Oregon State Hospital advisers want to focus on making fixes

From the Salem Statesman Journal, October 30, 2009

The board must address more issues than patient treatment, Courtney says

A new Oregon State Hospital advisory board needs to focus on fixing problems at the psychiatric facility instead of being cheerleaders for reforms already achieved, several panel members said Thursday.

“I don’t want this group to turn into a showcase for what you think you’re doing well,” Dr. Maggie Bennington-Davis said during the panel’s inaugural meeting.

Bennington-Davis, the chief medical officer for Cascadia Behavioral Health care, urged state hospital officials to bring chronic problems and struggles to the advisory board, opening the door for possible solutions.

Another board member concurred.

“We don’t need to be your cheerleaders,” said Dr. Robin Henderson, the director of behavioral health services at St. Charles Medical Center in Bend.

The 16-member citizen-led board was created by the 2009 Legislature to provide oversight of the state-run psychiatric facility. The U.S. Department of Justice issued a searing critique of patient care and hospital conditions in a January 2008 report, and the federal investigation remains unresolved.

The advisory panel is charged with conducting a comprehensive review of hospital rules, policies and procedures related to the safety, security and care of patients.

The board can make recommendations to Roy Orr, the hospital superintendent; Dr. Bruce Goldberg, the state human services director; and the legislative assembly.

On Thursday, Senate President Peter Courtney, D-Salem, a nonvoting member of the advisory board, raised concerns about the scope of the panel’s oversight.

Courtney said the legislative intent was to create a general-purpose advisory board.

In keeping with that, he said, the panel should examine many hospital-related issues, from parking and traffic concerns to possible changes in state laws.

Focusing only on patient treatment would be a mistake, he said.

No decisions were made during the opening session about board priorities or specific issues to tackle. The board initially plans to meet monthly.

At the start of the first meeting, Mike Adelman, one of two former hospital patients on the panel, spoke briefly about the Oct. 17 death of patient Moises Perez.

It’s important, he said, that the case not be swept under the carpet.

Perez, 42, was discovered dead in his bed on Ward 50F, a secure treatment ward in the hospital’s forensic program.

Other patients and mental-health advocates have alleged that staffers neglected Perez and that he was dead a long time before anybody noticed.

An autopsy concluded that Perez died from coronary artery disease.

Inquiries into his death are being made by the Oregon State Police and the State Office of Investigations and Training. Hospital officials have said that confidentiality laws, as well as ongoing investigations, prevent them from talking in detail about the case.

Adelman, who was released from the hospital in 2005, said he was troubled by the “suspicious circumstances” of Perez’ death and the lack of information released to the public about it.

“It may never be known to the public what the whole story is because of privacy laws,” he said.

Other than Adelman’s remarks, the advisory board did not discuss the case.

OUR COMMENT – The new Oregon State Hospital advisory board is charged with reviewing the safety, security and care of patients and may delve into other hospital-related issues. The panel can make recommendations directly to the hospital superintendent, the state human services director and the Oregon Legislature.


The advisory board was created by legislative action in June and finally met for the first time on October 29, 2009. No roster of members, no leadership, no agenda and no information about the time or place of the meeting were widely distributed or are on the OSH web site.


As for Peter Courtney’s comment, the voting members of the advisory board should do what they like within the legislative mandate.

READ – Oregon State Hospital employee newsletter, Recovery Times, October 2009

MORE – Oregon State Hospital Advisory Board members include the following:
• Mike Adelman, Salem, former state hospital patient
• Beckie Child, Portland, mental health advocate and president of Mental Health America of Oregon;
• Nona Clarke, Hillsboro, former state hospital patient
• Dr. Robin Henderson, Bend, director of behavioral health services at St. Charles Medical Center
• Corbett Monica, Sandy, executive director of Dual Diagnosis Anonymous of Oregon, a peer support program for persons recovering from mental illness and substance abuse
• Herbert Ozer, Portland, administrator of behavioral health services at Providence Health and Services
• Janet Spinosa, Salem, mother of a state hospital patient
• Deborah Weston, Portland, staff attorney for the Oregon Law Center

Non-voting members include:
• Sen. Peter Courtney
• Brant Johnson, Salem, state hospital mental health therapist
• Dr. Lorraine Skach, Keizer, state hospital psychiatrist
• Frank Warner Jr., Keizer, state hospital nurse
• Rep. Carolyn Tomei