Seeking solutions state and counties study a tiny fraction of deaths of patients in Oregon’s mental health system

From The Oregonian, December 31, 2002 – not available online

For more than a decade, Oregon has relied on county mental health agencies to investigate themselves when a mentally ill patient dies under their care.

The result: County officials have faulted their own conduct in only two of 247 deaths during the past 3-1/2 years.

State records show that in nearly 50 of those cases, county officials performed a cursory inquiry in which they did not interview the families of the people who died or the mental health workers responsible for their treatment.

Officials at Oregon’s Department of Human Services acknowledged in interviews that their system for tracking patient deaths is inadequate and that their records included a number of cases that should have been more closely examined. They said they had assigned only one person to review the countys’ reports of deaths and had neither the staff nor the budget for more in-depth investigations.

Shown The Oregonian’s analysis of his own agency’s files, Bob Nikkel, community services manager for the DHS Office of Mental Health & Addiction Services, said the statistics were “not a surprise” and reflected the state’s longstanding failure to track deaths in county mental health agencies.

“Aside from whether people are whitewashing certain aspects of the investigations, when you do these things on an absolute shoestring you’re asking for problems,” he said of the death reports counties send to his department.

Several officials suggested patients’ groups go to court to force tighter scrutiny of county mental health agencies.

“Someone should sue us,” said Kevin Moynahan, regional protective services coordinator for the DHS Office of Investigations and Training.

Moynahan and his supervisor, Eva Kutas, said a lawsuit had prompted the state to assign four workers to review death and abuse cases involving developmentally disabled people, even though they number 15,000 statewide, compared to the 66,000 Oregonians with mental illness who are under state care.

“I read all the stuff that comes in, and I’m thinking, ‘This is just wrong,’ ” said Karla Kerstner, the lone state worker reviewing mental health death reports. “But our hands are tied. We don’t have the people, the budget or the law on our side. And it’s sad for the people who’ve been hurt and all the potential victims out there.”

Among the mental health deaths the state did not question:

* Amelia Scott, a 44-year-old schizophrenic homeless woman, who died “suddenly and unexpectedly” inside the psychiatric unit of a Portland hospital. The only explanation the hospital could offer was that she stopped breathing. State and county officials never asked why.

* A 38-year-old man in Baker County who committed suicide. In explaining why the county chose not to investigate the case, a supervisor wrote that the man’s suicide note “exonerated others for his suicide choice.”

* Norrine Sharkey, 52, who visited a Linn County mental health office, where she admitted drinking alcohol with her medications. Both her therapist and the doctor asked for the pills, but she refused, promising to flush them down the toilet. She was found dead the next day from an overdose. The state closed the case after a phoned-in account from the county.

The counties play a crucial role in Oregon’s mental health system. Almost $300 million a year in state and federal money to help the mentally ill is distributed to 33 county agencies. They in turn hire mental health workers and psychiatrists, or contract the work out to companies or local nonprofits.

It is up to state officials in Salem to make sure the money is well spent and that patients are properly cared for.

Counties were not even required to report deaths until 1991. That year, the Legislature passed a law that ordered mental health agencies to file a report on patients who die “by anything other than accidental or natural means.” The law gives counties 45 days to investigate whether “abuse” played any role in the deaths.

Under pressure from county officials, lawmakers drafting the statute drew an important distinction: Abuse was defined only as deliberate or “willful” acts to harm a patient. Neglect or serious errors by mental health workers were not covered.

In the nearly four years for which records were available to examine, nearly 100 Oregonians have died after significant lapses by county agencies, state records show. None was defined as “abuse.”

Only five cases were subsequently examined by DHS, which has broad authority to look at how the counties are spending their mental health dollars. Experts say patient deaths are one crucial warning sign of potential problems with the work of a county or its contractors.

DHS officials said they investigate deaths when they perceive something unusual in the county reports.

