SPOKANE, Wash. – A state Department of Health investigation found that a series of miscommunications and policy failures at Providence Sacred Heart Medical Center contributed to the tragic death of 12-year-old Sarah Niyimbona last April.
The information was first reported by The Spokesman-Review
Sarah, who was under constant observation due to her high risk of suicide, left her monitored room unnoticed on April 13. She reached the top of a hospital parking garage and jumped to her death before security guards could intervene.
The investigation revealed that it took staff 11 minutes to trigger a hospital-wide alarm after discovering Sarah was missing. This delay was critical, as security footage showed she reached the fourth level of the parking garage just minutes after leaving her room.
Providence failed to follow its own protocols, placing patients like Sarah at risk, according to records obtained by The Spokesman-Review. Due to ongoing litigation, Sacred Heart officials declined to comment on specific findings but stated that all concerns raised by the state had been addressed.
“We are heartbroken about the tragedy that occurred at Sacred Heart Medical Center. Safe, compassionate care is always our top priority,” Providence spokeswoman Allie Hyams said.
Sarah’s family, represented by attorney Matt Conner, remains hopeful for justice and appreciates efforts to review the case at both state and federal levels.
Sarah had been admitted to Sacred Heart after a suicide attempt involving an overdose of her anti-depression medication. Despite being rated at high risk of suicide, both the remote visual monitoring and constant observation by a sitter were discontinued without proper documentation or assessment.
The investigation highlighted a lack of communication between the medical unit staff and the behavioral health team, which contributed to the delay in activating the “missing child” alert. Staff initially believed Sarah was with another caregiver, delaying the response.
Providence policy mandates continuous observation for high-risk patients. However, only 28 out of 92 required suicide screenings were documented during Sarah’s stay, raising questions about procedural adherence.
The hospital was placed under Immediate Jeopardy by the Department of Health, indicating severe non-compliance with safety regulations. Sacred Heart quickly submitted an abatement plan, which was approved, lifting the jeopardy notice.
The tragedy underscores the need for stringent adherence to safety protocols and effective communication within healthcare settings to prevent such incidents in the future.
