Press Release

6/6/05
For Immediate Release:

Three-month investigation concludes patients at Arkansas State Hospital were physically and verbally abused by Hospital employees.

The investigation was conducted by Disability Rights Center, the federally established Protection & Advocacy System, authorized by federal law to investigate incidents of abuse and neglect of people with disabilities in Arkansas.

"There exists a culture of abuse at the Arkansas State Hospital," according to Dee Blakley, DRC lead investigator. "We fear there may be many more cases which have gone unreported due to the culture which exists there."

Some of DRC's findings include:

• 16 year old female patient choked during restraint
• 38 year old female patient whose arm was broken during restraint
• 49 year old male patient kneed in the side and received a fracture to the ninth rib during restraint.
• 34 year old male patient lifted into the air and allowed to fall to the floor
• 21 year old male verbally abused and required protection from an attacking staff member.
• 24 year old male was verbally abused
• 26 year old male was shoved and provoked by staff.
• Numerous violations of Hospital Policy and failure to comply with State Law requiring the reporting of abuse

At the June 6, 2005 press conference, Executive Director, Nan Ellen East; Quality Assurance Team Leader and Lead State Hospital investigator Dee Blakley, and Sr. Staff attorney Jan Baker made presentations as follows:

Statements from Nan Ellen East, Executive Director:

Good morning. Thank you for coming to our press conference.

I am Nan Ellen East, Executive Director, Disability Rights Center (DRC). DRC is the Arkansas Protection and Advocacy system for people with disabilities.

Our mission is "To passionately assist the lives of people with disabilities through education, empowerment and protection of their legal rights."

We appreciate you for coming - family members of people with disabilities, individuals with disabilities, professional staff, policy makers, the press and other concerned citizens and our Board and Staff members.

We are here to release our report of an investigation into alleged patient abuse at the Arkansas State Hospital.

This report is a result of the DRC Quality Assurance Team and Legal Team working with the Department of Behavioral Health staff administration.

Our Quality Assurance Team lead investigator was Dee Blakley and the Senior Staff Attorney was Jan Baker. Please come to the podium and after Dee and Jan present the results of our investigation, we will be happy to take questions.

Thank you.

Statements from Dee Blakley:

I'm Dee Blakley, the team leader for the DRC investigative team that spent three months finding the truth about the allegations of patient abuse at the Arkansas State Hospital. On behalf of DRC, I'd like to thank the members of the press who began comprehensive coverage of the release of our investigation report. I'd also like to address portions of the official DHS response to that report.

First, the DRC investigation team would like to thank some courageous employees of the Arkansas State Hospital, who, despite incredible pressure to do otherwise, told the truth during their interviews about the patient abuse and "inmate mentality" that has existed in the past, and - given Friday's comments from the DHS spokeswoman - continues to exist to this day. We can only hope that these employees will not find themselves casualties of the fallout of the investigation due to their disclosures.

Second, I find myself almost sympathizing with the DHS spokeswoman when she characterized the abuse as "isolated" occurrences - after all, the hospital administrator told us in his March 17 interview that he was unaware that four of the incidents had even occurred, until DRC had called them to the attention of the Division and the hospital at the beginning of our investigation. But ignorance of abuse is what happens when policies and laws designed to ensure the protection of vulnerable populations are ignored and administration routinely refuses to enforce them - because, in the words of the administrator, there are just too many policies to enforce. On Friday, DHS officials were probably not aware that DRC was notified of allegations of abuse occurring even while we investigated the previous nine - which tends to make the use of the word "isolated" a mischaracterization. And we are certain DHS is unaware of the e-mails DRC found waiting this morning from former ASH patients, telling their own stories of abuse.

Third, it is very fortunate for the patients of the Arkansas State Hospital that the federal government, which defined "immediate jeopardy" and is charged with investigating it, does not take the narrow view of enormity of the immediate jeopardy which each and every patient of ASH faces - daily. The Centers for Medicare and Medicaid Services has stated in regulatory guidance to state survey agencies that a finding of immediate jeopardy can be made with a single patient incident - and no one has to even have been injured in order for a finding to be made. It disappoints, but unfortunately, does not surprise me that officials at DHS are unaware of that regulatory guidance to the state survey agency.

