From the Salem Statesman-Journal, February 26, 2010

A blistering federal critique of patient care at the Oregon State Hospital wasn’t shared with a new hospital advisory board before it appeared this week in the press, prompting anger and complaints from members of the governor-appointed panel.

“I was pretty disturbed that I read it in the Statesman Journal, and that as a board member I didn’t hear about it in advance,” said Robin Henderson, the director of behavioral health services at St. Charles Medical Center in Bend. “As a board member, I have a right to see those types of reports. It’s part of my responsibility. Otherwise, what am I?”

Board member Mike Adelman, a former state hospital patient, said he fears that the panel is being kept in the dark about lingering problems at the Salem psychiatric facility.

So far, he said, the panel has mainly received rosy reports from hospital officials during three meetings held in October, December and January.

“If we’re going to be worth our salt, we need to do something other than just listen to them talk about how well they’re doing, when obviously, according to the feds, they’re not,” Adelman said.

Amid the flap, OSH Superintendent Roy Orr said Thursday that “there’s no cover-up going on here, there’s no sweeping anything under the rug.”

The hospital chief said he didn’t share the federal critique of OSH with the board until after it was reported in the press because of confidentiality ground rules set by the U.S. Department of Justice.

“From the outset of our relationship with the Department of Justice, they’ve been very clear that they do not want any of their correspondence, which I would emphasize is attorney to attorney, made available publicly,” Orr said.

“I’m very respectful of the somewhat fragile nature of our current relationship with the DOJ. … If we don’t abide by some of the ground rules they have given us, we will become one of those state hospitals around the country which has gone from being under their watchful eye to being sued in federal court.”

The feds have been investigating Oregon’s main mental hospital since mid-2006.

The 2009 Legislature created a state hospital oversight board after patient care and hospital conditions were assailed in a report issued by the U.S. DOJ’s Civil Rights Division in January 2008.

The report alarmed state officials and spurred reforms, ranging from the hiring of hundreds of new hospital employees to the opening of centralized treatment malls designed to give patients better treatment.

New criticism of the 127-year-old institution surfaced in a federal review of care for patient Moises Perez, who was found dead in his bed Oct. 17 at the psychiatric facility.

Perez, 42, died in a secure treatment unit in the hospital’s forensic psychiatric program. An autopsy determined that he died from coronary artery disease.

A federal review of the deceased patient’s care, conducted by scrutinizing hospital records in the year leading up to his death, found that therapists, nurses and staffers consistently failed to provide him with adequate supervision, nursing, medication, medical care and psychiatric treatment.

Shanetta Cutlar, chief of the Special Litigation Section of the U.S. DOJ’s Civil Rights Division, outlined the care defects last month in a letter to the Oregon Department of Justice. She said the gravity of the case triggered federal alarm about the overall health and safety of OSH patients.

Cutlar’s Jan. 7 letter to the state arrived before the hospital advisory board’s latest meeting, held Jan 21.

Orr talked about aspects of Perez’ care at the meeting but made no mention of the federal critique.

“He didn’t even bring it up,” Adelman said. “That’s very troubling. It’s like he’s hiding stuff from us.”

State Rep. Carolyn Tomei, D-Milwaukie, a non-voting member of the hospital advisory board, said she was taken aback by the newspaper report that detailed the federal critique of OSH.

“We did talk about the young man’s death at the last advisory committee meeting, but I had no idea that the feds were looking into that, nor did I have any idea they had written this letter,” Tomei said. “I guess I would have appreciated knowing that there was such a missive from the federal government.”

Tomei said she was dismayed by the litany of care defects cited in Cutlar’s letter to the state.

“That’s terrible,” she said. “That’s very discouraging.”

Senate President Peter Courtney, D-Salem, who has championed the Legislature’s financial support for hospital reforms and is a non-voting member of the advisory board, did not return a phone call seeking comment on the new federal criticism of OSH.

After this week’s newspaper story, Orr e-mailed to all the advisory board members Cutlar’s Jan. 7 letter and a Feb. 12 state response letter written by Micky Logan, a senior state assistant attorney general. The e-mail stated: “From the onset, the USDOJ has asked that none of its correspondence be disseminated. Our attorneys will continue to honor that request. By law, however, we are bound to release records that are public when a request, such as the one from the Statesman Journal, is made.”

The newspaper recently obtained Cutlar’s letter and Logan’s response to it through a public records request filed with the Oregon Department of Justice.

Orr assured board members that he is committed to providing them “with timely information about OSH, and whenever possible, advance notice of news coverage.”

