From The Oregonian, December 31, 2002 – not available online

For more than a decade, Oregon has relied on county mental health agencies to investigate themselves when a mentally ill patient dies under their care.

The result: County officials have faulted their own conduct in only two of 247 deaths during the past 3-1/2 years.

State records show that in nearly 50 of those cases, county officials performed a cursory inquiry in which they did not interview the families of the people who died or the mental health workers responsible for their treatment.

Officials at Oregon’s Department of Human Services acknowledged in interviews that their system for tracking patient deaths is inadequate and that their records included a number of cases that should have been more closely examined. They said they had assigned only one person to review the countys’ reports of deaths and had neither the staff nor the budget for more in-depth investigations.

Shown The Oregonian’s analysis of his own agency’s files, Bob Nikkel, community services manager for the DHS Office of Mental Health & Addiction Services, said the statistics were “not a surprise” and reflected the state’s longstanding failure to track deaths in county mental health agencies.

“Aside from whether people are whitewashing certain aspects of the investigations, when you do these things on an absolute shoestring you’re asking for problems,” he said of the death reports counties send to his department.

Several officials suggested patients’ groups go to court to force tighter scrutiny of county mental health agencies.

“Someone should sue us,” said Kevin Moynahan, regional protective services coordinator for the DHS Office of Investigations and Training.

Moynahan and his supervisor, Eva Kutas, said a lawsuit had prompted the state to assign four workers to review death and abuse cases involving developmentally disabled people, even though they number 15,000 statewide, compared to the 66,000 Oregonians with mental illness who are under state care.

“I read all the stuff that comes in, and I’m thinking, ‘This is just wrong,’ ” said Karla Kerstner, the lone state worker reviewing mental health death reports. “But our hands are tied. We don’t have the people, the budget or the law on our side. And it’s sad for the people who’ve been hurt and all the potential victims out there.”

Among the mental health deaths the state did not question:

* Amelia Scott, a 44-year-old schizophrenic homeless woman, who died “suddenly and unexpectedly” inside the psychiatric unit of a Portland hospital. The only explanation the hospital could offer was that she stopped breathing. State and county officials never asked why.

* A 38-year-old man in Baker County who committed suicide. In explaining why the county chose not to investigate the case, a supervisor wrote that the man’s suicide note “exonerated others for his suicide choice.”

* Norrine Sharkey, 52, who visited a Linn County mental health office, where she admitted drinking alcohol with her medications. Both her therapist and the doctor asked for the pills, but she refused, promising to flush them down the toilet. She was found dead the next day from an overdose. The state closed the case after a phoned-in account from the county.

The counties play a crucial role in Oregon’s mental health system. Almost $300 million a year in state and federal money to help the mentally ill is distributed to 33 county agencies. They in turn hire mental health workers and psychiatrists, or contract the work out to companies or local nonprofits.

It is up to state officials in Salem to make sure the money is well spent and that patients are properly cared for.

Counties were not even required to report deaths until 1991. That year, the Legislature passed a law that ordered mental health agencies to file a report on patients who die “by anything other than accidental or natural means.” The law gives counties 45 days to investigate whether “abuse” played any role in the deaths.

Under pressure from county officials, lawmakers drafting the statute drew an important distinction: Abuse was defined only as deliberate or “willful” acts to harm a patient. Neglect or serious errors by mental health workers were not covered.

In the nearly four years for which records were available to examine, nearly 100 Oregonians have died after significant lapses by county agencies, state records show. None was defined as “abuse.”

Only five cases were subsequently examined by DHS, which has broad authority to look at how the counties are spending their mental health dollars. Experts say patient deaths are one crucial warning sign of potential problems with the work of a county or its contractors.

DHS officials said they investigate deaths when they perceive something unusual in the county reports.

The DHS investigator who handles death cases has no authority to shut down a county mental health agency. If serious flaws are found, the matter is referred to another part of DHS, which licenses mental health agencies. None of the deaths of mentally ill patients in the past 3-1/2 years has prompted the state to strip a county’s authority to provide care.

Some patient deaths are never even reported to the counties. Dr. Peter Davidson, head of Multnomah County’s mental health department, said that in 2000 when he took over the agency, he discovered 20 unreported deaths in a 15-month period in one facility under contract with the county.

Davidson said he called the state and said, ” ‘You’ve got a company here pretending that it’s taking care of people in order to keep its cash flow going. You have to close them to admissions because they are killing people.’ ”

Davidson said the state workers “got a little upset with me,” but briefly looked into it and said they couldn’t find problems because the program kept no documentation.

“They would never allow this in surgical practice,” he said. “But in psychiatric practice, a lack of record keeping is considered prima facie evidence of competency?”

The company was bought by Cascadia Behavioral Healthcare, the largest mental health provider in Multnomah County, and now provides services under that name. Mark Schorr, a Cascadia spokesman, said, “Clearly having 20 unreported deaths, in fact, any unreported deaths, is unacceptable,” but he could not say how it had happened because the former program officials no longer work for the agency.

+++

Amelia Scott, a 44-year-old homeless woman with schizophrenia and no known family, was placed in the “quiet room” of the psychiatric unit at Legacy Good Samaritan Hospital and Medical Center in Portland on April 13. Twenty minutes later, she was dead.

No one ever bothered to find out why.

A hospital doctor conducted a “provisional autopsy” that found Scott had died of “cardiorespiratory failure, etiology not determined.” In other words, she stopped breathing for unknown reasons. The medical examiner did not take the case after being told that Scott had died of natural causes, records and interviews show.

Another stone unturned: Toxicology tests ordered upon Scott’s admission were canceled after her death, DHS records show.

Despite such sketchy information, a mental health worker urged the state to close the case. Even though Scott died “suddenly and unexpectedly,” wrote Iris Kern, a protective services investigator for the Multnomah County mental health department, “It is my impression that there is no allegation that the treatment given to Scott by any mental health providers contributed to her death.”

The state agreed, and on May 1 filed away Kern’s 1-1/2-page report, one of the few pieces of obtainable proof that Scott ever lived.

It wasn’t until The Oregonian questioned how abuse could be ruled out based on so little information that state officials conceded that Scott’s case might have deserved a closer look. “You’re right,” said Kerstner, the state employee who handles all abuse and death reports within the mental health system. “It’s unclear from that why she died.”

