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Below are a list of articles published in The Oregonian, Statesman Journal, and on KATU Channel 2.
For your convenience, you can find the listed articles below.

E-board OKs study to consider Oregon State Hospital closure
Group looks at solutions for hospital
This hospital should be history(MUST READ)
Psychiatric hospital aid sought
Years in the shadows (MUST READ)
Suit brings changes at Oregon State Hospital
Oregon's High-Priced Hospital Of Hurt (MUST READ)
Senator Fears Loss Of Hospital
Restoring Trust To Our Mental Health System
Gordly seeks federal investigation of state hospital
The blind corners of Ward 40 (MUST READ)
Kulongoski orders look at ward
Governor Calls for Review of Oregon State Hospital Policies Regarding Patient Abuse Press release from the
governor's Office
No tolerance for such crimes
Depraved examples of abuse
Where's outcry about abuse?
Ward of state, world of hurt (MUST READ)
Betraying a fragile trust (MUST READ)
Officials in Oregon are investigating allegations of abuse by a senior psychiatrist at the Oregon State Hospital in


The Oregonian
Lawmakers hoping to improve conditions at the Oregon State Hospital propose financing for a mental health
master plan
Friday, November 19, 2004
SALEM -- Lawmakers acted on Thursday to relieve overcrowding at the Oregon State Hospital and to launch a
study that could lead to replacement of the crumbling, 121-year-old psychiatric hospital in Salem.
"We have to get started immediately, to begin to make decisions about the future of the hospital," said Senate
President Peter Courtney, D-Salem, who put together the proposal to finance a mental health master plan and
to create 75 beds in community settings for patients eligible to leave the hospital.
A subcommittee of the Emergency Board approved spending $467,000 in general fund money during the current
budget period, which ends in June. The cost to continue the program in 2005-07 would be $1.7 million. The plan
has the support of House Speaker Karen Minnis, R-Wood Village, and other legislative leaders and is expected
to be confirmed when the full board meets today.
The money would come from savings found elsewhere in the Department of Human Services budget. The state's
emergency fund would not be used.
Courtney began looking into conditions at the hospital after a series in The Oregonian in September detailed
psychiatric aides' sexual abuse of as many as a dozen patients in the hospital's adolescent unit from 1989 to
1994. He sent a letter to fellow senators that said that hospital conditions were so appalling that the institution
was vulnerable to a federal lawsuit and possible takeover by the courts.
"The hospital is not a place I would want to place any of my relatives with a mental problem," said Rep. Alan
Bates, D-Ashland, a physician who was elected to the Senate earlier this month.
Bob Nikkel, administrator of the Office of Mental Health and Addiction Services, said the number of patients
committed through the criminal justice system has been rapidly climbing. This week, the hospital housed 480
such patients, 46 more than anticipated in the agency's budget and close to the building's capacity of 500.
The Emergency Board's actions would finance creation of 25 adult foster home placements and 50 new
"step-down" placements, or housing for lower-security patients.
Nikkel said finding sites for that kind of housing can be a difficult and probably will take several months to
complete. Legislators turned down a proposal to spend an additional $720,000 to contract for eight beds for
state inmates in a private hospital. That plan could have been put in motion in weeks, officials said.
Nikkel cited cuts in state mental health services and the methamphetamine epidemic as possible reasons for
the increases in criminal commitments. "We have created a lot of psychiatric casualties for a number of years,"
he said.
The plan includes $126,000 to begin a study of the hospital and its role in the mental health system. Nikkel said
issues will include the size and placement of any new hospitals. He said he hoped to have at least a preliminary
report for the 2005 Legislature.
Such a planning exercise is overdue, Courtney said. "Corrections and the Oregon Youth Authority have master
plans that guide them," he said, "but I don't feel we have ever had that in the area of mental health."
Lawmakers took up the mental hospital issue as part of a complex rebalance of the human services budget that
the Emergency Board undertakes every six months as costs and revenues fluctuate. The board makes budget
decisions between sessions.
In another piece of the complex proposal, human services officials had proposed eliminating the $6 premium the
state's poorest residents pay to stay enrolled in the Oregon Health Plan.
The state imposed premiums of $6 to $20 a month last year for OHP Standard coverage, which handles single
adults and couples with incomes below the federal poverty line. Enrollment has fallen from almost 100,000 to
about 40,000. Falling enrollment helps keep the health plan within a tightening budget but also cuts off the
state's poorest people from insurance and sends them to emergency rooms for more expensive care.
With the proposal, the roughly 16,000 health plan members making less than $77 a month for a single person
and $112 a month for a couple no longer would pay the $6. Premiums for people with higher incomes would
remain intact.
Gary Weeks, human services director, said that would slightly reduce state revenues but help the poorest
people stay insured.
Rep. Dan Doyle, R-Salem, opposed the idea, saying a small group of lawmakers should not overturn the 2003
Legislature's "difficult decision" to impose the premiums. The committee voted to delay action on the proposal
until the Emergency Board's next meeting in January. The full board could revisit the decision today.
James Mayer: 503-294-4109; jimmayer@news.oregonian.com

The Oregonian
It's 2004, not 1966: It's long past time to replace the hulking, overcrowded state psychiatric hospital in Salem
Sunday, November 14, 2004
Like an untreated mental illness, every year the Oregon State Hospital gets a little worse, and a little more
dangerous. Its problems are painfully obvious -- it takes only a glance to see them -- but most of Oregon's public
leaders keep averting their eyes.
This neglect can't go on any longer. Oregon is risking a full-blown mental health crisis if it keeps shoving
patients and pouring money into an overcrowded, understaffed and, in places, thoroughly decrepit hospital.
One of the few Oregon legislators to take a hard look at the state hospital, Senate President Peter Courtney,
D-Salem, has seen enough. Courtney will formally ask the Legislative Emergency Board this week to launch a
process that should end with the replacement of the Oregon State Hospital.
Courtney will request that the E-Board appropriate about $1 million to pay for temporary measures to relieve
overcrowding at the hospital and to start work on a master plan that will provide the 2005 Legislature a blueprint
for replacing it.
It's not as simple as just tearing the hospital down. It will take several years and tens of millions of dollars to
create what's needed -- a smaller, modern hospital and a network of six to eight more community mental health
centers that would be both less expensive for the state to operate and more effective at treating patients.
Yet it's time to start now, even while Oregon is struggling with a budget shortfall. This state always seems to
have an excuse for failing to address the appalling conditions at its main state psychiatric hospital, and for
refusing to properly invest in mental health, all the while it keeps building prisons, roads and even a new Salem
headquarters for its Department of Fish and Wildlife.
"I'm not interested in any more excuses," Courtney says. "That's all we've been doing. It's time to start getting
those people out of this hospital and into community care facilities."
If work on the hospital master plan begins now, the 2005 Legislature will have an opportunity to put real change
into motion before its summer adjournment. If the E-Board fails to act this week, the planning won't get done,
and the ramshackle hospital will still be sitting there, as is, when the 2007 Legislature convenes.
That kind of avoidance is exactly how this state has ended up warehousing its mentally ill in a hospital that
dates back not only to the last century, but also the century before that. Today Oregon is still housing some of
its most vulnerable citizens in buildings that opened in 1883.
A visit to the Oregon State Hospital is like a trip back in time to the 1950s and 60s, when states still herded
their mentally ill citizens into huge hospitals. The long corridors, tiny rooms and jam-packed day rooms are a
throwback to the old ways of mental health care.
Since the 1960s, many other states have dramatically remodeled or abandoned old hospitals and moved to
systems of small, community-based mental health facilities that are cheaper, more effective and partially funded
by the federal government.
Oregon, too, has tried to follow this trend. It closed one of its large mental hospitals, Dammasch, in the early
1990s and in recent years has opened nearly 800 beds in smaller community facilities. Yet it is still putting far
too much money and far too many patients into the Oregon State Hospital.
It's time to begin marshaling the resources and summoning the will to close and replace the hospital. The
problem doesn't need any more study. It's been 16 years since a report urged lawmakers to demolish the oldest
buildings at the hospital because of health and safety risks. There are already enough studies on what's wrong
with Oregon's mental health system to fill one of the claustrophobic hospital rooms where Oregon now crams up
to three mentally ill patients.
By now, this state's mental health problem is plain to see.
And so is the only possible cure.

The Oregonian
Senate President Peter Courtney asks for almost $1 million to help the troubled Oregon State Hospital and plan
for its future
Saturday, November 13, 2004
Oregon's Senate president is seeking nearly $1 million for improvements to the Oregon State Hospital.
Sen. Peter Courtney, D-Salem, said Friday that he will ask the Legislative Emergency Board, which meets next
Thursday and Friday, for $976,242 to pay for three additional staff positions and to contract with other hospitals
to house Oregon State Hospital patients when the facility nears capacity.
The money also would be used to finance a master plan to determine what role the state psychiatric hospital
would play in the future of Oregon's mental health system. Under Courtney's proposal, the master plan could
recommend a reduced role for the hospital or even its replacement.
The proposals would give the state hospital more leeway to contract with other hospitals to take patients,
particularly those committed under civil processes. Forensic patients -- those who have been committed for law
enforcement reasons -- would remain at the state hospital, but those under civil commitment could be
transferred elsewhere to reduce crowding.
Courtney began investigating the hospital after a series in The Oregonian detailed the sexual abuse by
psychiatric aides of as many as a dozen patients in the hospital's adolescent unit from 1989 to 1994. He met
last month with hospital Superintendent Marvin Fickle and later sent a letter to fellow senators that said
conditions at the 121-year-old hospital were so appalling that the institution was vulnerable to a federal lawsuit
and possible takeover by the courts.
Other Oregonian articles have documented recent patient abuse, chronic understaffing and decrepit conditions
at the Salem facility.
Courtney said Friday that it's questionable whether the Emergency Board will consider the proposals.
"It's a matter of the players wanting to put the proposals on the agenda," Courtney said. "I don't know how
they're going to react to it."
Courtney's proposals note that, currently, while 491 patients have been committed through the criminal process,
the hospital has a budgeted capacity of 477 and a physical capacity of 500. Because the number of forensic
patients increases at an average of six a month, the physical capacity soon will be overwhelmed.
Courtney said the hospital's condition "is not an exaggerated need." He called his proposals "strictly a stopgap
"It can help us buy some time to plan for the long range," he said.
If Emergency Board members refuse to act on the requests, he said, "we'll just continue to slop along, not deal
with it, not prioritize it."
Bob Nikkel, administrator of the Oregon Department of Human Services' Office of Mental Health Services, said
he hasn't seen the proposal but welcomes additional hospital resources.
"I'm hopeful," he said. "We've been putting on the record for some time the difficulties we've been having,
particularly with the forensic census. We have no control over the admissions. There's been a significant upturn
in admissions, and we're required to take them all."
Brian Shipley, a senior policy adviser to Courtney, said the money would come from a savings of $4 million in
the Oregon Department of Human Services. The agency had overestimated its overall caseload early in the
budget process. Shipley estimated that the proposals would cost $3.7 million if they were carried through the
2005-07 biennium.
The Emergency Board would not make a decision to carry the proposals past June 30, the end of the current
Michelle Roberts of The Oregonian staff contributed to this report. Patrick O'Neill: 503-221-8233;

The Oregonian
Friday, November 05, 2004
Dave Jobe, Kay Reichlin, Mike Robinson, Lori Skach and Patty Zurflieh
Invest in the health care of Oregon's most vulnerable
Problems do exist at Oregon State Hospital, but patients continue to recover and transition to the community,
and the hospital maintains its national accreditation. More importantly, cutting beds will not solve the state's
systemwide problems in public mental health care.
It was the closure of Dammasch State Hospital in 1995 that directly contributed to the current problems at
Oregon State Hospital. That decrease in beds for civil commitment patients resulted in a marked increase in
mentally ill people being arrested and placed in jails, prisons and the forensic program at Oregon State Hospital.
Community treatment only partially replaced Dammasch. When Oregon experienced an economic downturn,
community mental health programs were drastically cut, leaving no flexibility in an already stressed system.
Forensic patients occupy almost 500 of more than 700 beds at Oregon State Hospital. Those patients are
committed by the criminal courts, with crimes ranging from minor misdemeanors to serious felonies. Many need
treatment that is simply unavailable elsewhere in the state. Only the courts and the Psychiatric Security Review
Board control these admissions and discharges.
While every other medical facility in Oregon has a maximum number of patients, the state hospital must, by
law, admit and treat every forensic referral. Many forensic patients ready for discharge remain in the hospital
because it is increasingly difficult to find adequate housing and follow-up treatment for them in the community.
The wards at the state hospital are indeed overcrowded and understaffed, especially in the forensic program.
However, even on crowded wards patients receive medication, medical and psychiatric treatment, and clean
living conditions. Some buildings are old, poorly designed for current use, often not air-conditioned or even not
properly heated in cold weather. The hospital lacks modern efficiencies such as computerized records. For
decades there has been a vast need for capital improvements as well as improved operations to serve the
patients. In a state with limited resources, the mentally ill have suffered disproportionately.
State hospital employees are dedicated to working with people with mental illness and disability. They deserve
recognition for their efforts under difficult circumstances. Understaffing and overcrowding -- combined with the
patients' mental illnesses -- can lead to dangerous situations for both patients and staff. These conditions also
inhibit the ability to hire and retain nurses, line staff, social workers, psychologists, psychiatrists and other
But the solution is not to cut Oregon State Hospital. The answer is to consider and repair the entire system of
mental health care in our state. Community availability of affordable medication, decent housing and adequate
treatment for medical, psychiatric and substance-abuse disorders would certainly decrease the number of
people being charged with crimes and sent to the state hospital, and also would facilitate discharges from the
A well-functioning mental health system provides an accessible continuum from outpatient appointments to
secure hospital care, and Oregon State Hospital is a crucial part of that system. We must invest in the care of
the most vulnerable.
Ulista Brooks, David Eason, Alex Horwitz, Dave Jobe, Kay Reichlin, Mike Robinson, Lori Skach, and Patty
Zurflieh are physicians serving at Oregon State Hospital. The views expressed here are their own, not the

