Patient's Killing Brings Change

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posted by Jim Pettyjohn, Oregon DHS, Office of Multicultural Health;

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Patient's killing initiates changes

http://www.oregonlive.com/news/oregonian/index.ssf?/xml/story.ssf/html_standard.\

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from the Oregonian

http://www.oregonian.com/

04/01/02

MARK LARABEE

The police gunfire that rang out in the hallways of a small psychiatric

hospital nestled in a quiet Sellwood neighborhood still reverberates a year

later.

The shooting at BHC-Pacific Gateway Hospital, which killed patient

Santos Victor Mejia Poot, gives pause to police who daily confront the

mentally ill as they patrol the streets and to gatekeepers at Multnomah

County jails who often must subdue mentally unstable, combative

prisoners.

It should never have happened, experts say. But it has served as a

reference point as Multnomah County officials overhaul the flawed and

fragmented system that provides mental health care to Portland's indigent.

And state regulators charged with monitoring those systems say Mejia's

death has been a catalyst for rules that will provide safeguards for these

fragile members of society.

So far, increased communication between state and county overseers,

coordination with law enforcement about acceptable practices in medical

settings and more immediate regulatory oversight at mental health

facilities have resulted.

Yet as regulators and care managers work to reshape the bureaucracies

that failed Mejia, budget realities, politics and the complex dynamics of

having government providing psychiatric care to thousands of poor patients

continue to influence the debate and slow progress. Although they think

they have taken significant steps to prevent tragedies like Mejia's death,

authorities admit that there is much to do before things are truly safe.

New rules in motion It was no secret that care at BHC-Pacific Gateway

was substandard. According to a state investigation, Multnomah County

and state mental health officials had been aware of serious deficiencies at

BHC-Pacific Gateway but failed to address them.

That's been a key area for change. " Our communication lines are much

more open than they were before, " said Bob Nikkel, community services

manager for the state's Office of Mental Health and Addiction Services.

" We've really upgraded our attention to acute-care issues. It needed to

happen, but the shoot ing was one of the catalysts. "

Mejia, a 29-year-old Mexican who had been arrested March 30, 2001,

after an incident on a Tri-Met bus, was booked at the Justice Center jail

downtown and later released. Police found him sobbing outside the jail

and took him to the now-closed Providence Crisis Triage Center.

Providence determined he was a danger to himself and transferred him to

BHC-Pacific Gateway.

Mejia spoke little English and suffered epileptic seizures, unbeknown to

the staff, who hadn't made significant inquiries to his family. At the time of

his death, he hadn't taken his anti-seizure medication for more than a

week.

Combative, Mejia escaped from a locked hold room April 1 and threatened

staff, who called police. He advanced on officers with a metal rod he had

ripped from a door. They shot him twice.

State investigators found substandard patient assessment and treatment,

inadequate staffing and training, and a failure to provide good-quality social

work and language interpretation services at the hospital. All contributed

to an environment wherein Mejia's death, " while shocking, cannot be said

to be totally unexpected, " they wrote.

Portland police had complained that officers were routinely called to help

subdue unruly patients, to the point that some officers, concerned for their

safety, refused to go into the secure wards without their weapons. Yet the

concerns weren't addressed.

The state is near completing new rules for hospitals that address specific

problems the shooting investigation uncovered. Among them is a

requirement that mental hospitals provide immediate translation services

so doctors and patients can communicate effectively.

Also under the rules, a report must be filed with the state any time an

armed officer is called to restrain a patient. Calling the police " should

rarely happen, if ever, " Nikkel said. " Those reports will be our red flag.

They will allow us to know every time it happens, which we didn't before. "

Hospitals also will have to provide a place where officers can lock their

guns before entering the wards.

Officer Ed Riddell, who coordinates the Portland Police Bureau's crisis

intervention team, said the shooting has brought together people from

many disciplines to address a problem that was long overlooked. " I don't

think anyone wants to make the same mistake twice, " he said. " We're

making changes. What lives are we saving by having these

conversations? "

Responses growing Facing a shrinking budget and a mental health

system that was not meeting the needs of the people it was meant to

serve, Multnomah County was in the early stages of drafting a plan to

redesign the system when the shooting occurred.

Mejia's death isn't the reason for major reform, but it certainly helped

focus it and bring increased public scrutiny, said Dr. son,

director of the county's Office of Mental Health and Addiction Services.

At the urging of Latino leaders and activists, county mental health experts

are trying to make the system more culturally responsive, not only by

improving access to language interpreters, but also by learning how

people of different cultures expect to be served so the services reach

those who need them, son said.

son said his staff regularly meets with police and corrections officers

to create an understanding about mental illnesses, how to recognize them

and how to treat people who suffer from them. Security and other staff at

county-run mental health clinics are being trained to subdue combative

patients so flare-ups can be stopped before they escalate.

" If there's a busting-up of furniture, everyone can't cower in the corner and

call 9-1-1, " he said. " When you introduce arms into the ordinary psychotic

episode, it's a matter of statistical time until an incident like Mejia's death

occurs. "

son also said new walk-in clinics and mobile crisis response teams,

which are already operating, will help ensure that people will get help

earlier and in a less-restrictive setting, which is also less expensive. While

these services work for some patients, he said, the challenge is educating

patients to use them before they're in crisis.

Changes still to come Multnomah County regulators have increased

inspections of hospitals and clinics that provide emergency mental health

services and assigned a team to investigate complaints and rumors, and

assure standards of quality.

But despite a strong recommendation from auditors, the state has no one

doing spot inspections of mental health facilities, something Nikkel thinks

will go a long way toward improving care.

His agency doesn't have the money to hire the person to do the surprise

inspections, he said. The agency does regularly scheduled inspections of

more than 400 facilities, from clinics to group homes to hospitals. Nikkel

said regulators could move an existing employee into that job, but regular

inspections would suffer.

" It's hard to justify, given the pressure to stay on top of the required

timelines for all these other reviews, " he said. " We are keeping up, but

just barely. "

In general, psychiatric services in Oregon are underfunded and overtaxed,

providers have said. People having a breakdown too often land in jail or

emergency rooms.

As for BHC-Pacific Gateway, it never recovered from the shooting. The

66-bed hospital closed June 7. Pierce, manager of emergency room

social workers for Providence Health System, said that has meant more

patients spend more time in emergency rooms waiting for beds in hospital

psychiatric wards. It's not uncommon that patients wait for days, she

said. " I see no end in sight for that, " she said.

Dr. Maggie Bennington-, head of psychiatric services at Salem

Hospital, said the shooting galvanized concerns that use of force and

restraint techniques were outdated and counterproductive to healing.

" What it did was focus the hospital staff on the need for that kind of

change, " she said.

Yet perhaps the most important outcome of the death is the moral

pressure it put on the people in charge of helping the mentally ill.

" I don't know of anybody in the system who doesn't think this was a

horrible tragedy, " Nikkel said. " We never want this kind of thing to happen

again. "

son called the system failures shameful and said that not a day has

gone by that he hasn't thought of Mejia and his family. He hopes to

establish a memorial to Mejia, perhaps at a treatment facility, although he

said the idea has not been seriously explored.

" It was a system that wasn't there for all, " he said. " It would be nice to

keep track of how far we've come. "

You can reach Mark Larabee at 503-294-7664 or by e-mail at

marklarabee@....