Death at West Oaks Hospital

He blames himself for turning off the radio, knowing that would further set off his brother. He blames himself again for not getting his brother out of West Oaks. "He told me they were being mean to him. He asked me to take him out on Wednesday. And I didn't do it. But I didn't know."

Teresa Kennedy, the nursing program director for West Oaks, told police Mario "had been expelled from several other facilities due to violent behavior and prior assaults of patients and staff," the investigators wrote.

"I suspect he was too much for anybody to handle unless you were willing to tie him up and keep him restrained at all times, which I don't think too many people would have stood for," criminal attorney Azzo says.

But even he doesn't blame Mario for all of what happened.

"You had a person who was mentally ill, had exhibited violence before and again, you know, when you're mentally ill you're not in control of yourself. It's not like being a bad person and deciding to do bad things. You're just out of control. That's what happened here," Azzo says.

Just before he left St. Joseph, Mario enrolled in Houston STRIDES (Steps Toward Recovery, Independence, Dignity, Empowerment and Success) through Telecare, a private company that provides support services for mental patients. Unfortunately, they lost track of Mario until the day of his death.

In "client progress notes" dated June 14, the STRIDES nurse, Lee Villarruel, writes that she called West Oaks to say she planned to visit Mario that afternoon. She was told by a West Oaks nurse that Mario "was extremely violent," and that he put a staff member in a headlock; the employee was only able to break free when his T-shirt ripped. Mario spent the rest of his day doing kickbox moves.

After hearing this and consulting with coworkers, Villarruel postponed her trip. "We decided I would visit when the member's behavior was less violent." The next day STRIDES was notified of Mario's death.

It is clear that West Oaks would prefer to file this under the heading of "unfortunate and unforeseeable." But as the state investigation makes clear, that was not the case. Mario demonstrated repeatedly that he was violent. The staff members demonstrated just as often that they were unable to control him. One employee told investigators Mario "had superhuman strength." But there are 2:1 procedures designed for the most violent patients, and there were supposed to be restrictions on where Mario went. Neither was employed.

Brother Chazz's attorney, Aziz, says it is clear the hospital knew what they were dealing with in Mario and just as clearly failed to take the right precautions. "If Mario was acting violent, he should have been sedated or restrained. At the end of the day, you can't really blame him because he was mentally disturbed. The reason he was there was that they were supposed to take care of him.

"Yes, he was violent. His brain was not functioning like a normal human being would. Just the level of violence that was used against him was pretty extreme. When you have someone aggressive like that, you need a system to take care of it. The whole thing should never have occurred."

margaret.downing@houstonpress.com