The Oregonian
Problems have beset the Oregon State Hospital and its mentally ill for more than a century
Sunday, October 31, 2004
The first patients arrived by train, shades drawn, in the dead of night.
Almost 400 people -- their conditions attributed to everything from brain fever to broken hearts -- were shuttled
into the Oregon State Insane Asylum under the cover of darkness.
The year was 1883. Despite the secrecy, the hospital's looming J Building, with its red brick and ornate turrets,
became the subject of morbid fascination as Salem residents rode trolley cars along Asylum Avenue, now
Center Street, to gawk.
Today, the institution -- renamed Oregon State Hospital in 1907 -- is one of the oldest, most dilapidated mental
institutions in the United States, a hulking reminder of the state's failure to forge a modern approach to treating
people with mental illnesses. Patients still live in parts of the J Building, in renovated wards next to those that
have been abandoned.
Oregon first took on responsibility for people with mental disorders in 1843, 16 years before statehood. The
provisional government adopted laws and appropriated $500 "for purposes of defraying expenses of keeping
lunatic or insane persons in Oregon," according to a 1945 article in the Oregon Historical Quarterly.
By 1861, Dr. J.C. Hawthorne opened a private institution in Portland to care for people with mental illnesses.
The state contracted with Hawthorne initially to care for 12 patients. By 1874, the doctor housed 194 patients --
and received 52 percent of the total state budget to do so.
The numbers of patients grew steadily until the state opened its own institution in 1883, when 370 people were
transferred from Portland to the J building in Salem.
As decades passed, the numbers of patients grew exponentially. A hospital superintendent complained in 1928
that counties were committing the elderly, alcoholics, the physically disabled and others who didn't belong, just
so they wouldn't have to care for them.
Patients sometimes lived four, five or more decades behind the J Building's barred windows, enduring the
treatments of the day.
In the 1930s, that meant wet-sheet restraints and insulin-induced comas. In the late 1940s and early '50s,
surgical lobotomies were done to cut off the emotions of about 150 patients. At the same time, a crude form of
electroshock therapy was used on as many as 50 patients a day.
In 1942, a tragedy at the hospital shocked the nation. A patient, George Nosen, working in the kitchen,
mistakenly substituted cockroach poison for powdered milk in the scrambled eggs. Forty-seven patients died;
another 400 were sickened.
Nosen remained four more decades at the hospital, dying in 1983 of a heart attack after a fight with another
The hospital's population peaked in 1958, the year the hospital's last lobotomy was performed, with nearly 3,600
patients crowded into identical wards that consisted of tiny, boxlike rooms -- no handles on the doors -- running
the length of long, white corridors.
In the late 1950s, journalists and government commissions exposed the dirty, overcrowded and dehumanizing
conditions within many state psychiatric hospitals. President Kennedy called for a system that would
emphasize community-based care. New drugs such as Thorazine, effective in controlling violent behavior,
hallucinations and delusions, made the vision possible.
Congress passed laws that stopped federal Medicaid payments to state-run "institutions of mental disease" in
an effort to push states into building community-based mental health centers that would be eligible for federal
But the new system never completely emerged.
Oregon, like many states, did not fully reinvest the money it saved by eliminating hospital beds. To this day,
community-based services remain underfunded, restrictive and largely inaccessible.
While untold numbers of Oregonians reaped the rewards of deinstitutionalization, thousands of others ended up
sleeping on the streets, howling in jail cells or heading back to the hospital in handcuffs.
At a time when many states are shuttering their hospitals, Oregon continues to pour millions of dollars into
renovating wards that were deserted in the 1960s.
The hospital is chronically short-staffed, overcrowded and, records show, a place that fosters neglect and abuse
of those it was intended to protect.
Michelle Roberts: 503-294-5041; michelleroberts@news.oregonian.com

The Oregonian
Advocates say the death of a 41-year-old man after an altercation with psychiatric aides was avoidable
Thursday, October 28, 2004
The Oregon State Hospital has agreed to pay $200,000 to the family of a patient who died in 2001 when a group
of hospital workers tackled him after a disagreement over soda pop, then tied him to a restraint bed while he
was unconscious.
Workers eventually noticed that Ben Bartow, 41, was not breathing and tried to revive him. The state medical
examiner determined that he died of a heart attack caused by the struggle.
The amount for the two claims of negligence in Bartow's death is the maximum allowed under the Oregon Tort
Claim Act, which places a limit on the extent to which a public entity may be held liable. The settlement comes
at a time of increased scrutiny of the state hospital.
His death "was an avoidable incident," said Stephen J. Mathieu, an attorney for the Oregon Advocacy Center,
which sued on behalf of Bartow's family. "Oregon State Hospital staff should have intervened to prevent the
escalation. But because of the overcrowding and understaffing, staff were unable to pay as much attention to the
warning signs as they should have."
Mathieu said Wednesday that several employees who restrained Bartow testified in depositions that they'd
never heard the term "positional asphyxiation." In fact, when Bartow screamed that he couldn't breathe, they
assumed that because he could scream, he could, in fact, breathe.
That "fatal error" led to Bartow's death, Mathieu said.
A Justice Department spokesman, Kevin Neely, said the hospital admitted no wrongdoing in settling the case.
After Bartow's death, he said, the hospital installed defibrillators on wards, updated restraint training to include
information on positional asphyxia and instructed workers on how to de-escalate situations rather than use
physical restraint.
Bartow was supposed to drink only one caffeinated beverage per day. On Aug. 11, 2001, he sneaked two.
According to the lawsuit, a psychiatric aide told Bartow that because he had broken the rule, he would lose his
soda pop privileges the following day. When two patients returned to the ward after the next day's "pop run," the
same psychiatric aide commented loudly that Bartow, who suffered from paranoid schizophrenia, would not
receive a soda.
Bartow became agitated and exchanged words with the worker. Soon, the workers and Bartow squared off.
The lawsuit alleges that the workers called for help from other wards "without attempting to verbally or physically
de-escalate this adverse interaction."
According to the complaint, at least six hospital workers formed a "dog pile" on top of Bartow. "Hands and
knees were placed on Benjamin Bartow's head, neck, extremities, shoulders, shoulder blades, hips and
mid-back by six to 10, or possibly more, staff members," the suit states."
Lawyers, witnesses and state records indicate that other patients pleaded with staff members to let up, but
workers continued, eventually injecting Bartow with tranquilizers until he went limp. Employees then placed him
in steel handcuffs and ankle restraints, carried him to a seclusion room -- his head dangling between his
shoulders -- and strapped him to the bed.
Sometime later, staff noticed that Bartow's face was blue, that he had no pulse and he wasn't breathing, state
records show. A nurse tried to revive Bartow, using manual chest compressions and a breathing tube, but he
"It wasn't just his family that was devastated. So were the patients who witnessed it," said Bartow's sister,
Loyette, who didn't want her last name used. "Many of them were his friends."
Bartow, a former football player at Neah-Kah-Nie High School in Rockaway Beach, was diagnosed with paranoid
schizophrenia at age 19, according to his sister. From then on, her brother was in and out of hospitals and
group homes. The sounds of voices in his head often terrified him, causing him to react unpredictably.
While living in a rooming house in the Medford area in 1990, Bartow severely beat a fellow resident. He was
charged with attempted murder and ultimately found guilty of assault, except for insanity. He was placed under
the jurisdiction of the Psychiatric Security Review Board for 20 years.
Bartow worked as a janitor in the hospital and dreamed of owning his own cleaning service.
"The amount of money wasn't the reason we sued," Bartow's sister said. "We wanted to let the hospital know
that what had happened there wasn't right and, if we could, bring about some changes for the other patients who
are still there."
In addition to the money paid to Bartow's family, the state has agreed to discuss supplying each ward in the
psychiatric hospital with a emergency crash cart to help resuscitate patients, Mathieu said.
The settlement comes days after Sen. Peter Courtney, D-Salem, said conditions inside the 121-year-old
institution are so appalling that it is vulnerable to a federal lawsuit and possible takeover by the courts.
Bob Joondeph, executive director of the Oregon Advocacy Center, a watchdog agency for people with
disabilities, agreed with that assessment. Joondeph said that while he believes understaffing and overcrowding
played a large role in Bartow's death, the center requested that the claim be dismissed "without prejudice" from
the Bartow lawsuit, which would allow advocacy center lawyers to pursue that issue in the future.
"Sen. Courtney's warnings about potential legal liability are real," Joondeph said. "We're hoping the state will
move quickly to fix these problems on its own."
Michelle Roberts: 503-294-5041; michelleroberts@news.oregonian.com

