Care and conditions at Oregon State Hospital violate patients' safety and their constitutional right to good care, said a U.S. Department of Justice report released Wednesday, Jan. 16.
READ THE REPORT
• The U.S. Department of Justice report
PAST NEWS STORIES
• From The Oregonian of Tuesday, July 15, 2003 -- Reports detail psychiatrist's mistreatment of patients: An inquiry finds that a doctor at the Oregon State Hospital withheld medications, causing a mentally ill man to suffer
• From The Oregonian of Tuesday, July 22, 2003 -- Superintendent of state hospital resigns: Stanley Mazur-Hart will leave his post at Oregon State Hospital on Sept. 30 but probably will be given another job
• From The Oregonian of Tuesday, Sept. 2, 2003 -- Hospital's status hurts hiring: Perceptions on the quality of care and the realities of workplace and pay make Oregon State Hospital a tough sell to top psychiatrists
• From The Oregonian of Tuesday, March 9, 2004 -- Deal reached in state hospital patients' suit: The accord means 75 new community mental-health beds and added services for hard-to-place patients
• From The Oregonian of Friday, May 7, 2004 -- Accused killer hit by patient at hospital: Police confirm an attack on Edward Paul Morris, who was found unfit to face trial in the deaths of his family
• From The Oregonian of Sunday, Sept. 19, 2004 -- Betraying a fragile trust: Oregon State Hospital (1st of 2 parts): Some Oregon State Hospital caretakers have sexually abused mentally ill children, preying on patients in a ward still at risk because of systemic security failures
• From The Oregonian of Sunday, Sept. 19, 2004 -- Whistle-blower forced out, records suggest
• From The Oregonian of Monday, Sept. 20, 2004 -- Ward of State, world of hurt; Betraying a fragile trust: Oregon State Hospital (2nd of 2 parts) Oregon allowed two of its employees to molest a mentally ill girl in their care and then paid her to keep quiet
• From The Oregonian of Friday, Sept. 24, 2004 -- Gordly seeks federal investigation of state hospital: The Portland senator says an outside agency should determine if patients' civil rights have been violated
• From The Oregonian of Sunday, Oct. 31, 2004 -- Years in the shadows: Problems have beset the Oregon State Hospital and its mentally ill for more than a century
• From The Oregonian of Thursday, Jan. 27, 2005 -- State will shut youth ward of hospital: Oregon human services officials say patients will leave the adolescent unit in Salem, where sex abuse occurred in the past
• From The Oregonian of Friday, Feb. 11, 2005 -- Indignity's shelf will not remain urns' final stop: Lawmakers move to pay respects to patients left unclaimed at the state hospital after cremation
• From The Oregonian of Tuesday, May 17, 2005 -- Report: Tear down hospital: The Oregon State Hospital must be replaced and one building for patients would likely collapse in an earthquake, a study says
OPINION COVERAGE
• Read Read "Oregon's forgotten hospital," the Oregonian series that won the 2006 Pulitzer Prize for editorial writing, and see a photo gallery
From The Oregonian of Tuesday, July 15, 2003 -- Reports detail psychiatrist's mistreatment of patients: An inquiry finds that a doctor at the Oregon State Hospital withheld medications, causing a mentally ill man to suffer
By Michelle Roberts
State officials investigating allegations of abuse by a senior psychiatrist at the Oregon State Hospital in Salem have found that he denied medications to a severely mentally ill patient, causing the man to unduly suffer for months.
The allegations against Dr. Charles E. Faulk, 53, were outlined in Department of Human Services investigative reports and other records obtained Monday by The Oregonian.
According to the records, Faulk stopped prescribing antipsychotic medications to Neil Norton, 59, in June 2002 after accusing him of being "a pill seeker."
Norton at the time was a patient in one of the hospital's secured forensics wards, which house people accused or convicted of crimes. Norton was found guilty except for insanity in 2002 in a Washington County arson case.
Norton, who suffers from depression so severe he becomes psychotic, quickly sank into despondency. In the seven months after Faulk cut off his medicine, Norton lost nearly 40 pounds, frequently cried through the night and became persuaded that someone had left a dead fetus near a soda machine on the ward.
Faulk, the ward's full-time psychiatrist, visited his ailing patient only once during that period, records show, and ignored repeated staff warnings that Norton was "decompensating."
When Faulk finally intervened in January, he did so with six electroshock treatments instead of the medications that had worked well for Norton, records show.
Electroshock therapy is a controversial but sometimes effective treatment for severe disorders, but experts say it should only be used when other, less invasive treatments fail.
"This is a very serious matter, and we will take corrective action appropriate to what has happened," hospital Superintendent Stanley Mazur-Hart said Monday, a month after he determined that Faulk's treatment of Norton violated Oregon patient-abuse laws.
Mazur-Hart said administrative rules require him to take some sort of punitive action, but he would not say whether he plans to fire Faulk.
Faulk has been on leave from the hospital since May 15, a break he requested a month after officials in the Human Services Department concluded their questioning of dozens of his patients and co-workers. Mazur-Hart refused to say Monday whether Faulk is being paid while on leave. Faulk is paid $9,756 a month.
Contacted Monday at his Salem home, Faulk declined to comment, saying to do so would violate doctor-patient privilege.
Norton said Monday the electroshock therapy was painful, terrifying and "totally unnecessary."
"If he had paid attention to what was happening to me and started me on antidepressants again, I would have been fine," Norton told The Oregonian.
Faulk, who headed the hospital's electroconvulsive therapy program, was hired July 15, 1984.
License endangered
Four years earlier, he nearly lost his medical license for what the Oregon Board of Medical Examiners called "habitual or excessive use of intoxicants or drugs."
At the time, he acknowledged "a history of alcohol abuse and depression," according to medical board records. In July 1980, the board put Faulk on a 10-year probation and required him to "completely abstain" from drinking and using any prescription drugs unless they were "prescribed for him as a bona fide patient by another physician."
To keep his license, the board also required Faulk to see a psychiatrist and notify the administrator of any hospital in which he worked about the terms of his probation.
Mazur-Hart, who became the hospital's superintendent in 1991, said Monday that he was not aware of Faulk's disciplinary history with the board. There is no mention of alcohol or drug problems in the abuse investigation records released Monday.
The investigation into Faulk's treatment of patients was touched off Jan. 10 when Wayne Skeen, another patient, became concerned about Norton's rapidly deteriorating condition.
"I was angry when I saw what was happening to Neil, and I told staff members they needed to do something about it," Skeen told The Oregonian. "They told me to keep out of it, that it was up to the doctor."
Skeen, on behalf of Norton, himself and more than a dozen other patients, filed a wide-ranging complaint that alleged Faulk had neglected them and had verbally abused at least a dozen patients on his ward.
Other accusations
The patients claimed that Faulk had called one a "homicidal maniac" and told Skeen, "You are the worst patient I have ever had." The alleged abuse also included Faulk telling a Cuban patient to "go back to where you came from."
Many of those allegations were never investigated by the Human Services Department because they did not constitute abuse under Oregon law, officials said. Others were investigated, but Mazur-Hart determined evidence was insufficient to substantiate an abuse charge.
The Oregonian first requested the reports in May, shortly after the investigation concluded, and obtained written releases from all patients involved. Despite their permission, the department refused to release its records until Thursday, and Mazur-Hart would not disclose his findings until Monday.
The report comes at a time of increasing scrutiny for the hospital, which receives nearly half of the state's budget to care for the mentally ill yet serves only 1.5 percent of them.
Last week, the hospital was locked down after a patient escaped July 3 from an overcrowded forensics ward. Michael Marks, 23, was captured six days later by Clark County, Wash., sheriff's deputies.
As of late Monday, the hospital remained on lockdown while Mazur-Hart assessed security measures.
From The Oregonian of Tuesday, July 22, 2003 -- Superintendent of state hospital resigns: Stanley Mazur-Hart will leave his post at Oregon State Hospital on Sept. 30 but probably will be given another job
By Michelle Roberts
The superintendent of Oregon State Hospital resigned Monday following a highly publicized patient escape and a state investigation alleging that a senior staff psychiatrist abused a patient.
Stanley Mazur-Hart's resignation will take effect Sept. 30. He has headed the state hospital's Salem and Portland campuses since 1991.
Barry Kast, assistant director for the Department of Human Services' Health Services, declined to comment on whether Mazur-Hart was asked to resign, saying only, "We discussed it with him."
"It's not been a pleasant month or two, and there's been a recognition that new leadership may be the way to go," Kast said. "I think it's time for a change, and I think Stan agreed with that."
Mazur-Hart did not return phone messages left Monday at his office and home.
His resignation comes at a time of increasing scrutiny for the state hospital system, which receives nearly half of Oregon's budget to care for people with mental illness, yet serves only 1.5 percent of them.
Earlier this month, the hospital was locked down after a patient escaped July 3 from an overcrowded forensics ward. Michael Marks, 23, was captured six days later by Clark County sheriff's deputies.
Last week, The Oregonian reported state investigators determined that Dr. Charles E. Faulk, a full-time ward psychiatrist at the Oregon State Hospital in Salem, stopped prescribing psychiatric medications to Neil Norton, 59, after accusing him of being "a pill seeker." Norton was in a secure ward of the hospital after having been found guilty except for insanity in a Washington County arson case in 2002.
During the seven months Norton was denied the medicine, he became so depressed he was psychotic, according to an investigative report obtained by the newspaper. He lost almost 40 pounds, frequently cried through the night and became convinced that someone had left a dead fetus near a soda machine on the ward.
Records indicate the doctor visited Norton only once in this period and ignored staff warnings that the patient's condition was deteriorating.
Faulk intervened in January with six electroshock treatments instead of the medications that had worked for Norton.
Became superintendent in 1991
"There are concerns about the quality of patient care," Kast said Monday when asked whether the Faulk case played a role in Mazur-Hart's resignation. "Some of that has to do with resources, but it has to do with supervision, too."
Kast declined to say what disciplinary action, if any, would be taken against Faulk. The psychiatrist has been on paid leave since May 15, DHS officials said.
After earning his doctorate in psychology from the University of Nebraska in 1976, Mazur-Hart taught college in Michigan before joining the Department of Human Services in 1980 as a clinical psychologist at the state hospital.
He became the hospital's chief psychologist the following year and served as acting superintendent for seven months in 1987. In December 1987, was named superintendent at the now-closed Dammasch State Hospital in Wilsonville.
Mazur-Hart became Oregon State Hospital superintendent in 1991. At the time, DHS officials lauded him as a "hard-line" administrator who would run a "tighter ship." His promotion came after 23 patients had escaped in one year under the previous administration.
On Monday, Kast lauded Mazur-Hart's "remarkable progress in patient care and in safety and security at the hospital." He also noted that Mazur-Hart had improved staffing levels.
Mazur-Hart cites accomplishments
But Kast and Human Services director Jean Thorne also said a department work group recently pointed to problems in medical care at the hospital, which was part of the decision to seek new leadership.
"I don't want to diminish what he accomplished," Thorne said. "But our work group illustrated a number of changes that need to be made in how the state hospital operates."
Kast said Mazur-Hart, who was paid $101,844 a year as superintendent, probably would remain on the department's payroll in another capacity, probably "in a management position related to mental health work."
In his resignation letter to Kast, Mazur-Hart said the hospital's accomplishments "are the direct result of hard-working, dedicated employees, both clinical and non-clinical, both union and management staff. The result is more effective and safer care and treatment for the patients we serve.
"These accomplishments are especially noteworthy because they have occurred in antiquated, deteriorating facilities while the hospital has been significantly overcrowded and understaffed."
Kast would not release the full text of the letter, saying it is a personnel matter.
Patients responded to the resignation with cheers, song and strong support for new leadership.
"With Dr. Mazur-Hart leaving, there's a chance we can improve things here," Norton told The Oregonian on Monday.
