When Christine Miranda died last April, the consequences of a decades-long cutting habit were etched into her body. “There are scars up and down both arms,” observed a social worker who had recently treated her.
“I was taught [as a little girl] to [cut],” Miranda told me a few months before her death. “My father cut me, punched me, kicked me. He literally would sit me on the coffee table in the kitchen. It was sessions of it. It was torture. The point was not to cry or react.”
Miranda had reached out to me days after she had made a nearly 2.5-inch-long subcutaneous cut into her upper right arm, as well as a similarly sized cut into her left thigh. “It was the worst she’s ever done,” her mom says.
But Miranda said she wasn’t attempting suicide when she made the cuts. Instead, she explained, she made the cuts, “to avoid getting to the point of suicidality,” which she added, “every day I think about.” Her outpatient treatment team, whom she called for help, arranged for an ambulance to pick her up at her Bronx home and take her to Mount Sinai Hospital in Midtown Manhattan.
In Mount Sinai’s emergency room, according to medical records the hospital shared with Miranda, doctors stitched up her wounds. There is no indication in the ER records that Miranda was uncooperative or combative.
The ER staffers then transferred Miranda to the psychiatric emergency department for a mental health evaluation.
“I think about it and I wanna cry”
As soon as Miranda was moved to Mount Sinai’s psychiatric ER, staffers there reported that she abruptly became uncooperative and unruly. “[She was] yelling at [staff] members,” according to one of the hospital’s psychiatrists. “Demanding to be discharged, demanding to get a phone call, she was banging on walls taking down objects on walls.”
To “treat the aggression and dangerousness to self/others,” another psychiatrist noted, staffers injected her with three medication-filled syringes: the first containing a high dose of an antipsychotic, the second containing a similarly high dose of the anti-anxiety drug Ativan, and the last containing Benadryl to treat the side effects linked with the first two drugs.
Miranda—who was clinically obese at the time, used a walker to get around, and according to hospital records had no history of violence towards others—insisted that the timeline of events in her medical records omitted critical context. “They told me when I got to the [psych ER] that I was being admitted [to the overnight psychiatric inpatient unit],” she said. “That’s why I was upset. I hadn’t seen a doctor yet. I saw nobody. Why are [they] making a decision?”
Miranda also said that staffers, who took her cell phone for security purposes, refused to let her use one of the hospital’s phones to call her son and tell him where she was. “I have a right to make a phone call,” she said. “Even a criminal gets a phone call.”
Miranda conceded that she “lost it” after not being allowed to call her son, but clarified that her outburst was limited to ripping a “stupid little cardboard thing” off a bathroom door (which she said she “didn’t throw”) and raising her voice at staff (“I never scream”).
After that, Miranda said, she “went to lay in bed, calming down,” when about six staffers—including doctors, security officers and a nurse—surrounded her, held her down, and medicated her by force. “There was no violence that preceded [that]. None,” she asserted. “There was no time to de-escalate me. They completely ignored me and came with the injection.”
“I think about it and I wanna cry,” Miranda added. “I literally feel raped.”
State laws across the country regulate the circumstances under which psychiatric hospital staffers are permitted to forcibly medicate patients. In New York, hospital staff are only legally allowed to medicate by force if “less restrictive interventions” have been attempted first, and only if the patient is exhibiting “violent or self-destructive behavior” that if not thwarted will cause “imminent, serious injury to the patient or others.”
New York hospital staffers who medicate by force are additionally mandated to obtain a written and signed doctor’s order documenting, among other details, the failure of less restrictive interventions and the patient’s response to being medicated.
Despite those regulations, in the 176 pages of hospital records Mount Sinai shared with Miranda, there is not a single such doctor’s order authorizing staff to medicate by force.
More conflicting accounts
Before sedating her, Mount Sinai’s psych ER staffers reported that Miranda refused to let them examine her or conduct blood or Covid tests.
After the injection of the three medications, though, a psychiatrist reported that Miranda suddenly changed her mind and consented to the tests, “when staff approached her and explained carefully the need for these [tests].”
Miranda, who said she didn’t remember anything that happened in the ER after being sedated, insisted she never would have consented to having her blood drawn or her nose swabbed. “I have a right to refuse blood work,” she explained. “In no way, shape, or form; I’m not gonna say yes. They are lying.” She added that she had always refused blood work during past emergency room mental health evaluations, “because it’s harder for them to inpatient me,” and that she never took Covid tests because, “I don’t like (the swab) up my nose.”
What likely happened, Miranda theorized, is that the ER staffers sedated her to avoid having to obtain her consent for the blood and Covid tests. “I’ve had it so many times with the blood work,” she said. “Oh, we will just give an injection [and then do a blood test].”
A note in Miranda’s medical records seems to validate her assertion that she never consented to the tests. When staffers drew her blood and swabbed her nose, according to a nurse on duty, Miranda was “dozing in bed.”
Prior reports of staff misconduct
Other patients have similarly accused New York City emergency room staffers of forcibly sedating them solely to perform blood work and other medical tests. In 2015, the New York state public defender service for psychiatric patients filed a complaint that “standard policy” in the psychiatric ER of Bellevue Hospital was, “the administration of emergency intramuscular medication to force compliance with routine admissions procedures and blood work.”
In a news report about the public defender’s complaint, a patient told the publication City Limits that, “At Bellevue you just look at someone wrong and they shoot you up with [an antipsychotic].”
More missing documents
Approximately ten and a half hours after the ambulance had dropped Miranda off at Mount Sinai, psych ER staffers reported in her records that they had transferred her to the hospital’s locked inpatient psychiatric unit.