The Oregonian
Sunday, October 24, 2004
SALEM -- Oregon spends half of its annual $180 million budget for mental health on the Oregon State Hospital,
an overcrowded, decrepit institution that serves less than 1 percent of patients who need psychiatric care.
The hospital -- only a mile from the Capitol -- is a hulking reminder of the state's failure to forge a modern
approach to treating people with mental illnesses.
Study after study has recommended that Oregon scale back the hospital and invest in a network of community
homes that would be both cheaper and more effective for patients.
But until now, mental health leaders and advocates have feared that if they pushed this approach, the hospital
would close and, given the Legislature's consistent failure to adequately fund community mental health services,
nothing would replace it. State officials also have been reluctant to risk a fight with the unions that represent the
hospital's 1,150 employees.
As a result of this impasse, the state has spent millions of dollars renovating the 121-year-old hospital.
A significant shortage of group homes and other community-based services has forced hundreds of patients who
could live in less restrictive surroundings to remain in the hospital, despite growing evidence that long-term
institutionalization makes psychiatric patients sicker. Most patients who arrive at the hospital psychotic quickly
stabilize with modern medications.
On Friday, Senate President Peter Courtney, D-Salem, said the hospital is in such dire straits, it's in danger of
being shut down by federal authorities. He warned that the issue could no longer be avoided.
"The physical condition of our state hospital is merely a metaphor for the ramshackle state of our larger mental
health system," Courtney wrote in a letter to fellow senators last week. "We must address this crisis, and we
must do so before we adjourn the next legislative session."
Experts agree. "It's astounding that Oregon is operating such a massively large institution in the 21st century,
and unthinkable that they are adding more wards," said Robert Bernstein, executive director of the Washington,
D.C.-based David L. Bazelon Center for Mental Health Law, a leading advocacy group for people with mental
"It runs counter to all that we know about people with mental illnesses, the treatments that really work and the
ability of people to recover," Bernstein said.
Many states have shuttered or dramatically reduced the size of their mental hospitals, responding to federal
policies that reward creation of community-based centers to treat the acutely ill.
State officials acknowledge that if they invested the Oregon State Hospital's $90 million annual budget into such
projects, the state would receive a matching $90 million from the federal Medicaid program, allowing the state to
help tens of thousands of Oregonians who now go untreated.
The hospital is the most expensive way to treat people with mental illnesses, costing taxpayers an average of
$11,000 per patient per month.
In September, the hospital housed at least 130 patients who had been cleared to live in group homes or
assisted living centers, which cost between $1,000 and $5,000 a month. Such patients are routinely held for an
average six months after state hospital doctors approve them for release, hospital data show. Some wait more
than a year.
Top state officials insist that Oregon's mental health system is on the verge of reform.
A 21-member task force, appointed a year ago by Gov. Ted Kulongoski, recently recommended examining the
possibility of building a single forensics mental health facility for patients who can't be treated in the community.
In addition, state mental health leaders are working to create 80 community beds for forensics patients who are
able to live outside the hospital.
However, even the governor's own task force questions whether its recommendations will be followed.
Bob Nikkel, who heads the Department of Human Services' mental health and addictions office, promised the
task force updates on progress. "It is my intent to make things happen to the degree I have the ability," he said.
Advocates and lawmakers are disappointed that the task force failed to recommend shutting down the hospital.
They blame a lack of political will: To close the hospital now would be an indictment of state officials who, they
say, have long recognized the need for change but will not risk upsetting the status quo.
State Sen. Avel Gordly, D-Portland, said the state needs to salvage the lives of state hospital patients rather
than the careers of bureaucrats.
"It can't go on," she said. "Everything that happens there happens in our name -- and let's be real clear, what
happens there is shameful."
Any attempt to do so will run into political reality: Hospital workers have much more clout than those they treat.
"There are a lot of jobs at stake," said Bob Joondeph, director of the Oregon Advocacy Center. "Why take on a
group of public employee unions in something in which you're going to have to invest a whole lot more money
upfront for a population that, frankly, the public's primary concern is their safety from these folks rather than the
quality of their care?"
"Cuckoo's Nest" revisited
Thirty years ago, the Oregon State Hospital molded the nation's image of institutionalization when it became the
setting for the movie "One Flew Over the Cuckoo's Nest."
A look behind hospital walls shows that many of the conditions depicted in the film still exist.
The J Building, named for its shape, borders a blocklong stretch of Center Street. Except for two disjointed
wards at either end, much of the building is uninhabitable.
On one empty ward, lead paint curls from the walls. Asbestos frost floats in the air. On a recent day, a dead rat
lay rotting in an oversized trap on the day-room floor.
One ward over, where patients live, conditions aren't much better. Aging pipes emit cloudy water. Strange
smells float from vents. Asbestos floor tiles, when chipped, are treated as hazardous material. Raw sewage
occasionally leaks through the ceilings of patient rooms.
The hospital, built in 1883, is one of the oldest, most dilapidated state mental institutions in the United States.
In fact, a 1988 report urged lawmakers to demolish the J Building because of health and safety dangers.
But two years ago, after another 14 years of decay, state officials did the opposite, pouring nearly $1 million into
a corner of the crumbling structure to make room for more patients. Another ward was added last month.
"When it comes to opening new wards, this is the kind of space we have left," said Maynard Hammer, a deputy
superintendent, as he stood last summer in a vacant corridor inside the J Building, kicking chunks of plaster
that had dropped from above. "We're not talking about what's best for patients. We're only talking about having a
place to put them."
The J Building isn't the hospital's only structural liability. The 1988 report also warned that the outside walls of
the newest building on the 148-acre campus, the five-story 50 Building erected in the 1950s, were at risk of
The top floor of the 50 Building, which houses locked forensics wards, was vacant for years because faulty
plumbing could not deliver water high enough. A $4 million renovation was completed in the 1990s to secure the
walls and fix the plumbing, but doors throughout the structure, including those on elevators, often refuse to open
and close.
A year ago, a group of patients was so desperate to document living conditions that they sneaked a disposable
camera into the hospital. Their pictures showed steel beds crammed into dirty, crowded rooms, filthy toilets,
torn furniture, broken sinks, and portable bathrooms in the outdoor yard overflowing with urine and feces.
More than 100 patients in the 50 Building asked for a state investigation.
A 2003 report by the Oregon Health Services Health Care Licensure and Certification Section stated that the
hospital had broken several state rules. Each of the building's seven wards exceeded capacity by two to 12
patients. Ward 50 I, which ideally would hold no more than 30 patients, held 43.
Toll of thin staffing
Administrators estimate that the hospital is 30 percent to 40 percent understaffed. It houses 760 patients and
has 1,150 staff members -- one of the lowest patient-to-staff ratios in the nation, Courtney said. A comparable
facility in Washington state employs 1,900 staff for roughly the same number of patients.
Seven physician and 40 to 50 nurse positions stand vacant. Openings for more than 40 psychiatric aides --
employees who do the bulk of direct care -- go unfilled because many qualified professionals are unwilling to
accept low salaries and what Courtney called "awful working conditions."
State records show the hospital relies on overtime, both mandated and voluntary, to fill shifts.
According to a recent audit by the Department of Administrative Services, the hospital could save more than $1
million every two years if administrators filled staff vacancies instead of habitually using overtime.
Records examined by The Oregonian reveal the dangers of thin staffing. Two years ago, hospital administrators
sent a memo "reminding people that it was not OK to sleep on the job," state records show.
However, the state documented four subsequent cases in which employees fell asleep when they were
supposed to be watching dangerous or suicidal patients.
An examination of state documents further shows that patients were beaten, kicked, humiliated and tormented
by staff in more than 50 substantiated incidents of abuse within the past 31/2 years.
In case after case, staff demeaned patients, calling them names, such as "retarded" and "zombies." Some
patients sat in dirty diapers for hours because workers were too busy to change them.
"Honestly, the care we provide is of low quality," said Jon Sears, a mental health specialist who gives group and
individual therapy at the hospital. "I say that with reservation because we have so many people who are trying
so hard. But with so many things against us . . . we're in a situation where all we do is triage, over and over."
"They're warehousing us"
Psychiatric research has long shown that people with mental illnesses can recover -- a notion unfathomed when
the country's first "insane asylums" were erected in the 1800s.
Today, mental health experts widely accept research that shows that, with supports such as medication,
housing and meaningful human interaction, most people, even those with serious mental illnesses, can lead
productive lives outside of institutions.
In fact, long-term isolation from family and community can slow, even thwart, their recovery.
"What's happening in Oregon is a throwback to a time in which patients were treated in a way we no longer
believe is appropriate," said Dr. Paul Fink, professor of psychiatry at Temple University School of Medicine and
past president of the American Psychiatric Association.
Patients at the hospital put it more bluntly.
"They're warehousing us," said Richard I. Laing, a 64-year-old patient who has been hospitalized since 2002.
"We get here and there's no treatment. There's no interaction. Just a bunch of people sitting in a room getting
on each other's nerves."
Exhausted ward staff often must break up fistfights on the tense, cramped wards. Injuries against staff are up
nearly 40 percent this year, to 200 incidents, Sears said. Patients often go months without seeing psychiatrists,
languishing instead of moving forward with therapy.
Some patients arrive at the hospital under civil commitment, meaning a judge has determined they are so ill
they are either a danger to themselves or others, or they are unable to survive on their own. Others are forensics
patients under the jurisdiction of the Oregon Psychiatric Security Review Board, which monitors people who
plead guilty, except for insanity, to crimes that range from misdemeanors to murder. Only a very small number
have committed heinous crimes. Most, say their therapists, are accused of offenses that never would have
occurred had the patient had medications and services in the community.
In December 2000, the federally funded Oregon Advocacy Center, which monitors rights for people with
disabilities, filed a class-action lawsuit against DHS and the hospital, alleging that the agency failed to provide
adequate community-based mental health services, resulting in "unnecessary segregation" of state hospital
Earlier this year, the state agreed to settle the suit brought on behalf of more than 100 patients who had been
held in the hospital for months and years longer than necessary. Under the settlement, the state must create 75
community-based mental-health slots by next summer and spend $1.5 million for other outside services for
hard-to-place patients.
But the problem is far from solved.
The settlement, although a major victory for patients under civil commitment, did not affect forensics patients,
who are similarly stranded in the hospital.
According to records examined by The Oregonian, 86 forensics patients last month were deemed ready for
discharge by doctors but couldn't leave the hospital because of a lack of alternatives outside. The psychiatric
security board, which gives final approval to discharges, won't grant them until beds are available in the
community. And those beds don't yet exist.
This year, the board is expected to take on 140 new cases, more than double the number four years ago.
Most forensics patients are not inherently dangerous and can live safely and productively if given proper
community support. While some will always need treatment in a secure setting, they represent only a fraction of
the total state hospital population, said Joondeph, of the Oregon Advocacy Center, which successfully fought to
close Dammasch State Hospital, another psychiatric institution, in the mid-1990s.
He said the state would benefit by creating small, acute-care facilities that serve people with special mental
health needs. If kept smaller than 16 beds, such facilities would be eligible for the Medicaid match, effectively
doubling the state's investment in mental health care.
The Oregon State Hospital is funded completely by general state funds. A 1965 congressional act excluded
nearly all payments to state psychiatric hospitals from Medicaid because the federal government did not want to
take over what, historically, had been a state responsibility. Congress also wanted to provide an incentive for
states to build systems of community mental health centers to replace psychiatric hospitals.
"The hospital shouldn't exist," Joondeph said. "The science of mental health treatment has advanced so much
that we're operating under a very old model that's becoming harder and harder to justify."
Michelle Roberts: 503-294-5041; michelleroberts@news.oregonian.com

The Oregonian
Peter Courtney urges legislators to act on problems at the Oregon State Hospital before it faces a federal
lawsuit or a court seizure
Saturday, October 23, 2004
Oregon Senate President Peter Courtney said Friday that conditions at the Oregon State Hospital in Salem are
so appalling the institution is vulnerable to a federal lawsuit and possible takeover by the courts.
In a two-page letter to fellow state senators, Courtney railed against the overcrowding, understaffing and decrepit
conditions at the 121-year-old hospital.
"All of these factors, compounded by a history of past patient abuses, make a federal lawsuit an imminent
probability," Courtney wrote.
"Not only will that cost the state a tremendous amount of money, but may result in a court taking over our
public mental health system. The matter will be taken out of our hands if we do not act quickly."
Courtney's letter came in response to a recent meeting with Dr. Marvin Fickle, hospital superintendent since
last summer. Courtney called for the meeting last month in response to a two-day series in The Oregonian that
detailed the sexual abuse of as many as a dozen patients in the hospital's adolescent unit by psychiatric aides
from 1989 to 1994.
The investigation disclosed that hospital officials and their supervisors -- most still employed in state government
-- did little to stop the abuses and often failed to report suspected sexual abuse immediately to police and child
welfare workers as required by state law. The articles also said the hospital had taken only limited steps to
prevent abuse in the years since.
Courtney characterized his meeting with Fickle (hospital superintendent) as "deeply troubling."
Courtney said Fickle denied that children were continuing to be abused in the hospital but did acknowledge that
patient conditions were dreadful.
The hospital is one of the oldest and most decrepit state mental health facilities in the United States. More than
40 percent of its building space is unusable.
"Water leaks from the roof down through three floors, walls are crumbling and asbestos insulation presents a
toxic hazard," Courtney wrote.
The hospital houses 760 patients, but has only 1,150 staff members, one of the lowest patient-to-staff ratios in
the country. By contrast, he pointed out, a comparable hospital in Washington state employs 1,900 staff for 790
A public records request by The Oregonian shows there have been more than 50 substantiated cases of
physical, vocal and sexual abuse against adult patients by staff in the past 31/2 years.
"I reached the conclusion after talking to (Fickle) that the hospital has reached the point of no return," Courtney
said in an interview Friday.
"If the courts get involved in this and we come under judicial watch, we're going to have to tear down the facility
and start anew, or tear down portions and rebuild.
"We've been getting away with this for decades."
Courtney said the state's mental health system -- and the future of the state hospital -- would be one of the key
issues for him in the coming legislative session.
"Mental health always gets put last -- always, always, always," he said. "I'm well aware of what the governor's
budget is going to be -- but that's too bad. That can't be used as an excuse anymore."
Reached late Friday, Gary Weeks, director of the Department of Human Services, which oversees the hospital,
said he is unsure whether the state is in danger of losing control of the hospital.
"I'm not prepared to say we've exposed ourselves to a lawsuit," Weeks said. "But (Courtney) may have a lot
more information than I have on this."
Also on Friday, Gov. Ted Kulongoski announced that he has received a review from Weeks of the Oregon State
Hospital's policies on patient abuse. Kulongoski requested the review after The Oregonian's stories.
A panel of the state's top mental health officials will examine the 200-page report to determine whether changes
in abuse reporting and investigations at the hospital are necessary.
"We must ensure," he said, "that the state is providing the best possible care to Oregonians with mental illness
being served at the state hospital."

The Oregonian
Monday, October 18, 2004
There is trouble at Oregon State Hospital. So what else is new?
The Oregonian's reports of sex-abuse and hush money in the 1990s ("Betraying a fragile trust," Sept. 19) may
seem like old news, but the hospital's problems are not. Think: deteriorating buildings, some of which are more
than 100 years old. Think: chronic over-crowding with patients sleeping in closets and seven to a room. Think:
chronic under-staffing with nursing, psychiatric and therapist positions remaining vacant for months and years.
And think about the 70 plus patients who have been found clinically ready to leave the hospital but can't
because of the lack of step-down community living arrangements.
And things are getting worse.
One cause may be state budget cuts that have left thousands of Oregonians without community mental health
and chemical dependency treatment. We don't know for sure. We do know that Oregon's jails and prisons have
recently been flooded with mentally ill inmates and that state hospital admissions of "criminally insane" patients
have grown three times faster than planned. Despite the efforts of state and county officials to create new
community placements with the money at hand, they are being overwhelmed by the numbers of new customers
and hamstrung by the need to use scarce resources to maintain the crumbling infrastructure of Oregon State
The solution? This is not a case of not knowing what to do. Nor is it a case of competing interests: Staff working
conditions, patient treatment and the public purse would all benefit from the changes suggested by the
just-released report of the Governor's Mental Health Task Force.
Among key task force recommendations are the following:
The Legislature should appropriate sufficient funds to permit the orderly restructuring of Oregon State Hospital
and the construction and operation of community facilities to support populations of individuals who will no
longer be hospitalized.
Local mental health authorities with support from the state will continue to accept increasing responsibility for
assisting individuals to leave State hospitals.
State and local mental health authorities will create a rolling three-year plan for the construction and operation of
community facilities.
These recommendations will take strong leadership to achieve. They will require a short-term influx of money to
construct a smaller, modern hospital and the community facilities needed to accept the present residents of
Oregon State Hospital.
It is worth the investment. Closure of the hospital will free our mental health system of a gigantic financial weight
and allow its dedicated staff to work in safer, more efficient environments. Patients will be safer and receive
better treatment. The public interest in promoting compassionate care and community safety will be achieved by
implementing a more modern, cost-effective approach to mental health treatment.
The governor and Legislature deserve our support to get this job done.
Bob Joondeph is executive director of the Oregon Advocacy Center, which advocates for individuals with

