached an agreement to settle the case,” Lee Moore, spokesman for the state Attorney General’s Office, which is representing the Health Department, the main defendant.

“The final settlement agreement will require court approval. Although the details of the agreement are not yet part of the public record, we believe that the terms are acceptable to all parties,” Moore said.

Neither side would comment on the terms of the settlement.

Carolyn Segura said she takes some comfort in her oldest son’s last journal entry, dated Christmas Eve. “He wrote that he knew he was loved. He felt very lucky he was adopted.”

“I’m getting out soon,” Shamir wrote.

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Susan K. Livio may be reached at slivio@njadvancemedia.com. Follow her on Twitter @SusanKLivio.