But not all patients were optimistic change would come soon.
"I think that the Oregon State Hospital has a deep-rooted problem that's not going to just scatter away with the departure of Stanley Mazur-Hart," said Wayne Skeen, a 22-year-old patient. "Patient care needs to be the priority, and right now I don't think that's the case."
From The Oregonian of Tuesday, Sept. 2, 2003 -- Hospital's status hurts hiring: Perceptions on the quality of care and the realities of workplace and pay make Oregon State Hospital a tough sell to top psychiatrists
By Michelle Roberts
Oregon's state mental hospital is struggling to attract top-flight psychiatrists to work in an overcrowded facility that one senior state official acknowledges is "falling down."
More than 700 patients are in residential treatment at Oregon State Hospital, many for psychoses so severe they cannot survive on their own.
Yet nearly one out of five psychiatrists who treat them have experienced serious substance abuse or other problems that mental health advocates say could affect their ability to care for such vulnerable patients.
Medical records in Oregon and other states show that four of the Salem hospital's 22 psychiatrists have been disciplined or had their medical licenses restricted, a rate far higher than the national average for physicians. Also, state officials say the demanding work and relatively low salary -- $9,756 a month -- have made it difficult to recruit psychiatrists to fill five openings.
"Most of the physicians we have at the state hospital are super physicians," said Barry Kast, assistant director for the Department of Human Services' Health Services division. "We are able to recruit competent and excellent people, but at the levels of compensation we offer, we still may not be competitive with the marketplace."
It's not just low pay that discourages applicants, Kast said. Even the appearance of the 120-year-old hospital repels them.
"Half the place is falling down," he said.
Questions about the quality of care provided by the hospital's psychiatrists arose in July after state investigators determined that Dr. Charles E. Faulk, a ward psychiatrist, had abused a severely mentally ill patient by denying him medications, causing the man to suffer unduly for months.
Faulk, 54, who headed the hospital's electroconvulsive therapy program, was hired July 15, 1984. Four years earlier, he had nearly lost his medical license for what the Oregon Board of Medical Examiners called "habitual or excessive use of intoxicants or drugs."
A week after the investigation became public, Stanley Mazur-Hart resigned as hospital superintendent, although he remains on staff until the end of September. Faulk is on paid leave.
The Oregonian's review of state records shows that three other hospital psychiatrists also had encounters with state licensing authorities. Their offenses ranged from drug addiction and spousal abuse to the improper transfer of prescription drugs across state lines.
One doctor is permitted to practice only under close supervision. The other two currently have no restrictions on their licenses.
After state investigators and hospital administrators determined that Faulk had abused the patient, the Oregon Board of Medical Examiners launched its own inquiry. According to board records, Faulk agreed Aug. 7 to cease practicing medicine until the board concludes its investigation.
Doctors' backgrounds reviewed
Human Services Director Jean Thorne said the state does not consider the disciplinary history of a doctor as an automatic bar to employment. Each of the four doctors' backgrounds was reviewed, she said.
"We were aware of this when these doctors were hired," she said, adding that the hospital recognizes that all people, even doctors, can overcome serious problems.
"Given that we are in the mental health business, we recognize that if there are issues in a physician's past, that does not always mean he or she is not qualified to practice at this time," she said. "We do not automatically disqualify them if they've been cited by the medical board. We look at what the situation is now."
Experts say there is no measurable correlation between a doctor's past troubles and future performance. Nor does anyone track whether psychiatrists, as a group, have a higher rate of disciplinary action than other physicians.
On average, about one doctor in 100 is cited by state boards, said Dale L. Austin, president and chief executive officer of the Dallas, Texas-based Federation of State Medical Boards.
Although the state hospital sample is too small to draw any statistical conclusions, Austin said, four doctors out of 22 nevertheless raises questions.
"For physicians as a whole, that ratio is extremely high," he said.
Austin, whose organization tracks public disciplinary actions against doctors in all 50 states, said any blemish on a physician's record is an impediment to employment in the private sector.
"Any kind of an action taken against a physician's license has a fairly significant marketplace consequence," he said. "It has the effect of making it very difficult for a doctor to practice."
"Either sinners or saints"
Bob Joondeph, executive director of the federally funded Oregon Advocacy Center, which monitors rights for people with disabilities, said doctors with disciplinary histories often find refuge in public settings such as state hospitals and prisons.
"People who work in state hospitals are usually either sinners or saints," he said. "They are people who are interested in dedicating their lives in an area that doesn't pay well because they want to help others, or people who have something that's interfering with them getting a better job."
Sen. Avel Gordly, D-Portland, whose son, a schizophrenic, was once a patient at the state hospital, called the histories of the four hospital psychiatrists "a cause for alarm."
"It's troubling information," she said. "It should always be about providing the best-quality care that aids in patients having good outcomes. It shouldn't be about taking whomever we can get."
Department of Human Services officials declined to comment on the four doctors' work performance, saying it was a personnel matter. Annual performance reviews are public record in Oregon. The Oregonian requested those reviews for all state hospital doctors and administrators on Aug. 6, but the agency so far has refused to release them.
The psychiatrists are David Mac Eason, Alexander E. Horwitz III and Lorraine Elizabeth Skach.
DAVID MAC EASON
The Oregon State Hospital hired Eason on Nov. 2, 1998 -- three days before the state Board of Medical Examiners reinstated his license to practice in Oregon, according to Board of Medical Examiner records.
In August 1997, members of Oregon's Impaired Physician Program learned that Eason was abusing illegal drugs and alcohol and staged an intervention at his office, records show.
Eason, then a psychiatrist for the Benton County Mental Health Department, voluntarily admitted himself to a drug and alcohol treatment center in Newberg, but left a week later against medical advice after his doctor recommended he transfer to a residential program.
Before checking himself out, Eason made two threatening phone calls to his wife of 11 years, according to her petition for a restraining order. On Aug. 13, 1997, a Benton County judge granted the order, barring the doctor from going within a quarter-mile of Kerri Eason and their three sons, then ages 9, 7 and 5.
Eason told the court her husband inflicted "bruises, physical restraints and blows to the head," during a "12-year history of physical abuse."
Reached at his state hospital office, Eason said he once struggled with an addiction to drugs, mainly marijuana. He did not dispute his ex-wife's abuse allegations.
"I don't want to elaborate on the issues we had when we separated," he said. "But I will say physical violence was not the major reason we separated."
Eason was forced to surrender his medical license on Aug. 18, 1997, after he left the treatment center. He was cited for unprofessional and dishonorable conduct and habitual use of intoxicants and drugs.
His license was reinstated with restrictions on Nov. 5, 1998, after he completed drug and alcohol treatment in a hospital near Chicago. State employment records show he started his job as a ward psychiatrist at the state hospital three days earlier.
Eason said that by the time he was hired, he was "14 months into recovery and had been seen by numerous evaluators who said I was fit to practice."
Eason, now 46 and remarried, will remain on probation through November 2008. He was required to attend four, 12-step meetings each week, regularly visit a psychiatrist, abstain from writing prescriptions for family members or friends, and attend a batterers' intervention program. He still submits to random urinalysis at least twice a month.
"I say it makes me a better psychiatrist because I have been through my own share of personal trauma and self-imposed problems and have dealt with them," Eason said.
ALEXANDER E. HORWITZ III
Horwitz was hired at the Oregon State Hospital in 1996. Six years earlier, he was censured by the Mississippi State Board of Medical Licensure after medical officials determined he was self-prescribing and inappropriately taking prescription drugs across state lines.
Horwitz underwent a comprehensive assessment in 1990 at the Baptist Recovery Center in Memphis, Tenn., which concluded he was not chemically dependent or impaired. But Horwitz, then 32, consented to restrictions on his license, the Mississippi board's records show.
The board ordered Horwitz to restrict his use of a category of controlled substances that includes such painkillers as Percodan, Dilaudid and morphine.
Horwitz was further barred from treating his family members, ordered to submit to random, unannounced and witnessed urine and blood screenings, and take 40 hours of American Medical Association classes on pharmacology.
Mississippi State Board of Medical Licensure records do not show whether Horwitz completed those requirements. Board officials said the doctor allowed his Mississippi medical license to expire in June 1995, six months after he applied for an Oregon license.
In granting his license, the Oregon Board of Medical Examiners required Horwitz to "make and retain written records on each and every person whom he treats, examines or counsels."
The Oregon board also restricted his authority to write prescriptions outside of a hospital.
In 1998, Oregon medical officials lifted all restrictions on Horwitz's license.
Horowitz initially agreed to answer faxed questions but did not respond when those questions were sent to his office. He also did not reply to three voice-mail messages.
LORRAINE ELIZABETH SKACH
Skach began work for the hospital on July 1, 1986. A year later, she entered into a voluntary supervision agreement with the Oregon Board of Medical Examiners.
Although Skach was not disciplined by the board, such agreements come only after "there's something in the background of the doctor that would make the board believe they need to be supervised," board investigator Mike Sherman said.
Records say only that she was to "remain under the supervision and direction of a psychiatrist" until the board deemed it no longer necessary.
The limits on Skach's license continued for eight years. During that time, the Oregon State Hospital had to submit progress reports to the board four times a year on her behalf. The board lifted the restrictions in 1995.
Skach did not respond to requests for an interview or questions submitted to her by e-mail.
Public records show Skach has twice been sued in her role as a psychiatrist at the hospital.
In 1995, she was named in a lawsuit brought by a 20-year-old woman who had spent four years of her adolescence in the children's unit, where Skach worked.
According to court records, a 49-year-old man hospital therapist was fired after he had a sexual relationship with the teenager. The suit alleged that Skach, as the girl's psychiatrist, "was responsible to ensure that the plaintiff was not subject to unduly hazardous treatment."
The state settled the case in 1996, 11 days after the multimillion-dollar lawsuit went to trial, said Gregory Smith, the plaintiff's lawyer. Terms of the settlement remain confidential.
Skach, who now works in a forensics ward, also was named in a wrongful death lawsuit filed against the hospital in Multnomah County Circuit Court in August.
Benjamin Bartow, a 41-year-old patient on Skach's ward, died of cardiac arrest in 2001 after being restrained by at least six staff members supervised by the doctor. The complaint does not indicate whether Skach was present when the incident occurred.
Both lawsuits allege that Skach had direct responsibility because she was the patients' primary caregiver. Other defendants in the suits included top administrators, and hospital staff members under Skach's supervision.
Peter Shepherd, a deputy attorney general, declined to comment on the case, saying the state hadn't yet completed its review of the lawsuit.
Panel will assess care
Last month, DHS administrators named a panel of experts to conduct a "careful but accelerated analysis" of patient care in the state hospital system, which includes campuses in Salem, Pendleton and Portland.
The move came shortly after the Faulk investigation became public, and a separate, five-month DHS review of the hospital's operations raised concerns about medical practices.
The panel will focus in large part on whether patient care is "of high quality" and how the hospital educates and supervises its employees, according to DHS documents.
Kast blamed state budget problems for the hospital's difficulty in attracting top-notch staff, saying the hospital hasn't been able to team up with Oregon Health & Science University, which trains some of the nation's leading forensic psychiatrists.
"We have brought forward budget proposals for at least three biennium, maybe more, to establish a forensic fellowship," Kast said, adding, that, "There's more that we can do to establish mechanisms for recruiting and retaining physicians, and I think we should do them. And if it weren't for the fact that we have a $2 billion budget shortfall, we'd probably be doing them today."
Gordly says she hopes that staffing qualifications and oversight will be a significant part of the panel's recommendations, which are due by Nov. 30.
"I think we should have the highest possible standards and expectations for the quality of professionals in our institutions," she said. "Anything less than that is unacceptable."
