Deaths cited
as failings of state’s
mental health system

A recent cluster of suicides and other deaths among state mental health patients is cited by a federal judge in a report that strongly criticizes state officials for not correcting problems in the Adult Mental Health Division.

U.S. Magistrate Kevin Chang, special master in a federal case ordering improvements in the state mental health system, said there were reportedly 16 deaths, including six suicides, from mid-February to mid-April. They occurred among people receiving mental health services in three counties, according to the report.

He said Kris McLoughlin, court-appointed special monitor, reported the death of "Jane Doe" on March 29 and asked to investigate it.

"The unfortunate death of Jane Doe, a member of the target population for the community plan, highlights a lack of awareness and the lack of progress by AMHD in the development of a system of care," Chang wrote.

The magistrate filed his 10th report with federal court yesterday in the case, which began with a lawsuit by the U.S. Justice Department against the state in 1991 over allegedly unconstitutional conditions in the state mental health system.

Hawaii State Hospital in Kaneohe was released from court oversight in December because of a successful remedial plan. The state Health Department was given a one-year extension to June 30, 2006, to complete a community system of care for residents with mental illness.

Dr. Thomas Hester, adult mental health chief, resigned last month, saying his authority was being reduced for the community plan. He withdrew his resignation two weeks later after an outcry from patients and providers.

The controversy over Hester's position prompted a public statement from Chang on Friday, the first since his appointment by Chief District Judge David Ezra in 2001. He suggested there was a misunderstanding and no intent to remove or replace Hester.

Chang's latest report to the court, however, is highly critical of Hester's leadership and the division's former medical director, Alan Radke.

Michelle Hill, Health Department deputy director for behavioral health administration, said yesterday afternoon neither she nor Hester had seen the report and could not comment until they review it. "We have to know what is being said, and probably also we want our attorneys to weigh in if it is extremely critical," she said. As for unresolved issues related to the community mental health system, Hill said every effort will be made to achieve compliance by the deadline.

Chang wrote that he could not say whether compliance with the plan would have prevented Jane Doe's death. However, he noted that despite repeated warnings from the court, "AMHD leadership has been unable to make meaningful progress in building the organizational structure of the AMHD system for community mental health services."

He said the court's evaluation team has been citing inadequacies in the division's leadership, supervision and oversight of providers for two years.

Chang noted he was troubled that a prevention plan prepared by the division after Jane Doe's death was "minimal and not focused on the internal mechanisms of the system that would need to change to prevent an occurrence like this from happening in the future."

He said the division's failure to make Jane Doe's death a high priority, along with "a cluster of suicide deaths ... and to treat it accordingly is appalling and reflects a serious lapse in judgment and questionable leadership."

Chang also described the case of "John Doe No. 1," who had a long history of mental illness and substance abuse and was discharged from the state hospital on a conditional release. The patient's case manager gave him a large sum of money, apparently unaware of his history, and less than a month after his release on March 4, the patient was found dead, apparently from a drug overdose, Chang wrote.

In a second case, "John Doe 2" was released from the hospital on condition that he not have contact with any family member without approval from his probation officer. On April 13 he went to his family home and stabbed his mother in the chest. She was hospitalized but survived. He faces criminal prosecution.

If the state had been further along in implementing its community plan, Chang said he believes "factors would have been in place which might have mitigated or increased the chances for avoidance of these two unfortunate and tragic incidents."

Chang said the increasing Hawaii State Hospital population is additional proof of lack of progress in developing a community system of mental health services. As of July 1 it had 178 patients in a budgeted capacity for 168.

Chang said the evaluation team will return Dec. 5-9 and review the state's progress on the community system. McLoughlin and Dr. Chad Koyanagi also will submit reports on their review of the deaths.