Was it lies and sins of omission that killed Brandon Nelson?
The promise of a professional mental health team’s care — psychiatrists, psychologists, therapists — that turned out to include guys with experience in furniture moving and construction and credit card processing and house painting, who took online CPR classes, who were too freaked out by his body dangling from the ceiling to recall the address for the 911 dispatcher?
Perhaps it was that the company was imploding financially and workers were fleeing. Or that the “facility” where Sovereign Health placed him was little more than a tract home in San Clemente. Or that no one “treating” him on that final day had any clue about his medical history, his psychotic breaks, his desire to die.
The powerful anti-psychotic medications he required twice daily were slow to be filled and forgotten on a desk in a corporate office — Nelson hadn’t taken them for nearly 24 hours and was howling and crying, “I want my meds! I want my meds!” just hours before he used a pair of sweatpants to hang himself from the sprinkler system in his room.
Workers said he should have been sent to a higher level of care. He should have been closely monitored. He should never have been left alone. There should have been “breakaway” systems to thwart suicide attempts in a facility for mentally ill patients.
“He needed, like, clinicians. He needed, like, doctors,” said a house manager on duty that night.
These harrowing, heartbreaking details are drawn from hundreds of pages of depositions in the wrongful death lawsuit Nelson’s family filed against Sovereign/Dual Diagnosis and its principal, Tonmoy Sharma, in 2019. The two sides have settled for $11 million, to be paid through insurer Capitol Specialty Insurance Corporation.
“We were pleased the parties could reach a settlement,” Laurie N. Stayton, attorney for Sovereign and Sharma, said by email. “We hope the settlement brings some comfort to the family for their loss. The settlement reflects the parties’ compromise of disputed claims and not an admission of liability.”
That’s not quite how Nelson’s parents see it.
“If Brandon didn’t go to Sovereign, he would be alive today,” said his mother, Rose Nelson. “I was totally lied to. I went online and looked — ‘Oh it’s beautiful!’ —he’ll have a psychiatrist and psychologist and group therapy! — ‘give us 30 days and he’ll be great.’ When your child is going through this, you’re so desperate. You sign on the dotted line.”
The Nelsons rejected a request for settlement confidentiality, they said. They want everyone to know exactly what happened and why — especially the lawmakers and regulators who can fix California’s fractured mental health system.
It has been plagued with dysfunction since psychiatric hospitals were shuttered in favor of more friendly — and less expensive — community-based treatment centers decades ago, experts say. The pursuit of profit among private-pay mental health providers, and the sloppiness of state regulatory systems tragically ill-equipped to oversee them, fail patients and cost lives.
California is committing billions to bolster mental and behavioral health services through CARE courts — for “Community Assistance, Recovery and Empowerment” — aiming to get people with mental health and substance use disorders the support and care they need. That sounds great on paper, but threatens to compound the problems, said Allen Nelson, Brandon’s father.
“I’m very concerned that it’s going to be placing tens of thousands of people into programs like (Sovereign’s), and you’re going to get more of these people who are in it for the wrong reasons, just for money,” he said. “They know there’s not going to be any oversight. There’s not any oversight now. Given our experience, it could be very detrimental to many people.”
It felt like a step forward when the governor signed “Brandon’s Law” in 2021, prohibiting operators from misrepresenting or making blatantly false claims about the services they offer or where they’re located. But the best laws in the world don’t matter if they’re not enforced.
Expressly non-medical providers continue to tout 24/7 “medical supervision” in promotional material. “Oversight,” Allen Nelson said, “is terribly lacking.”
‘Lives were ruined’
The Nelson settlement is just the latest in a series of multi-million-dollar hits for Sharma and his now-defunct companies.
An enormous loss came last year when a Los Angeles jury ordered Sharma/Sovereign/DD to pay Health Net nearly $45 million in damages and interest for, among other things, violating the Racketeering Influence and Corrupt Organization Act. Sovereign sued Health Net for not paying; Health Net accused Sovereign of massive fraud; and the jury found that Sharma acted with “malice, oppression or fraud.” That case is on appeal, said attorney Lisa Kantor.
In 2021, Sharma/Sovereign/DD settled for $2.3 million two lawsuits from women who said they were sexually assaulted by the employee supervising their care. The women alleged that the man at Sovereign’s Palm Desert facility offered them drugs and/or money for drugs in exchange for sexual favors. The man was not a licensed healthcare professional and Sovereign knew he had a history of harassing patients, but he was allowed to supervise and manage patients anyway, the suits said.
In 2019, a Sovereign client — who suffered brain damage after overdosing on painkillers while in outpatient treatment at a Sovereign facility in San Juan Capistrano — won an $8.88 million binding arbitration award against the company.