The Oregonian
The Portland senator says an outside agency should determine if patients' civil rights have been violated
Friday, September 24, 2004
State Sen. Avel Gordly, D-Portland, called for a federal investigation Thursday to examine possible civil rights
violations of current and former patients at the Oregon State Hospital in Salem.
Gordly's request came in response to a two-day series in The Oregonian that detailed the sexual abuse of as
many as a dozen patients in the adolescent unit by staff members from 1989 to 1994.
The investigation disclosed that hospital officials and their supervisors -- most still employed in state government
-- did little to stop the abuses and often failed to report suspected sexual abuse immediately to police and child
welfare workers, as required by state law. The articles also said the hospital has taken only limited steps to
prevent abuse in the years since.
"An independent investigation is the best way to get the complete truth about what has happened at the
hospital," Gordly said in a statement. "It's also the best way to make the changes necessary to protect and
care for patients in the future."
Gordly said she and Sen. Vicki Walker, D-Eugene, also are considering increasing penalties for staff who fail to
report abuse. Currently, the punishment is a Class A violation and a maximum $750 fine. The senators will
propose making it a Class A misdemeanor with a maximum $6,250 fine, a one-year jail sentence and possible
license revocation.
Gov. Ted Kulongoski on Tuesday ordered a full review of all abuse of mental patients on the adolescent ward in
response to the newspaper's reports. Although the incidents occurred a decade or more ago, the articles said
the hospital continues to follow abuse-reporting rules inconsistently.
The governor asked officials at the Department of Human Services, which oversees the hospital, to review all
reported cases of abuse in the adolescent ward since 1992 and make a report to him within 30 days.
But Gordly, whose son suffers from schizophrenia and was a patient at the hospital two years ago, said a review
should be done by an impartial, outside agency.
"I am concerned that some state officials who have been decision makers over the past several years would
also be involved in the investigation," she said, "and it's not enough for government to investigate itself."
Michelle Roberts: 503-294-5041; michelleroberts@news.oregonian.com

The Oregonian
The appalling history of sexual abuse of patients at the Oregon State Hospital demands a full investigation
Wednesday, September 22, 2004
Surveillance cameras, for all their uses, cannot begin to substitute for the hard, unblinking look that Oregon
must now give Ward 40, the adolescent unit of the state hospital, where as many as a dozen teenage patients
were sexually abused.
State administrators could place cameras all over Ward 40 and they would not fully protect the fragile,
vulnerable youngsters under the state's care from being raped or molested by staff members paid to help them.
The terrible violations of depressed and suicidal young patients in Ward 40 described by The Oregonian's
Michelle Roberts in a two-day series of reports demand much more than better "monitoring technology" at the
state hospital.
They require an impartial, outside investigation not only of the circumstances of the abuse that Roberts
documented at the state hospital from 1989 to 1994, but also the failures of hospital administrators and
supervisors to stop the offenses when they were reported. The probe also must examine the state's decision to
pay hush money to keep problems at Ward 40 secret from the public and the Legislature.
The secret is out now. Ten years ago severely disturbed and completely defenseless kids were systematically
abused in a place where the state promised to care for and treat them. Today, even though the hospital has
taken significant steps to protect its patients, there are signs that sexual abuse is still occurring and that the
hospital is still failing to fully report it.
In the past four years alone, state police have received reports of 10 allegations of sexual abuse involving the
Ward 40 staff, Roberts reported. Seven of those reports were never forwarded to the state Department of Human
Services officials, even though the hospital is required by law to inform the agency's Office of Investigation and
Training of all suspected abuse.
Eva Kutas, the chief Department of Human Services abuse investigator, says the underreporting makes it
impossible to know the full extent of the abuse at the hospital. Kutas said, "I have concerns about whether we're
hearing about everything at the hospital."
So do we. Even now, state officials don't know how many of their own patients were victims of sexual abuse.
The investigation into the sexual abuse of patients in Ward 40 also should examine whether the adolescent
treatment center should be closed and the patients transferred to other care facilities. In this day and age of
smaller, more homelike treatment facilities, should Oregon even have "a collection of the suffering" as Kutas
called the patients in Ward 40, housed in a century-old state hospital?
While Oregonians are finally looking, they should also think about the wisdom and morality of systematically
depriving the state's mental health system of funds and forcing the hospital to depend on low-paid, poorly trained
"psychiatric aides" to provide care for troubled young people.
Oregon's mental health system, like its state hospital, is full of blind corners and hidden spaces. The answer is
not more surveillance cameras. It is a state that is truly vigilant about care for its most vulnerable children.

The Oregonian
Saying there must be zero tolerance, the governor wants a review of reported abuse cases
Wednesday, September 22, 2004
Gov. Ted Kulongoski on Tuesday ordered a full review of all abuse of mental patients in the adolescent ward of
Oregon State Hospital dating back to 1992 following reports in The Oregonian about sexual abuse of at least a
dozen patients between 1989 and 1994.
"Clearly, the state must have zero tolerance for abuse or neglect of individuals in our care," Kulongoski wrote in
a letter to Gary Weeks, director of the Department of Human Resources, under which the state hospital for the
mentally ill operates.
Kulongoski's order came in the wake of a two-day series in The Oregonian this week detailing sexual abuse of
teenage girls by state hospital staff members. The articles disclosed that hospital officials and supervisors did
little at the time to stop the abuses, and that some of the conditions and procedures in the hospital at that time
have not changed.
Although the incidents occurred a decade or more ago, the governor said the state must assure Oregonians that
current patients at the hospital are getting "the best possible care."
The governor asked Weeks to review all reported cases of abuse in the adolescent ward since 1992 and make a
report to him in 30 days.
Kulongoski said he wanted to know how many cases were reported, how many were substantiated, and what
kind of abuse occurred -- verbal, neglect, physical or sexual. He asked for information on the abusers and what
kind of corrective action was taken if the abusers were state employees.
Kulongoski asked for a timeline of changes that have been made in the reporting of patient abuse or neglect
since 1991 and details of what the current policies and procedures are. He ordered Weeks to do a random
review of abuse reported among the larger adult population in the state hospital for each year since 1992.
Cindy Becker, Weeks' deputy, said she did not see the request as an indictment on the agency. She and
Weeks both emphasized that reforms within the past decade have made the department more accountable.
"To be honest, if we can do things better, we'll do it," Becker said. "There probably isn't another area that strikes
at people's guts more than this, and we want to make sure we're doing everything possible to prevent it."
Stephen Mathieu, an attorney for the Oregon Advocacy Center, an independent, federally funded agency that
defends the rights of the disabled, said the review was welcome.
"We need to find out exactly what happened," he said. "This is a very serious violation of state law and a threat
to the health and safety of patients in the Oregon State Hospital, if they are true."
Weeks' report will go to Stephen Schneider, a senior adviser, who will review it along with a panel of experts in
mental health services, law enforcement and abuse and neglect reporting and investigation.
Kulongoski said the aim is to see whether there should be more or different policies and procedures in place to
protect the 700-odd patients in the state hospital. The governor asked Schneider's group to make
recommendations to him by Dec. 3.
"If we find that change is needed, I intend to ensure that it is implemented quickly and thoroughly," Kulongoski
Schneider is a former Oregon assistant attorney general who is chairman of the governor's task force on elder
Reporter Janie Har contributed to this story. Steven Carter: 503-221-8521; stevencarter@news.oregonian.com

The Oregonian
Press release from the Governor's Office
Tuesday, September 21, 2004
Salem, Ore.) - Governor Ted Kulongoski today sent a letter to Department of Human Services Director Gary
Weeks calling for a review of the policies and protocol in place at the Oregon State Hospital to identify, report
and respond to allegations of abuse and patient mistreatment.

"Cearly, the state must have zero tolerance for abuse or neglect of individuals at the Oregon State Hospital,"
said the governor.

In the letter, the governor asked for a report back from DHS within 30 days. He also stated that he has directed
his Senior Advisor Stephen Schneider to review and evaluate the information - in consultation with experts in
public safety, abuse and neglect reporting and investigation, and mental health service delivery and
administration - to determine whether the policies and procedures currently in place at the State Hospital are
effective and to recommend changes if necessary.

The text of the governor's letter is copied below. A pdf copy of the letter is available on the governor's website at

Text of the governor's letter:

September 21, 2004

Gary Weeks
Department of Human Services
500 Summer St. NE, E-15
Salem, OR 97301

Dear Director Weeks,

There is no job I take more seriously as governor than my responsibility to ensure the health and safety of
Oregonians - particularly those who are most vulnerable, including children, senior citizens, people with
disabilities and those in state custody. As you are aware, recent media reports have unveiled disturbing stories
of past abuse at the Oregon State Hospital. Although the abuses contained in these reports took place over a
decade ago, I believe we must ensure that the state is providing the best possible care to Oregonians with
mental illness being served at the State Hospital.

Clearly, the state must have zero tolerance for abuse or neglect of individuals in our care. There must be
established, effective protocol for identifying, reporting and responding to allegations of abuse and patient
mistreatment. This protocol must ensure that, when necessary, intervention and corrective action-including
holding abuse perpetrators accountable-is immediate and prevents further harm.

In response to my inquiries yesterday, you provided me with information about changes in policy and protocol
regarding patient abuse or neglect reports at the State Hospital that have taken place since 1991. Before
amending or adding to the protocols included in that policy, I need to understand whether in fact those newly
existing protocols are effective.

Accordingly, by this letter, I am asking for a report from you within 30 days that includes the following:

1. A detailed timeline of changes that have taken place in policy and protocol governing the reporting of patient
abuse or neglect.

2. A detailed description of current protocol for the reporting of patient abuse and neglect, including information
regarding the role of the State Hospital Superintendent, the Oregon State Police, the Department's Office of
Investigations and Training, and a description of the process for reporting patient abuse information to DHS
leadership and to you.

3. A review of all patient abuse reports beginning in 1992 that came out of the child and adolescent wards at the
State Hospital. Included in that review should be a listing by year of how many patient abuse reports were
made; how many were substantiated, unsubstantiated, or inconclusive; and, of those that were substantiated, a
brief description of: (a) the type of abuse that occurred (for example, verbal, neglect, physical or sexual); (b)
information regarding the abuse perpetrator (for example, state hospital employee, family member, etc.); (c) the
process of investigation; and (d) the action that was taken, including corrective action regarding state

4. An annual listing of the total number of State Hospital patient abuse reports received since 1992 and a
breakdown by year of how many of those reports were substantiated, unsubstantiated, or inconclusive. In
addition, for each year beginning in 1992, a review of a random sample of those abuse reports. Each of those
samples should detail how many abuse reports were substantiated, unsubstantiated, or inconclusive and, of
those that were substantiated, a brief description of: (a) the type of abuse that occurred (for example, verbal,
neglect, physical or sexual); (b) information regarding the abuse perpetrator (for example, state hospital
employee, family member, etc.); (c) the process of investigation; and (d) the action that was taken, including
corrective action regarding state employees.

It should go without saying that the Department's report of all of the above data should protect the privacy of
hospital patients and comply with the laws regarding state employee records while providing accurate and
detailed information about the events that occurred.

The Department's report should be submitted to Stephen Schneider, my Senior Advisor. I have asked Mr.
Schneider to review and evaluate the information in the report - in consultation with a select group of experts in
public safety, abuse and neglect reporting and investigation, and mental health service delivery and
administration - to determine whether the policies and procedures currently in place at the State Hospital are
effective. I have also asked Mr. Schneider to submit a report to me by December 3, 2004, detailing his
conclusions. Mr. Schneider's report will also include any recommendations about how to strengthen the current
patient abuse and neglect protocols to assure that the state is doing all it can to prevent abuse from happening
in the first place, and to respond appropriately and effectively when abuse occurs. If we find that change is
needed, I intend to ensure that it is implemented quickly and thoroughly.

As I know you are aware, my commitment to this issue could not be more clear. Since taking office in January,
2003, I have established several advisory groups including a Mental Health Task Force, an Elder Abuse Task
Force, and a Child Welfare Critical Incident Response Workgroup, to review and analyze the systems we have
in place to identify, respond and treat the health and safety needs of our most vulnerable citizens. I expect
within the next 45 days to receive recommendations from each of those groups about how to improve services
and supports for individuals with mental illness, seniors, and children in state custody.