From The Oregonian of Tuesday, March 9, 2004 -- Deal reached in state hospital patients' suit: The accord means 75 new community mental-health beds and added services for hard-to-place patients
By Michelle Roberts
The state has agreed to settle a lawsuit brought on behalf of more than 100 Oregon State Hospital patients who languished there for months or years because of inadequate mental health services in the community.
U.S. Magistrate Dennis Hubel on Monday approved a settlement in the case, which was filed in 2000 by the Oregon Advocacy Center, a federally funded watchdog group for the disabled.
The state has agreed to create 75 community-based mental-health beds by July 1, 2005, and spend $1.5 million for other outside services for hard-to-place patients, including those with major medical conditions, traumatic brain injuries, histories of substance abuse or serious behavioral problems.
"It's a total victory given our current budget climate," said Kathy Wilde, the advocacy group's litigation director. "We've managed to achieve a whole new system of doing things within the hospital, as well as getting beds and supports."
State hospital patients in Salem, Portland and Pendleton must be released within 90 days of a treatment team's decision that they are "good to go," according to the settlement. Those who aren't released in that time must be referred to a new, state-operated Extended Care Management Unit that will then place them in the community.
If placement is not achieved within an additional 90 days, staff will be designated to review each person's situation to determine what other actions or resources are needed.
The settlement affects all civilly committed individuals who, as of Dec. 1, 2003, had been awaiting discharge for at least 90 days. A total of 69 people will benefit directly. The state has agreed to discharge at least 31 of those patients before July 1, 2005, and seek additional money in the 2005-06 state budget to place the rest.
"We're pleased the court has approved a reasonable solution to a very complex issue," said Kevin Neely, spokesman for Oregon Attorney General Hardy Myers.
The settlement, although a major victory for patients under civil commitment, will not affect forensics patients who are similarly stranded in the hospital. Those patients -- ordered to the hospital for treatment after committing crimes -- were not part of the lawsuit.
Hospital officials say that more than 70 forensics patients are ready for discharge but can't leave because there are no community resources for them. The Psychiatric Security Review Board, which must give final approval to those discharges, can't do so until beds are available.
Many forensics patients have awaited release for more than a year at a cost to the public of more than $8,000 a month per patient, contributing to overcrowding at the hospital's Salem campus.
From The Oregonian of Friday, May 7, 2004 -- Accused killer hit by patient at hospital: Police confirm an attack on Edward Paul Morris, who was found unfit to face trial in the deaths of his family
By Michelle Roberts
A Portland man accused of killing his pregnant wife and three children in December 2002 was assaulted late Wednesday at the Oregon State Hospital, patients and police said Thursday.
Edward Paul Morris was punched in the face by another patient who had heard details of Morris' criminal charges. The two patients were on the maximum-security forensics ward.
"Everyone knew he was going to get socked," said Richard Laing, 64, a patient recently transferred from the ward. "That ward is out of control. It's seriously overcrowded. There are assaults there every day."
Oregon State Police detectives began to investigate after hospital officials reported the assault Thursday, said Lt. Dale Rutledge, a police spokesman. Rutledge confirmed that Morris was the victim.
A judge ordered Morris to the hospital nearly eight weeks ago for an indefinite stay after Morris attempted suicide, volunteered for the death penalty and announced he would represent himself with God as his co-counsel.
Officials at the Oregon Department of Human Services, which oversees the hospital, said Thursday that federal privacy rules do not allow them to acknowledge Morris as a patient.
However, Jim Sellers, a department spokesman, offered to speak "generally about what happens in these situations."
"State hospital staff try to protect people who are subject to threats as much as possible, short of locking them in a cell," Sellers said. "And if there is an incident, certainly hospital staff intervene. Medical attention would be administered."
Charles Fryer, Morris' lawyer, declined to comment Thursday, saying he had not heard about an assault.
In March, a Tillamook County circuit judge granted Fryer's request to halt the case temporarily. The judge determined that Morris no longer was able to assist in his defense and said his mental state had deteriorated significantly after he stopped taking antipsychotic medication on Jan. 26.
The ruling means Morris will remain in the hospital until doctors say he is mentally competent to stand trial. If he never regains that ability, he could spend the rest of his life in the hospital.
According to court records and testimony, Morris suffers from schizo-affective disorder, an illness characterized by the severe mood swings of bipolar disorder and the psychotic symptoms of schizophrenia.
Morris is the second high-profile defendant who has been sent from jail to the Oregon State Hospital recently.
In early March in Clackamas County, Ward Weaver, accused of killing two Oregon City girls in 2002, was ordered to undergo an evaluation at the hospital after he reported hallucinations, refused antidepressants and carved his daughter's name on his arm.
From The Oregonian of Sunday, Sept. 19, 2004 -- Betraying a fragile trust: Oregon State Hospital (1st of 2 parts): Some Oregon State Hospital caretakers have sexually abused mentally ill children, preying on patients in a ward still at risk because of systemic security failures
By Michelle Roberts
The children sent to the Oregon State Hospital's Ward 40 for treatment were a danger to themselves or others. Some arrived in straitjackets. Many were depressed and suicidal. Others had begun to hear the shouts of schizophrenia.
They were among the state's most vulnerable residents -- troubled young people whose families could not afford private care or whose insurance had run out. The hospital's Child and Adolescent Treatment Program was supposed to quell their mental illnesses and shelter them from harm.
But an investigation by The Oregonian shows that hospital staff in positions of trust sexually abused as many as a dozen children, according to internal hospital records, police reports, court documents and interviews with witnesses.
Hospital officials and their supervisors in state government did little to stop the abuses, which occurred between 1989 and 1994. Supervisors and others on the ward failed to report the offenses when they were detected, allowing predators to attack additional victims. The hospital repeatedly failed to report suspected sexual abuse immediately to police and child welfare workers, as required by state law.
In the years since, the hospital has taken limited steps to prevent abuse. It did not begin conducting background checks on employees until 1991, and then reviewed only the histories of new hires. It has yet to install surveillance cameras, which are standard in comparable facilities elsewhere. And it has routinely ignored its own procedures, which require independent investigations of sex abuse allegations reported to Oregon State Police.
State officials said their records identify only three patients who were victims of sexual abuse on Ward 40 in the past 18 years. But The Oregonian found credible reports of nine additional abuse victims from police files, court documents and eyewitness accounts. Some never came to the hospital's attention. Others were reported but examined only cursorily.
"I was sent to the hospital because I tried to kill myself," said Kelly Darcey, who was molested repeatedly at age 15 by a ward employee. "I was in far worse shape when they discharged me."
The Oregonian does not identify victims of sex crimes. However, some of the women who were abused as children on Ward 40 have asked that their first or full names be published because they want the abuse brought to light.
Records and interviews with administrators and those who committed the abuse noted that the hospital's procedures and design problems -- most of which still exist -- offered pedophiles numerous opportunities.
Ward 40, which still houses about 20 young patients, is located in a century-old building full of blind corners and hidden spaces with no high-tech equipment to detect or deter abuse.
Stanley Mazur-Hart, the hospital superintendent from 1991 until last fall, blamed "budget constraints" and acknowledged "there is far better monitoring technology available than that which OSH has."
Administrators and state officials failed to recognize the pattern of abuse, even though it occurred on a small ward with no more than 60 patients ranging in age from 5 to 18. Over the years, a succession of unit directors, psychiatrists and nurses supervised the ward but the responsibility for what happened there and elsewhere in the hospital rested on the superintendent.
The first significant abuse case -- a psychiatric aide accused of having sex with multiple girls in the late 1980s -- was closely followed by four more credible reports that male employees molested female patients. In the mid-1990s, the state paid two women more than $1 million for abuses they suffered while patients on Ward 40.
Yet little changed.
No administrators from the hospital or the Department of Human Services, which oversees it, were disciplined or fired.
State officials say some abuse by employees is inevitable at psychiatric facilities such as Oregon State Hospital. "We never had the perception that the hospital was an institution beyond reproach," said Barry Kast, an assistant DHS director. Kast said he did not see the cases as part of a larger pattern.
The children's stories have never been told, in part because hospital executives and state officials have fought to keep them from the public.
In one case, the state paid an additional $50,000 to secure the silence of a victim whose attorney was poised to hold a news conference on the Marion County Courthouse steps. A lawyer in the office of then-Attorney General Ted Kulongoski told a judge in a closed-door hearing that the secrecy was needed to protect the hospital from political attack by the Legislature.
The scope of sexual abuse at the hospital was brought to light by The Oregonian's examination of records and interviews with more than 50 current and former patients and employees.
Records relating to the abuse of patients on Ward 40 are largely confidential under state and federal privacy laws. As part of a lawsuit, the state turned over to an attorney for one of the victims a detailed accounting of sex abuse allegations involving child patients from 1986 to 1995.
Those records, which were supposed to remain sealed, were inadvertently placed in public files at the Marion County Courthouse. They included police reports, medical records, internal hospital documents, transcripts of closed court hearings and personnel files.
State officials denied repeated requests for comparable records for the years since 1995, making it difficult to assess whether patients continue to be molested.
State records, however, show that the hospital is not following its procedures for investigating abuse. In the past four years, state police have received reports of 10 allegations of sexual abuse involving Ward 40 staff, none of which resulted in criminal charges.
DHS officials acknowledged that seven of those cases were never reported to them, even though the hospital is required by law to inform the agency's Office of Investigation and Training of all suspected abuse. Such agency investigations are crucial, identifying problems so the hospital can change policies or discipline abusive employees before their actions rise to the level of crimes.
Eva Kutas, the chief DHS investigator of possible abuse, said failure to notify her office highlights flaws in the reporting system and raises questions about the safety of the children on Ward 40.
"If the state police don't investigate, we still need to," she said. "That's the only way we can keep track of what's happening there."
The documented cases of sexual abuse spanned the administrations of Govs. Neil Goldschmidt, Barbara Roberts and John Kitzhaber. All three said they did not know what was happening on Ward 40.
"That's an issue that should have come straight to the top so we could make sure it stopped," Kitzhaber said. "I don't know why it didn't. Obviously, it should have."
Roberts told The Oregonian: "Never did anyone ever talk to me about sex abuse cases at the hospital. Had I known, I would have responded immediately. For me, there would not have been any tolerance."
"A collection of suffering"
Since 1976, hundreds of mentally ill children have been sent to live behind the brick walls of McKenzie Hall, a two-story fortress that houses Ward 40 on the northwest edge of Oregon State Hospital's 148-acre campus.
Ward 40 is one of the few places in the state that serves emotionally disturbed children ages 14 to 18. Many are wards of the state.
Former patients describe Ward 40 as intimidating and lonely, absent color and love. Children screamed for their mothers as "The Price Is Right" droned on the day-room television. So many kids were on suicide watch that the corridor was lined with their mattresses at night so staff could keep an eye on them.
"The best way to describe it is a collection of suffering," Kutas said.
Children often arrive at Ward 40 expecting to stay a month or two. Yet many languish hundreds of days, sometimes years, at taxpayer expense -- $30,700 per child per month today. Their illnesses make it difficult, if not impossible, to place them elsewhere. Families that visit are the exception, not the rule.
As a result, many children are reared by doctors and psychiatric aides in a place where razor wire divides the playground from an exercise lot for criminally insane adults.
Across the nation, states are moving from institutionalizing mentally ill children to creating smaller, homelike facilities that are cheaper and more effective.
A significant amount of the therapy at Ward 40 is administered by psychiatric aides who hold the title of mental health therapist. Although they can be hired with only a few days of certified nurse's assistant training, they conduct therapy sessions and plan patient schedules. Many have no college background in psychology. All the cases The Oregonian examined involved workers at this level.
Until two years ago, Ward 40 accepted children as young as 5. Today, it is set aside for teenagers, with younger children sent to the private Parry Center in Portland, which contracts with the state.
Mazur-Hart, superintendent when the younger children were transferred, acknowledged at the time that an institutional setting "isn't a proper home for children." Records obtained by The Oregonian dramatically illustrate that point.
