Is the patient just upset or is he a real threat?

The day of Dr. Dennis Sandlin's death at a Perry County clinic, a sheriff's deputy said he was told a patient accused in the killing had threatened to "blow up" the clinic two hours earlier.

That's not what the clinic's administrators and company managers told a Kentucky Occupational Safety and Health Program inspector several days after the shooting.

Managers told inspectors that the patient only said he would "be back." In interviews with the Herald-Leader, Mountain Comprehensive Health Corp. managers said they called police as a precaution and weren't sure how seriously to take the threat. The clinic did not press charges after that first visit.

The discrepancy between the two reports, and managers' hesitance to press charges against a patient, highlight a key question medical professionals face daily: At what point should aggressive behavior be considered a threat that requires police intervention?

A symposium on medical workplace safety, planned after Sandlin's death, will try to address that question Saturday.

An investigation by the Occupational Safety and Health program, overseen by the Kentucky Labor Cabinet, concluded with no citations issued to Mountain Comprehensive Health Corp., the clinic's owners, according to the report obtained by the Herald-Leader.

The report reveals new details about what happened the morning of Dec. 8 at the clinic in Cornettsville. John Carles Combs, 46, of Redfox in Knott County, was arrested the day of the shooting and charged with Sandlin's murder. He has pleaded not guilty.

The morning of Dec. 8, the OSH report says, a patient came to the clinic about 8:10 a.m. and asked for a drug prescription. After he was told a urine test would be needed to screen for drugs, per company protocol, "the patient became upset and said that this policy was a money racket and demanded his money back."

The patient's $15 copay was refunded, and he left the clinic shortly after 9 a.m., "saying he would be back," says the report, based on inspector Rick Pearcy's conversation with six Mountain Comprehensive managers, including CEO Mike Caudill and Clinic Administrator Ralph D. Hall Jr., who was at the clinic during the shooting. No other employees were interviewed.

"According to these management persons, the patient did not make any threats or mention of a violent act going to be committed," the report says.

Nevertheless, the Perry County sheriff's office was called, and Deputy Sam Mullins responded.

The day of the shooting, Mullins told a Herald-Leader reporter that clinic employees told him that Combs threatened to "blow the place up," but that the clinic administrator declined to press charges seeking Combs' arrest. The OSH report, based on conversations with clinic managers, said the deputy left promising to check KASPER, the statewide prescription database, and for outstanding warrants against Combs.

"No one here said that," about threats to blow up the clinic, said Hall, the clinic administrator, in an interview Friday. "I don't know how that got out to the media. To my knowledge no one here heard that was said."

Hall said he told the deputy that the patient was upset and that he said he would come back. Hall said he called the sheriff's office, even though he hadn't heard a specific threat, as a "precautionary" measure.

Deputy Mullins' official report on his response to the threat was filed as a supplement with the Kentucky State Police's murder investigation file, a Perry sheriff's officer said Friday. Hazard state police post spokesman Trooper Tony Watts said he couldn't release any more details of that investigation while it is ongoing.

About 11:15 a.m. on Dec. 8, the OSH report says, the patient came back through the main entrance of the clinic, went straight to a nurses' station and confronted Sandlin, who was reading a medical chart. The clinic administrator, Hall, was standing at the nurses' station, and "as soon as he saw the patient, he immediately turned to go into an office just across the hallway to phone 911."

"At that time, the patient turned to the doctor, took out a gun and apparently told the doctor that he did not deserve to live. The doctor tried to defuse the situation and turned back to look at the chart on the counter. At that time, the patient shot the doctor in the head. The patient then walked back down the hallway and out the main entrance," the report said.

The Mountain Comprehensive Health Corp. policy on workplace violence, contained in the OSH report, says "Persons threatening or engaging in such acts against staff members, patients or visitors will be prosecuted."

But the problem is knowing what constitutes a threat, Hall said.

"When you're in the medical field people get upset all the time," Hall said. "So you know, you don't really know what to consider a threat or what not. Of course we do now."

Federal standards govern some kinds of workplace hazards, such as handling chemicals or machinery, but not acts of violence, said Susan Draper, director of the division of occupational safety and health compliance for the Kentucky Labor Cabinet.

"There are no standards that cover this type of hazard," Draper said.

She said OSH standards don't require that an employer press charges against anyone making a threat, and police interviews or investigations aren't taken into consideration.

Doctors say drug-seeking patients "are more aggressive now than they've ever been," said Karen Engle, director for Operation UNITE, which is sponsoring Saturday's symposium.

"We need a protocol to follow. Some of it's going to be a judgment issue, but of course we have to learn from the murder of Dr. Sandlin what could have been done," she said.

Officials will be asking for volunteers at the symposium to advise UNITE on developing a set of suggestions and procedures that doctors can use.

The OSH report contains Mountain Comprehensive Health Corp. documentation of violence prevention training, as well as disaster and emergency training, including a 2008 drill about a man with a gun, trying to rob the clinic. In the training drill, clinic employees ushered patients and visitors into exam rooms, locking doors until the robber left. When a nurse heard the gunshot on Dec. 8, the OSH report said, patients were taken into a lounge area, and doors were locked.

The OSH inspection report concludes that Mountain Comprehensive employees "were trained as best they could be. It appeared they acted properly and with speed in handling the situation."

Clinic managers told the inspector they are placing "panic bars" on doors leading to doctors' and nurses' areas to allow opening from the inside only, the OSH report says. The company has also hired an armed security guard at the Cornettsville clinic.

"Literally you have to take every single upset patient seriously," Hall said.