Bloody killing at St. Peter mental hospital triggers call for outside oversight

  • Article by: CHRIS SERRES , Star Tribune
  • Updated: May 23, 2014 - 1:10 PM

Beating death of patient at mental hospital triggers a call for outside oversight.


Sue Abderholden, executive director of NAMI Minnesota, spoke Thursday, May 22, 2014, in St. Paul at a press conference regarding the care and treatment of patients at the Minnesota Security Hospital in St. Peter, Minn.

Photo: Elizabeth Flores, Star Tribune

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Shaken by revelations that a patient was beaten to death in his room at the Minnesota Security Hospital, families are demanding new and unprecedented measures to strengthen oversight of the state’s largest mental hospital.

“It breaks my heart that it came to this — that a man is now dead — for these problems to come into focus,” the mother of one patient said Thursday during a news briefing in St. Paul.

Saying they are frustrated by years of inaction, parents and advocates called for outside, independent experts to review therapy protocols and staff training at the hospital, the state’s core treatment facility for people who are mentally ill and dangerous. They also called on the state to give patients and their families a greater role in developing therapy plans, among other demands.

The call for reform comes just days after the Minnesota Department of Human Services (DHS) released a harshly worded investigation that pinned much of the blame for the bloody January killing of Michael F. Douglas, 41, on the hospital and its staff, calling the incident “an unacceptable ­failure” by the hospital.

Investigators concluded that some hospital staff chose to spend long hours inside protected offices rather than interact with patients; and that Douglas’ killer had twice asked to see a psychiatrist on the day of the killing but was denied. DHS Commissioner Lucinda Jesson responded to the report by calling for a radical change in the hospital’s culture and a “tidal wave of training” at the facility.

In interviews Thursday, mentally ill patients and their families painted a disturbing picture of a treatment center that provides little actual treatment, and where supervision is so lax that patients and staff live in daily fear of assault.

“I feel like someone could kill me at any time on any day,” said Travis Shon Johnson, 40, who is diagnosed with bipolar disorder and has been a patient since March. “It’s completely unsafe here.”

DHS Inspector General Jerry Kerber said he is open to discussing new approaches with advocacy groups, including external monitoring of the hospital. His office is ordering that a mentor be added to every work shift, to work shoulder-to-shoulder with staff to demonstrate how to respond to “high-tension situations,” he said.

“We all want the same outcomes here,” Kerber said. “We’re all in pursuit of the facility that will provide the best possible treatment but certainly do that in a safe environment.”

‘Critically understaffed’

Concerns about security and the quality of treatment at the St. Peter facility are hardly new. For decades, the hospital has struggled to balance the often-contradictory roles of treating mental illness while also preventing dangerous patients from hurting themselves and others.

As far back as 2002, a joint commission that accredits health care organizations said the center’s use of “protective isolation,” in which patients were locked in rooms apart from others, often for extended periods, was not always based on clinical evidence.

The hospital underwent a major restructuring of patient units in 2009, but four years later the state’s legislative auditor said the facility still suffered from an unclear mission, turnover of key medical staff, and frequent rule changes that left staff unsure of how to deal with disruptive patients.

In a February 2013 report, Legislative Auditor James Nobles said the hospital was “critically understaffed,” with just two full-time psychiatrists and a part-time psychiatric nurse practitioner. Today, the hospital has two full-time psychiatrists, but three more will start by October, according to DHS. The hospital also has four part-time psychiatrists.

Killer twice asked for help

The shortage of psychiatrists appears to have played a role in the January killing. Just a few hours before the deadly attack, the killer, Darnell D. Whitefeather, 32, twice asked to see a psychiatrist, but was told that a psychiatrist would not be visiting for another two days. That day, Whitefeather told a fellow patient that he had to assault someone in order to be heard by hospital staff, according to the state investigation.

“A patient begs to see a psychiatrist and that request is denied and put off,” said Sue Abderholden, executive director of the Minnesota chapter of the National Alliance on Mental Illness (NAMI), which organized Thursday’s briefing. “That’s unacceptable.”

At the briefing, the mother of one patient said it took nearly two years for her son to get a one-on-one visit with a psychologist after he arrived at the hospital three years ago. She also said her repeated calls to the hospital were often ignored, and she was told that a visit with a psychologist was only effective if her son “first recognized his mental illness,” she said.

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