Which brings me to the first and most important systemic conclusion reached by DRC - written in the report we have provided to you, and which must be repeated now - and hopefully understood for its horrifying meaning. . .

There is no coherent system of identification, reporting, investigation and remedial action with respect to patient abuse at the Arkansas State Hospital. As a result, each and every patient at ASH is at risk of abuse, which places patients in "immediate jeopardy."

Staff failure to comply with hospital policies and state laws designed to protect patients at ASH from abuse combined with staff viewing patients as inmates who must be punished with physical and verbal abuse, rather than sick patients who must be provided treatment for their illnesses, has led to the culture of abuse at ASH. This culture, and the immediate jeopardy created by it, must be investigated by federal authorities and appropriate action taken.

I must address the insinuation by the DHS spokeswoman that since most of the incidents occurred to patients on the forensic unit, the abuse isn't as bad as it looks. The health, safety and lives of forensic unit patients are worth just as much as those of any other patient in any other hospital in this great state. Forensic unit patients at ASH are not people who have been found guilty of crimes and are therefore placed there for punishment by ASH staff. Arkansas has a correctional system and it's not at the Arkansas State Hospital.

Last, an observation about a statement in the Saturday article in the Democrat-Gazette - the statement was that some employees had been fired "who were involved in incidents" investigated by DRC. Beware the spin. . . Ask if staff who abused patients were fired. Ask if staff who failed to report abuse that they witnessed were fired. Ask if staff who covered up abuse of patients once told of abuse were fired. Ask about stainless steel handcuffs, belly chains, ankle shackles and guns. The abuse will only stop once it is brought fully into the light. Until then, there is no assurance that patients at ASH will be free from abuse.

Statements from Jan Baker, Senior Staff Attorney:

In 2001 Governor Huckabee Commissioned a mental health system's task force to evaluate Arkansas' public mental health system - which includes the Arkansas State Hospital - and recommend changes to improve the system of care for people with mental illness.

In their report to Governor Huckabee dated June 2002, the task force concluded that "Arkansas has failed for decades to make significant changes in its public mental health system unless spurred to do so by some tragic set of circumstances. . ." Those of you here today who have listened to Dee Blakley and those of you who have read or seen the media accounts of the abuse of patients substantiated by our investigations know we have "a tragic set of circumstances" at the Arkansas State Hospital that must be addressed!

We hope our disturbing investigation findings will spur Governor Huckabee - who received a copy of our summary report - to use his executive authority to assure that the Department of Human Services and the Division of Behavioral Health - which are responsible for the oversight and operation of the Arkansas State Hospital - commit themselves to timely and appropriate implementation of the numerous recommendations we believe will lead to significant improvements. But the Governor needs our support.

California's Little Hoover Commission in a report to their Governor regarding their public mental health system found, "What sets mental health apart from other social and medical causes is that society does not share a collective expectation or sense of responsibility - and as a result, there is little outrage when mental health programs fail." I am here today to tell you - the Disability Rights Center is outraged by the horrific way patients are treated at the Arkansas State Hospital.

We challenge all of you and all of the citizens of our great and compassionate state to share our outrage and demand that people with mental illness in our state who need inpatient psychiatric care are provided quality care and treatment in a safe environment, staffed by professionals who are adequately trained.

We challenge you to share our outrage and demand that the culture of abuse which currently exists at the Arkansas State Hospital is forever eliminated.

Share our outrage and demand that the state meet its constitutional obligation to care for people with mental illness.

Thank you.

For further information, please contact either:

Nan Ellen East, DRC Executive Director, or

Jan Baker, Senior Staff Attorney

Disability Rights Center, 501-296-1775

Download the summary investigation report in PDF format.

Download the press release in PDF format.

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