Kern did not return calls for comment. Davidson, the Multnomah County mental health director, said his employees have to rely on the records hospitals provide, which frequently are incomplete, but allowed that “if this had been an important person, this wouldn’t have happened.”

Hospital officials declined to comment, saying medical privacy laws do not allow them to do more than confirm the time and date Scott died.

Asked what became of Scott’s body, a hospital spokeswoman would speak only in general terms about policy governing such matters: The unclaimed bodies of indigent people are disposed of by the crematorium with the lowest bid.

The death of Elise John, a 28-year-old woman suffering from schizophrenia, illustrates one reason Oregon’s counties are reluctant to look too closely at patient deaths: The cases sometimes involve hospitals that are the only providers of crucially needed psychiatric beds in a county.

John, an heiress to the Miller brewing fortune in Milwaukee, was involuntarily hospitalized after a suicide attempt in March 1999. She spent two weeks at Good Samaritan Hospital in Portland, mostly under her covers or cowering near the nurses’ station, hiding from an imagined killer. State records show she talked openly about hanging herself, tried to swallow a comb and ate soap.

Nonetheless, John’s psychiatrist released her on an evening pass, alone, to buy clothing for herself on March 26, 1999. John bought a rope, waited until dark and hanged herself from the Morrison Bridge.

Three days later, the state closed the case after a county investigator filed a report saying the death did not result from “abuse,” meaning it did not involve a deliberate act of wrongdoing.

Another county worker, Greg Monaco, the investigator who had petitioned a court to send John to the hospital, said he “discovered errors” in the investigative report of her suicide and challenged why she had been released.

“When I pointed out the errors to my superiors, I was stonewalled and worse,” he said in a letter to an advocacy agency. “The reaction I received convinced me that the county administrators at that time were more interested in denying complicity and protecting their relationship with the hospital involved than they were in honestly evaluating the preventable circumstances that led to Ms. John’s death. No one at either the county or state level seemed willing to look at this tragedy. It wasn’t worth their time.”

After Monaco’s complaint, another county worker revised the findings of the county’s report to the state to “inconclusive.” The state did not investigate further.

The agency Monaco wrote to later determined that the county’s inquiry into John’s suicide “lacked thoroughness and independence.”

“The county should not be investigating itself or its business partners, the hospitals,” Monaco later wrote in a letter to the advocacy agency.

Davidson, hired to reform the system in which Monaco works, said he has placed a much higher emphasis on getting to the bottom of why county mental health patients die.

But the potential conflict of interest that arises when counties investigate possible wrongdoing at hospitals or other contractors remains, not only in Multnomah County but throughout the state. In at least three cases The Oregonian examined, the state closed the files after case managers and therapists had investigated the deaths of their own clients.

A bill to provide independent oversight of investigations of care in county mental health agencies failed during the past legislative session. Advocates say they will try again next session.

“There needs to be an independent watchdog to keep everyone honest,” Monaco said in an interview by e-mail, “to ensure that the very necessary checks and balances are in place.”

Inconsistent practices

The Oregonian’s review of death reports by counties found a hodgepodge of procedures.

Some county workers routinely closed cases with no greater effort than clipping a client’s obituary and mailing it to the state. Other reports were written so unprofessionally they were either illegible or rife with misspellings. One investigator noted, “Due to suicide, (alleged victim) was not interviewed.”

An analysis of the records shows that of the 247 deaths collected in state files, 46 were closed with an obituary or brief account phoned in to DHS. Asked about the case in which a Baker County worker relied on a man’s suicide note to justify not investigating, Nikkel, the DHS official, rolled his eyes and said, “The obvious appearance is that it’s grasping for anything that would exonerate” the county.

Ninety-three death cases were given a cursory examination by county officials and were closed because they did not meet the state’s definition of abuse. In 98 additional deaths, counties looked more closely but still could find no fault with their actions or those of their contractors. Eight deaths, they found, were “inconclusive.” Only twice did county workers determine abuse had led to a client’s death.

DHS has been slow to build a system for dealing with the county reports, which began trickling into its offices after the law was passed in 1991. Before 1999, the reports were stuffed into a cardboard box and reviewed by a DHS worker allowed to devote only a quarter of her work week to the task, officials said.

That year, DHS transferred the job to its Office of Investigations and Training and hired Kerstner full time to serve as the gatekeeper to the reports.

Since then, the state has examined five deaths, a slight improvement from what it did before.

The state is well aware of the lack of accountability. Last year, DHS conducted focus groups and interviews in more than a dozen counties to try to gauge the law’s progress. The agency found that county mental health directors often placed the job of investigating death and abuse cases on the shoulders of already overworked case managers. The comments of those workers, published 11 months ago in a 30-page report, painted a picture of a system with little oversight.

One mental health worker said: “Sometimes we investigate and sometimes we don’t, depending on our workloads.”

Said another: “Our mental health program director has thrown away critical incident reports rather than assign them to be investigated because they don’t generate any program funding. He just doesn’t see them as a priority unless they are a politically sensitive case.”

Yet another: “We’re not funded to do this job, and we don’t have the money to train clinicians to become something they don’t want to be and never went to school to become.”

From The Oregonian, December 30, 2002 – not available elsewhere online

In the past three decades Oregon has made it much harder to send mentally ill people to institutions against their will. Today, those laws prevent some of the most severely ill Oregonians from getting the treatment they need.

An investigation by The Oregonian has found that at least 28 people have died in the past 3-1/2 years in the state after doctors, county mental health workers and other officials unsuccessfully sought to send them to psychiatric hospitals without their permission. The problem is almost certainly more widespread. The Oregonian studied only those whose deaths were documented in Department of Human Services records.

Judges, doctors and mental health workers say the laws intended to protect patients often work against them.

“I have had a number of cases in which I very much felt the people should be hospitalized,” said Multnomah County Circuit Judge Lewis Lawrence, who hears more involuntary hospitalization cases than any judge in the state. “But they weren’t committable under the law. And I felt terrible because I knew I was sending them to an unknown, perhaps horrific, fate.”

The painful life and tragic death of Mary Boos, a Portland woman with paranoid schizophrenia, is one such case.