One year, one man, six girls
One of the employees whose background supervisors did not check was Michael Paul Hake. A drug user who served jail time in 1978 in Idaho for delivery of a controlled substance, Hake began work in 1984 in the state hospital kitchen.
Three months later, he passed a certified nurse's assistant test and began to work in an adult unit. In 1987, he moved to Ward 40.
In the span of a year, in the dormitory, in a space beneath steps, behind thick-trunked trees that shade the hospital campus, Hake may have sexually abused as many as six girls in his care, according to records and interviews.
In August 1988, Hake's supervisors gave him a verbal warning for "spending an excessive amount of time with four of the female patients," according to hospital documents.
The next month, an outside social worker called the hospital to report a suspected sexual relationship between Hake and a 17-year-old girl who had been discharged from Ward 40 four days earlier. Hake had left his wife and two children and moved into the girl's subsidized Mill City apartment, the social worker reported.
Hospital records say he also invited a 16-year-old patient named Angela to that apartment for sex, sliding a key into her pants pocket. Police records state that hospital staff confiscated the key.
State laws passed in 1975 require "mandatory reporters" -- including doctors, teachers, social workers and mental health professionals -- to inform police and child-protective services immediately of suspected sexual abuse. Although hospital officials considered the alleged abuse of the 17-year-old plausible enough to launch an internal review and eventually fire Hake, there is no indication they called police.
Several Ward 40 girls attended classes at Chemeketa Community College and were allowed to leave hospital grounds unaccompanied. Hake, when he was their case manager, arranged many of their schedules.
Days after his firing, Hake approached Angela at a bus stop near the college on Oct. 7, 1988, she later told police. He told her he wanted to show her his new car. When she walked close, a second man pulled her inside the car and Hake drove to a nearby house, she said.
Angela, who weighed 79 pounds, told detectives that the men carried her into the basement and took turns holding her down as they raped and sodomized her.
"Mike then told me that if I tell anybody about this, they will do the same thing to me again and they will kill me," she said. Hospital records show she arrived back at McKenzie Hall without her textbooks, disheveled, dirty and distraught.
Nearly two weeks passed before a hospital official called state police, the agency's records show, after Angela drew a picture of two men raping her, labeling one of the figures "Mike Hake." She did not know who the other man was. A subsequent rape exam showed significant injury.
The criminal investigation took more than a year because Angela was so traumatized. For months, she lay silent, tied to a restraint bed and fed through a nasal tube. During that time, Hake worked in a Salem nursing home less than a mile away.
A Marion County grand jury indicted Hake for first-degree rape, sodomy and kidnapping in Angela's assault. But a June 1991 trial resulted in a hung jury.
Rather than retry the case, prosecutors allowed Hake to plead no contest to one count of first-degree criminal mistreatment of the girl with whom he shared an apartment, and had married, shortly before his rape trial.
Hake never went to prison. He was sentenced to five years' probation, ordered to have no contact with Angela, to participate in a sex offender treatment program and surrender his nurse's assistant license.
Hake, who now lives in Idaho, did not respond to a written request for an interview.
The hospital did not change its procedures as a result of the Hake case. Nor did it investigate on its own whether Hake had abused others on Ward 40. Confidential records of the criminal inquiry obtained by The Oregonian, as well as interviews with former patients, suggest there was much to examine.
In October 1989, as police investigated the attack on Angela, a 14-year-old patient came forward to say she, too, had been abused by Hake when she was 12.
"I have nightmares about what happened to me," she told authorities at the time. "I dream that Mike comes in and sits down beside me and starts touching me. I'm afraid to go to school."
An internal hospital memo contained in the police file shows that hospital staff decided not to investigate further for fear of interfering with the girl's psychiatric treatment.
Another teenage patient fled the hospital after learning Hake was a suspect in Angela's rape, police reports state. The girl had told Angela and other patients that she and Hake had had sexual intercourse on the ward. She was named in police records as a possible victim, but officers said they couldn't find her and never interviewed her.
The girl's mother, located recently by The Oregonian, said her daughter came home pregnant several weeks after fleeing the hospital. "She told us Michael Hake was the father," the woman said, adding that she helped her daughter get an abortion.
The former patient, now married and living in another state, declined to discuss the matter, saying she had "moved on."
Maureen Greiner, another former patient, also was mentioned in police and court records as a possible victim.
Her parents said recently that their daughter, a devout Roman Catholic, confided "something major," to a priest who visited her on the ward. The priest urged the Greiners to remove her from the hospital immediately.
Lynne Greiner said she and her husband were afraid to take their depressed daughter home.
"I had these little funny feelings," she said. But "I put things aside because, after all, this is the Oregon State Hospital. We trusted because we didn't know what else to do."
Greiner said she was never told that one of her daughter's caregivers was under investigation for rape. "Why were we never told? Why? Why?" she asked, her voice shaking.
Another teenage patient, Jennifer Borgelin, told others that Hake had molested her, too.
Borgelin's mother, Kathy Czupofski, said, "I always believed deep in my heart that something happened to her there. When she came out of there, she was different. Instead of being helped, I believe they ruined her."
All that happened to Maureen Greiner and Jennifer Borgelin will never be known. Both committed suicide in the early 1990s, shortly after their discharge from Ward 40.
Slow to investigate
In April 1990, a 17-year-old patient complained that a psychiatric aide, Ronnie Roy LaCross, had grabbed her breast during a full body hug -- and that it wasn't the first time.
"This is the one I actually told someone about," the patient told staff.
The Hake investigation was under way and records show that the hospital was slow to investigate another incident. Police were not called.
Two months later, after the girl turned 18, the hospital began an internal inquiry. The patient told hospital and DHS investigators that she "didn't feel safe here anymore" and that LaCross "shouldn't be working here."
A report called her "very credible" but noted "there has been some pressure by the staff for (her) to accept the fact that she may have wrongly perceived Ron's actions." At the same time, investigators called LaCross' accounts "inconsistent."
Another patient told investigators she felt uncomfortable around LaCross and had told him to stop hugging her.
George Bachik, then hospital superintendent, determined that abuse could not be substantiated.
"Perhaps and indeed in the process of hugging, with whatever clumsiness, unintentional contact may occur and events may be consequently misinterpreted," Bachik's report said. "No disciplinary action will be taken."
But state records show that at least one official recognized the warning signs on Ward 40. Kutas, who had been asked to help investigate the case, expressed concern about improper physical contact between staff and patients.
"I think this subject would be important in a program where you undoubtedly have a number of patients with sexual/physical abuse in their past and where not only trust building, but how people are touched, is important," she wrote in a memo.
Bachik subsequently ordered a review of the "practice of staff/patient hugging," hospital documents state.
It is unclear whether policies changed.
What is certain is that abuse did not stop.
Poem speaks of trust
Kelly Darcey was admitted to the hospital on June 15, 1990; she had suffered years of sexual abuse and had tried to kill herself. Within days of her admittance, the 15-year-old was molested by LaCross.
LaCross volunteered to be with Darcey one-on-one when she was on suicide watch. During these times, she later told detectives, he told her he wanted to make love to her, fondling her, exposing himself and asking her to do the same.
Once, he put his wedding ring on her finger and promised to divorce his wife when Darcey was released.
On July 10, 1990, Darcey typed a poem she said was about LaCross on the Ward 40 computer:
It's gone again. . . hard-earned trust,
You took it away by your excruciating lust.
A nurse found LaCross alone with Darcey 3-1/2 months later in the staff break room. Alarmed because of the earlier allegation against LaCross, the nurse alerted his supervisor, Stephen Brakebill.
Brakebill and the nurse confronted LaCross, who put up no argument, records show. He signed a contract agreeing to limit one-on-one contact with female patients to those on his caseload, which Darcey was not.
Brakebill kept handwritten notes on LaCross' adherence to the work plan.
"Observed playing game with female resident in the day room appropriately!" Brakebill noted Dec. 24, 1990. "Doing an excellent job!" said an entry five weeks later.
But LaCross, who worked swing shift, was continuing to sexually abuse Darcey. Twice in one month, he wrote in Darcey's chart that he had engaged in 10-minute "struggle holds" with her.
"When I was in struggle holds," Darcey later testified in court, "he put my hand right on his privates."
On Valentine's Day 1991, a day before Brakebill observed "No problems!" with LaCross' behavior, the psychiatric aide, in violation of hospital policy, gave Darcey a red and white teddy bear with a plastic tag that said, "I love you."
Records show that staff confiscated the tag when Darcey used it to carve bloody wounds on her arms.
About a month later, two teenage patients demanded that staff stop LaCross from abusing Darcey. But hospital officials failed to take action.
The hospital waited almost three days before calling her caseworker at the state's children's services agency. The hospital did not inform police as required by law. After pestering the hospital for two days to report the suspected abuse, the caseworker called state police herself, records show.
Five months later, Mazur-Hart, the hospital superintendent, ruled that Darcey's allegations were true. LaCross, who spent several months on paid leave, was eventually fired and convicted of second-degree sexual assault.
The girl who made the first complaint about LaCross more than a year earlier was named as an "additional victim" in police reports in the Darcey case. She told police that besides fondling her breast, LaCross had sex with her three times on the ward. LaCross was never charged in that case.
In 1992, Darcey sued state and hospital supervisors and LaCross, alleging she had been sent to Ward 40 despite "a pre-existing pattern" of sex abuse against young patients. A jury awarded her $530,000.
Today, LaCross lives in a nursing home in Washington state. He declined to comment.
Playing politics, buying silence
In 1991, the Oregon State Hospital adopted new rules for tracking suspected abuse of patients. The superintendent was to be notified immediately of any allegations. He was required to forward cases to DHS for independent examination but retained the power to ultimately decide whether abuse had occurred. Mazur-Hart said the change was prompted by the Ward 40 cases and patient abuse elsewhere in the hospital.
The new policy, however, was not always followed.
Mary Kay Gonzales was admitted to the state hospital in 1989 when she was 12. She lived in state care more than six years. By the time she was 18, she had been molested by two employees.
One was her longtime psychiatric aide on Ward 40, David Conner, 32 years her senior. The second, Brigham Clifton, worked at Dammasch State Hospital in Wilsonville, where Gonzales was committed for mutilating herself after Conner rejected her.
Records show hospital staff did not immediately report their suspected abuse of Gonzales in either case. In fact, Mazur-Hart never contacted DHS to investigate Conner until Greg Smith, the Salem lawyer who won Kelly Darcey's case, threatened to sue on Gonzales' behalf in 1995 -- more than two years after the alleged abuse on Ward 40 occurred.
Mazur-Hart eventually ruled that Gonzales had been sexually violated by both workers. But when her lawsuit went to trial, state attorneys tried to discredit her. In court papers, an assistant attorney general referred to her "bizarre mental abnormality" and said she was "extraordinarily manipulative."
Several days after the trial began, the attorney general's office, then directed by current Gov. Ted Kulongoski, agreed to settle the case for $300,000, records show. The state kicked in another $50,000 for a confidentiality clause to ensure that Gonzales never talk publicly about the outcome of the case.
Discussions -- which revealed the settlement amount -- would never have become public, but a transcript of a closed court hearing that should have been sealed was instead filed with other public records in the case.
Public court documents state that a Marion County Circuit judge had ordered the settlement sealed because "privacy interests of plaintiff . . . outweigh the public's interest."
But the transcript shows another reason why the state sought privacy: to protect the reputation of hospital administrators.
"We made it clear that we were buying confidentiality from the plaintiffs," Assistant Attorney General John McCulloch Jr. told the judge. "The real damage to the defendants is hardly calculable. I don't know how to put a dollar sign on the political aspect. What's somebody going to say in the next legislative session about Dr. Mazur-Hart and how he runs his ship out there?"