I know that you share my commitment to the health and safety of Oregonians and to strengthening the
accountability of state government. I look forward to hearing back from you in the next 30 days so we can
continue to move forward in making Oregon safe and secure for our citizens.



c: Karen Minnis, Speaker of the Oregon House of Representatives
Peter Courtney, Oregon Senate President
Barry Kast, Assistant Director, DHS Health Services
Bob Nikkel, Administrator, Office of Mental Health and Addiction Services
Dr. Marvin Fickle, State Hospital Superintendent

The Oregonian
I was nearly sick with rage and sadness in reading about the abuse that Mary Kay Gonzales suffered at the
Oregon State Hospital ("Betraying a fragile trust," Sept. 19). Unfortunately, I was not altogether surprised.
Those who stayed silent are as guilty as the offenders themselves. It seems there is still an enduring tolerance
for sex crimes, even within institutions designed to protect the most vulnerable segments of the population.
Only when this attitude is abolished at every level of society will those who carry out such heinous and cowardly
acts be swiftly and consistently brought to justice.
I have utmost admiration and respect for Gonzales' decision to prosecute, and for her courage to love and trust
after being hurt so deeply, so many times.
LAURA CRABTREE Northeast Portland
Michelle Roberts' articles on Sept. 19-20 pointed out multiple instances of sexual abuse of patients at the
Oregon State Hospital in the past.
Gov. Ted Kulongoski was right to ask for a full review and modification of the policies and procedures that are in
place to keep these unacceptable behaviors from happening in the future ("Kulongoski orders look at ward,"
Sept. 22).
The Oregon Psychiatric Association and its national organization, the American Psychiatric Association, have
long held sexual contact between psychiatrists and their current and former patients to be unethical.
While these allegations did not involve psychiatrists, the Oregon Psychiatric Association is very interested in
trying to prevent these depraved instances of abuse in society in general and in any kind of mental health
The governor might consider reaching out beyond the department of mental health and the Oregon government
to try to understand how to practically apply the best safeguards against such abuse.
THOMAS DODSON, M.D. Southwest Portland

Michelle Roberts' articles, "Betraying a fragile trust" (Sept. 19) and "Ward of state, world of hurt" (Sept. 20),
enumerated many of the reasons these sexual abuses occurred at the Oregon State Hospital and why the
abusers got away with them.
Lack of proper oversight (no camera surveillance), flaws in the abuse-reporting system (abusers report
themselves?), poor record-keeping, unqualified workers serving as therapists, underreporting of incidents, lack of
disciplinary measures, hush money paid to victims -- and the list goes on.
The abuses are not confined to Ward 40 at the state hospital, and, we believe, will continue under the lenient
policies of the current administration.
We are outraged by these revelations, but unfortunately, as parents of a mentally handicapped person in state
care, we are not surprised. Many of the responsible public officials are still in place, earning nice salaries and
probably sleeping well, too. Where is the public outcry?

The Oregonian
Oregon allowed two of its employees to molest a mentally ill girl in their care and then paid her to keep quiet
Monday, September 20, 2004
Second of a two-part series
SALEM -- Mary Kay Gonzales was 12 when state officials committed her to Oregon State Hospital. A skinny
foster kid with jet black hair, she had tried to kill herself after years of sexual abuse.
A caseworker promised that the hospital stay would last no more than a month. But nearly six years passed,
and Gonzales grew from a child into a young woman within the walls of Ward 40.
Hospital staff in the unit for the state's most mentally ill children used restraint cuffs and isolation to deal with
her despair.
David Conner, a psychiatric aide who counseled Gonzales for three years, told her he was the one person she
could trust, she recalled.
"He was working with me on every detail of my personal life -- it was really rough," said Gonzales, now 28.
"Then one day he pulled me aside and said he'd fallen in love with me. My stomach hit the floor."
She was 17. He was 49.
In the year that followed, hospital supervisors ignored their own observations and other staff members' warnings
about Conner's relationship with the girl. Left unchecked, Conner eventually quit his hospital job and ran away to
California with Gonzales.
Shortly after, records show, he rejected her, sending her into a tailspin that landed her in another mental
hospital, where another staffer sexually abused her.
An investigation by The Oregonian found that Gonzales was one of as many as 12 mentally ill children who were
sexually abused by staff members of Ward 40, subjected to everything from inappropriate touching to rape. In
most cases, hospital officials failed to report offenses in a timely manner, allowing predators to remain on the
Gonzales' case highlights some of the most serious shortcomings the newspaper found.
"I was a lot worse when I left," Gonzales said, "than when I came."
Childhood stolen
Innocence was something she never knew. Gonzales said the sexual abuse began before she was old enough
to speak. By the time she started kindergarten, it was, like the freckles on her nose, a fact of life.
During her early childhood, she lived in a mountain home in rural Oregon. She doesn't remember many happy
times. The only peace and safety she felt was when she hiked through the pines with her beagle, Ding.
"Every day I would get up, go outside and walk for miles and miles," she said, "trying to stay out of the house
for as long as I could."
Because of the secret, she never fit in with her peers.
"No one liked me because I was unapproachable," she said. "I didn't trust anyone."
Isolation and shame eventually gave way to rage and despair. She got into fights at school. She tried repeatedly
to kill herself, once swallowing fistfuls of aspirin. State officials placed her in foster care at age 12 when her
mother signed over custody.
After Gonzales threatened to kill herself while staying at a children's shelter, the state sent her to Ward 40. She
remembers arriving with a small blue suitcase and a heart that felt as if it would pound out of her chest.
Days moved like months on the ward. Gonzales watched the seasons change through the barred windows of
McKenzie Hall, the two-story brick building that housed the 60 young patients.
Records show she got into a lot of trouble, once trying to organize a mass escape by the children. She said
hospital staff often drugged her with medications that had severe physical side effects, including one that made
her tongue shoot out of her mouth involuntarily.
Gonzales didn't trust most of the staff, she said, until she met Conner, a certified nurse's assistant who worked
as a psychiatric aide.
"He wasn't as threatening-looking as the other staff," she said, "skinnier and not as aggressive."
Conner, she said, encouraged her to start writing in a journal. For the first time, at age 15, she trusted someone
enough to share the secret of her abuse. "I remember tossing the journal at him and running away," she said. "I
was so scared."
Once she had revealed the sexual abuse, Gonzales said Conner arranged family counseling, which resulted in
strained relations with some of her relatives. Soon, visits by Gonzales' family stopped.
"My heart sank at that point," Gonzales said. "David told me not to worry, that he'd always be there for me."
"Wrong" "scary" "a romance"
By early 1993, when Gonzales was 17, Conner declared he loved her, court records state. Soon after, the
interactions between the two were the talk of the ward. Court records show that staff at various times described
the relationship as "crazy," "nuts," "wrong," "scary," "dangerous" and "a romance."
Usually, Gonzales said, toward the end of Conner's shift, when other employees were busy, he took her to an
isolated locker area and molested her. She said the sexual touching made her feel sick but also "like I was
special, like I had something no one else had."
Hospital records and police reports show it wasn't the first time Conner had been accused of sexually abusing a
Ward 40 patient. Two years earlier, a 16-year-old girl complained that Conner had touched her inappropriately.
Hospital records state the girl later recanted, so the case was not pursued.
In April 1993, hospital records show, a nurse presented Conner's supervisor with a memo stating she had seen
Conner touching Gonzales inappropriately.
"We were in the storage room and we were kissing, and this one staff member walked in on us," Gonzales said.
Hospital officials took no immediate action. A month later, they gave Conner a verbal warning but did not remove
him from the ward.
Records show a ward supervisor remained concerned enough to give Conner, who was going through a divorce,
an article titled, "Psychotherapists who transgress sexual boundaries with patients."
The supervisor underlined passages, such as, "the most common scenario is that of a middle aged male
therapist who falls in love with a much younger patient while he is experiencing divorce." Another highlighted
sentence: "Incest victims tend to put themselves in situations where they become revictimized and therefore are
'sitting ducks' for therapist/patient sex."
Other staff expressed worries about Conner, records show.
On June 28, 1993, a nurse noted in the unit's communication log that she was "very concerned regarding this
relationship," in part because Conner had given the girl his home phone number, which is a major violation of
hospital policy.
A month later, the unit director gave Conner a written reprimand regarding the ongoing "violations of the touching
policy and orders to restrict his contact" with Gonzales.
Finally, more than two months after a nurse witnessed Conner kissing Gonzales, Conner was transferred to
another ward -- with the stipulation that it was only for as long as Gonzales remained on Ward 40.
Two months before she turned 18, the hospital discharged Gonzales to a foster home. Soon, her new guardians
listened in on a "highly sexualized" telephone call from a man who identified himself as Gonzales' "Uncle
Alarmed, the foster parents notified the hospital and Gonzales confirmed that the caller was Conner.
Conner resigned that day.
A week later, both disappeared.
Abandonment ignites despair
Conner drove Gonzales to California, where, he later admitted in court, they camped for six weeks and had sex.
On Gonzales' 18th birthday, he drove her back to Salem. Police were never alerted to the situation.
"That's when he started losing interest in me," Gonzales said. "The excitement of me not being legal must have
done something for him. The day I turned 18, he became very withdrawn, cold and distant."
Three months later, after Conner got another job working with troubled children at the Oregon Youth Authority,
he told Gonzales to leave his apartment where she had been living.
Gonzales became distraught and began severely mutilating herself, medical records show, including slashing
her arms from shoulder to wrist with broken glass and hurting herself with razor blades.
"I started slipping," she said. "At one point, I swallowed a double-edged razor blade and it got stuck in my
She was admitted to Dammasch State Hospital in Wilsonville on Feb. 23, 1994. Medical records note that the
self-harm began after Conner abandoned her, referring to him as "this boyfriend she had known for five years, as
he was a member of the staff of the Oregon State Hospital."
Though Gonzales was no longer a minor, a 1991 policy required state hospitals to report all suspected patient
abuse, sexual or otherwise, to the Oregon Department of Human Services and police. Records show hospital
officials not only failed to report Conner, but also allowed him to visit Gonzales at Dammasch.
The psychiatrist in charge of Gonzales' treatment at Dammasch later testified that he was concerned enough
about the relationship to check with the personnel department at the Oregon State Hospital to see whether
Conner had had problems on Ward 40.
Because Conner's employee-separation report described the quality of his work as "adequate," he was
permitted to visit the troubled young woman he had abused repeatedly.
"Easy target" for second aide
After her release from Dammasch on May 31, 1994, Gonzales cycled through hospital psychiatric wards; she
was recommitted to Dammasch in July. Hospital records note she was so ill that she removed 16 metal springs
from her hospital bed and swallowed them. They had to be removed surgically from her intestines.
About this time, Gonzales caught the eye of Brigham Clifton, 38, a psychiatric aide who had been disciplined for
calling patients by their case numbers instead of their names. He had nearly lost his job the year before,
records show, after he and several other staff suffocated an adult patient to death while restraining him for
refusing to take off his shoe.
Dammasch employees also had complained about Clifton's inappropriate behavior with female patients.
Soon, records show, staff began to joke about Clifton's frequent trips with Gonzales to the ward linen closet. "He
had heard about what had happened with David and me," Gonzales recalled, "and figured I was an easy target."
Two months after Clifton began having frequent sex with Gonzales, records show, Gonzales complained to a
Dammasch nursing supervisor. "I put a stop to it," Gonzales said. "I said, 'I've been through this before. I don't
want to go through it all over again.' "
Hospital officials conveyed Gonzales' allegation against Clifton to the DHS Office of Investigations and Training,
court records show, but did not call police. So lawyers at the Oregon Advocacy Center, a federally funded group
that works closely with disabled residents in the state hospital, called for a criminal investigation. Because of
her illness, advocates questioned Gonzales' ability to consent to sexual contact with Clifton, even though she
was legally an adult.
A state trooper met with Superintendent Stanley Mazur-Hart, then overseer of both Oregon State Hospital and
Dammasch. "I was informed by (Mazur-Hart) that the ability of (Gonzales) to consent to sexual activity was not
in question," the trooper wrote. "At no time was she incapable of giving consent. She was there strictly on a civil
commitment and she was not suffering from mental defect or inability to consent."
In fact, records show Gonzales had been committed to the hospital involuntarily because a judge found that she
had a mental disorder and was a danger to herself.
After Clifton admitted to DHS investigators that he had had sex repeatedly with Gonzales, Mazur-Hart
determined that the abuse had occurred. But no abuse was reported to DHS or police in the Conner case until
1995, after an attorney representing Gonzales filed notice with the court that he planned to sue on her behalf.
State settles, buys silence
Gonzales sued Conner, Clifton and several top hospital administrators in 1996, alleging that officials had ignored
a long-standing pattern of sex abuse at Oregon State Hospital and Dammasch.
When the case went to trial, state attorneys tried to discredit Gonzales, though by then Mazur-Hart had
substantiated the allegations against both therapists.
"They said the sex abuse I suffered (before being in state care) is what screwed me up, not what the state
hospital did," she told The Oregonian. "That -- and my mental state -- was their main defense against me."
Court records support her recollection.
Clifton said in a telephone interview that, despite his court testimony to the contrary, he never sexually abused
any patients, including Gonzales. "I was happily married at the time and came from a good religious
background," he said. "I wouldn't do anything like that."
Conner admitted to having sex with Gonzales when she was a minor but told The Oregonian the girl was to
blame. "I'm not a sex abuser," Conner said. "I'd worked with that girl as her therapist since she was 13. I was
going through a divorce and I was very vulnerable. She drew me in."
Conner faulted the hospital for lax employee supervision and failure to train him properly.
Mazur-Hart, who now works elsewhere in DHS, said he did all he could to keep patients safe.
"The abuse of patients at a psychiatric hospital is a terrible wrong," he wrote in response to questions posed by
The Oregonian. "While I was superintendent at OSH, I insisted on vigilance in this area by all employees. Most
OSH employees had this vigilance on their own."
Shortly after Gonzales testified during the trial, the attorney general's office, then led by current Gov. Ted
Kulongoski, agreed to settle the case for $300,000 but admitted no wrongdoing by hospital administrators.
State lawyers kicked in another $50,000 for a confidentiality clause to ensure that Gonzales never speak
publicly about the outcome of the case and to keep her attorney from holding a news conference on the Marion
County Courthouse steps. After the state paid her legal bills, the settlement amounted to the largest loss in
state hospital history -- $584,809.
Gonzales remains bound by the agreement. She would talk only about her time on Ward 40, saying, "I want
people to know what happens there so (officials) will shut that place down."
The Oregonian discovered details of the settlement through sealed records that were mistakenly placed in a
public court file.
The years since the settlement have been difficult, she said; most of the money went to counseling and medical
bills. Since getting married five years ago, she has started to heal the emotional wounds of her childhood.
"I finally have someone I can trust," she said of her husband, Chris Gonzales, with whom she has a 3-year-old
Gonzales, who is diagnosed with depression but has not been hospitalized in many years, says she no longer
feels responsible for what Conner and Clifton did to her. "I forgive myself," she said, "because I was so young,
naive and taken advantage of."
Yet the scars remain.
She still can't look at McKenzie Hall, though her bus has been passing it for years. She gets irritable when her
husband, reading in bed beside her, brushes her back with his elbow.
"Staff used to always put their elbows in my back when they were holding me down," she said.
She used to hate summers because she could never wear short sleeves -- the scars from the gashes on her
arms draw stares. Yet, in recent weeks, since beginning to talk about what happened to her at the hospitals,
she has become "gutsy" about showing her arms in public.
"I've had a lot of people stare," she said. "But it still feels good. Like I'm finally free."
Michelle Roberts: 503-294-5041; michelleroberts@news.oregonian.com