Miranda vehemently disagreed with the decision to commit her. “No one inpatients me for cutting,” she said. “They [didn’t] understand. Most people who cut don’t go inpatient. We aren’t trying to kill ourselves.”
According to medical records, a member of Miranda’s outpatient treatment team also believed involuntary commitment was unnecessary. “[Outpatient treatment] team not advocating for admission stating admission does more harm than good,” an ER psychiatrist reported.
Nonetheless, Mount Sinai staffers claimed they were following the law when they involuntarily committed Miranda. According to a nurse’s note, a doctor had submitted the legally required involuntary commitment application just before Miranda’s admission to the psych unit.
Yet there is no involuntary commitment application among the 176 pages of Miranda’s hospital records. Like the application to medicate by force, it is missing from the trove of documents the hospital shared with Miranda.
Mount Sinai’s failure to fill out an involuntary commitment application—or at least its failure to share the application with Miranda—appears to be part of a larger pattern of administrative negligence. In 2020, the U.S. Office of the Inspector General (OIG) reviewed a random national sampling of inpatient hospitalizations. In 71 percent of the cases, the OIG found, the required certifications that the person actually needed to be hospitalized were missing.
In his new book Your Consent Is Not Required: The Rise in Psychiatric Detentions, Forced Treatment, and Abusive Guardianships, investigative journalist (and Mad in America contributor) Rob Wipond asked OIG media officer Donald White about the trend of missing certifications. “Often,” White explained, “I hear, and our auditors hear [from hospital staffers], ‘Well, that’s just paperwork.’”
The problem, White added, is that, “It’s not just paperwork!”
“HIPAA laws are weapons in our cases”
Miranda was held against her will in Mount Sinai’s inpatient psychiatric unit for nearly three full days, during which she said she was unable to contact her family. “When I got my phone back [after discharge] I had crazy texts from my son,” she recalled. “[He texted] ‘Where are you? Are you safe?’ He was gonna call the police to put in a missing person’s report. The hospital said they would call him. They had his number. But he said no one called him.”
Citing patient confidentiality laws, Ilana Nikravesh, Mount Sinai’s Media Relations representative, refused to comment on any of Miranda’s allegations. When I pointed out that Miranda had granted the hospital permission to speak with me (this conversation occurred while Miranda was alive), Nikravesh stopped responding to my phone calls and email messages.
Chicago civil rights attorney Joe Cecala, who regularly represents psychiatric hospital patients, said it’s routine for hospital employees and administrators to hide behind confidentiality laws (officially known as HIPAA) to avoid accountability. “HIPAA laws are weapons in our cases,” Cecala said. “‘Oh we can’t tell you because of HIPAA [the employees and administrators say].’ In the meantime, HIPAA becomes an excuse to cover up really abusive situations.”
In addition to refusing to comment publicly on her hospitalization, Mount Sinai administrators didn’t make it easy for Miranda to obtain her medical records. “I requested the records,” Miranda said. “That night I got out of the hospital, when I got home, I called the [psychiatric ER] to ask what happened, what kind of medicine they gave me. They couldn’t say. They wouldn’t speak to me. They didn’t give a reason.”
That’s when Miranda called me. I had interviewed her previously for Mad in America and had experience going through the formal process of obtaining medical records. I printed out the medical records request form on Mount Sinai’s website and, with Miranda’s permission, filled it out on her behalf and mailed it to the hospital. A few days later, Miranda received the 176 pages of records documenting her three-day hospitalization.
“He gave her something and she took it”
Miranda cut herself at least two more times after her Mount Sinai hospitalization. “I’m not gonna go to the hospital now when I cut,” she explained, “because I’m afraid of how I’m gonna be treated.”
Last April, Miranda’s son and mom walked into her bedroom and found her covered by a blanket. “I thought she was sleeping really hard,” her mom recalls. “I shook her arm and realized she was not here anymore.”
Miranda’s mom, who is in poor health, hasn’t been able to obtain an autopsy report, but suspects her daughter took her own life. She said that Miranda’s boyfriend, who had a habit of bringing her drugs, had been by their home the day she died. “He gave her something,” she elaborated, “and she took it.”
Miranda’s son also told me that his mom had a potentially lethal drug in her system when she died, though he believes the overdose was unintentional.
“No one is watching these hospitals”
In 1996, a New York State government watchdog agency published the results of a survey of 1,040 former patients who had been treated in the state’s psychiatric facilities. More than half of the ex-patients reported that they had been subjected to restraint or seclusion during their hospital stays. Like Miranda, two-thirds of them said they were not dangerous to themselves or others when they were restrained, secluded, and/or sedated, while nearly half said staffers made no attempt to calm them down or resolve the problem that preceded the interventions.
“I wish people would have talked to me instead of restraining me,” one ex-patient told the researchers. “I was not told why or given an opportunity to object verbally [to restraint/seclusion],” another patient stated. “It was out of my hands.”
This April, the USA Today-owned Journal News similarly reported that at least 50 patients faced improper restraint at 15 different New York hospitals between 2015 and 2018. “But the true scope of restraint use, and misuse, in hospitals—including suspected racial disparities among patients subjected to it—remains shrouded in secrecy because the incidents are not fully tracked by authorities,” reporter David Robinson noted. “In other words: Thousands of patients are restrained in emergency rooms and other hospital wards across New York with limited independent oversight.”
Though the USA Today report was published twelve days after her death, Miranda was well aware of the issues it would uncover when I interviewed her last January. “No one is watching these hospitals,” she warned. “No one is listening. Our rights are being violated left and right. They can do whatever they want.”
MIA Reports are supported, in part, by a grant from The Thomas Jobe Fund.