According to The Oregonian, Moises Perez‘ death at Oregon State Hospital in October 2009 was preceded a year earlier by the suicide of another patient, David Morse. Both were on Ward 50F, and both were being treated by the same psychiatrist, Dr. Michael Robinson.
Despite two tragedies only a year apart, a report released to The Oregonian concluded that Robinson treated Morse with an “appropriate standard of care.”
Morse, age 56, hanged himself Oct. 29, 2008. He used a piece of cloth attached to a tilted metal bed frame, setting off a review by the state Office of Investigations and Training to investigate whether Robinson was negligent, overlooking Morse’s worsening condition.
According to the report, Morse had an empty bed in his room, which may have been standing up on end for three days or more. After hospital personnel noticed Morse’s suicide attempt, they cut the cloth strips from his neck. He was still breathing. Emergency medical responders were called, but they were delayed. One of the building’s elevators was closed for repair, and the other was being used to haul lunch trays.
Morse continued to hang on to life for several days, but died on Nov. 10.
Although the report said Robinson’s care met an appropriate standard, it also listed additional problems on Ward 50F, a medium security ward that housed Perez when he died last year. Perez lay dead in his room for several hours without anyone noticing.
According to The Oregonian, “Fallout from the Perez case led to the forced resignation last week of the Oregon State Hospital superintendent, a sharp warning letter from the U.S. Department of Justice, and calls from patient advocates for greater scrutiny of an institution that has seen decades of troubles.”
Bob Joondeph, executive director of Disability Rights Oregon, told The Oregonian that two deaths, with a year of each other, on the same ward, with the victims under the care of the same doctor, are “disturbing.” But, he went on to say, it is consistent with the ward’s repution. Interim Superintendent Nena Strickland, who has worked at OSH for 15 years, told the newspaper that officials “recognize there are issues on Ward 50F.”
Three weeks ago, the hospital assigned a physician to evaluate the ward’s functioning and develop plans for improvement. Those plans, sadly, will come too late for Perez and Morse.