After escapes, Oregon State Hospital promises changes

Matthew Ingle in court after his capture

Matthew Ingle in court after his capture

By Dan Tilkin,, Feb. 10, 2012

After 18 months of care, Matthew Ingle, 21, had earned the privilege of taking a supervised walk outside the Oregon State Hospital in Salem.  Doctors and therapists at the secure facility that treats the mentally ill thought Ingle was progressing well in his treatment for schizophrenia.

On Sept. 3, 2011, two staff members were supervising Ingle and three other patients as they strolled along the hospital grounds. Suddenly, Ingle bolted from the group and ran to a car parked curbside with an open passenger door.

Ingle jumped inside and the car sped off.

For 17 days Ingle was on the run until a tip led Oregon State Police to where he was hiding near the town of Sandy, Ore.

Ingle’s escape threw a spotlight on the state hospital’s security procedures.  At the time, hospital Superintendent Greg Roberts promised KATU he would quickly release a report detailing what happened and what exactly went wrong.

Four months went by before KATU finally received the report; however, it was almost useless.

Most of the information in the report had been redacted due to federal patient confidentiality laws.

READRedacted OHS Report (PDF, 230KB)

Recently, hospital officials offered to take a KATU investigative reporter into the facility for a tour of its new wing that will open in March. Their goal was to prove administrators have delivered on the promise to chance the hospital’s culture.

They were incompetent in what they were doing,” said Kathy Pollock when she spoke to KATU News in September after learning of Matthew Ingle’s escape.

OSH security fencing with anti-climb mesh

OSH security fencing with anti-climb mesh

Pollock lost her granddaughter, Clarice Benson, and daughter-in-law, Pamela Benson, when Ingle rammed into their car on April 25, 2009 at the intersection of Highway 26 and SE Orient Drive near Sandy.

Court records show Ingle was driving under the influence of marijuana, anti-depression and antipsychotic medications.  He was eventually sentenced to 20 years under the supervision of the Oregon Psychiatric Security Review Board, which placed him in the secure Oregon State Hospital for treatment.

Ingle was just the latest patient to escape from the state hospital.  A KATU investigation in 2007 found ten escapes in a two year period, including seven people with violent histories.

They included escapees like Chris Walker, who murdered his girlfriend; Thaddeus Zemlack, who killed his mother; and Tamarra Thomas, who shot and wounded her son.

In the last five years 24 patients with criminal backgrounds have escaped from the state hospital. That’s out of an average criminal population of 400.

Matthew Ingle’s escape was one of three escapes in 2011 alone.

Within days of Ingle’s disappearance, the Clackamas County District Attorney’s office, which prosecuted Ingle, sent a terse letter to Roberts.

“That Mr. Ingle had the opportunity to simply run off … raises serious questions about the hospital’s commitment to the legitimate safety concerns of the public,” wrote Greg Horner, Chief Deputy District Attorney.  “An in-depth, transparent and critical assessment of this case is important. As I am sure you agree, for there to be positive change, there must be accountability.”

READ – Clackamas County Letter (PDF, 52KB)

“The case in itself is troubling, but in some ways it’s a reflection of the mindset down there that really didn’t prioritize the fact that some of these folks are really quite dangerous. And that’s the part that needs to change,” Horner told KATU News in an interview.

“They are patients, I agree with that as far as it goes, but they are patients who have committed very, very serious act, at least some of them are, Mr. Ingle is,” he added. “That historical perspective needs to be incorporated into their treatment of these people in terms of how they manage security issues.”

WATCH After many escapes, state promises changes at Oregon State Hospital


The new Oregon State Hospital wing is the second new wing to open since August.

Chief Medical Officer and psychiatrist Dr. Rupert Goetz showed KATU News rooms specially designed to hold patients during a “behavioral emergency”.

Goetz showed “sensory” rooms that will have things patients can touch and listen to, which will help them calm down.

The new facility also has hardware to prevent patients from hanging themselves, such as sloped hinges and lighting.

The new facility also has new fencing with “anti-climb” mesh. It’s designed to prevent patients from escaping.

Perhaps more important than the physical structures of the hospital is the attempt to change security policies:

  • The hospital says it has developed a hospital-wide “culture of safety” initiative to balance clinical treatment needs of patients with the safety needs of patients, staff and the community.
  • The state hospital has started a new program to notify victims if a patient escapes. That wasn’t done prior to Matthew Ingle’s escape.
  • Computer and Internet privileges of patients have been reviewed, as well as the hospital’s ability to monitor internet and social media. Matthew Ingle talked about escaping on his Facebook page. Patients still have to earn the privilege to use the internet.
  • Staffing ratios on excursions have been reviewed. Ratios depend on the level of escape risk.
  • The hospital completed audit of all privilege levels to make sure each patient is in line with their risk level.
  • The nursing supervisor will evaluate each patient on the day of an outing to make sure nothing has changed in the patient’s health.
  • The hospital assessed outings to make sure they are being done for therapeutic reasons.

“We’re to make sure that everybody who goes out is out there for a good clinical reason and the risk they pose to the community has been looked at in a very standard and accountable process,” Goetz said.

Goetz began working at the state hospital just days before Ingle escaped.

“Our whole risk review process was completely reviewed and updated,” he said.

The hospital had already changed its security polices for how it handles packages mailed to patients. They are now X-rayed and opened by staff in front of the patient. Packages used to be opened by patients in front of staff.

The change was made because of a 2009 incident when patient David Anderson was mailed wire cutters and a DVD Player.

Clackamas County prosecutors told KATU they are encouraged by the new leadership and policies at the hospital.

Meanwhile, the state hospital has to balance security demands with the fact the hospital is not a prison.  The hospital’s job is to rehabilitate and re-introduce patients to society and that means giving them more freedom as they earn it.

A KATU News reporter watched just last week as patient Nick Teixeira, who shot Clackamas County Sgt. Damon Coates in the face in 2003, simply walked out of the state hospital’s headquarters after a psychiatric hearing and went across the street to his housing unit.

He was escorted by hospital employees who are unarmed. All hospital employees are unarmed. They carry radios to call for help if a patient tries to escape. Oregon State Police and local law enforcement would be notified if a patient tried to escape.

As for Ingle, he will be free from state care at the end of his 20 year sentence.

“We also have to understand the reality of the crime they were involved in,” said Goetz, “It may be guilty except for insanity, but there was a crime there. That means there were victims there. We have empathy for our patients but we have to have a huge understanding for the pain and suffering of the victims.”

Raw interview with Dr. Rupert Goetz:

WATCHDr. Rupert Goetz Interview – Part 1

WATCH Dr. Rupert Goetz Interview – Part 2