Mental health workers, her parents and two court psychiatrists agreed that Boos, 40, was in grave danger and should be hospitalized. A judge, not Lawrence, refused, saying her case didn’t meet Oregon’s standard, under which a person must be a danger to herself, others or unable to provide for her basic personal needs. The Oregon Court of Appeals has told judges not to force patients into treatment unless they are unable to “survive in the near future.”

Boos lived 10 more months. But without treatment, she sank so deeply into her delusions that she would not leave her apartment. She would not eat the food her parents faithfully and frantically set outside the door no law could make her open. Her decomposing remains were found almost a year later on Oct. 20, 1997. The medical examiner ruled she died of “natural causes probably related to schizophrenia.” In other words, she starved to death.

Oregon lawmakers have been reluctant to touch the politically charged issue. In response to Boos’ death, they did add some provisions making it easier to hospitalize chronically mentally ill people. But because the process is so restrictive, judges and mental health officials acknowledge that the additional criteria rarely are used.

The laws in Oregon and other states were drafted as part of a nationwide reform in the 1960s spawned by revelations that thousands of Americans had been locked away against their will in barbaric, state-run psychiatric hospitals.

The reforms closed many of the hospitals and made it much harder for doctors or state officials to hospitalize, or “commit,” people without their consent. Reformers envisioned a benevolent system in which patients would have the deciding voice in determining their course of treatment. Studies in the past three decades have shown that this approach ignores the medical reality that severely ill people are sometimes too sick to recognize they need help.

“Nearly 30 years ago civil libertarians forced a national agenda that has made it virtually impossible to treat a large number of people with severe psychiatric disorders,” said Dr. E. Fuller Torrey, author of two books calling deinstitutionalization a “failed social experiment.”

Torrey said Oregon has been particularly reluctant to use civil commitment because of its tradition ” of independent living and not wanting government to interfere.”

As outraged as many people were by Boos’ death, which was openly discussed by her family, others said it was her right to decide and, ultimately, to die.

“As a society, we have set a very high bar,” Lawrence said. “We’re saying this is someone’s freedom. Who are we to try to control eccentricity if it’s not causing immediate harm?”

Even supporters of forced hospitalization in extreme cases do not want a return to the dehumanizing conditions depicted in “One Flew Over the Cuckoo’s Nest,” a movie filmed at Oregon State Hospital.

“Institutional care is really grim,” said Dr. Peter Davidson, head of Multnomah County’s mental health department. “We don’t have to force treatment on people all the time. We don’t have to ignore them, either.”

Illness creeps in

Mary Boos was raised on a maple-canopied block in Portland’s Laurelhurst neighborhood. A faded snapshot shows a toddler with blunt-cut bangs in a crisp cotton dress wedged and grinning between her two sisters.

At Laurelhurst Elementary School, Boos was curious and quick. At Grant High School, energetic and popular. By her sophomore year at the University of Oregon, she was sullen and withdrawn.

Boos managed to graduate with a bachelor’s degree in recreational therapy but couldn’t keep a job. A position as a nursing home activities director ended after three months when she was unable to follow through on basic tasks.

Many schizophrenics experience a sudden split with reality. The illness crept up on Boos so quietly that her family was left for years to wonder what was wrong.

When her parents, Carol and Richard Boos, finally persuaded her to confide in them, Boos couldn’t stop. During an eight-hour rant, she told them that the FBI and CIA were engaged in a conspiracy against her.

The Booses used their insurance to try to get her help, but their daughter wouldn’t go. Studies show that about half the people with schizophrenia or bipolar disorder are afflicted with a little understood symptom of the illness: lack of insight. That is, the disease impairs the part of the brain that enables them to evaluate themselves. In her mind, Boos didn’t need mental health treatment — she needed protection from the government operatives who were stalking her.

By the late 1980s, Boos’ parents put her up in a Northeast Portland apartment, which she decorated with an artist’s eye and yards of white linen. But before long, Boos was too paranoid to venture out.

The Booses thought their daughter needed to be hospitalized, so they turned to the public system. There, a mental health worker gave this advice: Stop supporting her. She’ll be evicted, act out violently and be hospitalized.

The worker knew that without Boos’ permission, the state could not intervene until she was a danger to herself or others. If she could be provoked into a violent outburst, chances were good that authorities would initiate the civil commitment process.

The Booses didn’t understand why they had to abandon their child to help her, but they went with the plan.

Eviction notices soon fluttered on Boos’ long-unopened door. But when a Multnomah County sheriff’s deputy came to remove her, she did not erupt. Instead, she collected her belongings, placed them on the porch and walked away in silence.

She was gone for a week. The Booses canvassed parks with her photo. Late one night, they heard a scraping sound on their patio. It was their daughter, disheveled and delusional, pulling up a chair to sleep.

Boos moved in with her parents but tumbled deeper into illness. She emerged from her room only to sneak unopened cans of food upstairs, checking them for tampering because she feared neighbors were poisoning them.

Carol Boos, confronting her worst fear, bought a book about schizophrenia and read it in secret. She once forgot and left it on a table.

“I do not have schizophrenia!” Boos screamed when she saw it.

The Booses called the public mental health system again. Weeks passed before a case manager visited their home.

On the day of the appointment, Boos came downstairs, fully dressed for the first time in weeks.

“The caseworker’s going to be here,” Carol Boos remembers telling her daughter.

“Not for me,” Boos said and walked out the door.

Hospitalized in South Carolina

As her parents frantically looked for her, Boos crisscrossed the country for 11 months in 1989 and 1990, searching for clues about why the government was after her.

She lived on the kindness of strangers. Passers-by slipped coins into her hands. Truck-stop waitresses tucked sandwiches in her pockets. But mental health officials in at least five states did nothing.

In Washington, a Pierce County sheriff’s deputy called Western Washington Mental Hospital when Boos showed up, talking of conspiracy. A hospital worker “talked to her for a while and said, ‘Well, nice meeting you, Mary,’ and left,” the deputy later told the Booses.

From there, Boos hitchhiked to Washington, D.C., and parked herself in the lobby of the Pentagon, records show, rambling that she’d been drugged as a child and in college.

“They told me they had nothing,” Boos later wrote in a letter to family. “But a Pentagon official said there was something too confidential for me to know.”