The Oregonian
Some Oregon State Hospital caretakers have sexually abused mentally ill children, preying on patients in a
ward still at risk because of systemic security failures
Sunday, September 19, 2004
SALEM -- The children sent to the Oregon State Hospital's Ward 40 for treatment were a danger to themselves
or others. Some arrived in straitjackets. Many were depressed and suicidal. Others had begun to hear the
shouts of schizophrenia.
They were among the state's most vulnerable residents -- troubled young people whose families could not afford
private care or whose insurance had run out. The hospital's Child and Adolescent Treatment Program was
supposed to quell their mental illnesses and shelter them from harm.
But an investigation by The Oregonian shows that hospital staff in positions of trust sexually abused as many
as a dozen children, according to internal hospital records, police reports, court documents and interviews with
Hospital officials and their supervisors in state government did little to stop the abuses, which occurred between
1989 and 1994. Supervisors and others on the ward failed to report the offenses when they were detected,
allowing predators to attack additional victims. The hospital repeatedly failed to report suspected sexual abuse
immediately to police and child welfare workers, as required by state law.
In the years since, the hospital has taken limited steps to prevent abuse. It did not begin conducting
background checks on employees until 1991, and then reviewed only the histories of new hires. It has yet to
install surveillance cameras, which are standard in comparable facilities elsewhere. And it has routinely ignored
its own procedures, which require independent investigations of sex abuse allegations reported to Oregon State
State officials said their records identify only three patients who were victims of sexual abuse on Ward 40 in the
past 18 years. But The Oregonian found credible reports of nine additional abuse victims from police files, court
documents and eyewitness accounts. Some never came to the hospital's attention. Others were reported but
examined only cursorily.
"I was sent to the hospital because I tried to kill myself," said Kelly Darcey, who was molested repeatedly at
age 15 by a ward employee. "I was in far worse shape when they discharged me."
The Oregonian does not identify victims of sex crimes. However, some of the women who were abused as
children on Ward 40 have asked that their first or full names be published because they want the abuse brought
to light.
Records and interviews with administrators and those who committed the abuse noted that the hospital's
procedures and design problems -- most of which still exist -- offered pedophiles numerous opportunities.
Ward 40, which still houses about 20 young patients, is located in a century-old building full of blind corners and
hidden spaces with no high-tech equipment to detect or deter abuse.
Stanley Mazur-Hart, the hospital superintendent from 1991 until last fall, blamed "budget constraints" and
acknowledged "there is far better monitoring technology available than that which OSH has."
Administrators and state officials failed to recognize the pattern of abuse, even though it occurred on a small
ward with no more than 60 patients ranging in age from 5 to 18. Over the years, a succession of unit directors,
psychiatrists and nurses supervised the ward but the responsibility for what happened there and elsewhere in
the hospital rested on the superintendent.
The first significant abuse case -- a psychiatric aide accused of having sex with multiple girls in the late 1980s --
was closely followed by four more credible reports that male employees molested female patients. In the
mid-1990s, the state paid two women more than $1 million for abuses they suffered while patients on Ward 40.
Yet little changed.
No administrators from the hospital or the Department of Human Services, which oversees it, were disciplined or
State officials say some abuse by employees is inevitable at psychiatric facilities such as Oregon State
Hospital. "We never had the perception that the hospital was an institution beyond reproach," said Barry Kast,
an assistant DHS director. Kast said he did not see the cases as part of a larger pattern.
The children's stories have never been told, in part because hospital executives and state officials have fought to
keep them from the public.
In one case, the state paid an additional $50,000 to secure the silence of a victim whose attorney was poised to
hold a news conference on the Marion County Courthouse steps. A lawyer in the office of then-Attorney General
Ted Kulongoski told a judge in a closed-door hearing that the secrecy was needed to protect the hospital from
political attack by the Legislature.
The scope of sexual abuse at the hospital was brought to light by The Oregonian's examination of records and
interviews with more than 50 current and former patients and employees.
Records relating to the abuse of patients on Ward 40 are largely confidential under state and federal privacy
laws. As part of a lawsuit, the state turned over to an attorney for one of the victims a detailed accounting of sex
abuse allegations involving child patients from 1986 to 1995.
Those records, which were supposed to remain sealed, were inadvertently placed in public files at the Marion
County Courthouse. They included police reports, medical records, internal hospital documents, transcripts of
closed court hearings and personnel files.
State officials denied repeated requests for comparable records for the years since 1995, making it difficult to
assess whether patients continue to be molested.
State records, however, show that the hospital is not following its procedures for investigating abuse. In the past
four years, state police have received reports of 10 allegations of sexual abuse involving Ward 40 staff, none of
which resulted in criminal charges.
DHS officials acknowledged that seven of those cases were never reported to them, even though the hospital is
required by law to inform the agency's Office of Investigation and Training of all suspected abuse. Such agency
investigations are crucial, identifying problems so the hospital can change policies or discipline abusive
employees before their actions rise to the level of crimes.
Eva Kutas, the chief DHS investigator of possible abuse, said failure to notify her office highlights flaws in the
reporting system and raises questions about the safety of the children on Ward 40.
"If the state police don't investigate, we still need to," she said. "That's the only way we can keep track of what's
happening there."
The documented cases of sexual abuse spanned the administrations of Govs. Neil Goldschmidt, Barbara
Roberts and John Kitzhaber. All three said they did not know what was happening on Ward 40.
"That's an issue that should have come straight to the top so we could make sure it stopped," Kitzhaber said. "I
don't know why it didn't. Obviously, it should have."
Roberts told The Oregonian: "Never did anyone ever talk to me about sex abuse cases at the hospital. Had I
known, I would have responded immediately. For me, there would not have been any tolerance."
"A collection of suffering"
Since 1976, hundreds of mentally ill children have been sent to live behind the brick walls of McKenzie Hall, a
two-story fortress that houses Ward 40 on the northwest edge of Oregon State Hospital's 148-acre campus.
Ward 40 is one of the few places in the state that serves emotionally disturbed children ages 14 to 18. Many are
wards of the state.
Former patients describe Ward 40 as intimidating and lonely, absent color and love. Children screamed for their
mothers as "The Price Is Right" droned on the day-room television. So many kids were on suicide watch that
the corridor was lined with their mattresses at night so staff could keep an eye on them.
"The best way to describe it is a collection of suffering," Kutas said.
Children often arrive at Ward 40 expecting to stay a month or two. Yet many languish hundreds of days,
sometimes years, at taxpayer expense -- $30,700 per child per month today. Their illnesses make it difficult, if
not impossible, to place them elsewhere. Families that visit are the exception, not the rule.
As a result, many children are reared by doctors and psychiatric aides in a place where razor wire divides the
playground from an exercise lot for criminally insane adults.
Across the nation, states are moving from institutionalizing mentally ill children to creating smaller, homelike
facilities that are cheaper and more effective.
A significant amount of the therapy at Ward 40 is administered by psychiatric aides who hold the title of mental
health therapist. Although they can be hired with only a few days of certified nurse's assistant training, they
conduct therapy sessions and plan patient schedules. Many have no college background in psychology. All the
cases The Oregonian examined involved workers at this level.
Until two years ago, Ward 40 accepted children as young as 5. Today, it is set aside for teenagers, with
younger children sent to the private Parry Center in Portland, which contracts with the state.
Mazur-Hart, superintendent when the younger children were transferred, acknowledged at the time that an
institutional setting "isn't a proper home for children." Records obtained by The Oregonian dramatically illustrate
that point.
One year, one man, six girls
One of the employees whose background supervisors did not check was Michael Paul Hake. A drug user who
served jail time in 1978 in Idaho for delivery of a controlled substance, Hake began work in 1984 in the state
hospital kitchen.
Three months later, he passed a certified nurse's assistant test and began to work in an adult unit. In 1987, he
moved to Ward 40.
In the span of a year, in the dormitory, in a space beneath steps, behind thick-trunked trees that shade the
hospital campus, Hake may have sexually abused as many as six girls in his care, according to records and
In August 1988, Hake's supervisors gave him a verbal warning for "spending an excessive amount of time with
four of the female patients," according to hospital documents.
The next month, an outside social worker called the hospital to report a suspected sexual relationship between
Hake and a 17-year-old girl who had been discharged from Ward 40 four days earlier. Hake had left his wife and
two children and moved into the girl's subsidized Mill City apartment, the social worker reported.
Hospital records say he also invited a 16-year-old patient named Angela to that apartment for sex, sliding a key
into her pants pocket. Police records state that hospital staff confiscated the key.
State laws passed in 1975 require "mandatory reporters" -- including doctors, teachers, social workers and
mental health professionals -- to inform police and child-protective services immediately of suspected sexual
abuse. Although hospital officials considered the alleged abuse of the 17-year-old plausible enough to launch an
internal review and eventually fire Hake, there is no indication they called police.
Several Ward 40 girls attended classes at Chemeketa Community College and were allowed to leave hospital
grounds unaccompanied. Hake, when he was their case manager, arranged many of their schedules.
Days after his firing, Hake approached Angela at a bus stop near the college on Oct. 7, 1988, she later told
police. He told her he wanted to show her his new car. When she walked close, a second man pulled her inside
the car and Hake drove to a nearby house, she said.
Angela, who weighed 79 pounds, told detectives that the men carried her into the basement and took turns
holding her down as they raped and sodomized her.
"Mike then told me that if I tell anybody about this, they will do the same thing to me again and they will kill
me," she said. Hospital records show she arrived back at McKenzie Hall without her textbooks, disheveled, dirty
and distraught.
Nearly two weeks passed before a hospital official called state police, the agency's records show, after Angela
drew a picture of two men raping her, labeling one of the figures "Mike Hake." She did not know who the other
man was. A subsequent rape exam showed significant injury.
The criminal investigation took more than a year because Angela was so traumatized. For months, she lay
silent, tied to a restraint bed and fed through a nasal tube. During that time, Hake worked in a Salem nursing
home less than a mile away.
A Marion County grand jury indicted Hake for first-degree rape, sodomy and kidnapping in Angela's assault. But
a June 1991 trial resulted in a hung jury.
Rather than retry the case, prosecutors allowed Hake to plead no contest to one count of first-degree criminal
mistreatment of the girl with whom he shared an apartment, and had married, shortly before his rape trial.
Hake never went to prison. He was sentenced to five years' probation, ordered to have no contact with Angela,
to participate in a sex offender treatment program and surrender his nurse's assistant license.
Hake, who now lives in Idaho, did not respond to a written request for an interview.
The hospital did not change its procedures as a result of the Hake case. Nor did it investigate on its own
whether Hake had abused others on Ward 40. Confidential records of the criminal inquiry obtained by The
Oregonian, as well as interviews with former patients, suggest there was much to examine.
In October 1989, as police investigated the attack on Angela, a 14-year-old patient came forward to say she,
too, had been abused by Hake when she was 12.
"I have nightmares about what happened to me," she told authorities at the time. "I dream that Mike comes in
and sits down beside me and starts touching me. I'm afraid to go to school."
An internal hospital memo contained in the police file shows that hospital staff decided not to investigate further
for fear of interfering with the girl's psychiatric treatment.
Another teenage patient fled the hospital after learning Hake was a suspect in Angela's rape, police reports
state. The girl had told Angela and other patients that she and Hake had had sexual intercourse on the ward.
She was named in police records as a possible victim, but officers said they couldn't find her and never
interviewed her.
The girl's mother, located recently by The Oregonian, said her daughter came home pregnant several weeks
after fleeing the hospital. "She told us Michael Hake was the father," the woman said, adding that she helped
her daughter get an abortion.
The former patient, now married and living in another state, declined to discuss the matter, saying she had
"moved on."
Maureen Greiner, another former patient, also was mentioned in police and court records as a possible victim.
Her parents said recently that their daughter, a devout Roman Catholic, confided "something major," to a priest
who visited her on the ward. The priest urged the Greiners to remove her from the hospital immediately.
Lynne Greiner said she and her husband were afraid to take their depressed daughter home.
"I had these little funny feelings," she said. But "I put things aside because, after all, this is the Oregon State
Hospital. We trusted because we didn't know what else to do."
Greiner said she was never told that one of her daughter's caregivers was under investigation for rape. "Why
were we never told? Why? Why?" she asked, her voice shaking.
Another teenage patient, Jennifer Borgelin, told others that Hake had molested her, too.
Borgelin's mother, Kathy Czupofski, said, "I always believed deep in my heart that something happened to her
there. When she came out of there, she was different. Instead of being helped, I believe they ruined her."
All that happened to Maureen Greiner and Jennifer Borgelin will never be known. Both committed suicide in the
early 1990s, shortly after their discharge from Ward 40.
Slow to investigate
In April 1990, a 17-year-old patient complained that a psychiatric aide, Ronnie Roy LaCross, had grabbed her
breast during a full body hug -- and that it wasn't the first time.
"This is the one I actually told someone about," the patient told staff.
The Hake investigation was under way and records show that the hospital was slow to investigate another
incident. Police were not called.
Two months later, after the girl turned 18, the hospital began an internal inquiry. The patient told hospital and
DHS investigators that she "didn't feel safe here anymore" and that LaCross "shouldn't be working here."
A report called her "very credible" but noted "there has been some pressure by the staff for (her) to accept the
fact that she may have wrongly perceived Ron's actions." At the same time, investigators called LaCross'
accounts "inconsistent."
Another patient told investigators she felt uncomfortable around LaCross and had told him to stop hugging her.
George Bachik, then hospital superintendent, determined that abuse could not be substantiated.
"Perhaps and indeed in the process of hugging, with whatever clumsiness, unintentional contact may occur and
events may be consequently misinterpreted," Bachik's report said. "No disciplinary action will be taken."
But state records show that at least one official recognized the warning signs on Ward 40. Kutas, who had been
asked to help investigate the case, expressed concern about improper physical contact between staff and
"I think this subject would be important in a program where you undoubtedly have a number of patients with
sexual/physical abuse in their past and where not only trust building, but how people are touched, is important,"
she wrote in a memo.
Bachik subsequently ordered a review of the "practice of staff/patient hugging," hospital documents state.
It is unclear whether policies changed.
What is certain is that abuse did not stop.
Poem speaks of trust
Kelly Darcey was admitted to the hospital on June 15, 1990; she had suffered years of sexual abuse and had
tried to kill herself. Within days of her admittance, the 15-year-old was molested by LaCross.
LaCross volunteered to be with Darcey one-on-one when she was on suicide watch. During these times, she
later told detectives, he told her he wanted to make love to her, fondling her, exposing himself and asking her to
do the same. Once, he put his wedding ring on her finger and promised to divorce his wife when Darcey was
On July 10, 1990, Darcey typed a poem she said was about LaCross on the Ward 40 computer:
It's gone again. . . hard-earned trust,
You took it away by your excruciating lust.
A nurse found LaCross alone with Darcey 31/2 months later in the staff break room. Alarmed because of the
earlier allegation against LaCross, the nurse alerted his supervisor, Stephen Brakebill.
Brakebill and the nurse confronted LaCross, who put up no argument, records show. He signed a contract
agreeing to limit one-on-one contact with female patients to those on his caseload, which Darcey was not.
Brakebill kept handwritten notes on LaCross' adherence to the work plan.
"Observed playing game with female resident in the day room appropriately!" Brakebill noted Dec. 24, 1990.
"Doing an excellent job!" said an entry five weeks later.
But LaCross, who worked swing shift, was continuing to sexually abuse Darcey. Twice in one month, he wrote
in Darcey's chart that he had engaged in 10-minute "struggle holds" with her.
"When I was in struggle holds," Darcey later testified in court, "he put my hand right on his privates."
On Valentine's Day 1991, a day before Brakebill observed "No problems!" with LaCross' behavior, the psychiatric
aide, in violation of hospital policy, gave Darcey a red and white teddy bear with a plastic tag that said, "I love
Records show that staff confiscated the tag when Darcey used it to carve bloody wounds on her arms.
About a month later, two teenage patients demanded that staff stop LaCross from abusing Darcey. But hospital
officials failed to take action.
The hospital waited almost three days before calling her caseworker at the state's children's services agency.
The hospital did not inform police as required by law. After pestering the hospital for two days to report the
suspected abuse, the caseworker called state police herself, records show.
Five months later, Mazur-Hart, the hospital superintendent, ruled that Darcey's allegations were true. LaCross,
who spent several months on paid leave, was eventually fired and convicted of second-degree sexual assault.
The girl who made the first complaint about LaCross more than a year earlier was named as an "additional
victim" in police reports in the Darcey case. She told police that besides fondling her breast, LaCross had sex
with her three times on the ward. LaCross was never charged in that case.
In 1992, Darcey sued state and hospital supervisors and LaCross, alleging she had been sent to Ward 40
despite "a pre-existing pattern" of sex abuse against young patients. A jury awarded her $530,000.
Today, LaCross lives in a nursing home in Washington state. He declined to comment.
Playing politics, buying silence
In 1991, the Oregon State Hospital adopted new rules for tracking suspected abuse of patients. The
superintendent was to be notified immediately of any allegations. He was required to forward cases to DHS for
independent examination but retained the power to ultimately decide whether abuse had occurred. Mazur-Hart
said the change was prompted by the Ward 40 cases and patient abuse elsewhere in the hospital.
The new policy, however, was not always followed.
Mary Kay Gonzales was admitted to the state hospital in 1989 when she was 12. She lived in state care more
than six years. By the time she was 18, she had been molested by two employees.
One was her longtime psychiatric aide on Ward 40, David Conner, 32 years her senior. The second, Brigham
Clifton, worked at Dammasch State Hospital in Wilsonville, where Gonzales was committed for mutilating
herself after Conner rejected her.
Records show hospital staff did not immediately report their suspected abuse of Gonzales in either case. In
fact, Mazur-Hart never contacted DHS to investigate Conner until Greg Smith, the Salem lawyer who won Kelly
Darcey's case, threatened to sue on Gonzales' behalf in 1995 -- more than two years after the alleged abuse on
Ward 40 occurred.
Mazur-Hart eventually ruled that Gonzales had been sexually violated by both workers. But when her lawsuit
went to trial, state attorneys tried to discredit her. In court papers, an assistant attorney general referred to her
"bizarre mental abnormality" and said she was "extraordinarily manipulative."
Several days after the trial began, the attorney general's office, then directed by current Gov. Ted Kulongoski,
agreed to settle the case for $300,000, records show. The state kicked in another $50,000 for a confidentiality
clause to ensure that Gonzales never talk publicly about the outcome of the case.
Discussions -- which revealed the settlement amount -- would never have become public, but a transcript of a
closed court hearing that should have been sealed was instead filed with other public records in the case.
Public court documents state that a Marion County Circuit judge had ordered the settlement sealed because
"privacy interests of plaintiff . . . outweigh the public's interest."
But the transcript shows another reason why the state sought privacy: to protect the reputation of hospital
"We made it clear that we were buying confidentiality from the plaintiffs," Assistant Attorney General John
McCulloch Jr. told the judge. "The real damage to the defendants is hardly calculable. I don't know how to put a
dollar sign on the political aspect. What's somebody going to say in the next legislative session about Dr.
Mazur-Hart and how he runs his ship out there?"
Smith said McCulloch offered the additional $50,000 after he said he was planning to hold a news conference on
the courthouse steps, an interpretation McCulloch accepted in a recent interview.
Kulongoski declined repeated requests for interviews but released the following statement: "The Oregon
Department of Justice annually handles thousands of legal matters, both civil and criminal. As the Attorney
General, my role was to oversee the attorneys who represented the state in these legal matters. I have no
recollection of the facts or circumstances of this specific legal matter that occurred nearly a decade ago."
Potential underreporting
Hospital officials say that serious abuse on Ward 40 is a thing of the past.
But Kutas, the chief DHS investigator, said she thinks there has been underreporting of abuse that makes it
impossible to know its full extent. "I have concerns," she said, "about whether we're hearing about everything at
the hospital."
For a three-year period ending in 2000, Kutas said, her office received no reports of alleged sex abuse on Ward
40 from Mazur-Hart, who resigned last fall amid controversy about an escape by a forensics patient and a
neglect case on an adult ward.
Kutas was taken aback to learn that her office had no record of seven allegations of child sex abuse by Ward 40
staff that were reported to state police in the past four years.
A database kept by her office shows the last case the hospital substantiated as sex abuse on Ward 40 was in
1996, when a male staff member was discovered staring at girls in various states of undress.
In the eight years since, only three other accusations have been reported to DHS, including a former patient's
allegation in 2000 of being raped as a child by a Ward 40 aide and a complaint by two former patients in 2002
that another worker had had sex with them on the ward.
State police and DHS administrators in charge of the hospital refused to release records of the incidents that
were not reported to Kutas, citing privacy concerns for the patients.
Mazur-Hart, who now makes nearly $80,000 a year studying problems in the state's mental health system for
DHS, declined repeated interview requests. He agreed to answer questions in writing, defending the hospital's
handling of child sex abuse allegations during his 12-year tenure. "At times the conduct of a few staff was very
wrong," he wrote. "When aware of this, we took strong action to stop it and prevent any future recurrence."
A former worker who has since been convicted of attacking young boys, however, said the hospital was a
pedophile's dream.
In a letter to The Oregonian, Frank Milligan detailed a litany of oversight problems at the hospital, including "far
too many blind corners" and a "lack of cameras or even simple surveillance equipment."
"Should a staff member be so inclined, he/she need only wait for an emergency situation, or a patient to act out
and draw the attention of the other staff, to take advantage of the chaos and slip away with a victim," he wrote.
"Just as disturbing is the fact that I worked side-by-side with psychiatrists, psychologists and social workers
and not one of them ever suspected that a man who, since the age of 13, had gruesome fantasies about
kidnapping, raping, mutilating and murdering young boys, was standing right next to them. One would think that
at least one of them might have detected something."
Milligan, who worked on Ward 40 as a psychiatric aide from 1994 to 1997, wrote that he groomed a 10-year-old
boy on Ward 40 by "plying him with things such as extra privileges, compliments and a soda pop." He said the
boy was "both needy and passive -- two traits that all pedophiles look for in a victim."
A law enforcement official told The Oregonian that police strongly suspect that Milligan victimized at least one
mentally ill boy on Ward 40 but could not bring charges because the child was afraid to talk.
In 2000, Milligan was convicted of abducting a 10-year-old boy from a Dallas park. He raped and strangled the
boy, slashed his throat and left him for dead. The boy survived. Milligan is serving a 36-year prison term.
At the time of the attack, Milligan worked as a counselor at MacLaren Youth Correctional Facility in Woodburn.
He also was out on bail in a sexual assault case of an 11-year-old boy in Seaside. Milligan had met that boy
through a Ward 40 staff member, whose daughter ran a Salem foster home where the boy lived.
The hospital did not try to determine whether Milligan, by then one of the state's most notorious pedophiles, had
abused patients on the children's ward.
Kutas said she wanted to investigate but lacked the authority unless invited by the superintendent.
That invitation never came.
Reporter Kim Christensen and news researchers Margie Gultry and Kathleen Blythe contributed to this report.
Michelle Roberts: 503-294-5041; michelleroberts@news.oregonian.com

