He was supposed to be on a secure locked-down floor.
The doors were locked. The patients could not leave voluntarily. They were in the psychiatric ward for specific reasons.
This man was known to have eaten and ingested items before that should never have been swallowed.
His medical records revealed he had swallowed dominos. The endoscopy showed actual photos of the dominos resting in his stomach. Luckily for the patient, the doctors were able to retrieve the dominos before they did massive damage.
He also swallowed coins and marbles. Don't ask why.
One day, while on the locked psychiatric floor, a cleaning closet was left unlocked...by mistake.
This patient decided he would drink the contents of what is commonly known as drano, an acidic drain cleaner.
And that's exactly what he did. The acid burned his mouth. It burned his esophagus. It burned his stomach. He needed emergency medical treatment and surgery.
This was not a smart thing to do. Unfortunately for him, he didn't realize it until it was much too late.
An investigation revealed that the cleaning person had accidentally left the utility closet unlocked which led to this tragedy.
The key here was not that the patient was mentally unstable. Rather, it was the carelessness of the psychiatric hospital staff that allowed this unstable patient to drink the drano.