But several board members said they intend to raise concerns about what they perceive as a lack of critical information coming before the board. They plan to bring it up at the board’s next meeting, set for March 18.

Henderson, a veteran administrator at psychiatric hospital units in Oregon, said it’s essential for the board to delve into problems affecting patient care.

“Those are things that need to see the light of day,” she said. “I’m intimately familiar with how things work in inpatient psychiatric units, and I’m very concerned that we’re not privy to pieces of information that would help us be of assistance, real assistance, at the state hospital.”

Bruce Rogers, a Salem City Council member who serves as chairman of the advisory board, said the panel still has to figure out its role and determine what information can and can’t be discussed at its public meetings.

“I think that’s the dilemma we’re working through,” he said. “We’re not a confidential committee. Everything that comes to us is in the public arena.”

The Oregon State Hospital Advisory Board is not competently chaired. Eight months after its formation no roster of members has been released to the public, no meeting announcements, no agenda, no minutes from meetings have been issued. The scope of work of the Board, the names and contact information of staff, it’s objective and powers are entirely obscure. Until these basic organizational tools are implemented by chair Bruce Rogers, participation breeds contempt.

Joe Anybody’s made a good documentary video about the Albina Ministerial Alliance’s rally about the shooting of Aaron Campbell, from February 17, 2010

Part I

Part II

Part III

Part IV

Part V

From the Salem Statesman Journal, February 24, 2010

Federal investigators have slammed Oregon State Hospital again, citing “alarming” failures in care for a patient who died at the Salem psychiatric facility in October.

The U.S. Department of Justice found numerous flaws and failings in hospital care provided to Moises Perez during the year before his death, documents obtained by the Statesman Journal show.

Writing last month to the Oregon Department of Justice, a U.S. DOJ official said the case has triggered concerns about the overall health and safety of patients at Oregon’s main mental hospital.

Breakdowns in Perez’s care mirrored hospital problems that federal investigators reported to the state two years ago, wrote Shanetta Cutlar, chief of the Special Litigation Section of the U.S. DOJ’s Civil Rights Division.

“Given the amount of time that OSH has had to remedy these deficiencies, we are particularly alarmed by the failures that appeared to have occurred in this case,” she wrote. “We urge OSH to take immediate measures to address these deficiencies in order to prevent similar harm to other patients and to comply with OSH’s obligations under the U.S. Constitution, the Americans with Disabilities Act, and other applicable federal laws.”

On Oct. 17, Perez, 42, was found dead in his bed in a secure treatment unit in the hospital’s forensic psychiatric program. His death was discovered about 7:35 p.m. by a staffer delivering his evening medication.

Perez’s death sparked complaints from other patients and mental health advocates who alleged that staffers neglected Perez and that he was dead for hours before anybody noticed.

A state police investigation found no criminal wrongdoing. An autopsy determined that Perez died from coronary artery disease.

The U.S. Department of Justice reviewed Perez’s care as part of its ongoing investigation into patient care and hospital conditions.

OSH therapists, nurses and staffers consistently failed to provide Perez with adequate supervision, nursing, medication, medical care and psychiatric treatment during the last year of his life, Cutlar wrote. His care “failed to meet generally accepted professional standards” and “consistently fell well below constitutional and statutory standards,” she reported.

The federal agency has concerns that similar defects in care may “likewise violate patients’ rights and foreseeably could give rise to serious harm or death in other situations,” states the letter.

The Statesman Journal obtained Cutlar’s letter, along with a state lawyer’s response to it, through a public records request filed with the state Department of Justice.

The federal review of the case stopped short of concluding that any treatment flaws or failings directly contributed to the patient’s death.

“We understand OSH is conducting its own review, and we respect that process and await those findings,” Cutlar wrote. “We received a limited amount of information, which did not include autopsy reports. We therefore refrain from making any determination as to whether the failures that occurred contributed to the patient’s death.”

Feds uncover familiar problems

The U.S. DOJ’s latest criticism of OSH comes as the state is building a new psychiatric hospital on the Salem campus. The $280 million complex, billed as a world-class facility by state officials, is scheduled to partially open in the fall and become fully operational in 2011.

Cutlar’s letter demonstrates that federal investigators are far from satisfied about reform-minded efforts at the existing 127-year-old mental institution. It also indicates that tough federal monitoring of the hospital won’t end anytime soon.

The U.S. DOJ’s investigation of the hospital began in June 2006.