From there, Boos took a bus to New Jersey to find a lawyer who could force the Pentagon to cooperate. Social services workers there gave Boos a bus ticket to New York, a tactic social scientists have dubbed “Greyhound therapy.”

Boos slept on the steps of a Roman Catholic Church in New York City, where nuns fed her and helped her secure welfare benefits. But she wandered the streets delusional and afraid. After several months, Boos handed her welfare check to a bus ticket agent and asked, “How far will this take me?”

The Booses didn’t learn what had become of her until a family in Columbia, S.C., called police late one night in May 1990 to report that a psychotic woman was wandering their property.

They called the highest mental health officials in Oregon and South Carolina. Both states told them Boos was not an imminent danger to herself and could not be involuntarily committed.

“The law doesn’t mean just an immediate danger of going without a meal,” said Lawrence, the Multnomah County judge. “It means immediate danger of serious bodily harm or death. That is such a subjective area . . . . People who are on the streets and who are in need of fairly substantial medical care are still not committable because they’re not going to become seriously ill at any appreciable time in the near future.”

Kay McCrary, a mental health worker who learned about Boos through a family organization that tracks missing mentally ill people, thought otherwise.

She petitioned a South Carolina court without her boss’s permission. “I know that sometimes a person has to do the right thing,” she wrote to the Booses in 1991. “So, the next Mary Boos who comes homeless to Columbia won’t be left to their symptoms, deserted by the mental health system.”

Boos spent the next five weeks at the Bryan Psychiatric Hospital in Columbia. She would have been sent straight back to Oregon, but none of the state’s psychiatric hospitals had an open bed.

Boos was outraged when she was placed in a straitjacket and medicated against her will with Haldol, a highly potent antipsychotic drug with harsh side effects. But in less than two weeks, her psychosis dissipated.

She was diagnosed with paranoid schizophrenia and attended classes about the illness.

Boos began a new life.

“Getting here, in the hospital under medication, is what it took to free me from the thoughts and thinking I had,” she wrote her family. “It really was all my illness’ fault because now I can see how irrational I was. I’m determined to beat this illness as best as I possibly can.”

Brief respite, then lost
The brief hospital stay made it possible for Boos to function on her own for three years.

Back in Oregon in the summer of 1990, she faithfully took her medication and met with her Multnomah County mental health case manager.

Once too afraid to venture outside her apartment, she mingled with friends and family and joined a new church. She talked openly about her illness, sometimes even joking about it.

Boos’ improvement illustrates what reformers had in mind when they closed state-run mental hospitals: Although chronically ill patients might need occasional hospitalization, they would not have to be sent away for life.

But mentally ill people need structure and support to remain stable. At the same time civil libertarians made it difficult to treat those who refuse it, lawmakers, advocacy groups and mental health officials say the state abdicated its responsibility for the mentally ill, slashing budgets and cutting the very services that can keep them from ever needing involuntary care.Because of her parents, Boos had more help than most. It still wasn’t enough.

As with many patients, the side effects of Haldol — lethargy, blurred vision and involuntary facial movements — made it difficult for Boos to hold down anything but a menial job. Her parents remember her offense at being given a position “sorting screws” at a day treatment program.

But when Boos got her own job at a foster home for the developmentally disabled, she was so confused that on the third day she showed up at 8 p.m. instead of 8 a.m. and never returned.

Another problem: Boos, always a svelte beauty, had gained at least 60 pounds, another dangerous but common side effect of the drug.

In early 1993, Boos asked her Multnomah County psychiatrist to change her medication to Moban, a less potent antipsychotic medication that was less likely to cause weight gain and seizures.

It failed to control her illness.

A few months later, Boos was convinced that God had healed her and that she no longer needed medication. By October, she would talk to her parents only through her apartment window, which she had decorated with crosses.

Neighbors heard her chanting night and day. She stopped paying her rent.

Afraid she would run away if they again forced treatment, on Dec. 18, 1993, the Booses wrote a letter to the director of their daughter’s mental health agency, begging for help. “In her way, she has given us all plenty of warning. Now we must take action,” they wrote.

In Oregon the process to involuntarily commit someone can begin when two people sign a paper saying someone is a danger to herself. The Boos’ persuaded their daughter’s caseworker to sign such a document, and that allowed Boos to be temporarily hospitalized until a judge could determine whether she needed more long-term treatment.

A judge sent Boos to Adventist Medical Center on Jan. 26, 1994. She was released in slightly better condition after just two weeks of medication. But doctors did not change the medication to what had worked in the past, allowing her to stay on the less-potent Moban.

Boos soon slipped back into darkness. She kept no food in her apartment. She wore the same clothes day after day. She didn’t recognize her sisters.

When her parents came to her door, she smiled, took her father’s hand and said, “Dead.” She then took her mother’s hand and said, “Dead.”

This time the Booses petitioned the court on their own. They said the case manager had never checked on Boos after her release from the hospital nine months before.

After a petition, such cases are first assessed by county investigators, who interview the patient. Boos was hostile when the investigator came to her door. She demanded to see the paperwork, grabbed it from his hand and refused to return it. The investigator noted that Boos shouted at the voices in her head to, “Shut up! Shut up!” Asked whether she had taken her medications, she said, “Poison is your war.”

The investigator agreed that Boos was a danger to herself. Sheriff’s deputies pulled her kicking and screaming from her apartment. She told them they were from Satan.

At a hearing on Dec. 22, 1996, two psychiatrists recommended Boos for treatment, saying she was incoherent.

Boos’ court-appointed lawyer argued what she was paid by the state to argue: Boos might be a danger to herself, but not an imminent danger. The judge agreed and released Boos. She left the courtroom wearing nothing but a flimsy hospital gown.

When her father learned that her lawyer planned to put Boos on a bus to her apartment, he slipped $20 to a court official and said, “At least put her in a cab.”

They never saw her again.

Ten months passed. Boos sat inside her apartment and chanted.

The Booses wanted to pound the door down, but were told they could be arrested if they did. They left groceries at Boos’ door but had no idea whether she ate them or threw them away.

The county mental health agency charged with her care never sought her out, records show. When a mental health provider finally visited her apartment, Boos told him to go away. The agency complied and took her off the rolls. Under law, the agency could not force her to accept services. And it would not be paid for unproductive visits.

