A Department of Health and Human Services report has found that UCLA's Resnick Neuropsychiatric Hospital breached safety protocols in the care of actor Robert Carradine, who died by suicide in February. The findings were submitted to Los Angeles Superior Court as an addendum to a lawsuit filed by Carradine's children.
The lawsuit, filed by Carradine's daughters Ever and Marika, and son Ian, claims staffing failures at the hospital led to the 71-year-old actor's death. Carradine died on February 23 from an anoxic brain injury sustained during a suicide attempt while a patient at the facility.
According to the report, an inspection conducted in April found the hospital out of compliance with rules concerning patient rights and nursing services. Specifically, the report stated the facility 'failed to provide a safe environment for care.' It cited a rule requiring patient checks every 15 minutes, noting that these checks were not consistently performed according to the hospital's own policies.
Contraband and Monitoring Failures
The report also highlighted the presence of two contraband items – a belt and a bedside table – that Carradine used in his suicide attempt. The facility's director of quality management reportedly told DHHS officials in April that a nurse failed to confiscate Carradine's belt, cellphone, and wallet upon his admission on January 16. The director was reportedly unaware of whose responsibility it was to remove the bedside table, which may have belonged to a previous patient.
Carradine's children allege in their lawsuit that he was never stripped of his belt, which is listed as contraband. The lawsuit also states that a rolling bedside table, not standard for the locked psychiatric unit, was left in his room. They claim that the hospital generated a belongings form showing the facility failed to confiscate his belt.
Patient Monitoring Allegations
Adding to the claims, the lawsuit asserts that no one watched or checked on Carradine for extended periods, despite orders for 15-minute observations. According to the filing, the assigned staff member reportedly sat in the hallway and entered observations into an iPad without visually checking on the patient. The lawsuit claims the iPad allowed staff to record checks without actually performing them, creating a false record of compliance.
Carradine voluntarily admitted himself to the Resnick hospital twice in January. He was initially discharged on January 9 after seven days but returned on January 16 due to experiencing a manic episode with suicidal ideation. He had expressed hope that inpatient treatment would reduce his anxiety, but his children claim he instead entered a facility that broke rules for psychiatric patients with active suicidal thoughts.
Medical History and Death
Carradine's manner of death was ruled a suicide in June. Medical examiner records indicate he had a history of bipolar disorder, severe depression with psychotic features, anxiety, and prior suicidal ideation. His family has spoken publicly about his long struggle with serious mental illness.
According to the medical examiner's investigative summary, hospital staff found Carradine unresponsive in his room on January 17, the day after his admission, following an apparent hanging involving a leather belt. Medical personnel restored circulation, and Carradine was transferred to intensive care, where he remained for over five weeks. He was pronounced dead on February 23 from an anoxic brain injury due to hanging. The medical examiner's report stated no foul play was suspected.
The plaintiffs are seeking general, special, economic, and wrongful death damages. The family's lawsuit contends that the failures occurred not due to a lack of knowledge or resources, but because UCLA allegedly took shortcuts with safeguards intended to protect Carradine's life.