In January 2008, the agency issued a scathing report that criticized nearly every aspect of patient care and hospital conditions. The report shocked state officials and spurred sweeping reform-minded efforts.

State officials have touted improved patient care. But federal reviewers reportedly found all-too-familiar problems during their review of Perez’s care.

“Specifically, our review revealed inadequate nursing, medical, mental health, and psychiatric care, including a failure to provide individualized treatment,” Cutlar wrote.

Additional shortcomings included deficiencies in the patient’s medication management, supervision and planned interventions for his risky behavior.

“Unfortunately, these are all issues that we have identified as system-wide issues in our findings letter issued January 9, 2008, and that we largely continued to observe during our latest tour of the facility in July 2009,” Cutlar wrote. “We therefore believe that a pattern or practice of violations of patients’ rights continues to exist at OSH.”

Barring an out-of-court settlement with the feds on terms for hospital reforms, the state continues to face the threat of a federal lawsuit that could place the state-run facility under federal court control.

State lawyer defends OSH

Responding to Cutlar’s letter, an Oregon lawyer acknowledged that Perez’s death stirred concerns, but she defended the state’s push to provide patients with better care.

“Like USDOJ, OSH was and is very concerned about this death,” Micky Logan, a senior state assistant attorney general, wrote in a letter to Cutlar dated Feb. 12.

There’s “no doubt” that Perez’s death brought added momentum to the hospital’s drive for reforms, prompting the facility “to redouble its improvement efforts generally and to focus specifically on several issues that you and OSH each identified,” Logan stated.

Her letter outlined 25 “significant changes” made at the hospital since Perez died, including enhanced patient monitoring, increased medical and nursing staffing levels and new standards for dispensing medication.

Logan, the state’s lead attorney in dealing with the feds, denied the U.S. DOJ’s assertion that systemic hospital deficiencies jeopardize patients’ safety and constitute sweeping violations of their civil rights.

“As serious as this event was,” she wrote, “Oregon does not agree that it demonstrates a pattern or practice of violations of patients’ rights.”

Logan emphasized various hospital reforms adopted in recent years, and she said that members of a federal team who made a weeklong visit to OSH last summer appeared to be favorably impressed with the progress. Logan said she was taken aback by Cutlar’s assertion that the federal team observed lingering problems at OSH.

“This statement comes as a surprise to us, as our interactions with the US DOJ experts throughout their July 2009 visit suggested to us that they were favorably impressed by the significant improvements they observed,” she wrote.

The state attorney complained about Oregon officials being kept in the dark about key federal findings during the prolonged investigation.

“We note that we have requested on multiple occasions that US DOJ provide us with the reports of all its experts,” she wrote. “While such reports (especially the most recent) would be of particular assistance to OSH in its ongoing efforts, we have not received copies of any of these reports.”

Letter from Special Litigation Chief, U.S Department of Justice Civil Rights Division Shanetta Cutler to Oregon Assistant Attorney General Mickey Logan, 2 12 2010

Letter from Oregon Assistant Attorney General Mickey Logan to Special Litigation Chief, U.S Department of Justice Civil Rights Division Shanetta Cutler, 2 12 2010

READ – Letter lists oversights in patient’s death, Salem Statesman-Journal, February 24 2010

Going to a good horror movie is a great way to spend a Saturday afternoon. And going to a bad one can be even better. “The Crazies,” opening in Portland on Feb. 26, promises plenty of horror–but probably not the kind the filmmakers intended.

In this remake of George Romero’s 1973 parable on the Vietnam War, the residents of a small Midwestern town start to descend into madness, and a small band of neighbors must fight for their lives.

The official movie website says that, as residents start to go insane (due to a mysterious toxin in the water supply), they are turned into mindless, depraved killers with an uncontrollable thirst for violence and horrific bloodshed. The few healthy citizens are plunged into a terrifying nightmare, and must battle their neighbors for survival.

Sound like a satisfying bit of mindless fun? Maybe. Except that it’s part of a genre of psycho killer movies informed by fear, misunderstanding, and deep-seated prejudice.

To put the movie and its message in perspective, imagine this:

What if the residents of a small town, infected by a mysterious toxin, turned into members of any other minority group–and became depraved killers?

What if people started developing any other kind of disability, and then automatically went on a killing spree?

Most people would find it shocking–even for a horror movie.

People with mental health challenges are human beings. They are moms, dads, employees, professionals, community members. They have daily struggles, just like anyone else. They’re a diverse group of people, with individual likes, dislikes, talents, and dreams.