Mary Boos was found dead on Oct. 20, 1997.

State mental health officials at the highest levels sent their condolences to the Booses with a promise that they would investigate the circumstances of their daughter’s death. More than five years later, the Booses haven’t heard back.

A family friend, Eugene Minnard, lobbied legislators to dramatically change the laws. But the bills never made it out of committee.

Only after their daughter’s death were the Booses allowed to go into her apartment. They were horrified at what they saw.

The place was void of food or personal items but for some heirloom dishes Boos had ritualistically laid on the floor. Her curtains hung in tatters, and her bed was shredded, soiled and propped up on one corner by telephone books.

In the years since, the Booses have campaigned for changes in Oregon’s involuntary hospitalization laws, so far to no avail. They take small comfort in letters their daughter sent them from a psychiatric hospital in South Carolina, thanking them for never abandoning her to her illness.

“I really can’t thank you enough for that,” Mary Boos wrote. “I just hope I could do the same for you if you needed.”

From the Oregonian, December 29, 2002. Not online.

Jason Curtis Koontz, 23, utility worker, bowler, movie buff.

Jason Curtis Koontz, who suffered from schizophrenia, was involuntarily committed to the Lane County Psychiatric Hospital on Sept. 10, 1999, in what records called “a severe psychotic state.”

During a visit there, Koontz made his mother, Teresa Dupret, promise that if he were to ever suffer a head injury and be placed on life support, she would allow him to die, information Dupret said she immediately passed on to hospital staff.

The next day, records show that a hospital employee found Koontz on the floor of the quiet room in a puddle of blood. Records show he had fallen off a chair backwards. His mother said he threw himself to the floor.

The hospital had no medical staff on duty to tend to Koontz’s head wound and not enough psychiatric staff to take him to another hospital. So they called a volunteer shuttle, records show.

Once outside, an unrestrained Koontz, 23, bolted to a nearby two-story building and dived off.

He never lost consciousness. He did, however, break his neck, his back in three places, puncture his lung and was paralyzed.

Two days later, he won the legal right to be removed from life support and died on Oct. 4, 1999.

From the Oregonian, December 29, 2002 – not online.

Elias Laskey said he heard “divine revelations from God” and thought it was his responsibility to “cleanse the Willamette Valley.”

“He was awesome,” said Laskey’s mother, Jeanette. “But he was ill.”

In March 2000, Laskey climbed to the summit of 1,514-foot Mount Pisgah southeast of Eugene and toppled a bronze sculpture dedicated to two University of Oregon wrestlers who had died in a 1984 van wreck.

Laskey immediately confessed to damaging the monument, saying it went against his religious beliefs. When his parents took him to the Lane County mental health office, Laskey refused medication and counseling, insisting he was not mentally ill.

After Laskey, 21, picked up the family dog — a pet he loved — and threw it, his parents pushed for him to be involuntarily committed to a psychiatric hospital. A judge considered the case on June 20, 2000, but decided Laskey did not meet the legal criteria for involuntary commitment, which requires a person to be a danger to himself, others or unable to meet his basic needs.

Seven days later, another judge ordered Laskey to 10 days in jail for the Mount Pisgah incident, urging him to take advantage of the jail’s mental health resources. But Laskey didn’t get help there, either. The jail was full, and Laskey was released in 24 hours.

His parents never saw him again. He disappeared into the woods and was found dead of a self-inflicted shotgun wound to the head on Sept. 21, 2000.

From the Oregonian, December 29, 2002 – not online

Corrine Reed believed she was on fire.

She could feel her hair crackle and singe, her fingers char at the tips. Mental illness can bring the voices of heaven or hell, but Reed heard a relentless sizzling sound she swore was the burning of her own flesh.

Reed thought food and water fueled the fire, so she refused to eat and drink. On July 19, 2000, a housemate found Reed’s cold body on the floor of an adult foster care home in Coos Bay, where her caseworker — whose training largely consisted of a weekend conference in Las Vegas — had dutifully documented her suffering for almost 10 months. Also noted was Reed’s terrified observation: “I’m dying,” she repeatedly sobbed to anyone who would listen. “I am going to die.”

Reed, 67, a capable woman whose mental illness could be controlled with medication, did not have to die. She was under the care of a state system that turns away thousands every year. Unlike many who end up homeless or alone, she had a place to live and a loving husband. Yet Reed starved herself to death under the daily watch of Coos County mental health workers.

State officials concluded that her death had resulted from a series of missteps by her caseworker, the director of her group home and the doctor who treated her. An investigation by The Oregonian found that Reed was one of 94 Oregonians who died during the past 3-1/2 years after significant lapses by the state’s mental health system. Her case highlights some of the most serious shortcomings the newspaper found.

A state investigation of Reed’s death, one of only five such inquiries since 1999, concluded that her psychiatrist and case manager neglected her most basic needs and did not take advantage of state laws that would have allowed her commitment to a psychiatric hospital. Since the mid-19th century, states throughout the nation, including Oregon, have shouldered the responsibility for caring for the mentally ill.

The state made no effort to draw larger conclusions from Reed’s death. The Oregon Department of Human Services did not refer the findings of its investigation to law enforcement for possible criminal prosecution, and it did not examine whether the case was typical. State officials did determine that Coos County was out of compliance with state regulations and recommended procedural changes. But state officials say they have never checked to see whether Coos County put them in place.

Bright mind falters

Reed was a genius who could recite long passages of the Bible by heart. All you had to do was call out a number, and she could recite every verse on the page.

At age 4, Reed appeared on a radio talk show in Roseburg, spouting answers to brainteasers posed by listeners. North Bend High School awarded the brunette beauty a diploma when she was 15.

Reed married in her 20s, raised three children and worked as a payroll clerk and bookkeeper for a large Coos Bay plywood and pulp mill. Her husband said she regretted choosing a good-paying job over college, but her intelligence still shone. She was “unbelievable,” her husband, John, remembers. “She could add numbers up faster than a calculator.”

But in her 40s, her mind began to falter. Doctors diagnosed her with delusional disorder, a mental disease that usually strikes in mid-life. A form of the disease skews people’s realities about bodily functions. Reed believed she was on fire; others with this type of disorder are convinced they smell or that their skin is infested with bugs.