The DHS investigator who handles death cases has no authority to shut down a county mental health agency. If serious flaws are found, the matter is referred to another part of DHS, which licenses mental health agencies. None of the deaths of mentally ill patients in the past 3-1/2 years has prompted the state to strip a county’s authority to provide care.

Some patient deaths are never even reported to the counties. Dr. Peter Davidson, head of Multnomah County’s mental health department, said that in 2000 when he took over the agency, he discovered 20 unreported deaths in a 15-month period in one facility under contract with the county.

Davidson said he called the state and said, ” ‘You’ve got a company here pretending that it’s taking care of people in order to keep its cash flow going. You have to close them to admissions because they are killing people.’ ”

Davidson said the state workers “got a little upset with me,” but briefly looked into it and said they couldn’t find problems because the program kept no documentation.

“They would never allow this in surgical practice,” he said. “But in psychiatric practice, a lack of record keeping is considered prima facie evidence of competency?”

The company was bought by Cascadia Behavioral Healthcare, the largest mental health provider in Multnomah County, and now provides services under that name. Mark Schorr, a Cascadia spokesman, said, “Clearly having 20 unreported deaths, in fact, any unreported deaths, is unacceptable,” but he could not say how it had happened because the former program officials no longer work for the agency.


Amelia Scott, a 44-year-old homeless woman with schizophrenia and no known family, was placed in the “quiet room” of the psychiatric unit at Legacy Good Samaritan Hospital and Medical Center in Portland on April 13. Twenty minutes later, she was dead.

No one ever bothered to find out why.

A hospital doctor conducted a “provisional autopsy” that found Scott had died of “cardiorespiratory failure, etiology not determined.” In other words, she stopped breathing for unknown reasons. The medical examiner did not take the case after being told that Scott had died of natural causes, records and interviews show.

Another stone unturned: Toxicology tests ordered upon Scott’s admission were canceled after her death, DHS records show.

Despite such sketchy information, a mental health worker urged the state to close the case. Even though Scott died “suddenly and unexpectedly,” wrote Iris Kern, a protective services investigator for the Multnomah County mental health department, “It is my impression that there is no allegation that the treatment given to Scott by any mental health providers contributed to her death.”

The state agreed, and on May 1 filed away Kern’s 1-1/2-page report, one of the few pieces of obtainable proof that Scott ever lived.

It wasn’t until The Oregonian questioned how abuse could be ruled out based on so little information that state officials conceded that Scott’s case might have deserved a closer look. “You’re right,” said Kerstner, the state employee who handles all abuse and death reports within the mental health system. “It’s unclear from that why she died.”

Kern did not return calls for comment. Davidson, the Multnomah County mental health director, said his employees have to rely on the records hospitals provide, which frequently are incomplete, but allowed that “if this had been an important person, this wouldn’t have happened.”

Hospital officials declined to comment, saying medical privacy laws do not allow them to do more than confirm the time and date Scott died.

Asked what became of Scott’s body, a hospital spokeswoman would speak only in general terms about policy governing such matters: The unclaimed bodies of indigent people are disposed of by the crematorium with the lowest bid.

The death of Elise John, a 28-year-old woman suffering from schizophrenia, illustrates one reason Oregon’s counties are reluctant to look too closely at patient deaths: The cases sometimes involve hospitals that are the only providers of crucially needed psychiatric beds in a county.

John, an heiress to the Miller brewing fortune in Milwaukee, was involuntarily hospitalized after a suicide attempt in March 1999. She spent two weeks at Good Samaritan Hospital in Portland, mostly under her covers or cowering near the nurses’ station, hiding from an imagined killer. State records show she talked openly about hanging herself, tried to swallow a comb and ate soap.

Nonetheless, John’s psychiatrist released her on an evening pass, alone, to buy clothing for herself on March 26, 1999. John bought a rope, waited until dark and hanged herself from the Morrison Bridge.

