Amber Mace, 20, was found dead by staff at Pembroke Hospital. Seven months later, her family says there are unanswered questions about how she died.

PEMBROKE - Seven months after Amber Mace died at a psychiatric hospital in Pembroke, her family still reels from the loss. And they are filled with questions about what caused the death of a 20-year-old woman who loved to hug people and write poems.



"She made a lot of people smile. She was always ready with a hug and to tell you that she loved you," her mother Tammy Mace said Wednesday, sitting at a diner in Lynn surrounded by six family members – Amber Mace’s aunts and uncles and a cousin.

As Tammy Mace listened to her family reminisce about her daughter’s creativity, playfulness and love of fishing and camping trips, the tears started and she leaned into the big shoulder of her brother-in-law, Mark Savio.

"I gotcha," said Savio, pulling her close with his right arm.

The sadness for Tammy Mace and the Savio clan only intensifies when they try to unpack what happened to Amber and read state reports that criticize Pembroke Hospital’s handling of her case.

A state investigation last fall never laid the blame for Amber Mace’s death on Pembroke Hospital, a for-profit hospital owned by Arbour Health System, but concluded that the hospital had failed in their nighttime safety checks and created "dangerous and inhumane" conditions for her.

Amber Mace had struggled through adolescence with serious mental illness – depression, bipolar disorder, suicide attempts and cutting herself – but she was trying to get help when she checked into Union Hospital in Lynn on Friday, Aug. 28, and was sent to Pembroke Hospital at 1 a.m.

She called her mother and left a voicemail.

"I still have it," said Tammy Mace, holding out her cell phone and playing it back, a vestige of her daughter’s voice saying she loved her.

A day later on Saturday, Tammy Mace and one of Amber’s aunts drove to see her in Pembroke.

"This is not my daughter. She seems like a zombie," Tammy Mace told the nurse, a state investigation document said.

Tammy Mace’s observation was important, but Pembroke Hospital did not share it with the staff physician, state official Janet Ross wrote in the report last November. Ross is the director of licensing for the State Department of Mental Health.

Tammy Mace asked what drugs had been prescribed, but the nurse refused to tell her.

"I had Amber sign a release," Tammy Mace said this week. "They were giving her Suboxone and another one where they don’t belong together. I told (the nurse) that didn’t make sense, and she agreed … I said ‘Have the doctor call me.’ This was Saturday, and she said the doctor would call me on Monday."

But Monday didn’t come for Amber Mace.

At 5 a.m. Sunday, a mental health worker at Pembroke Hospital found her dead in her room, her limbs and her jaw stiffened into full rigor mortis, according to the state’s investigation.

That detail alone enrages the family. The hospital policy called for staff to check patients’ well being every 15 minutes, but those safety checks were done improperly, the state report said.

"It could have been prevented. It should have been prevented," said Jill Haserlat, an aunt who lives in Gloucester.

In her sharp criticism of Pembroke Hospital, Ross expressed a similar sentiment.

"Had checks been conducted in accordance with policy, it is likely that the patient’s condition could have been discovered much sooner," Ross wrote. "(The) failure of safety checks constituted a dangerous condition, which may have delayed treatment for a medical condition beyond the point where intervention could be effective."

Ross also criticized Pembroke Hospital for recording pulse rates of 106 and 113 for Amber Mace as stable vital signs.

"(They) are not considered to be stable vital signs for a young woman of 20 years old," Ross added.

Another investigation completed two months ago by the State Department of Public Health for the Centers for Medicare and Medicaid found that Pembroke Hospital failed to follow its own policy by not completing a comprehensive assessment of Amber Mace. However, the investigation concluded that Pembroke Hospital still met Medicare requirements.

"My daughter asked for help that day, and she got nothing," said Tammy Mace.

Mixed with the outrage and grief are unanswered questions. The family hired a lawyer to help Tammy Mace, Amber Mace’s mother, get the legal authority to access all hospital records and government reports connected with her daughter’s treatment and death.

They want to know what drugs she was prescribed and the possible interactions and complications they might have caused.

The state cited a statement from the Office of the Chief Medical Examiner, saying Amber Mace probably died from an inflammation of her heart that could have followed a viral infection..

"She didn’t have heart problems before this," said Tammy Mace. "She played softball and volleyball."

Haserlat, Amber Mace’s aunt, wishes someone at Pembroke Hospital had sat down with the family.

"Why didn’t a counselor explain to us about the drugs or at least talk to us in terms we’ll understand?" Haserlat said.

Tammy Mace said she isn’t seeking money from her daughter’s death but she and her family don’t want another family to suffer the same tragedy they have.

"I want the harm (that came to her) to help someone else," said Tammy Mace.

Around the big table at 3 Yolks Restaurant, Tammy Mace held up photos of Amber on a memorial card and on a raffle ticket. The family raised money to help pay for her cremation and funeral.

On the reverse is a poem Amber Mace wrote, titled Letting Go:

"I’m finally saying no/ To bad thoughts in my mind / To myself I’m trying to be kind .. So I can let the sunshine in."

Tammy Mace visits her daughter’s grave two or three times a week at Pine Grove Cemetery two miles north of the diner in Lynn. And she thinks a lot about the life Amber could have lived.

Two years ago, Amber spoke at a breakfast meeting held by the Department of Mental Health. She was working on a documentary film about recovering from mental illness, and she volunteered to read to children at the Salvation Army in Lynn.

"Amber would have been huge in the mental health field," said her mother. "She would have helped people."

These are the unredacted documents provided to The Patriot Ledger by the Mace family.

The Department of Mental Health issued its first decision letter in November, following a two-month investigation into Amber Mace's death on Aug. 30 at Pembroke Hospital. The investigator interviewed 11 people and reviewed about 500 pages of documents, the state said.

The state amended its decision in December, after an appeal from Pembroke Hospital CEO Thomas Hickey.

This is the state's amended decision letter, shared with the family of Amber Mace in December.