July 16, 2004
Kulongoski invited to inspect Oregon State Hospital
SALEM, Ore. - Frustration over overcrowding at the Oregon State Hospital prompted patients and workers to
invite Gov. Ted Kulongoski to inspect conditions for the criminally insane.
Sixteen staff members and 18 patients in the hospital's forensic psychiatric program wrote a letter to
Kulongoski, inviting him to visit Ward 50I "so that you can meet with us and hear our stories."
"Overcrowding and understaffing causes unbelievable hardship to those who live and work here, and to the
families and friends who care about us," they wrote.
Mental-health specialist Jon Sears told the Statesman Journal that he delivered the letter to the governor's office
on June 30. But he has received no immediate response about a visit.
"I want the public to know this is a terrible condition," Sears said. "The standard of care because of this is
Mary Ellen Glynn, a spokeswoman for Kulongoski, said the governor is committed to improving conditions at the
state hospital.
In December, he appointed a task force to examine flaws in the mental-health system and recommend
changes. The final report is expected before the end of the year.
Glynn said she couldn't say whether the governor might accept the invitation to visit Ward 50I.
About 460 patients occupy the hospital's forensic psychiatric program, which has a budgeted capacity of 404.
One patient, Richard Laing, described conditions this way: "Lots of security. Terrible food. No treatment. And
lots of crowding."
His unit, Ward 50I, has 44 patients living in a space designed for 30.
"Just trying to live together under these conditions increases the chance of violence," Sears said. "Also, the
quality of care is greatly decreased."
Most patients have psychiatric troubles and criminal histories, ranging from shoplifting to substance abuse and
murder. As criminal defendants, judges deemed them guilty but insane, sending them to the Oregon State
Sears said that some patients don't even belong in the hospital, because they were misdiagnosed or pretended
being mentally ill.
A new ward is set to open in September. But hospital officials say that probably won't provide much relief, citing
a steady influx of new patients.

