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.”