Smith said McCulloch offered the additional $50,000 after he said he was planning to hold a news conference on the courthouse steps, an interpretation McCulloch accepted in a recent interview.
Kulongoski declined repeated requests for interviews but released the following statement: "The Oregon Department of Justice annually handles thousands of legal matters, both civil and criminal. As the Attorney General, my role was to oversee the attorneys who represented the state in these legal matters. I have no recollection of the facts or circumstances of this specific legal matter that occurred nearly a decade ago."
Potential underreporting
Hospital officials say that serious abuse on Ward 40 is a thing of the past.
But Kutas, the chief DHS investigator, said she thinks there has been underreporting of abuse that makes it impossible to know its full extent. "I have concerns," she said, "about whether we're hearing about everything at the hospital."
For a three-year period ending in 2000, Kutas said, her office received no reports of alleged sex abuse on Ward 40 from Mazur-Hart, who resigned last fall amid controversy about an escape by a forensics patient and a neglect case on an adult ward.
Kutas was taken aback to learn that her office had no record of seven allegations of child sex abuse by Ward 40 staff that were reported to state police in the past four years.
A database kept by her office shows the last case the hospital substantiated as sex abuse on Ward 40 was in 1996, when a male staff member was discovered staring at girls in various states of undress.
In the eight years since, only three other accusations have been reported to DHS, including a former patient's allegation in 2000 of being raped as a child by a Ward 40 aide and a complaint by two former patients in 2002 that another worker had had sex with them on the ward.
State police and DHS administrators in charge of the hospital refused to release records of the incidents that were not reported to Kutas, citing privacy concerns for the patients.
Mazur-Hart, who now makes nearly $80,000 a year studying problems in the state's mental health system for DHS, declined repeated interview requests. He agreed to answer questions in writing, defending the hospital's handling of child sex abuse allegations during his 12-year tenure. "At times the conduct of a few staff was very wrong," he wrote. "When aware of this, we took strong action to stop it and prevent any future recurrence."
A former worker who has since been convicted of attacking young boys, however, said the hospital was a pedophile's dream.
In a letter to The Oregonian, Frank Milligan detailed a litany of oversight problems at the hospital, including "far too many blind corners" and a "lack of cameras or even simple surveillance equipment."
"Should a staff member be so inclined, he/she need only wait for an emergency situation, or a patient to act out and draw the attention of the other staff, to take advantage of the chaos and slip away with a victim," he wrote. "Just as disturbing is the fact that I worked side-by-side with psychiatrists, psychologists and social workers and not one of them ever suspected that a man who, since the age of 13, had gruesome fantasies about kidnapping, raping, mutilating and murdering young boys, was standing right next to them. One would think that at least one of them might have detected something."
Milligan, who worked on Ward 40 as a psychiatric aide from 1994 to 1997, wrote that he groomed a 10-year-old boy on Ward 40 by "plying him with things such as extra privileges, compliments and a soda pop." He said the boy was "both needy and passive -- two traits that all pedophiles look for in a victim."
A law enforcement official told The Oregonian that police strongly suspect that Milligan victimized at least one mentally ill boy on Ward 40 but could not bring charges because the child was afraid to talk.
In 2000, Milligan was convicted of abducting a 10-year-old boy from a Dallas park. He raped and strangled the boy, slashed his throat and left him for dead. The boy survived. Milligan is serving a 36-year prison term.
At the time of the attack, Milligan worked as a counselor at MacLaren Youth Correctional Facility in Woodburn. He also was out on bail in a sexual assault case of an 11-year-old boy in Seaside. Milligan had met that boy through a Ward 40 staff member, whose daughter ran a Salem foster home where the boy lived.
The hospital did not try to determine whether Milligan, by then one of the state's most notorious pedophiles, had abused patients on the children's ward.
Kutas said she wanted to investigate but lacked the authority unless invited by the superintendent.
That invitation never came.
From The Oregonian of Sunday, Sept. 19, 2004 -- Whistle-blower forced out, records suggest
By Michelle Roberts
In 1995, former patient Mary Kay Gonzales sued the Oregon State Hospital. She had been molested by two employees: David Conner, her longtime therapist on the hospital's Ward 40, and Brigham Clifton, who worked at the sister institution, Dammasch State Hospital in Wilsonville.
Oregon Department of Justice investigators asked if hospital staff had heard about sexual abuse of mentally ill patients.
One person stepped forward. Michael Donnelly, a mental health therapist at Dammasch, told investigators that he had tried to warn hospital supervisors about Clifton's drug use and contacts with female patients long before Clifton abused Gonzales.
In an affidavit, Donnelly said his supervisors did not take his complaints seriously, one stating only, "Well, (Clifton's) just a jerk." Nor did they ask him to file a report on patient abuse.
Shortly after filing the affidavit, Donnelly received a predismissal notice from Superintendent Stanley Mazur-Hart, who oversaw both mental institutions.
The notice was based on an earlier abuse claim against Donnelly for allegedly telling a soon-to-be-discharged patient, "You are not going anywhere," causing the patient to become confused and disappointed.
After Donnelly's affidavit, Mazur-Hart reassigned Donnelly for eight months to the state hospital kitchen in Salem, where he scrubbed pots and pans alongside prison inmates.
Donnelly, who today supervises psychiatric aides at Arizona State Hospital, called Mazur-Hart's abuse claim "a sham." "The primary reason for this allegation," he said, "was to taint my reputation so I would make an unreliable witness against the hospital."
Donnelly eventually was fired. But an arbitrator ruled that allegations leading to his dismissal were unfounded and ordered the hospital to give him back his job. The Board of Nursing also found the complaint baseless and refused to restrict his license.
The hospital did not file similar complaints with the nursing board against Conner or Clifton, though Mazur-Hart had substantiated Gonzales' sex abuse allegations against them.
Conner was allowed to resign from the hospital and went on to work with disabled children at a state school for the blind and, briefly, with juveniles at the state-run Hillcrest Youth Correctional Facility.
Clifton also continued with patient care, working at two Portland hospitals after his firing. He remained a certified nursing assistant in good standing until he allowed his license to expire in 1998.
Mazur-Hart was superintendent from 1991 until he resigned last fall . He remains on state payroll as a $79,908-a-year Department of Human Services manager. He declined repeated interview requests but agreed to answer questions in writing.
"I never retaliated against anyone for making an allegation of patient abuse," he wrote. "On the contrary, I made a point to employees that they were expected to report all abuse."
From The Oregonian of Monday, Sept. 20, 2004 -- Ward of State, world of hurt; Betraying a fragile trust: Oregon State Hospital (2nd of 2 parts) Oregon allowed two of its employees to molest a mentally ill girl in their care and then paid her to keep quiet
By Michelle Roberts
Mary Kay Gonzales was 12 when state officials committed her to Oregon State Hospital. A skinny foster kid with jet black hair, she had tried to kill herself after years of sexual abuse.
A caseworker promised that the hospital stay would last no more than a month. But nearly six years passed, and Gonzales grew from a child into a young woman within the walls of Ward 40.
Hospital staff in the unit for the state's most mentally ill children used restraint cuffs and isolation to deal with her despair.
David Conner, a psychiatric aide who counseled Gonzales for three years, told her he was the one person she could trust, she recalled.
"He was working with me on every detail of my personal life -- it was really rough," said Gonzales, now 28. "Then one day he pulled me aside and said he'd fallen in love with me. My stomach hit the floor."
She was 17. He was 49.
In the year that followed, hospital supervisors ignored their own observations and other staff members' warnings about Conner's relationship with the girl. Left unchecked, Conner eventually quit his hospital job and ran away to California with Gonzales.
Shortly after, records show, he rejected her, sending her into a tailspin that landed her in another mental hospital, where another staffer sexually abused her.
An investigation by The Oregonian found that Gonzales was one of as many as 12 mentally ill children who were sexually abused by staff members of Ward 40, subjected to everything from inappropriate touching to rape. In most cases, hospital officials failed to report offenses in a timely manner, allowing predators to remain on the ward.
Gonzales' case highlights some of the most serious shortcomings the newspaper found.
"I was a lot worse when I left," Gonzales said, "than when I came."
Childhood stolen
Innocence was something she never knew. Gonzales said the sexual abuse began before she was old enough to speak. By the time she started kindergarten, it was, like the freckles on her nose, a fact of life.
During her early childhood, she lived in a mountain home in rural Oregon. She doesn't remember many happy times. The only peace and safety she felt was when she hiked through the pines with her beagle, Ding.
"Every day I would get up, go outside and walk for miles and miles," she said, "trying to stay out of the house for as long as I could."
Because of the secret, she never fit in with her peers.
"No one liked me because I was unapproachable," she said. "I didn't trust anyone."
Isolation and shame eventually gave way to rage and despair. She got into fights at school. She tried repeatedly to kill herself, once swallowing fistfuls of aspirin. State officials placed her in foster care at age 12 when her mother signed over custody.
After Gonzales threatened to kill herself while staying at a children's shelter, the state sent her to Ward 40. She remembers arriving with a small blue suitcase and a heart that felt as if it would pound out of her chest.
Days moved like months on the ward. Gonzales watched the seasons change through the barred windows of McKenzie Hall, the two-story brick building that housed the 60 young patients.
Records show she got into a lot of trouble, once trying to organize a mass escape by the children. She said hospital staff often drugged her with medications that had severe physical side effects, including one that made her tongue shoot out of her mouth involuntarily.
Gonzales didn't trust most of the staff, she said, until she met Conner, a certified nurse's assistant who worked as a psychiatric aide.
"He wasn't as threatening-looking as the other staff," she said, "skinnier and not as aggressive."
Conner, she said, encouraged her to start writing in a journal. For the first time, at age 15, she trusted someone enough to share the secret of her abuse. "I remember tossing the journal at him and running away," she said. "I was so scared."
Once she had revealed the sexual abuse, Gonzales said Conner arranged family counseling, which resulted in strained relations with some of her relatives. Soon, visits by Gonzales' family stopped.
"My heart sank at that point," Gonzales said. "David told me not to worry, that he'd always be there for me."
"Wrong" "scary" "a romance"
By early 1993, when Gonzales was 17, Conner declared he loved her, court records state. Soon after, the interactions between the two were the talk of the ward. Court records show that staff at various times described the relationship as "crazy," "nuts," "wrong," "scary," "dangerous" and "a romance."
Usually, Gonzales said, toward the end of Conner's shift, when other employees were busy, he took her to an isolated locker area and molested her. She said the sexual touching made her feel sick but also "like I was special, like I had something no one else had."
Hospital records and police reports show it wasn't the first time Conner had been accused of sexually abusing a Ward 40 patient. Two years earlier, a 16-year-old girl complained that Conner had touched her inappropriately. Hospital records state the girl later recanted, so the case was not pursued.
In April 1993, hospital records show, a nurse presented Conner's supervisor with a memo stating she had seen Conner touching Gonzales inappropriately.
"We were in the storage room and we were kissing, and this one staff member walked in on us," Gonzales said.
Hospital officials took no immediate action. A month later, they gave Conner a verbal warning but did not remove him from the ward.
Records show a ward supervisor remained concerned enough to give Conner, who was going through a divorce, an article titled, "Psychotherapists who transgress sexual boundaries with patients."
The supervisor underlined passages, such as, "the most common scenario is that of a middle aged male therapist who falls in love with a much younger patient while he is experiencing divorce." Another highlighted sentence: "Incest victims tend to put themselves in situations where they become revictimized and therefore are 'sitting ducks' for therapist/patient sex."
Other staff expressed worries about Conner, records show.
On June 28, 1993, a nurse noted in the unit's communication log that she was "very concerned regarding this relationship," in part because Conner had given the girl his home phone number, which is a major violation of hospital policy.
A month later, the unit director gave Conner a written reprimand regarding the ongoing "violations of the touching policy and orders to restrict his contact" with Gonzales.