In 1990, Reed sliced her wrists and jumped into Coos Bay, shrieking that her skin was on fire. The Bay Area Hospital in North Bend treated her injuries and referred her to the Coos County Mental Health Department.

Reed’s illness slipped into a predictable pattern. Delusions not only convinced Reed that her body was on fire, but also that food, water and medication fanned the flames. Reed often refused all three, causing her to become so weak and deranged that the woman with opinions on everything — why the Oregon State Beavers rule over the University of Oregon Ducks, why only Democrats deserve her vote — could do little more than lie in bed and drool.

In 1996, Reed’s case was assigned to Margie Matthews, then 51, who had begun work in 1990 as the agency’s receptionist. Her educational background couldn’t be determined, but according to a state investigation, the bulk of Matthews’ case management training came from a weekend conference in Las Vegas in 1999.

Coos County mental health officials petitioned to have Reed involuntarily committed to the Oregon State Hospital in June 1997, saying she required help with “basic functions such as eating and bathing.”

The Oregon State Hospital in Salem treated Reed for failure to thrive, a condition usually diagnosed in children whose growth is retarded from poor nutrition or neglect.

For 11 months, Reed received iron, protein and nutritional supplements through a tube in her nose. When she was strong enough, she received 12 electroconvulsive therapy treatments, which hospital records show markedly improved her mental state. She was discharged “in full remission” on May 21, 1998.

Reed returned home to North Bend, where she was stable for eight months. She painted ceramic animals, mostly elephants and dogs, at a day treatment program twice a week, walked to a salon to have her hair rolled and accompanied her husband on dinner dates to the Kozy Kitchen, always ordering a hamburger platter and vanilla milkshake.

But like many people with mental illness, as Reed felt better, she stopped taking her medications. The illusory fire returned, and she stopped eating, drinking and showing up for mental health appointments.

“She appeared more delusional today,” Matthews wrote on Feb. 16, 1999, after visiting her client at home. “She even described to me that her fecal matter comes out through her skin and her face, and that she has been afraid to tell me that because she knew I would think she was crazy.”

Matthews took no action.

Nine days later, Reed flung herself again into the frigid, gray waters of Coos Bay. When officers pulled her out, the report said the soaked, shivering woman whispered through blue lips: “I’m too hot.”

The county went to court again, and Reed was sent back to the state hospital on May 5, 1999.

After five more months of treatment, she was released on condition that she visit Matthews once a week and attend a day treatment program.

Within two weeks, Reed was convinced that her face had dried up and peeled back like the papery layers of an onion. “She’s complaining about her face feeling like it was on fire, peeling, her jaw cracking and popping and hissing noises in her head,” Matthews wrote.

Why Coos County mental health officials failed to send Reed to the state hospital a third time is unclear. Instead, Matthews sent Reed to an adult foster home.

Into foster home, decline

Jereda Lynn, the owner of Harbor House Adult Foster Care Home in Coos Bay, expressed doubts about her ability to care for Reed but decided to fill the empty bed anyway, collecting more than $6,200 a month in public mental health money for Reed and the four other mentally ill residents under her care.

Harbor House records show Reed sat slumped and delirious, day after day. She frequently went weeks refusing to eat or drink anything substantial. Her husband, John, visited her almost daily. Frequently he found her alone upstairs with no way to summon help if it were needed, records show.

John Reed begged Matthews to help him find a nursing care center for his wife. But Matthews assured him she “was better off in a foster home.”

By May 8, 2000, the situation was critical. Lynn called Matthews, who was already aware of Reed’s worsening condition. “Client still not eating or drinking,” Matthews wrote. “Has not voided in at least two days. Client can hardly stand.”

Instead of calling Reed’s primary care physician, Matthews dialed Dr. Richard Staggenborg, a psychiatrist employed by the Coos County Mental Health Department. Staggenborg sent Reed to a local hospital but did not call her primary care doctor.

NOTE - On August 3, 2011, the Oregon Medical Board issued a Complaint and Notice of Proposed Disciplinary Action alleging violations of the Medical Practice Act (state law) regarding unprofessional or dishonorable conduct, gross or repeated acts of negligence and willful violation of the Medical Practice Act. This is a preliminary action by the Board. A final Board action in this matter has not been taken.
READ - Oregon Medical Board Richard Staggenborg – interim stipulated order, 10/21/2010 – Licensee entered into an Interim Stipulated Order with the Board on October 21, 2010. In this Order Licensee agreed with voluntarily withdraw from practice pending the conclusion of the Board’s investigation.
READ - Oregon Medical Board Richard Staggenborg – voluntary limitation, 07/25/1996 – COUNSELING, NO SELF-PRESCRIBING OF CONTROLLED DRUGS. MODIFIED 7/14/05

“Disheveled and mute,” is how records show Staggenborg described Reed. “Judgment is undoubtedly impaired by psychosis, as manifested in her refusal to take medications which are necessary for her functioning.”

Involuntary commitment laws exist because half of all people with mental disorders are often too ill to realize it. The very thing that should have signaled to Reed that she was in danger — her brain — was malfunctioning. But Staggenborg did not act, despite his determination that Reed “is clearly unable to care for herself and would have to be (committed) if she tried to leave.”

Sent back to foster home

On May 14, 2000, instead of sending Reed back to the state hospital, Staggenborg sent Reed to the foster home in a condition the doctor would later admit was “barely stabilized.”

One week passed. Two. Then three. By June 5, Reed had not eaten solid food in almost a month. Almost every day, John Reed armed himself with a sack of McDonald’s hamburgers and sat at the bedside of his wife of 39 years, pleading with her to eat, records show. He failed, leaving his trust in the professionals who assured him she was fine. “I thought they were aware and were taking care of it,” he said.

Matthews could have stepped in and pushed for Reed to be rehospitalized. But records indicate that the case manager didn’t fully understand Oregon’s involuntary commitment laws even though it was an essential function of her job. “If the client refused to follow (treatment), they cannot be forced,” Matthews later told a state investigator. Instead, records show Matthews requested an increase in Reed’s public benefits because Lynn “needed more money.”

On June 19, 2000, the owner of the foster home found a 6-inch-wide spot of what appeared to be bloody vomit on the floor in Reed’s bedroom.