What about the risk of violence, then?

Even among persons with severe problems, including psychosis, an August 2009 review by Martin Grann, Ph.D., found that the risk of violence was insignificant, unless the person also abused alcohol or drugs. Grann reached this conclusion based on 20 studies, which included a total of 18,423 individuals with mental illness and 1,714,904 individuals from the general population.

In other words: mental illness by itself does not predict violence.

Sadly, in the movies, according to a study cited in the Surgeon General’s Report on Mental Health, people with mental illness are frequently portrayed as homicidal maniacs. This perpetuates a stigma that’s more toxic than anything in the water.

According to the Surgeon General’s Report, “Stigma leads others to avoid living, socializing or working with, renting to, or employing people with mental disorders… It leads to low self-esteem, isolation, and hopelessness, [and can even result in] outright discrimination and abuse.

“More tragically, it deprives people of their dignity and interferes with their full participation in society.”

We just noticed – the Oregon Health Forum died back in December 2009. Likely cause? Boredom and a bad board.

When the four-page newsletter first came to our attention in the early 1990s it was a fascinating read, a true dope-sheet with the inside stuff, the real close-the-door-I-gotta-tell-you gossip we all want to read. Who got fired and who got rehired. Who’s suing who. The payrolls of insurance and HMO presidents. On-the-record interviews with the middle-managers who wrote and broke policies.

If you were a health-politic-geek it was a necessary read. Remember way back when, in the olden days, when you would pick up Willamette Week to make sure you weren’t in it, and stay to laugh at the mug shots of your friends and enemies? It was like that. But about healthcare.

The newsletter grew under the auspices of Diane Lund-Muzikant who chose, for reasons we could never quite understand, a nonprofit model. Finding friends and industry-insiders who knew to keep their enemies close, her board also grew. Lund-Muzikant, a hard-headed former Oregonian reporter, knew all the sore spots and kept poking, seeking accountability, transparency, and good government.

The board veered away from independent advocacy and toward industrial-sympathies and in October 2006 Lund-Muzikant was out.

The Oregon Health Forum limped along for a couple of years, and under new publisher Carol Robinson content dissipated, good healthcare writers came and went, and the spirit to write – and bite – was lost. The nonprofit board, now filled with PR flacks from a dozen different agencies suitable for criticism, had won.

In 2009 Lund-Muzikant launched The Lund Report, and wrote the obits for the OHF, see below.

Health, next to government and education, is one of the biggest industries in Oregon. The public spends billions on it each year – and most of us haven’t a clue about the value of our exchange. It takes independent and impartial reporter to bring us this information – so the crack-up of the OHF in 2006 was a great loss. That it finally stopped printing in 2009 was hardly a blip.

Oregon Health Forum Closes Doors – The announcement makes The Lund Report the sole provider of dedicated Oregon healthcare news, December 2009

My Take on Why Oregon Health Forum Went Under – Diane Lund-Muzikant offers her thoughts on the demise of the organization she founded, December 2009

Many people think psychosurgery is a thing of the past, and it’s true that lobotomies have become rare. However, psychosurgery is very much alive. Neurosurgeons are trying to rehabilitate the practice, and they may be succeeding.

Because of its dark history, psychosurgery has been restricted and forced to take a low profile. But in 2010, with a new name–“functional neurosurgery for psychiatric disease”–and new techniques like deep brain stimulation, some clinicians are predicting a comeback.

Psychosurgery is now being explored for everything from depression to addiction. In a two-part article, psychosurgery’s grim history–and quiet comeback–are explored.

Read more:

Part 1 – A chilling history, and a possible comeback

Part 2 – From lobotomy to deep brain stimulation

Thanks to The Skanner Newspaper for this video.

The newspaper article below expresses the continuing discrimination against persons with mental illness in the housing, neighbor relations, and the media.

We were recently told over 60 persons were kept under lock and key at the state hospital for no reason other than there is no housing available outside of the hospital for them. This is a violation of their civil rights, their human rights, and arguably a crime. Ignorant neighbors like those in Portland’s Centennial neighborhood are largely to blame.

The media perpetuates the Not-In-My-Backyard discrimination by giving voice to the ignorant and uninformed. The Oregonian reports a wide variety of news about persons with mental illness – not all of it well-meaning or well-informed. We can get their story straightened out by telling our stories of housing discrimination.

ACTION ITEM: Contact Richard Bixby, Executive Director, East Portland Neighborhood Office, rbixby@ci.portland.or.us – phone: (503) 823-4501. Bixby is a city employee and an accountable person for issues about use of neighborhood resources.