Finally, more than two months after a nurse witnessed Conner kissing Gonzales, Conner was transferred to another ward -- with the stipulation that it was only for as long as Gonzales remained on Ward 40.
Two months before she turned 18, the hospital discharged Gonzales to a foster home. Soon, her new guardians listened in on a "highly sexualized" telephone call from a man who identified himself as Gonzales' "Uncle Bernie."
Alarmed, the foster parents notified the hospital and Gonzales confirmed that the caller was Conner.
Conner resigned that day.
A week later, both disappeared.
Abandonment ignites despair
Conner drove Gonzales to California, where, he later admitted in court, they camped for six weeks and had sex. On Gonzales' 18th birthday, he drove her back to Salem. Police were never alerted to the situation.
"That's when he started losing interest in me," Gonzales said. "The excitement of me not being legal must have done something for him. The day I turned 18, he became very withdrawn, cold and distant."
Three months later, after Conner got another job working with troubled children at the Oregon Youth Authority, he told Gonzales to leave his apartment where she had been living.
Gonzales became distraught and began severely mutilating herself, medical records show, including slashing her arms from shoulder to wrist with broken glass and hurting herself with razor blades.
"I started slipping," she said. "At one point, I swallowed a double-edged razor blade and it got stuck in my throat."
She was admitted to Dammasch State Hospital in Wilsonville on Feb. 23, 1994. Medical records note that the self-harm began after Conner abandoned her, referring to him as "this boyfriend she had known for five years, as he was a member of the staff of the Oregon State Hospital."
Though Gonzales was no longer a minor, a 1991 policy required state hospitals to report all suspected patient abuse, sexual or otherwise, to the Oregon Department of Human Services and police. Records show hospital officials not only failed to report Conner, but also allowed him to visit Gonzales at Dammasch.
The psychiatrist in charge of Gonzales' treatment at Dammasch later testified that he was concerned enough about the relationship to check with the personnel department at the Oregon State Hospital to see whether Conner had had problems on Ward 40.
Because Conner's employee-separation report described the quality of his work as "adequate," he was permitted to visit the troubled young woman he had abused repeatedly.
"Easy target" for second aide
After her release from Dammasch on May 31, 1994, Gonzales cycled through hospital psychiatric wards; she was recommitted to Dammasch in July. Hospital records note she was so ill that she removed 16 metal springs from her hospital bed and swallowed them. They had to be removed surgically from her intestines.
About this time, Gonzales caught the eye of Brigham Clifton, 38, a psychiatric aide who had been disciplined for calling patients by their case numbers instead of their names. He had nearly lost his job the year before, records show, after he and several other staff suffocated an adult patient to death while restraining him for refusing to take off his shoe.
Dammasch employees also had complained about Clifton's inappropriate behavior with female patients.
Soon, records show, staff began to joke about Clifton's frequent trips with Gonzales to the ward linen closet. "He had heard about what had happened with David and me," Gonzales recalled, "and figured I was an easy target."
Two months after Clifton began having frequent sex with Gonzales, records show, Gonzales complained to a Dammasch nursing supervisor. "I put a stop to it," Gonzales said. "I said, 'I've been through this before. I don't want to go through it all over again.' "
Hospital officials conveyed Gonzales' allegation against Clifton to the DHS Office of Investigations and Training, court records show, but did not call police. So lawyers at the Oregon Advocacy Center, a federally funded group that works closely with disabled residents in the state hospital, called for a criminal investigation. Because of her illness, advocates questioned Gonzales' ability to consent to sexual contact with Clifton, even though she was legally an adult.
A state trooper met with Superintendent Stanley Mazur-Hart, then overseer of both Oregon State Hospital and Dammasch. "I was informed by (Mazur-Hart) that the ability of (Gonzales) to consent to sexual activity was not in question," the trooper wrote. "At no time was she incapable of giving consent. She was there strictly on a civil commitment and she was not suffering from mental defect or inability to consent."
In fact, records show Gonzales had been committed to the hospital involuntarily because a judge found that she had a mental disorder and was a danger to herself.
After Clifton admitted to DHS investigators that he had had sex repeatedly with Gonzales, Mazur-Hart determined that the abuse had occurred. But no abuse was reported to DHS or police in the Conner case until 1995, after an attorney representing Gonzales filed notice with the court that he planned to sue on her behalf.
State settles, buys silence
Gonzales sued Conner, Clifton and several top hospital administrators in 1996, alleging that officials had ignored a long-standing pattern of sex abuse at Oregon State Hospital and Dammasch.
When the case went to trial, state attorneys tried to discredit Gonzales, though by then Mazur-Hart had substantiated the allegations against both therapists.
"They said the sex abuse I suffered (before being in state care) is what screwed me up, not what the state hospital did," she told The Oregonian. "That -- and my mental state -- was their main defense against me." Court records support her recollection.
Clifton said in a telephone interview that, despite his court testimony to the contrary, he never sexually abused any patients, including Gonzales. "I was happily married at the time and came from a good religious background," he said. "I wouldn't do anything like that."
Conner admitted to having sex with Gonzales when she was a minor but told The Oregonian the girl was to blame. "I'm not a sex abuser," Conner said. "I'd worked with that girl as her therapist since she was 13. I was going through a divorce and I was very vulnerable. She drew me in."
Conner faulted the hospital for lax employee supervision and failure to train him properly.
Mazur-Hart, who now works elsewhere in DHS, said he did all he could to keep patients safe.
"The abuse of patients at a psychiatric hospital is a terrible wrong," he wrote in response to questions posed by The Oregonian. "While I was superintendent at OSH, I insisted on vigilance in this area by all employees. Most OSH employees had this vigilance on their own."
Shortly after Gonzales testified during the trial, the attorney general's office, then led by current Gov. Ted Kulongoski, agreed to settle the case for $300,000 but admitted no wrongdoing by hospital administrators.
State lawyers kicked in another $50,000 for a confidentiality clause to ensure that Gonzales never speak publicly about the outcome of the case and to keep her attorney from holding a news conference on the Marion County Courthouse steps. After the state paid her legal bills, the settlement amounted to the largest loss in state hospital history -- $584,809.
Gonzales remains bound by the agreement. She would talk only about her time on Ward 40, saying, "I want people to know what happens there so (officials) will shut that place down."
The Oregonian discovered details of the settlement through sealed records that were mistakenly placed in a public court file.
The years since the settlement have been difficult, she said; most of the money went to counseling and medical bills. Since getting married five years ago, she has started to heal the emotional wounds of her childhood.
"I finally have someone I can trust," she said of her husband, Chris Gonzales, with whom she has a 3-year-old daughter.
Gonzales, who is diagnosed with depression but has not been hospitalized in many years, says she no longer feels responsible for what Conner and Clifton did to her. "I forgive myself," she said, "because I was so young, naive and taken advantage of."
Yet the scars remain.
She still can't look at McKenzie Hall, though her bus has been passing it for years. She gets irritable when her husband, reading in bed beside her, brushes her back with his elbow.
"Staff used to always put their elbows in my back when they were holding me down," she said.
She used to hate summers because she could never wear short sleeves -- the scars from the gashes on her arms draw stares. Yet, in recent weeks, since beginning to talk about what happened to her at the hospitals, she has become "gutsy" about showing her arms in public.
"I've had a lot of people stare," she said. "But it still feels good. Like I'm finally free."
From The Oregonian of Friday, Sept. 24, 2004 -- Gordly seeks federal investigation of state hospital: The Portland senator says an outside agency should determine if patients' civil rights have been violated
By Michelle Roberts
State Sen. Avel Gordly, D-Portland, called for a federal investigation Thursday to examine possible civil rights violations of current and former patients at the Oregon State Hospital in Salem.
Gordly's request came in response to a two-day series in The Oregonian that detailed the sexual abuse of as many as a dozen patients in the adolescent unit by staff members from 1989 to 1994.
The investigation disclosed that hospital officials and their supervisors -- most still employed in state government -- did little to stop the abuses and often failed to report suspected sexual abuse immediately to police and child welfare workers, as required by state law. The articles also said the hospital has taken only limited steps to prevent abuse in the years since.
"An independent investigation is the best way to get the complete truth about what has happened at the hospital," Gordly said in a statement. "It's also the best way to make the changes necessary to protect and care for patients in the future."
Gordly said she and Sen. Vicki Walker, D-Eugene, also are considering increasing penalties for staff who fail to report abuse. Currently, the punishment is a Class A violation and a maximum $750 fine. The senators will propose making it a Class A misdemeanor with a maximum $6,250 fine, a one-year jail sentence and possible license revocation.
Gov. Ted Kulongoski on Tuesday ordered a full review of all abuse of mental patients on the adolescent ward in response to the newspaper's reports. Although the incidents occurred a decade or more ago, the articles said the hospital continues to follow abuse-reporting rules inconsistently.
The governor asked officials at the Department of Human Services, which oversees the hospital, to review all reported cases of abuse in the adolescent ward since 1992 and make a report to him within 30 days.
But Gordly, whose son suffers from schizophrenia and was a patient at the hospital two years ago, said a review should be done by an impartial, outside agency.
"I am concerned that some state officials who have been decision makers over the past several years would also be involved in the investigation," she said, "and it's not enough for government to investigate itself."
From The Oregonian of Sunday, Oct. 24, 2004 -- Oregon's high-priced hospital of hurt: The state mental hospital survives on legislative inertia, thwarting patients' recovery while costing taxpayers dearly
By Michelle Roberts
Oregon spends half of its annual $180 million budget for mental health on the Oregon State Hospital, an overcrowded, decrepit institution that serves less than 1 percent of patients who need psychiatric care.
The hospital -- only a mile from the Capitol -- is a hulking reminder of the state's failure to forge a modern approach to treating people with mental illnesses.
Study after study has recommended that Oregon scale back the hospital and invest in a network of community homes that would be both cheaper and more effective for patients.
But until now, mental health leaders and advocates have feared that if they pushed this approach, the hospital would close and, given the Legislature's consistent failure to adequately fund community mental health services, nothing would replace it. State officials also have been reluctant to risk a fight with the unions that represent the hospital's 1,150 employees.
As a result of this impasse, the state has spent millions of dollars renovating the 121-year-old hospital.
A significant shortage of group homes and other community-based services has forced hundreds of patients who could live in less restrictive surroundings to remain in the hospital, despite growing evidence that long-term institutionalization makes psychiatric patients sicker. Most patients who arrive at the hospital psychotic quickly stabilize with modern medications.
On Friday, Senate President Peter Courtney, D-Salem, said the hospital is in such dire straits, it's in danger of being shut down by federal authorities. He warned that the issue could no longer be avoided.
"The physical condition of our state hospital is merely a metaphor for the ramshackle state of our larger mental health system," Courtney wrote in a letter to fellow senators last week. "We must address this crisis, and we must do so before we adjourn the next legislative session."
Experts agree.
"It's astounding that Oregon is operating such a massively large institution in the 21st century, and unthinkable that they are adding more wards," said Robert Bernstein, executive director of the Washington, D.C.-based David L. Bazelon Center for Mental Health Law, a leading advocacy group for people with mental disabilities.
"It runs counter to all that we know about people with mental illnesses, the treatments that really work and the ability of people to recover," Bernstein said.
Many states have shuttered or dramatically reduced the size of their mental hospitals, responding to federal policies that reward creation of community-based centers to treat the acutely ill.
State officials acknowledge that if they invested the Oregon State Hospital's $90 million annual budget into such projects, the state would receive a matching $90 million from the federal Medicaid program, allowing the state to help tens of thousands of Oregonians who now go untreated.
The hospital is the most expensive way to treat people with mental illnesses, costing taxpayers an average of $11,000 per patient per month.
In September, the hospital housed at least 130 patients who had been cleared to live in group homes or assisted living centers, which cost between $1,000 and $5,000 a month. Such patients are routinely held for an average six months after state hospital doctors approve them for release, hospital data show. Some wait more than a year.
