A rogue investigation involving three high-ranking psychiatrists has come to light at the Minnesota Department of Human Services, angering the agency’s top officials and underscoring a pattern of management breakdowns in the state’s mental health system.
The incident — which started with a psychiatrist secretly monitoring one of her superiors, then escalated into an unauthorized outside investigation — has undercut agency professionalism and attention to patient care, according to senior officials.
Dr. Suzanne Witterholt, a psychiatrist at the state’s regional treatment center in Anoka, has alleged that she was instructed last summer to covertly monitor the activities of Dr. Steven Pratt, medical director at the Minnesota Security Hospital in St. Peter, according to a source with direct knowledge of the case.
The order, she has said, came from the state’s top medical officer, Dr. Alan Radke. When Witterholt’s inquiries triggered staff complaints in St. Peter and came to Pratt’s attention, he filed a formal complaint with his superiors, who then hired an outside investigator without telling the agency’s commissioner or her deputy.
Top officials at the department were unaware of the episode until the Star Tribune asked for an explanation of events taking place in St. Peter.
Radke submitted his resignation last week, effective in October. Officials said that his departure is unrelated to the St. Peter incident and that he is leaving for a position in Hawaii.
Radke is the fourth top mental-health administrator to leave the department since 2010, a period marked by managerial turmoil and staff turnover.
Deputy Human Services Commissioner Anne Barry said that the incident is an example of senior managers failing to put patient care first and that she will redouble her efforts to change the workplace culture in the agency’s mental health division.
“I was surprised — I was not aware, and we didn’t realize an investigation had taken place,” Barry said in an interview.
As a result, Barry has ordered that any investigation involving a high-level manager or division director be first approved by her and the agency’s human resources director.
According to sources familiar with the case, Radke told the outside investigator that he merely asked Witterholt “to see what’s going on” and fill staffing shortages at the security hospital, the state’s largest psychiatric facility and home to nearly 400 of the state’s most dangerous and mentally ill patients.
Radke declined to comment on the incident when contacted by the Star Tribune. Witterholt, a state psychiatrist since 1994, also declined to comment.
The investigation revealed that Witterholt, and a nurse who has since been fired, raised questions about the quality of patient care under Pratt’s watch, according to sources familiar with the case.
At one point, sources said, the nurse referred to Witterholt in front of another employee as “a DHS investigator.”
When Pratt learned from hospital staff that he was being investigated by colleagues, he lodged an official complaint with his superiors, sources said.
Pratt, who became the hospital’s medical director last year, has been scrutinized over — and cleared of — allegations of serious misconduct in the past.
In 2002, he came under review in connection with a patient death when he worked at the Anoka Regional Treatment Center. He also was investigated for a sexual harassment claim brought by Witterholt and two other women in 2006, a source with knowledge of those cases said. He was exonerated in both investigations. Pratt declined to comment.
The probe into Radke’s and Witterholt’s actions ended last fall without any disciplinary action, apparently because it was too difficult to determine the facts, the source said.
Still, the department’s top executives expressed anger that an investigation was conducted without their knowledge because it created the impression that they are not in control of a statewide operation responsible for more than 600 psychiatric patients.
Barry said the hospital’s top staff will face heightened scrutiny over patient care and staffing matters.
The St. Peter hospital’s operations have long been overshadowed by internal rivalries, grudges and distrust, staff and administrators say. Barry said some employees used to operate with the philosophy, “If something goes wrong, do your best and don’t share it — especially with the commissioner’s office.”
Now, she added, “There is a new level of scrutiny and review. The most important thing is that in the last year we have built a new team of people who believe in creating a healthy work environment. There is, in the last year, a real desire to hold one another accountable.”
In the last three years, a series of high-ranking state mental health officials have resigned, or been fired or transferred under the tenure of Human Services Commissioner Lucinda Jesson.
Two directors of the security hospital — Larry TeBrake and David Proffitt — were fired in succession because of leadership inadequacies, and Jesson assigned Barry to oversee the facility. Assistant Commissioner Maureen O’Connell, who was responsible in part for problems in the hiring of Proffitt, resigned from her post overseeing chemical and mental health issues in the department to head the planning for community mental health programming.
Mike Tessneer, the former director of the agency’s sprawling State Operated Services division, was fired from that post in late 2011 after repeated reports of patient maltreatment and deaths at state facilities. His interim successor, Pat Carlson, was herself replaced last April.
Dr. Robert Jones, the former director of the state’s community behavioral health hospital system in northern Minnesota, was fired in February after an investigation revealed he had overbilled the state for nearly a half-million dollars for overtime and on-call pay.
Within the St. Peter security hospital, at least six psychiatrists have left voluntarily in the last three years, complaining to colleagues that they had received inadequate professional support.
In an interview with the staff of Minnesota’s legislative auditor, James Nobles, last year, Radke said public scrutiny of the agency’s mental health system makes it difficult to respond “to every nuance of concern,” especially if it ends up “on the front page.”
He said the State Operated Services division, which includes the security hospital, operates “in crisis mode.”