ACTION ITEM: Write a letter to the editor of the Oregonian, Therese Bottomly at theresebottomly@news.oregonian.com

ACTION ITEM: Learn more about ColumbiaCare Services.

Home for mentally ill worries East Portland neighbors, Oregonian, February 20, 2010

The opening of a home for two mentally-ill people in the Centennial neighborhood of East Portland brought about a dozen angry and suspicious neighbors to Betty Englestad’s home tonight to confront the home’s operators and state officials.

“Why were we not notified?” Englestad asked. “Maybe if we had known, this wouldn’t have happened.”

Jennifer Jones, communications manager for Medford-based ColumbiaCare Services, Inc., explained that federal fair housing law doesn’t allow them to do that.

“We have to protect the residents’ confidentiality, and try to avoid discrimination or harassment,” Jones said.

CLICK HERE FOR THE REST OF THE STORY

Despite a recent warning in The Skanner, Derald Walker, CEO of Cascadia Behavioral Healthcare, thinks Portlanders can, and should, call 911 in crisis, if needed. It’s appropriate, Walker said, and can connect people with resources.

The Skanner’s warning came after the shooting death of Aaron Campbell on Jan. 29. Campbell was, according to The Oregonian, “an unarmed African American guilty of nothing except being suicidal and distraught.” Rev. Jesse Jackson called the death an “execution.”

Walker said he realizes that people have concerns and fears, which he called unfortunate, but, to some extent, understandable.

He added, “I think the Portland city police are trying to handle a lot of things on the streets that, quite frankly, if mental health services were more available, they probably wouldn’t be confronted with.”

Resources Needed

Walker believes that Portland police are trying to reduce the number of bad outcomes. The bureau has adopted crisis intervention training, which is now required for all officers.

But additional resources are needed, said Walker.

“We need more housing for people with mental illness, more after-hours service for people with mental illness – for everybody. And people aren’t always eligible for treatment. If you’re not on the Oregon Health Plan, you may not have access to mental health treatment; we need universal funding for mental health services. Funding is just not adequate at this point.”

Build Networks

Dan Handelman, of Portland Copwatch, said that police shootings are actually down in recent years.

Still, in the past five years, at least five people with mental illness, or in crisis, have been killed by Portland police:

Aaron Campbell, 2010
James Chasse, Jr., 2006
Jerry Goins, 2006
Tim Grant, 2006
Raymond Gwerder, 2005

Handelman points out that it’s difficult to pinpoint the exact number of cases, since mental illness is not always reported, and “crisis” is open to interpretation.

Asked whether people should call 911 in crisis, Handelman said ideally, people wouldn’t have to.

“In my opinion, people should build networks with family, friends, coworkers and neighbors so that, to the extent possible and reasonable, there is no need to call police. I also believe that a person should be able to call 911 and explain they have a mental health crisis situation and that should be able to be resolved without an armed police presence.

“People need to make up their own minds about what to do, but certainly given the possible outcomes I hope that more community building and less reliance on armed intervention is in this city’s future.”

A comprehensive record of media items and public documents about what happened to Aaron Campbell is available at http://www.mentalhealthportland.org/?page_id=4359 or click on the Aaron Campbell button above.


If you have items to add to this page, email them to info@mentalhealthportland.org.


If you would like to volunteer to help maintain and protect this archive send a message to info@mentalhealthportland.org. You must have a good working understanding of Wordpress to help with this task.


The Mental Health Association of Portland has no relationship with the Campbell or Davis families or with their legal representatives. We cannot put you in contact with them or forward messages to them for you.

Many people use advance directives to express their wishes for end-of-life care. But that’s not their only use. In Oregon, a Declaration for Mental Health Treatment can be used to indicate preferences for psychiatric treatment, helping to ensure that, should you be hospitalized and unable to give or withhold consent, your wishes will be honored.

Why prepare a Declaration for Mental Health Treatment? It can be difficult for anybody to assert themselves in a hospital situation. For someone in crisis, it might be almost impossible.

A person with severe depression, for instance, might be handed a consent form and be told, “This is the best treatment for you” – and scribble a signature, without fully apprehending that he or she just consented to ECT.

A Declaration for Mental Health Treatment can help prevent this from occurring. You may expressly tell physicians, beforehand, that you absolutely do not want certain interventions, such as electroshock treatment, medications you can’t tolerate, or the use of seclusion and restraints.

