SYRACUSE, N.Y. - Hutchings Psychiatric Center "likely contributed" to the death of a 14-year-old patient by misdiagnosing her and failing to quickly get her to an emergency room, a state investigation shows.

An ambulance took Amaya Stethers from Hutchings on May 31, 2017 to Upstate University Hospital where she died the next day of a severe case of constipation and bowel obstruction. Staff at Upstate removed five pounds of stool from Amaya's bowel before she went into cardiac arrest three times and died.

Amaya's stomach was so distended when she arrived at Upstate she looked like she was nine months pregnant, said Deborah Hobbs, her mother.

The state Justice Center for the Protection of People with Special Needs says in a report that staff at the state mental hospital mistakenly thought Amaya had a urinary tract infection or a stomach bug even though she had a history of severe constipation and bowel obstruction. Staff ignored her worsening symptoms and delayed emergency medical intervention, the report says.

Before the ambulance arrived at Hutchings, Amaya's eyes were "rolling back in her head," the report says.

Hobbs filed a lawsuit Monday in state Supreme Court against some of the Hutchings staff members who cared for Amaya. She also plans to sue Hutchings in the state Court of Claims.

"This whole thing was preventable," Hobbs said. "I'm sick to my stomach every time I think of how unjust this whole thing has been."

Deborah Hobbs, left, and her daughter, Amaya Stethers

Syracuse.com obtained a copy of the Justice Center report from Robin Zimpel-Fontaine, Hobbs' attorney. The Justice Center redacted the names of Hutchings staff interviewed by investigators.

Named as defendants in Hobbs' lawsuit are Hutchings psychiatrist Dr. Robert Kallinicos and pediatrician Dr. Elizabeth Nguyen. Both Kallinicos and Nguyen declined to comment. Also listed as defendants are three Hutchings nurses whose names are not known yet, the complaint says.

Amaya, who had autism and schizophrenia, was put on the antipsychotic drug clozapine at Hutchings. Constipation is one of the drug's side effects. A warning on the drug's label states clozapine has been associated with constipation and intestinal obstruction. "On rare occasions, these cases have been fatal," the label says.

Amaya had been on the drug before and developed severe constipation requiring hospitalization. Hobbs told Kallinicos, the Hutchings psychiatrist who prescribed the drug, about this in early May and asked him to check Amaya for any signs of constipation, according to the lawsuit.

The drug is not commonly used with children, according to the Justice Center report.

Hutchings has a policy which says the drug cannot be prescribed to a child or teen without the review and approval of the state mental hospital's clinical director, according to the Justice Center report.

But the report says investigators could find no evidence the psychiatrist who prescribed the drug to Amaya followed the policy.

The state agency's report also found:

A nurse who cared for Amaya was unaware of the girl's history of severe constipation and did not tell an on-call medical doctor about the girl's "alarming" symptoms. The same nurse failed to brief paramedics about Amaya's condition, further delaying care once the girl arrived at Upstate. Initially Upstate staff thought Amaya had overdosed on drugs.

Hutchings' chief nursing officer put an inexperienced nurse in a charge nurse position on Amaya's unit. The chief nursing officer's "lack of attention to the ineptitude of a registered nurse permitted to function in the role of a charge nurse likely was a contributing factor in the death of ... Amaya Stethers."

Investigators identified "substantial systemic problems" at Hutchings, including inadequate management, supervision and training that exposed the Amaya "to harm or risk of harm."

The lawsuit seeks a monetary judgment to be determined by a jury.

The state Office of Mental Health says it did its own investigation after Amaya's death.

"Corrective action plans were issued and put in place. These plans include revision of policies and procedures governing use of certain medications, increased supervision and performance standards of nursing staff, and the retraining of staff on issues including medical evaluations and proper communication of medical concerns," the state agency said in a prepared statement.

Hobbs is a case manager at the Salvation Army. She says she advocated for her daughter and was very involved in her care at Hutchings.

"Amaya died on their watch and there has to be an acknowledgment that it happened and they made a lot of mistakes," Hobbs said.

She said her daughter was a joyful girl who liked to dance.

"I don't care how mentally ill she was, she captivated people everywhere she went," Hobbs said.

A therapy aide interviewed by investigators called Amaya's death "embarrassing."

"The kid was 14 years old, it's not supposed to happen," he said. "We didn't get the information we needed to help her."

Contact James T. Mulder anytime: Email | Twitter | 315-470-2245