The paramedics were not summoned for several hours, and then only after Reed’s face had turned white, her lips and fingertips were blue and she had collapsed on the floor, records and interviews show.

Workers at the home did not accompany the ambulance or alert her husband, and she arrived at the Bay Area Hospital emergency room alone, unable to speak. The only history the emergency room doctor could find was Staggenborg’s notes from her hospitalization a month earlier.

Medics who carried Reed to the ambulance told the treating doctors that she had vomited a “large amount” of blood. The doctor later said he saw no evidence of bleeding. But records also show that he was never told she had starved herself for months, and he released her. In less than three hours, Reed was back at the foster home.

Another two weeks passed with no meals. Reed lost 24-1/2 pounds in 13 days and was too weak to rise from her bed, records show. She howled in anguish. Other mentally ill residents in the home pleaded frantically with Reed to eat or drink, records show. Just after dawn on July 19, a fellow resident found her dead on the floor of her bedroom.

Reed’s eyes were open, but her body was cold.

“The whole system failed”

Oregon law requires that counties report any death that is not accidental or natural.

Coos County did not do so, and Reed’s death would most certainly have passed without state inquiry, as did nearly all the 94 deaths The Oregonian reviewed.

But a state hospital employee who heard about the death from Reed’s family told state officials, who requested a copy of Reed’s death certificate. DHS officials were startled to discover that Reed was the second person to die in a Coos County group home that year and began to look more closely at both cases.

Nearly a year later, state officials drafted a scathing 59-page report that laid blame squarely on Reed’s psychiatrist, caseworker and the owner of her group home. Neither Staggenborg nor Lynn’s lawyer returned calls for comment; Matthews could not be reached.

“The whole system failed,” state investigators wrote. Reed’s death was nothing less than “abuse by neglect.” Investigators criticized Matthews, the caseworker, for failing to push for Reed’s involuntary hospitalization and for relying on the group home too heavily for information. The report said Matthews overlooked basic aspects of her client’s care and did not even ask the group home to keep a record of Reed’s eating and drinking.

Matthews told an investigator she did not think Reed needed to be hospitalized. She was not catatonic or drooling, as she had been in the past.

“At the time, it didn’t seem like it was that bad,” Matthews said. “But looking at all of this now, it obviously was. This looks bad.”

State investigators faulted Lynn, the owner of the group home, for taking on “a clearly deteriorating client” whose needs were well beyond what could be provided in such a setting. The state found a “significant absence” of records and said the medication logs Lynn provided were “suspiciously consistent, appearing to have been written all at one time.”

The state report found that Staggenborg, the psychiatrist who treated Reed for nine months, should have intervened more aggressively. Staggenborg, the investigators wrote, “failed to provide adequate medical evaluation and treatment.”

Staggenborg acknowledged that he was out of touch with Reed’s deteriorating condition. He told investigators he knew she “once again” had to be coaxed into eating and drinking, but he did not specifically recall details.

When an investigator confronted him with Matthews’ notes, Staggenborg acknowledged that the caseworker had talked to him about Reed’s dire circumstances, but said “it was one of those things where they catch you in the hall.”

He acknowledged that Reed’s situation “should have been looked at more closely.”

Death brings no discipline

Lynn, Matthews, Staggenborg and their supervisors were never disciplined as a result of Reed’s death. State officials eventually took a closer look at the Coos County Mental Health Department, which serves more than 2,000 people, and noted a “substantial failure to comply” with key Oregon rules.

State officials offered recommendations on how to address the lapses, which included a failure to keep basic records. There was no further follow-up, but Bob Nikkel, the community services manager for the Oregon Department of Human Services Office of Mental Health & Addiction Services, says the county “appears to be in compliance with our basic requirements,” but he is unsure.

“If we had oodles of staff, we’d send someone down there to check on them again,” Nikkel said. “We don’t.”

Coos County Mental Health Director Ginger Swan declined The Oregonian’s request for an interview, citing a lawsuit filed by Reed’s family.

The group home where Reed died, Harbor House, stayed open a year after Reed’s death, until a state investigator found that Lynn still wasn’t documenting her clients’ medications, declaring that “the health and safety of residents in your adult foster home cannot be assured.”

Lynn filed for bankruptcy. Matthews retired a month after Reed’s death and collects Public Employees Retirement System benefits. Staggenborg remains on contract with Coos County to treat its mentally ill.

Beyond the family she loved, Corrine Reed ‘s death didn’t resonate much.

John Reed still can’t bring himself to scatter the ashes of the woman who always feared she’d burn to dust.

“She could do anything,” he said. “That’s why I hate the way she had to die.”

From The Oregonian, December 29, 2002 – not available online

There were times when Elise John understood that her schizophrenia could, without notice, take away her volition to care for herself.

During a moment of clarity, she wrote these instructions so her family would know how she wanted to be treated while in the hospital:

1. I like animals, dogs.

2. Check to see if they’ve mistreated me, raped me, etc.

3. Bring me nice children’s music, things to do with my hands — balls and squishy stuff.

4. Speak to me calmly, like a sick child.

5. I have no anger in me.

6. Visit me as often as possible — the words I will not understand, but the calm voice I will.

7. Have (an older brother) tell me jokes. His laughter will bring me joy.

8. Check to see that I have not been mistreated like an animal. I will not understand the words, but the emotions I feel are real.

9. If I look “insane” and out of control, it is only because I lack attention. Talk to me calmly, and I will calm down.

10. Peace.

John was involuntarily committed after a suicide attempt in March 1999. She spent two weeks at Legacy Good Samaritan Hospital and Medical Center in Northwest Portland, mostly under her covers or cowering near the nurses’ station, hiding from an imagined killer. State records show she talked openly about hanging herself, tried to swallow a comb and ate soap.

Nonetheless, John’s psychiatrist released her on an evening pass, alone, to buy clothing for herself on March 26, 1999. John, 28, bought a rope, waited until dark and hanged herself from the Morrison Bridge.

+++

Lloyd Dean Seaman Jr., 33, auto-body worker, fisherman, electronics enthusiast

Lloyd Dean Seaman Jr. was so afraid that he would kill himself he called police on April 28, 2001, and asked to be arrested.