You can also use the form to give providers information they wouldn’t otherwise have. For instance, you could tell them it helps to give you privacy – or that you do not want to be left alone for long periods.

While there are certain situations where your wishes can be overridden, these are extremely limited.

Some people might hesitate before preparing a Declaration for Mental Health Treatment; does it mean you are resigned to the eventuality of a future hospitalization? Actually, an Advance Directive is more like an insurance policy. Maybe you won’t have to use it, but it’s nice to know it’s there.

Forms and Information

Declaration for Mental Health Treatment (PDF)

Declaration for Mental Health Treatment (Word)

Directions for preparing a Declaration for Mental Health Treatment (State of Oregon)

How to Write a Psychiatric Advance Directive (eHow.com)

Oregon law pertaining to mental health directives

On Feb. 10, the American Psychiatric Association released proposed diagnostic criteria for a revised version of the “psychiatric bible,” the Diagnostic and Statistical Manual of Mental Disorders, and is now accepting public comments on the draft.

APA President Alan Schatzberg, MD says the revision is “by no means final” at this point.

The DSM classifies and describes psychiatric disorders, aiming to ensure accurate and consistent diagnostic practice. It is fundamental to the medical model of psychiatry. Even the smallest change to the text carries tremendous weight – and now, some big changes are on the table.

Among the proposed changes for the fifth edition of the manual (DSM-V), currently planned for release in May 2013, are the following:

• Elimination of the “bipolar” label for kids. The suggested criteria eliminate the diagnosis of pediatric bipolar disorder, replacing it with “Temper Dysregulation Disorder.” While the change could reduce overdiagnosis of bipolar disorder in children, with accompanying overprescription of pharmaceuticals, some are saying the new label is so broad it could “diagnose” most kids.
• Replacement of “Asperger’s Syndrome” with high-functioning autism, eliminating Asperger’s as a separate diagnosis. This proposal is causing consternation among those currently diagnosed with Asperger’s, who would, under the draft language, be relabeled “autistic.”
• Addition of a new category, “behavioral addictions” – with gambling as the sole disorder. Other behaviors, such as Internet use, were considered for this category, but were rejected.
• Inclusion of “risk syndromes,” intended to allow diagnosis of certain disorders in their earliest stages. This change, however, might prompt some doctors to diagnose and treat “illnesses” before they actually exist.

Being diagnosed with a psychiatric disorder can impact your life, your self-image, and even your ability to get insurance or a job. Take the time to read more about proposed changes for the DSM-V, and take the time to tell the APA what you think. Submit your comments at the DSM-V website by April 20, 2010.

About 100 people gathered this morning on the steps of the Downtown Justice Center in Portland to issue a call for justice in the Aaron Campbell shooting, a botched effort at crisis response that ended up taking a young man’s life.

The rally was organized by the Mental Health Association of Portland and the Albina Ministerial Alliance to draw attention to the police shooting of Campbell, 25.

Supporters called for a public inquest into the death, and the appointment of a special prosecutor to look into excessive use of force by Portland Police.

Dr. LeRoy Haynes, of the Albina Ministerial Alliance, said that, although the community had been disappointed by a grand jury’s refusal to indict Officer Ronald Frashour in the death, they will continue to struggle.

“We will continue to knock on the doors of City Hall and the criminal justice system for justice,” said Dr. Haynes.

Read more

In a three-page letter delivered to District Attorney Michael Schrunk, members of the grand jury in the Aaron Campbell police shooting case said that, although they did not return indictments against officers involved, “something went terribly, terribly wrong… Aaron Campbell should not have died that day.”

“He was not accused of a crime,” the letter continues. “The police were called to do a ‘welfare check’ because Mr. Campbell was distraught over his brother’s death and family members were worried about him.”

“We feel that his death resulted from flawed police policies, incomplete or inappropriate training, incomplete communication, and other issues with the police effort. We feel strongly that something must be done to correct this, and the Portland Police Bureau should be held responsible for this tragedy.”

The grand jurors believe that no single officer was at fault, but the entire police bureau. They said, however, that they could not indict or censure the police bureau.

Aaron Campbell, 25, of Portland, was shot and killed by police in what some are calling a “suicide by cop.”

However, according to Campbell’s mother, Marva Davis, Campbell was trying to surrender to police when they shot the distraught man in the back.

Campbell was unarmed.

An account at Wells Fargo Bank has been opened to help the Campbell family pay funeral expenses and create trust funds for the surviving children. To contribute, click here.

Read the entire grand jury letter here.