Top state officials insist that Oregon's mental health system is on the verge of reform.
A 21-member task force, appointed a year ago by Gov. Ted Kulongoski, recently recommended examining the possibility of building a single forensics mental health facility for patients who can't be treated in the community.
In addition, state mental health leaders are working to create 80 community beds for forensics patients who are able to live outside the hospital.
However, even the governor's own task force questions whether its recommendations will be followed.
Bob Nikkel, who heads the Department of Human Services' mental health and addictions office, promised the task force updates on progress. "It is my intent to make things happen to the degree I have the ability," he said.
Advocates and lawmakers are disappointed that the task force failed to recommend shutting down the hospital.
They blame a lack of political will: To close the hospital now would be an indictment of state officials who, they say, have long recognized the need for change but will not risk upsetting the status quo.
State Sen. Avel Gordly, D-Portland, said the state needs to salvage the lives of state hospital patients rather than the careers of bureaucrats.
"It can't go on," she said. "Everything that happens there happens in our name -- and let's be real clear, what happens there is shameful."
Any attempt to do so will run into political reality: Hospital workers have much more clout than those they treat.
"There are a lot of jobs at stake," said Bob Joondeph, director of the Oregon Advocacy Center. "Why take on a group of public employee unions in something in which you're going to have to invest a whole lot more money upfront for a population that, frankly, the public's primary concern is their safety from these folks rather than the quality of their care?"
"Cuckoo's Nest" revisited
Thirty years ago, the Oregon State Hospital molded the nation's image of institutionalization when it became the setting for the movie "One Flew Over the Cuckoo's Nest."
A look behind hospital walls shows that many of the conditions depicted in the film still exist.
The J Building, named for its shape, borders a blocklong stretch of Center Street. Except for two disjointed wards at either end, much of the building is uninhabitable.
On one empty ward, lead paint curls from the walls. Asbestos frost floats in the air. On a recent day, a dead rat lay rotting in an oversized trap on the day-room floor.
One ward over, where patients live, conditions aren't much better. Aging pipes emit cloudy water. Strange smells float from vents. Asbestos floor tiles, when chipped, are treated as hazardous material. Raw sewage occasionally leaks through the ceilings of patient rooms.
The hospital, built in 1883, is one of the oldest, most dilapidated state mental institutions in the United States. In fact, a 1988 report urged lawmakers to demolish the J Building because of health and safety dangers.
But two years ago, after another 14 years of decay, state officials did the opposite, pouring nearly $1 million into a corner of the crumbling structure to make room for more patients. Another ward was added last month.
"When it comes to opening new wards, this is the kind of space we have left," said Maynard Hammer, a deputy superintendent, as he stood last summer in a vacant corridor inside the J Building, kicking chunks of plaster that had dropped from above. "We're not talking about what's best for patients. We're only talking about having a place to put them."
The J Building isn't the hospital's only structural liability. The 1988 report also warned that the outside walls of the newest building on the 148-acre campus, the five-story 50 Building erected in the 1950s, were at risk of crumbling.
The top floor of the 50 Building, which houses locked forensics wards, was vacant for years because faulty plumbing could not deliver water high enough. A $4 million renovation was completed in the 1990s to secure the walls and fix the plumbing, but doors throughout the structure, including those on elevators, often refuse to open and close.
A year ago, a group of patients was so desperate to document living conditions that they sneaked a disposable camera into the hospital. Their pictures showed steel beds crammed into dirty, crowded rooms, filthy toilets, torn furniture, broken sinks, and portable bathrooms in the outdoor yard overflowing with urine and feces.
More than 100 patients in the 50 Building asked for a state investigation.
A 2003 report by the Oregon Health Services Health Care Licensure and Certification Section stated that the hospital had broken several state rules. Each of the building's seven wards exceeded capacity by two to 12 patients. Ward 50 I, which ideally would hold no more than 30 patients, held 43.
Toll of thin staffing
Administrators estimate that the hospital is 30 percent to 40 percent understaffed. It houses 760 patients and has 1,150 staff members -- one of the lowest patient-to-staff ratios in the nation, Courtney said. A comparable facility in Washington state employs 1,900 staff for roughly the same number of patients.
Seven physician and 40 to 50 nurse positions stand vacant. Openings for more than 40 psychiatric aides -- employees who do the bulk of direct care -- go unfilled because many qualified professionals are unwilling to accept low salaries and what Courtney called "awful working conditions."
State records show the hospital relies on overtime, both mandated and voluntary, to fill shifts.
According to a recent audit by the Department of Administrative Services, the hospital could save more than $1 million every two years if administrators filled staff vacancies instead of habitually using overtime.
Records examined by The Oregonian reveal the dangers of thin staffing. Two years ago, hospital administrators sent a memo "reminding people that it was not OK to sleep on the job," state records show.
However, the state documented four subsequent cases in which employees fell asleep when they were supposed to be watching dangerous or suicidal patients.
An examination of state documents further shows that patients were beaten, kicked, humiliated and tormented by staff in more than 50 substantiated incidents of abuse within the past 3-1/2 years.
In case after case, staff demeaned patients, calling them names, such as "retarded" and "zombies." Some patients sat in dirty diapers for hours because workers were too busy to change them.
"Honestly, the care we provide is of low quality," said Jon Sears, a mental health specialist who gives group and individual therapy at the hospital. "I say that with reservation because we have so many people who are trying so hard. But with so many things against us . . . we're in a situation where all we do is triage, over and over."
"They're warehousing us"
Psychiatric research has long shown that people with mental illnesses can recover -- a notion unfathomed when the country's first "insane asylums" were erected in the 1800s.
Today, mental health experts widely accept research that shows that, with supports such as medication, housing and meaningful human interaction, most people, even those with serious mental illnesses, can lead productive lives outside of institutions.
In fact, long-term isolation from family and community can slow, even thwart, their recovery.
"What's happening in Oregon is a throwback to a time in which patients were treated in a way we no longer believe is appropriate," said Dr. Paul Fink, professor of psychiatry at Temple University School of Medicine and past president of the American Psychiatric Association.
Patients at the hospital put it more bluntly.
"They're warehousing us," said Richard I. Laing, a 64-year-old patient who has been hospitalized since 2002. "We get here and there's no treatment. There's no interaction. Just a bunch of people sitting in a room getting on each other's nerves."
Exhausted ward staff often must break up fistfights on the tense, cramped wards. Injuries against staff are up nearly 40 percent this year, to 200 incidents, Sears said. Patients often go months without seeing psychiatrists, languishing instead of moving forward with therapy.
Some patients arrive at the hospital under civil commitment, meaning a judge has determined they are so ill they are either a danger to themselves or others, or they are unable to survive on their own. Others are forensics patients under the jurisdiction of the Oregon Psychiatric Security Review Board, which monitors people who plead guilty, except for insanity, to crimes that range from misdemeanors to murder. Only a very small number have committed heinous crimes.
Most, say their therapists, are accused of offenses that never would have occurred had the patient had medications and services in the community.
In December 2000, the federally funded Oregon Advocacy Center, which monitors rights for people with disabilities, filed a class-action lawsuit against DHS and the hospital, alleging that the agency failed to provide adequate community-based mental health services, resulting in "unnecessary segregation" of state hospital patients.
Earlier this year, the state agreed to settle the suit brought on behalf of more than 100 patients who had been held in the hospital for months and years longer than necessary. Under the settlement, the state must create 75 community-based mental-health slots by next summer and spend $1.5 million for other outside services for hard-to-place patients.
But the problem is far from solved.
The settlement, although a major victory for patients under civil commitment, did not affect forensics patients, who are similarly stranded in the hospital.
According to records examined by The Oregonian, 86 forensics patients last month were deemed ready for discharge by doctors but couldn't leave the hospital because of a lack of alternatives outside. The psychiatric security board, which gives final approval to discharges, won't grant them until beds are available in the community. And those beds don't yet exist.
This year, the board is expected to take on 140 new cases, more than double the number four years ago.
Most forensics patients are not inherently dangerous and can live safely and productively if given proper community support. While some will always need treatment in a secure setting, they represent only a fraction of the total state hospital population, said Joondeph, of the Oregon Advocacy Center, which successfully fought to close Dammasch State Hospital, another psychiatric institution, in the mid-1990s.
He said the state would benefit by creating small, acute-care facilities that serve people with special mental health needs. If kept smaller than 16 beds, such facilities would be eligible for the Medicaid match, effectively doubling the state's investment in mental health care.
The Oregon State Hospital is funded completely by general state funds. A 1965 congressional act excluded nearly all payments to state psychiatric hospitals from Medicaid because the federal government did not want to take over what, historically, had been a state responsibility. Congress also wanted to provide an incentive for states to build systems of community mental health centers to replace psychiatric hospitals.
"The hospital shouldn't exist," Joondeph said. "The science of mental health treatment has advanced so much that we're operating under a very old model that's becoming harder and harder to justify."
From The Oregonian of Sunday, Oct. 31, 2004 -- Years in the shadows: Problems have beset the Oregon State Hospital and its mentally ill for more than a century
By Michelle Roberts
The first patients arrived by train, shades drawn, in the dead of night.
Almost 400 people -- their conditions attributed to everything from brain fever to broken hearts -- were shuttled into the Oregon State Insane Asylum under the cover of darkness.
The year was 1883. Despite the secrecy, the hospital's looming J Building, with its red brick and ornate turrets, became the subject of morbid fascination as Salem residents rode trolley cars along Asylum Avenue, now Center Street, to gawk.
Today, the institution -- renamed Oregon State Hospital in 1907 -- is one of the oldest, most dilapidated mental institutions in the United States, a hulking reminder of the state's failure to forge a modern approach to treating people with mental illnesses. Patients still live in parts of the J Building, in renovated wards next to those that have been abandoned.
Oregon first took on responsibility for people with mental disorders in 1843, 16 years before statehood. The provisional government adopted laws and appropriated $500 "for purposes of defraying expenses of keeping lunatic or insane persons in Oregon," according to a 1945 article in the Oregon Historical Quarterly.
By 1861, Dr. J.C. Hawthorne opened a private institution in Portland to care for people with mental illnesses. The state contracted with Hawthorne initially to care for 12 patients. By 1874, the doctor housed 194 patients -- and received 52 percent of the total state budget to do so.
The numbers of patients grew steadily until the state opened its own institution in 1883, when 370 people were transferred from Portland to the J building in Salem.
As decades passed, the numbers of patients grew exponentially. A hospital superintendent complained in 1928 that counties were committing the elderly, alcoholics, the physically disabled and others who didn't belong, just so they wouldn't have to care for them.
Patients sometimes lived four, five or more decades behind the J Building's barred windows, enduring the treatments of the day.
In the 1930s, that meant wet-sheet restraints and insulin-induced comas. In the late 1940s and early '50s, surgical lobotomies were done to cut off the emotions of about 150 patients. At the same time, a crude form of electroshock therapy was used on as many as 50 patients a day.
In 1942, a tragedy at the hospital shocked the nation. A patient, George Nosen, working in the kitchen, mistakenly substituted cockroach poison for powdered milk in the scrambled eggs. Forty-seven patients died; another 400 were sickened.
Nosen remained four more decades at the hospital, dying in 1983 of a heart attack after a fight with another patient.
The hospital's population peaked in 1958, the year the hospital's last lobotomy was performed, with nearly 3,600 patients crowded into identical wards that consisted of tiny, boxlike rooms -- no handles on the doors -- running the length of long, white corridors.
In the late 1950s, journalists and government commissions exposed the dirty, overcrowded and dehumanizing conditions within many state psychiatric hospitals. President Kennedy called for a system that would emphasize community-based care. New drugs such as Thorazine, effective in controlling violent behavior, hallucinations and delusions, made the vision possible.