Medford police delivered Seaman, who suffered from paranoid schizophrenia, to Rogue Valley Memorial Hospital, where an urgent response worker from Jackson County’s mental health department evaluated him.

The worker decided that Seaman, who had waited several hours in the emergency room, was no longer a danger to himself or others and did not merit an expensive hospital bed. The worker gave Seaman a phone number to call if he felt suicidal again and sent him home.

Hours later, Seaman, 33, swerved his pickup into oncoming traffic on Oregon 140 near Medford. Witnesses called it a miracle that no one else was seriously injured in the horrific four-car pileup. Seaman, however, was thrown from his truck. A witness recalled him sprawled in the road, alive with outstretched arms, begging for help as a motor home, unable to stop, crushed him.

Authorities ruled Seaman’s death a suicide. Jackson County mental health officials decided it wasn’t their fault.

“While hospitalization may have prevented (Seaman’s) death, the facts do not support hospitalization,” wrote a county worker in a report the state filed away.

+++

Any guilt was left for a 12-year-old boy in Klamath Falls.

“It was an illness,” Melinda Johnson says she still tries to explain to her and Seaman’s son. “He didn’t do it because he wanted to leave you.”

John Klamath Jackson, 37, member of the Wintun Tribe, his sister’s “big, cuddly teddy bear”

Deinstitutionalization was supposed to put John Klamath Jackson under the caring watch of his community. Instead, it put him in a retirement center at age 37.

Workers from Clackamas County’s mental health department sent Jackson, who suffered from schizoaffective disorder, to the Oregon City Retirement Center on April 22, 2001, after his delusions became too much for him to bear.

In his delusional state, Jackson promptly fell in love with a woman in her 70s, herself with dementia. He wistfully told his sister and center staff that he wanted to elope with the woman to Arizona. Seventeen days after he was admitted, the center “evicted” Jackson after he had run afoul of the home’s fraternization policy, medical examiner’s records show.

Records and interviews show Jackson sat in the nursing home parking lot and sobbed. He left and later swallowed 35 antidepressant and antipsychotic pills that nursing home staff had handed him upon his departure. He died at the Willamette Falls Hospital in Oregon City four excruciating hours later on May 8, 2001.

Kevin Canales, a nursing home administrator, said no fraternization policy exists, that a case manager had cleared Jackson’s release and that the medical examiner’s report was wrong.

Why Jackson wasn’t sent to a psychiatric hospital in the first place isn’t noted in DHS records. But Jackson’s sister, Mary Haemker, said she was told he “did not meet the criteria for acute inpatient hospitalization at a psychiatric facility.”

A retirement center didn’t meet Haemker’s criteria for the best place for her mentally ill brother. “They should have known you can’t just throw someone like that out in the street. Especially with a broken heart,” Haemker said.

by Peter Davidson, MD, Multnomah County MHASD Chief Clinical Officer/Medical Director, December 2002

Recession:
First the bad news. No one can tell where the bottom is, there are too many variables in play, most of which are interdependent. But it is safe to say that we will emerge next spring even smaller than we are now. So far, cuts have been relatively evenly distributed between the various categories like county employees and contracts, administration, clinicians, addictions, and mental health.

We will attempt to maintain this balance, but of course some revenue streams are more categorical than others. The overarching principle of cut priorities is that we must attempt to preserve services which may not be able to be reconstituted once cut and/or which have life and death significance for the beneficiaries.

We will need to preserve the mental health crisis system including the Call Center, but it looks as though we may lose most or all of the Verity Plus programs and “special arrangement” services. We have already lost all County General funds in the adult mental health system contracts. It is not clear how much longer we will be able to maintain the panel of “non-participating” providers.

There are no plans to “out source” the county role as a way to cut costs. In fact, we may be able to bring in some contracted services as a way to maintain jobs. Stevie Bullock was been wonderful at this.

The End of the Adult versus Child Tension:
Child-centric thinking has given way to the System of Care set of values and it makes poor sense to treat the adults in a family in a manner entirely distinct from the child or children. Both the Children’s System of Care committee chaired by Commissioner Naito and the School Age Framework group have been highly critical of the series-of-projects approach to the mental health system for children and families.

Throughout the winter we will be bringing together the administration of key elements of the System of Care for families, in order to implement the recommendations of the aforementioned design groups. The Call Center will work directly with both the Children’s Care Coordinators and the work units like Member Services to create seamless transitions between the care of children and their families. We are working to get all of the major Primary Providers dually certified to treat both children and adults.

In the near future we will see work unit changes to get our systems more closely aligned with their clinical functions. We will see a natural distinction develop between the system of care for families at various stages of child development and that for “level one” adults, by which we mean those who, due to a severe mental disorder, are at risk for high level (multi-systemic) interventions and/or are a danger to self or others, etc.

What must be borne in mind, however, is that the mental health system can not be built as it has been, whereby we create a program that seems like a good idea and then we look for clients who are appropriate for the program. We have to adapt our programming to the actual presentations of anyone. There are “Level One” adults who are parents of school age children and there are level one children with no real family and everything in between. In the public sector, the paradoxical phrase “outliers are normal” is the best touchstone for program design.

We will need to upgrade our software systems so that the folks seen in our family programs can be tracked through the Raintree database and so that whole families can be kept intact in our data system in a manner similar to the system used by the State’s Department of Human Services.

With all of this said, we will continue to maintain a distinct boundary in the payment structures for the care of children versus adults. In most circumstances, we will braid funding and not blend, to ensure that services for families are not diminished to pay for the very expensive care of Level One adults.

In fact, the concern about children’s dollars being taken for adult services will be turned on its ear. There is a tremendous amount of “adult” system capacity which can be brought to the table for the care of families, the School Age framework and System of Care implementation in particular.

The Mobile Outreach for family crisis services, for example, can be brought to the School Age Framework as available to schools and other family serving agencies to do on-site mental health crisis work.

Conclusion:
Very difficult times are ahead as a result of the simultaneous arrival in these coming months of budget cuts in all of our revenue streams. But even if all the projected cuts on the lists we receive do happen, there will be around $60 million dollars in the mental health and addictions budget going into Fiscal Year 2003-04. That is a lot of services. More than ever they will need to be very efficient to be effective. People need what we do and we have to do it as well as we can.