The Oregonian
ON JULY 15, 2003.]
The allegations against Dr. Charles E. Faulk, 53, were outlined in Department of Human Services investigative
reports and other records obtained Monday by The Oregonian. They have found that he denied medications to a
severely mentally ill patient, causing the man to unduly suffer for months. Apparently Dr Faulk cut off the
medicine for a severely psychotic inmate, essentially abandoning him and apparently doing nothing significant
to help him out. Records show that Faulk, the ward's full-time psychiatrist, visited his ailing patient only once
during that period, and ignored repeated staff warnings that Norton was "decompensating."
The patient, Neil Norton, 59, lost nearly 40 pounds, frequently cried through the night and became persuaded
that someone had left a dead fetus near a soda machine on the ward. Faulk had cut Norton off his medications
in June 2002 after accusing him of being "a pill seeker." When Faulk finally intervened in January, 2003, he did
so with six electroshock treatments.
According to the report, Dr. Faulk is paid $9,756 a month.
Additional Note: Four years earlier, Dr. Faulk nearly lost his medical license for what the Oregon Board of
Medical Examiners called "habitual or excessive use of intoxicants or drugs."
Additional Note: This comes at a time of increasing scrutiny for the hospital, which receives nearly half of the
state's budget to care for the mentally ill yet serves only 1.5 percent of them.
Other Accusations: The patients claimed that Faulk had called one a "homicidal maniac" and told another, "You
are the worst patient I have ever had." The alleged abuse also included Faulk telling a Cuban patient to "go back
to where you came from." Many of those allegations were never investigated by the Human Services Department
because they did not constitute abuse under Oregon law, officials said.

Article 11 of 108
September 30, 2003
NO TEARS FOR STATE PSYCHIATRISTS Henry Grass' Sept. 29 letter denounced The Oregonian for running a
story about Oregon State Hospital psychiatrists who have been disciplined.
Two of those psychiatrists mentioned in the article treated me while they were active addicts/alcoholics.
Psychiatrists treating county clients have great power over powerless people. Bad psychiatrists damage lives
further and increase taxpayer-borne expense.
Addiction-recovered psychiatrists return to high-powered, high-paying jobs while those Full article: 182 words

Article 19 of 108
September 2, 2003
HOSPITAL'S STATUS HURTS HIRING Summary: Perceptions on the quality of care and the realities of
workplace and pay make Oregon State Hospital a tough sell to top psychiatrists
Oregon's state mental hospital is struggling to attract top-flight psychiatrists to work in an overcrowded facility
that one senior state official acknowledges is "falling down."
More than 700 patients are in residential treatment at Oregon State Hospital, many for psychoses so severe
they cannot survive on their own.
Yet nearly Full article: 2497 words

Article 20 of 108
August 2, 2003
STATE HOSPITAL WASTES FOOD I am confined at the Oregon State Hospital in Salem as an involuntary
It is a continuing policy and practice at the state hospital to throw away large quantities of uneaten food. This
food is definitely edible. This happens despite patients' desire to eat this food.
The uncaring and unconcerned hospital staff ignore patients' pleas and state, "I'm just doing what I'm told."
On July 20, this paper published an article in the editorial section Full article: 187 words

Article 21 of 108
July 26, 2003
TIME FOR CHANGE AT STATE HOSPITAL Summary: Superintendent wisely retires after a patient escapes,
another is abused and a study recommends reforms
Stanley Mazur-Hart has served a respectable 12-year stint as superintendent of Oregon State Hospital. He's
wise enough to see that it's time for him to move on.
State officials have become concerned about the quality of patient care at the mental health institution,
particularly after the recent escape of one patient and abuse of another. Barry Kast, an assistant Full article:
629 words

Article 22 of 108
July 22, 2003
SUPERINTENDENT OF STATE HOSPITAL RESIGNS Summary: Stanley Mazur-Hart will leave his post at
Oregon State Hospital on Sept. 30 but probably will be given another job
The superintendent of Oregon State Hospital resigned Monday following a highly publicized patient escape and
a state investigation alleging that a senior staff psychiatrist abused a patient.
Stanley Mazur-Hart's resignation will take effect Sept. 30. He has headed the state hospital's Salem and
Portland campuses since 1991.
Barry Kast, assistant Full article: 977 words

Article 23 of 108
July 18, 2003
MORE THAN ONE IS RESPONSIBLE Summary: Patient abuse at Oregon State Hospital shows a need for staff
training and a cultural makeover
An inquiry has found that an Oregon State Hospital doctor withheld medications, causing a mentally ill man to
suffer. Dealing with this serious issue, we are concerned that Stanley F. Mazur-Hart, Oregon State Hospital
superintendent, confront the difference between accounting and accountability.
Accounting involves use of relevant indicators to collect and describe failures and Full article: 508 words

Article 24 of 108
July 15, 2003
at the Oregon State Hospital withheld medications, causing a mentally ill man to suffer
State officials investigating allegations of abuse by a senior psychiatrist at the Oregon State Hospital in Salem
have found that he denied medications to a severely mentally ill patient, causing the man to unduly suffer for
The allegations against Dr. Charles E. Faulk, 53, were outlined in Department of Human Services investigative
reports and other Full article: 1061 words

Article 6 of 200
December 9, 2002
TREATMENT OR ABUSE? Concerning your editorial applause for the state's public apology on eugenics, does
this state feel righteous apologizing for past offenses when gross abuse still occurs routinely on private hospital
psychiatric wards and at Oregon State Hospital in Salem?
I await an on-the-knees apology for beatings and other abuses I endured at the hands of mental health
professionals, not in 1917 or in 1970, but in the 1990s.

Article 51 of 108
July 24, 2002
technician who disparaged Tyrone Wayne Waters no longer works at the facility
Investigators have determined that an African American psychiatric patient who is the son of state Sen. Avel
Gordly was verbally abused two months ago during his stay at the Oregon State Hospital in Portland.
The Office of Investigations and Training found that on May 1, an EKG technician working in the psychiatric ward
made disparaging remarks to Tyrone Wayne Waters, Full article: 493 words

Article 57 of 108
June 15, 2002
STATE TEAM FINDS FAULTS AT HOSPITAL Summary: An inquiry into alleged racism at Oregon State
Hospital calls for cultural training of staff
The Oregon attorney general's office concluded Friday that the Oregon State Hospital should provide its
employees with in-depth and ongoing cultural training after an investigation found that "inappropriate" racial
conversations took place inside the state's largest psychiatric facility.
The attorney general created a three-person team in March to review management Full article: 1374 words

Article 64 of 108
May 14, 2002
JUDGE SAYS STATE MUST SPEED CARE OF INMATES Summary: The decision says Oregon is violating the
rights of mentally ill persons who aren't quickly transferred to the state hospital
Oregon is violating the due process rights of mentally ill inmates who have been found unfit to stand trial by
making them wait weeks or months in county jails before transferring them to the Oregon State Hospital for
psychiatric care, a federal judge ruled.
In a scathing order released Monday, U.S. District Judge Owen Panner gave the state hospital Full article: 993

Article 69 of 108
April 7, 2002
ALLEGED RACISM AT STATE HOSPITAL PROMPTS REVIEW Summary: Officials scrutinize management
and treatment after a senator gets a letter about her son's care
The state attorney general's office will review management practices at Oregon State Hospital after employees
allegedly made racist comments about an African American psychiatric patient who is the son of Sen. Avel
Gordly, The Oregonian has learned.
The inquiry by the Oregon Department of Justice will seek to determine whether management practices have led
to racial Full article: 1389 words

Article 16 of 210
July 24, 2002
technician who disparaged Tyrone Wayne Waters no longer works at the facility
Investigators have determined that an African American psychiatric patient who is the son of state Sen. Avel
Gordly was verbally abused two months ago during his stay at the Oregon State Hospital in Portland.
The Office of Investigations and Training found that on May 1, an EKG technician working in the psychiatric ward
made disparaging remarks to Tyrone Wayne Waters

Article 22 of 220
June 15, 2002
STATE TEAM FINDS FAULTS AT HOSPITAL Summary: An inquiry into alleged racism at Oregon State
Hospital calls for cultural training of staff
The Oregon attorney general's office concluded Friday that the Oregon State Hospital should provide its
employees with in-depth and ongoing cultural training after an investigation found that "inappropriate" racial
conversations took place inside the state's largest psychiatric facility.
The attorney general created a three-person team in March to review management

Article 32 of 230
April 8, 2002
PLIGHT OF MENTALLY ILL INMATES ON TRIALSummary: Advocates will argue for those who are unfit to
stand trial and are kept in jail because there is no room at state hospitals
On March 29, 1999, Deputy Casey Walker was ordered to transport a mentally ill inmate from the Malheur
County jail in Vale to the Oregon State Hospital in Salem, where the inmate had been committed for treatment
prior to standing trial.
The inmate had been at the rural jail for three months waiting for a state hospital bed. Walker and Sgt. Roy

Article 34 of 230
April 7, 2002
ALLEGED RACISM AT STATE HOSPITAL PROMPTS REVIEW Summary: Officials scrutinize management
and treatment after a senator gets a letter about her son's care
The state attorney general's office will review management practices at Oregon State Hospital after employees
allegedly made racist comments about an African American psychiatric patient who is the son of Sen. Avel
Gordly, The Oregonian has learned.
The inquiry by the Oregon Department of Justice will seek to determine whether management practices have led
to racial

Article 43 of 240
January 30, 2002
PROFITING FROM THE SUFFERING Institutionalization is just fine if you like reading and rereading
decades-old Reader's Digests and pacing. It is A-OK if you like bad food, poor sanitation and suffering abuse at
the hands of a handful of brutal staff members. This is the reality I lived while at Oregon State Hospital for five
months of electro-shock therapy that was painful and ineffective. This was in the 1990s, not the Dark Ages.
The mental health system is effective only for those making big bucks off the

Article 45 of 240
January 19, 2002
STATE HOSPITAL WILL SHUT KIDS UNIT Summary: Officials look for better ways to care for seriously
mentally ill children, starting with sites away from the criminally insane
Twenty beds reserved for the state's most seriously mentally ill children will be gone Monday, replaced with a
new way of doing things.
Human services workers have decided that Oregon State Hospital's young children's unit in Salem, where razor
wire divides the playground from an exercise lot for the criminally insane, is no place for

Article 53 of 250
October 13, 2001
HOSPITAL PATIENT'S DEATH RULED ACCIDENT Summary: Ben Bartow suffered a heart attack after
struggling with Oregon State Hospital workers, the medical examiner finds
An Oregon State Hospital patient who died in August after being restrained by workers had a heart attack that
was caused by the struggle, according to the Oregon medical examiner's office.
Ben Bartow, who had spent 11 years on the ward for the criminally insane, had been inhaling an aerosol air
freshener the day of the struggle, which may have contributed to

Article 55 of 250
August 16, 2001
STRUGGLES DEFINED LIFE OF PATIENT Summary: Family and friends remember Ben Bartow, who died
after scuffling with staff who used sedatives to calm him
SALEM -- Ben Bartow didn't have an easy life, but it is his death that troubles family and friends.
The 41-year-old Oregon State Hospital patient died Sunday. Hospital officials say he struck and pushed staff
members before being overcome and pinned to the ground. Some patients who witnessed the scuffle say
employees used excessive force.

Article 56 of 250
August 15, 2001
Examiner's Office was unable to immediately determine why an Oregon State Hospital patient died Sunday after
being restrained.
Dr. Nikolas Hartshorne completed an autopsy Tuesday but said he needs more information to determine a
cause of death. He doesn't expect results for at least a week.
Hospital officials said Monday that employees held Ben Bartow, 41, to the ground after he hit one worker and
shoved another. After employees moved him to a restraint room

Article 57 of 250
August 14, 2001
STATE PATIENT DIES AFTER BEING HELD Summary: Employees of the hospital unit for the criminally
insane restrain a man following an outburst; the cause of his death is unclear
A 41-year-old man who had spent 11 years in the Oregon State Hospital unit for the criminally insane died
Sunday after being restrained by staff members following a violent outburst.
Hospital Superintendent Stan Mazur-Hart said hospital officials don't know the cause of Ben Bartow's death. The
state medical examiner will do an autopsy

Article 209 of 400
May 11, 1996
STATE TARGETS FRAUD IN OVERTIME WAGES Summary: Police investigate a mental hospital employee
who possibly collected $40,000 illegally, and a second worker may be involved
The Oregon State Police are investigating whether a state mental hospital worker illegally collected $40,000 in
No arrests have been made, but state police spokesman Lt. Bernie Giusto said a second worker could be
involved. Giusto would not release either name.
The apparent crime was uncovered in late April during a state Audits Division

Article 234 of 430
January 29, 1995
BILL WOULD CONTROL MAIL OF MENTALLY ILL Summary: Advocates for the disabled claim that state
Rep. Kevin Mannix's proposal would be open to abuse
Robert Martyr offended hundreds, maybe thousands, of Oregonians over the years by mailing them vicious,
sexually explicit letters.
Martyr is a murderer and a mental patient. He lives in the forensic unit of the Oregon State Hospital. But he is
free to mail whatever he wants, to whomever he wants.
Rep. Kevin Mannix, D-Salem, wants to put a stop to that.

Article 310 of 500
August 20, 1991
HOSPITAL WORKERS PROTEST Union workers at Oregon State Hospital staged a rally Monday to protest
conditions at the mental health institution and criticize management plans to fire eight employees.
About 75 workers attended the demonstration at noon, where union leaders objected to the way hospital
superintendent Stanley Mazur-Hart investigated allegations of employee misconduct and sent out pre-dismissal
notices to the employees.
Union leaders also castigated Richard Lippincott

Article 312 of 510
July 20, 1991
maximum-security ward is fired after a patient comes forward
State police are investigating a scheme to smuggle marijuana into a maximum-security ward at Oregon State
Hospital's forensic psychiatric center.
The hospital has fired a temporary worker who was implicated in the plot, said Richard S. Vohs, director of the
center, which houses psychiatric patients who have been acquitted of crimes because of insanity.

Combating Patient Abuse and Rights Violations