DOH launches exhaustive review in wake of fatal attack on nurse at state psychiatric facility

State Health Department officials say the fatal attack on a Hawaii State Hospital nurse Monday evening was “unprovoked and unanticipated.”
Published: Nov. 13, 2023 at 6:26 PM HST|Updated: Nov. 15, 2023 at 5:21 AM HST
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HONOLULU (HawaiiNewsNow) - State Health Department officials say the fatal attack on a Hawaii State Hospital nurse Monday evening was “unprovoked and unanticipated,” but add an exhaustive safety review of the facility and group homes on the campus is underway.

The nurse was identified as Justin Bautista, a four-year veteran of the program.

A former patient at the facility has been arrested for the fatal stabbing, which happened at a transitional group home on the hospital’s campus. State officials say that the suspect, 25-year-old Tommy Kekoa Carvalho, did have privileges to leave the specialized treatment home.

Kenneth Luke, administrator at the Hawaii State Hospital, said in a news conference Tuesday that Carvalho left the Kaneohe facility on Monday afternoon and then returned.

There’s speculation that’s how he got the weapon in the incident.

Authorities confirmed the victim was stabbed multiple times.

An employee at the state’s forensic psychiatric facility in Kaneohe was fatally stabbed on Monday night — and police said a former patient has been arrested for

Dr. Kenneth Fink, state Department of Health director, offered his condolences to the victim’s family and said grief counseling services were being made available to workers and patients.

“What happened yesterday is tragic and extremely sad,” he said at the news conference.

He added a clinical review appears to show all protocols were followed in Carvalho’s case and that he had not previously shown signs he was a threat. “The patient was stable,” Luke added.

“This seemed to be an unanticipated and unprovoked incident.”

Meanwhile, a safety review is also underway at the forensic psychiatric campus.

Fink noted that the newly-built Hawaii State Hospital is high security. But transitional group homes on the campus, designed to prepare former patients to live independently or in group settings in the community, are meant to be low security for those who have been stabilized.

He said the group home where the stabbing happened has 22 residents and five staff members.

All of those employees — Bautista and four psychiatric techs — were working Monday night.

Luke added that the nurse who died was a “good man, well-respected.”

“It’s a great loss to our organization,” he said.

Honolulu EMS officials say the fatal attack happened around 5:20 p.m. Officials said witnesses heard an argument, but it is unclear if the victim and suspect had a history together.

Records show the suspect has a history of violence at the Hawaii State Hospital.

Court documents show in 2016, Tommy Carvalho was arrested in a terroristic threatening case on Kauai; since then, he has been in and out of the state hospital in 2020.

He was charged with assault while under treatment at the state hospital.

His attorney said another case was pending charges now, in 2021.

He was sent to a group home Waianae in a letter from his case manager in May of 2022, said he tested positive for meth and had “escalating aggressive verbal threats to staff and peers and that “attempts to stabilize his current behaviors at community hospitals have not been successful.”

That led him to be sent to the state hospital again.

In August of 2023, a judge found that Carvalho could be safely released to that transitional living facility located on Hawaii State Hospital grounds.

Three months later, the deadly stabbing took place, and Carvalho was arrested.

A statement from the United Public Workers union’s state director, which represents some of the workers at the facility, read:

“We are deeply saddened by the tragic news of the fatal stabbing of a staff member at the Hawaii State Hospital. Our hearts go out to his family, friends, and all those affected by this senseless loss. At UPW, the safety and well-being of the members we represent are of utmost importance. Our bargaining units, which include a dedicated group of employees at the hospital, rely on us to prioritize their workplace safety and security. Every worker deserves to feel safe and secure in their workplace, and we are committed to advocating for policies that ensure just that.”

In 2021, a GoFundMe was created to cover Carvalho’s legal fees to bring him back home to Kauai.

His family said on the fundraising page that from a very young age, he struggled with mental disabilities, including autism, dyslexia, and ADHD.

Hawaii News Now reached out to Carvalho’s family and have yet to hear back.

Authorities are focused on the safety of the Kaneohe facility, which added a new wing with 144 beds a few years ago.

“We actually believe the hospital has been made safer since the opening of the new patient facility that assaults are down,” said Luke.

However, they’re still over capacity.

Luke said 325 people live at the psychiatric facility.

They have temporary permission to care for up to 350.

“We are not just throwing patients out even though we are over census,” said Luke. “We are not just opening the doors and being irresponsible and putting people back in the community.”

“We would rather be over census than put someone out that we knew should not have been discharged.”

“They’ve undergone some leadership turnover in the last six months, and so it’s been difficult to really see whether positive change has been made or not,” said State Sen. Jarrett Keohokalole, who represents the Kailua and Kaneohe District.

Keohokalole said there’s been a hesitance to allow people to undergo programming to reintegrate into the community ever since admitted killer Randall Saito escaped the state hospital and flew to California with a fake ID in 2017.

“So it’s going to be a real challenge to make sure that people that are deemed safe enough to reintegrate back into the community are able to get enough help in order to do that successfully, now that this has happened,” said Keohokalole.

The state hospital’s administration said they’re doing a thorough review to see if there’s an opportunity to see how they can improve patient, and staff safety.