JOHNSTOWN, Colo. — A recent death at Johnstown Heights Behavioral Health was ruled accidental by Johnstown police, but insiders with knowledge of the situation and new state inspection reports obtained by Denver7 Investigates tell a different story.
On Nov. 11, 2022, Christopher Dickson voluntarily admitted himself into Johnstown Heights Behavioral Health. But the 39-year-old father never walked out of the facility meant to treat him. He died two days later at approximately 5 p.m.
The tragic update follows multiple reports by Denver7 Investigates, interviewing current and former staff and patients. One veteran nurse, BJ Potts, resigned from Johnstown Heights two weeks before Dickson’s death after being assaulted by patients. Based on his experience, he called the 92-bed facility a "zoo."
“It was a disaster waiting to happen,” Potts said. “In so many ways, Johnstown Heights is a s***hole. Nothing they're doing is helping the patients. There's no safety measures. And you're lucky if you can get out of there alive.”
Days after Dickson’s death, inspectors with the Colorado Department of Public Health and Environment (CDPHE) moved in, declaring the facility in “immediate jeopardy,” the state’s most serious designation for a mental health hospital.
State inspectors produced a more than 50-page report, highlighting major deficiencies at Johnstown Heights, including failures in the detox unit where Dickson was admitted. Dickson is identified as “Patient #1” in the reports.
“The facility failed to ensure registered nurses assessed detox patients in 14 of 16 records reviewed,” the report states. “The facility’s failure created likelihood of serious harm affecting patients.”
Specific to Dickson’s treatment at the facility, inspectors note, “The time medication was administered was not documented.”
In one interview, a nurse admitted they knew Dickson was at a higher risk. Documentation of that interview describes the nurse stating, “Alcohol detox was deadly if not treated appropriately.”
“It didn't need to happen, and now it happened. There were people that could have stopped that,” Potts said after reviewing the investigation documents.
One portion of the report noted the lack of attention to Dickson, despite his condition at times requiring hourly checks. He had not been checked for eight hours prior to his death, according to the report.
Previous coverage: Two state agencies confirm investigation into Johnstown Heights Behavioral Health
The report also cites proper guidelines for care according to the Alcohol Withdrawal Assessment Flowsheet, a nationally recognized scale, “...transfer to ICU would be considered if the patient required every one hour assessment for more than eight hours.” It adds, “Patient #1 was not monitored and therefore was unable to be monitored for a higher level of care.”
Over the course of his three-day stay at Johnstown Heights, the state’s investigation shows at one time, Dickson went 16 hours without being checked.
“I'm not surprised. They found everything I thought they'd find. Inadequate staffing, inadequate safety measures,” Potts said. “He was not checked adequately. He was not checked every 15 minutes. As a result, his vital signs decreased to the point where they couldn't come back.”
According to Dickson's autopsy report, he died due to “complications of mixed drug interactions of therapeutic medications.” His death is listed as an accident. Potts disagrees.
“He should not have died. It was not an accident that he died. It was negligence, that's why he died,” he said.
Denver7 | Investigates
After Clear View Behavioral Health shut down, its successor has similar issues
Denver7 Investigates took Potts’ concerns to Larimer County Coroner Stephen Hanks, who oversaw Dickson's autopsy. Hanks said national standards do not include “negligence” as a manner of death. But his evaluation of the state’s investigative reports concluded the same as Potts.
“I think that the elements are there that both civil and criminal negligence could apply, and that those arguments could be made," Hanks said.
Earlier this month, the Johnstown Police Department closed its investigation into Johnstown Heights following Dickson’s death. But the department's report does provide details about the conditions inside, and what staffing levels may have looked like on the day Dickson died.
The police report includes a statement from Johnstown Heights CEO Sean Peterson saying he sometimes gets nervous on Sundays because the facility is staffed with a skeleton crew.
Hanks believes the new information from the state should prompt Johnstown Heights to reopen its investigation.
“I think it's worth taking a good hard look,” Hanks said. “That's not acceptable.”
Potts says based on what he saw while working in the facility, the skeleton crew extended beyond just Sundays.
“It was the norm to have a skeleton crew working,” Potts said.
Previous coverage: Former employees speak out against Johnstown Heights Behavioral Health
Johnstown Heights Behavioral Heath is on the site that formerly housed Clear View Behavioral Health, a mental health hospital that was shut down by the state in 2020 following more than a dozen reports from Denver7 Investigates over a 20-month span. That investigation exposed the death of Tibor Hetei.
While now under new ownership and a different name, Dickson is now the second person to die at the same location. Hanks was also a part of the team who investigated Hetei’s death.
“The commonality is that there was a lack of supervision, a lack of adequate assessments and vital checks by the nursing staff. It seems like a commonality is the skeleton crew,” Hanks said. “We can't bring Christopher back, but I think there could be hope that there's some justice out there that can be done.”
Johnstown Heights CEO Sean Peterson did not return multiple phone calls seeking comment.
Denver7 Investigates also reached out to the Johnstown Police Chief Brian Phillips to ask if he’d consider re-opening the investigation now that the state’s inspection reports are public. In a statement, Phillips said the department did its due diligence "until it became neither productive nor possible to pursue an accidental death with no probable cause that a crime occurred."
“As shown in Police Incident Report #2210336, the Johnstown Police Department is dedicated to doing its due diligence, and in this case, did so until it became neither productive nor possible to continue to pursue an accidental death with no probable cause that a crime occurred. With the Larimer County Coroner’s Office declaring an accidental death, the District Attorney’s Office not endorsing the Production of Records requests, and no additional information to suggest that the incident was not accidental, Johnstown Police Department closed the case."