Congress passed laws that stopped federal Medicaid payments to state-run "institutions of mental disease" in an effort to push states into building community-based mental health centers that would be eligible for federal subsidies.
But the new system never completely emerged.
Oregon, like many states, did not fully reinvest the money it saved by eliminating hospital beds. To this day, community-based services remain underfunded, restrictive and largely inaccessible.
While untold numbers of Oregonians reaped the rewards of deinstitutionalization, thousands of others ended up sleeping on the streets, howling in jail cells or heading back to the hospital in handcuffs.
At a time when many states are shuttering their hospitals, Oregon continues to pour millions of dollars into renovating wards that were deserted in the 1960s.
The hospital is chronically short-staffed, overcrowded and, records show, a place that fosters neglect and abuse of those it was intended to protect.
From The Oregonian of Thursday, Jan. 27, 2005 -- State will shut youth ward of hospital: Oregon human services officials say patients will leave the adolescent unit in Salem, where sex abuse occurred in the past
By Michelle Roberts
The Oregon Department of Human Services announced Wednesday that the state will shut down the adolescent treatment unit at the Oregon State Hospital, where as many as a dozen young patients were sexually abused by psychiatric aides from 1989 to 1994.
The abuses were brought to light last September in a two-day series in The Oregonian that disclosed that hospital officials and their supervisors -- most still employed in state government -- did little to stop the abuses and often failed to report suspected cases immediately to police and child welfare workers, as required by state law.
The articles also said the hospital in Salem had taken only limited steps to prevent abuse in the years since.
"I'm ecstatic about the closure," said Mary Kay Gonzales, 30, who lived inside Ward 40, where adolescents are housed, from ages 12 to 18. During that time, she was molested by two state psychiatric aides.
"I'm so relieved to know that no one else will have to live through what I did there," she said Wednesday.
In response to the series, Gov. Ted Kulongoski empaneled a group of experts to investigate procedures on Ward 40. In an eight-page report made public last month, the group found "significant gaps" in abuse-reporting procedures, "incomplete communication" among state agencies and "inadequate training of (state hospital) staff."
Panel members said they did not find a recent pattern of sexual abuse on Ward 40, even though the head of the DHS Office of Investigations and Training said in September that she believes hospital workers still are not consistently reporting abuses on the ward.
Kulongoski said Wednesday that he supports the decision to close Ward 40. All adolescents will be moved by March 1.
"One of my priorities since taking office has been to work . . . to improve the quality of mental health and support services for Oregon's children and families," the governor said. "Part of that effort has included a focus on moving children and adolescents out of the institutional care provided by the Oregon State Hospital and into community-based programs and facilities."
Children's Farm Home
Gary Weeks, DHS director, said 12 of the remaining 16 adolescent patients at the hospital will be moved to the Children's Farm Home near Corvallis. Operated by Trillium Family Services, the Farm Home is a secure community facility designed to serve children and adolescents.
The remaining four teens will be either discharged or moved into other private facilities.
Since 1976, hundreds of mentally ill children have been sent to live behind the brick walls of McKenzie Hall, a two-story fortress that houses Ward 40 on the northwest edge of the hospital's 148-acre campus.
The adolescent unit was one of the few places in the state that served emotionally disturbed children ages 14 to 18. Many were wards of the state.
Former patients described Ward 40 as intimidating and lonely, absent color and love. So many kids were on suicide watch that the corridor was lined with their mattresses at night so staff could keep an eye on them.
One state worker called the unit a "collection of suffering."
Children arrived at Ward 40 expecting to stay a month or two. Yet many languished there for hundreds of days, sometimes years, at great taxpayer expense -- today, $30,700 per child per month. Over the past three decades, hundreds of children have been reared by doctors and psychiatric aides in a place where razor wire divides the playground from an exercise lot for criminally insane adults.
Move a national trend
Across the nation, states are moving from institutionalizing mentally ill children to creating smaller, homelike facilities that are cheaper and more effective.
Weeks said moving adolescents from the hospital has been a long-standing goal of his department. He said the department began phasing out Oregon State Hospital children's wards in 2001, when it sent youngsters ages 5 to 11 to other facilities.
"This is a good opportunity for us to finish what we started in 2001, finding community treatment environments that are more well-suited to the needs of children and adolescents," Weeks said Wednesday.
Bob Nikkel, head of the state's mental health and addictions division, said workers will try to determine whether any of the adolescents could be discharged in the next five weeks.
Nikkel said the change will not involve additional costs for the state.
"We've worked out all the finances," he said. "It's a zero-sum game."
In addition to the Children's Farm Home, Trillium Family Services operates Waverly Children's Home and the Parry Center, both in Portland, and a new community-based treatment program in Bend. Trillium also plans to build an adolescent treatment center in Portland, said Chris Bouneff, a Trillium spokesman.
A Senate panel last week opened hearings into problems at the 121-year-old facility, including discussion of whether the entire state hospital should be torn down and replaced with a new hospital, community-based programs or a combination.
Concerns about conditions at the hospital -- one of the oldest, most dilapidated state mental institutions in the United States -- have grown in recent months after reports of patient abuse, short staffing and crumbling facilities. More than 740 adult patients reside there.
Senate President Peter Courtney, D-Salem, who is leading the effort to reform the hospital, said he supports the closure of Ward 40 and said it may be a "harbinger of things to come."
From The Oregonian of Friday, Feb. 11, 2005 -- Indignity's shelf will not remain urns' final stop: Lawmakers move to pay respects to patients left unclaimed at the state hospital after cremation
By Michelle Roberts
By the early 1900s, thousands of mentally ill patients had died anonymously inside Oregon State Hospital in Salem.
Today, the uncollected cremated remains of 3,490 of them are stored in corroding copper canisters. From ceiling to floor, they line dusty shelves near asbestos-abatement manuals kept in an abandoned hospital storage building.
On Thursday, Senate President Peter Courtney, D-Salem, said such "disrespect for the dead" won't stand, and he announced the creation of a legislative work group that will locate an "appropriate resting place" for the urns.
"When you see the cans and their condition and the room they're in, it is a stark commentary on how society views people in this situation and our whole mental health system," Courtney said.
"We're trying to get better, but we have so far to go."
In October, The Oregonian published photos of the copper cans, many of which are dented and fused together from decades of neglect. The photos were part of a series of stories examining unhealthy conditions at the 122-year-old hospital, which is home to more than 740 patients.
Shortly after the series was published, Courtney said he and his staff toured the hospital and the storage building.
"It was pretty upsetting," he said. "I won't deny it."
The work group, which will be led by Sen. Laurie Monnes Anderson, D-Gresham, will begin meeting next month to find a simple but dignified place to inter the remains, Courtney said. The group will include representatives from the Oregon Department of Human Services, which oversees the hospital, mental health advocacy groups, patients and others, including representatives of Lee Mission Cemetery, who have offered to help find a proper resting place for the urns.
The Mental Health Association of Portland, which has begun soliciting private donations for a memorial, also will participate.
Until the early 1900s, unclaimed hospital dead were buried in an asylum cemetery. But between 1913 and 1914, the state decided it needed the land and exhumed the bodies of more than 5,000 patients. All unclaimed remains were cremated, dumped in the crudely welded copper cans and stored in a hospital basement for more than six decades.
In 1976, the urns were moved to a modest, underground memorial on hospital grounds. But water seeped into the vaults, damaging the containers and obscuring most of their paper labels. A few years ago, the hospital unearthed them and stashed them in the storage building. Many cans are labeled with numbers rather than names.
"It's time for recognition of people whose remains were not made a high enough priority before," said Bob Nikkel, who heads mental health and addiction programs for the Department of Human Services.
The work group will meet March 13 and 28 and expects to make its recommendations at a final meeting April 4.
From The Oregonian of Tuesday, May 17, 2005 -- Report: Tear down hospital: The Oregon State Hospital must be replaced and one building for patients would likely collapse in an earthquake, a study says
By Michelle Roberts
The Oregon State Hospital is so decrepit and dangerous that it must be torn down and replaced with a new facility, according to a report released Monday.
KMD Architects, a San Francisco-based architectural firm hired by the state, found that the 122-year-old hospital does not comply with current building, fire and electrical codes. The firm also determined that the oldest structure on campus, the 500,000-square-foot J building, which holds more than 100 of the hospital's 750 patients, likely would collapse in an earthquake.
"When it comes to the existing state hospital, the status quo is unsustainable," Gov. Ted Kulongoski said Monday, shortly after the report was released during a joint hearing of the Senate Health Policy and House Health and Human Services committees.
"It is no longer a question about what to do," Kulongoski said. "The fact is that we must move forward with plans to construct a new state hospital facility."
The governor said he would urge lawmakers to fund $350,000 for Phase 2 of what's being called the state hospital master plan and ask for recommendations on where to put the more than 100 patients who remain in the J building.
The next phase of the master plan includes determining the design, location and role of a new hospital within the state's mental health system.
"I assure you that we will move forward with the decision-making process as quickly and thoughtfully as possible," Kulongoski said. "In the meantime, we also have an obligation to ensure the safety of all hospital clients and staff and to minimize the risks identified in the report."
Officials said even if the Legislature approves funds for a new hospital this session, it will take three to four years before it would be ready for patients.
KMD, hired by the state in February to study the dilapidated hospital and make recommendations about its future, found that the layout of the patient wards is inefficient, lacks appropriate program space and does not comply with Oregon's Psychiatric Patient Care Rules.
Wards designed for 32 patients frequently hold more than 44, according to the report, and the hospital's linear layout is "inefficient and severely restricts sightlines for patient observation."
The report also said exposed pipes, glass windows and hidden alcoves pose major hazards to patients.
The report did not include an estimate of how much a new facility would cost. But KMD representatives told legislators that even the newest building on the 144-acre campus -- built in 1950 -- would cost more to renovate than to reconstruct.
According to the report, the community mental health system relies too much on the hospital to provide patient services that might better be administered in a less structured environment.
"A project of this magnitude will take time, and there is a lot of information that needs to be developed exactly what that facility will look like and who will be served by that facility," Kulongoski said.
Concerns about conditions at the hospital -- one of the oldest, most rundown state mental institutions in the United States -- have grown in the past several months amid reports of patient abuse, short staffing and crumbling facilities.
In October, Oregon Senate President Peter Courtney, D-Salem, wrote a letter to fellow senators saying conditions at the hospital were so appalling that the institution was vulnerable to a federal lawsuit and possible takeover by the courts.
Courtney's letter followed a meeting with Dr. Marvin Fickle, hospital superintendent. Courtney called for the meeting in response to a two-day series in The Oregonian that detailed the sexual abuse of as many as a dozen patients in the hospital's adolescent unit by psychiatric aides from 1989 through 1994.
The newspaper also reported that the hospital is 30 percent to 40 percent understaffed, routinely overcrowded and that patients had been beaten, kicked, humiliated and tormented by staff in nearly 60 cases of substantiated abuse since 2001. The newspaper also published photos that depicted the hospital's deteriorating physical conditions.
Built in 1883, the hospital, a mile from the Capitol, is a hulking reminder of the state's failure to create a modern approach to treating people with mental illnesses. Several studies in recent years have recommended that Oregon scale back the hospital and invest in a network of community treatment centers that would be cheaper and more effective for patients.
The state has been adding community programs but has been unable to keep up with the growing number of patients, particularly forensics patients who have committed crimes.
Monday's report said that based upon population rates alone, the hospital will need more than 1,100 beds by 2020 unless more community-based services are provided.
Until recently, state officials had been reluctant to talk about closing or drastically reorganizing the hospital and risking a fight with the unions that represent the hospital's 1,250 employees.
But lawmakers on Monday said change would come.
"The state of Oregon now is on official notice that there are significant structural and systemic problems surrounding the hospital," Courtney said. "This is sobering news. We are concerned about the mental health and physical safety of our state hospital patients and workers."