Three days later, the state closed the case after a county investigator filed a report saying the death did not result from “abuse,” meaning it did not involve a deliberate act of wrongdoing.

Another county worker, Greg Monaco, the investigator who had petitioned a court to send John to the hospital, said he “discovered errors” in the investigative report of her suicide and challenged why she had been released.

“When I pointed out the errors to my superiors, I was stonewalled and worse,” he said in a letter to an advocacy agency. “The reaction I received convinced me that the county administrators at that time were more interested in denying complicity and protecting their relationship with the hospital involved than they were in honestly evaluating the preventable circumstances that led to Ms. John’s death. No one at either the county or state level seemed willing to look at this tragedy. It wasn’t worth their time.”

After Monaco’s complaint, another county worker revised the findings of the county’s report to the state to “inconclusive.” The state did not investigate further.

The agency Monaco wrote to later determined that the county’s inquiry into John’s suicide “lacked thoroughness and independence.”

“The county should not be investigating itself or its business partners, the hospitals,” Monaco later wrote in a letter to the advocacy agency.

Davidson, hired to reform the system in which Monaco works, said he has placed a much higher emphasis on getting to the bottom of why county mental health patients die.

But the potential conflict of interest that arises when counties investigate possible wrongdoing at hospitals or other contractors remains, not only in Multnomah County but throughout the state. In at least three cases The Oregonian examined, the state closed the files after case managers and therapists had investigated the deaths of their own clients.

A bill to provide independent oversight of investigations of care in county mental health agencies failed during the past legislative session. Advocates say they will try again next session.

“There needs to be an independent watchdog to keep everyone honest,” Monaco said in an interview by e-mail, “to ensure that the very necessary checks and balances are in place.”

Inconsistent practices

The Oregonian’s review of death reports by counties found a hodgepodge of procedures.

Some county workers routinely closed cases with no greater effort than clipping a client’s obituary and mailing it to the state. Other reports were written so unprofessionally they were either illegible or rife with misspellings. One investigator noted, “Due to suicide, (alleged victim) was not interviewed.”

An analysis of the records shows that of the 247 deaths collected in state files, 46 were closed with an obituary or brief account phoned in to DHS. Asked about the case in which a Baker County worker relied on a man’s suicide note to justify not investigating, Nikkel, the DHS official, rolled his eyes and said, “The obvious appearance is that it’s grasping for anything that would exonerate” the county.

Ninety-three death cases were given a cursory examination by county officials and were closed because they did not meet the state’s definition of abuse. In 98 additional deaths, counties looked more closely but still could find no fault with their actions or those of their contractors. Eight deaths, they found, were “inconclusive.” Only twice did county workers determine abuse had led to a client’s death.

DHS has been slow to build a system for dealing with the county reports, which began trickling into its offices after the law was passed in 1991. Before 1999, the reports were stuffed into a cardboard box and reviewed by a DHS worker allowed to devote only a quarter of her work week to the task, officials said.

That year, DHS transferred the job to its Office of Investigations and Training and hired Kerstner full time to serve as the gatekeeper to the reports.

Since then, the state has examined five deaths, a slight improvement from what it did before.

The state is well aware of the lack of accountability. Last year, DHS conducted focus groups and interviews in more than a dozen counties to try to gauge the law’s progress. The agency found that county mental health directors often placed the job of investigating death and abuse cases on the shoulders of already overworked case managers. The comments of those workers, published 11 months ago in a 30-page report, painted a picture of a system with little oversight.

One mental health worker said: “Sometimes we investigate and sometimes we don’t, depending on our workloads.”

Said another: “Our mental health program director has thrown away critical incident reports rather than assign them to be investigated because they don’t generate any program funding. He just doesn’t see them as a priority unless they are a politically sensitive case.”

Yet another: “We’re not funded to do this job, and we don’t have the money to train clinicians to become something they don’t want to be and never went to school to become.”