And more than 140 workers who felt compelled to remain on duty and help patients, even as Sovereign was imploding and they hadn’t been paid for weeks, then months, filed wage claims for tens of thousands of dollars with the state in 2018. Many abandoned those claims, giving up hope of ever being paid.
“So many lives were ruined,” said Malakiah McGuire, who was the school director for Sovereign’s adolescent treatment program in San Diego. Sharma owes her $27,255 in unpaid wages, plus interest, according to her claim with the state Department of Industrial Relations.
“I had a conscience, and there were still adolescents enrolled in our residential program, living there and attending classes,” she said by email. “I sacrificed a lot to help those kids in the end, and I know their parents were grateful. It is too bad the company thought it was enough for those of us who stayed to be told how humbled they were by our dedication. … Humility doesn’t pay the bills.”
McGuire hasn’t gotten far with the state. Officials want her to provide asset information and/or proof that Sovereign is operating under a different name, but she is not a private detective. Sharma has said he advised other treatment programs — including Invictus Health, which the Nelson family charged was simply Sovereign resurrected — but no businesses currently appear to be in his name.
It seems criminal that Sharma can get away with this, she said. “I am hopeful that one day I will get what I rightfully earned.”
‘I am a lie’
The Southern California News Group chronicled Brandon Nelson’s tragic death in a two-part series in 2018. He had a gift, his parents said: He taught himself computer programming, was an outstanding student at Santa Monica High, was enchanted with flight and earned a degree in aerospace engineering from UCLA. He loved basketball and soccer and played on the varsity football team in high school, where a coach predicted that his smarts would ensure that no dream was beyond his reach.
The lawsuit produced more agonizing details about his death.
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Nelson was released to Sovereign’s care from Mission Hospital Laguna Beach on March 7, 2018, with a diagnosis of bipolar affective disorder and obsessive-compulsive disorder. He was even-tempered the next morning, workers testified — until a group therapy session led by an addiction counselor who was told nothing about the individual diagnoses of the men, including that they were not there for addiction issues.
The conversation touched on careers. Nelson shared that he longed to be a pilot. Stop dreaming, one man told him — you have mental health issues and you’ll never be allowed to fly. “Brandon was like devastated….his whole demeanor shifted,” a social worker testified.
The social worker was the last person to see him alive. Nelson became more and more agitated as the day went on and his medications didn’t arrive, she said. “Without my medications I am evil, or cursed or something,” she quoted him as saying. “Without my medications, I feel like I’m withdrawing …. Now I’m feeling weird. I’m not a real person. I’m a lie.”
The social worker insisted that the distracted house managers find Nelson’s medications, and she didn’t leave him until they were delivered and he took them and appeared calm and ready for sleep. She would never have left him alone if she knew anything about his history, she said.
“Sovereign did not give you any information on Brandon’s background, correct?” asked the Nelsons’ attorney, Armine Safarian Khatchaturian.
“I had nothing. I had nothing,” the social worker said.
Testimony documented a woeful lack of meaningful experience or qualifications for many employees working directly with mentally ill and addiction clients. One worker had applied to be a driver, but that job was filled so they made him a house manager — the person responsible for overseeing all the people in a residential facility, as well as safekeeping and distributing their medications. (A clever bill by Assemblywoman Cottie Petrie-Norris to require employees distributing prescription drugs to actually be licensed to dispense prescription drugs died last year.)
It was not unusual to see clients in the stairwell of one particular building “loaded, yes, absolutely….There wasn’t a whole lot of supervision, you know,” one testified.
Workers also talked about the kinds of fraud at the heart of the Health Net case: The company inventing California addresses for out-of-state patients, buying health insurance for them so it could bill that health insurance, altering patient records so they appear sicker and higher billings would be justified.
The day of his death, Brandon Nelson’s insurance was billed for three group therapy sessions, but those who were with him that day could recall only one.
“There were no checks and balances, no training provided to these people,” said Khatchaturian, the Nelsons’ attorney. “Everyone literally was there for a check.”
The entire system needs to be torn down and rebuilt, she said. Mental illness and addiction need to be approached as the serious medical issues they are, attended to by competent professionals with education, training and experience.
“I don’t think enough people have been hurt to make the moves that we need for change,” she said. “I don’t think people really understand how bad it is. I don’t think people get it.”
The Nelsons get it all too well. Brandon Nelson would have been 32 on Tuesday, Sept. 12. They plan to use the settlement money to fund people and programs making a real difference for those with mental illness, and vow to keep lobbying lawmakers for change. It’s what Brandon would have wanted.
“Still,” Allen Nelson said heavily. “It’s sad to see your wonderful son’s life boil down to a dollar number on a piece of paper.”