Murder, Rape, Neglect in California Mental Health Institutions
More than 800 pages of records released by the California Department of Public Health have revealed horrific crimes, including deadly physical abuse and neglect, rape, and brutal beatings, inside five mental health institutions.
According to the documents, which were first obtained by the Center for Investigative Reporting, 13 developmentally disabled residents have died as a direct result of abuse and neglect at five state-run homes for more than 1,100 developmentally disabled men, women and minors: Fairview Developmental Center in Costa Mesa, Lanterman Developmental Center in Pomona (now closed), Porterville Developmental Center in Porterville, Canyon Springs Developmental Center in Cathedral City and Sonoma Developmental Center in Eldridge.
The report documents many incidents in which staff physically and sexually abused residents. In October 2013, a psychiatric technician at Canyon Springs choked a patient. A Porterville staff member kicked a patient who was having difficulty while using a toilet in January 2013. A blind Sonoma patient was struck in the head in November 2005. A Porterville resident died in 2003 after staff members used an “inappropriate restraint” to take him down after he stole a set of keys. Improper restraint was also blamed for the death of a wheelchair-bound female Porterville patient in 2011.
In December 2010, a 6’3″, 400-lb. (191 cm, 181 kg.) Porterville orderly ferociously attacked a patient who had disobeyed an order to remain in place. The patient, who has the cognitive level of a 10-year-old, had gone to his room to lay down, infuriating the orderly, who threw the victim to the floor before stomping on his back. As other staff members held the man down, the orderly climbed on him and choked him until he lost consciousness and suffered a heart attack. “Fuck him,” the orderly said as staff attempted to revive the patient, who survived but spent 11 days on a ventilator in an intensive care unit.
In other cases, staff neglect resulted in residents raping and sexually abusing other patients. At Porterville, staff “failed to ensure that clients were protected from sexual abuse” and failed to protect women housed with “male clients who had criminal sexual histories.” At Canyon Springs, staff also failed to protect residents from sexual abuse. One resident with a history of “overly sexual behavior” was involved in “at least nine incidents of abuse” targeting other residents. Sometimes staff members were the perpetrators of sexual abuse; several cases of assault and improper touching and relationships are documented. A male employee at Sonoma was also arrested in 2012 after masturbating in front of female patients.
Neglect has also proven deadly. At Porterville, an improperly restrained patient was left unattended and was strangled by a seatbelt in March 2011. “Lack of supervision” was blamed for the November 2004 choking death of a Fairview patient. That same year, another Fairview resident deemed a “choke risk” was “fed inappropriate food” and choked to death. Another Fairview patient died after falling out of a bed “because side rails weren’t operable or appropriate.” In September 2011, Fairview was also blamed for the death of a patient with “a history of pulling out his tracheostomy tube” who “was left unattended by facility staff” when he killed himself by removing the tube from his throat.
“Failure of the facility to protect” a Lanterman resident from “repeated client-to-client altercations” was cited in a 2003 beating death. Also at Lanterman, a patient “with history of bowel obstruction” died of medical neglect after suffering seizures, sepsis and bowel obstruction. Failure to notify medical staff and immediately initiate CPR is blamed for the October 2010 death of a Sonoma patient. A misplaced feeding tube by Sonoma nurses who “didn’t follow policy” resulted in the slow, painful death of a patient in 2012. Multiple deaths due to medication or treatment errors are also documented in the report.
There have also been many cases of resident-on-resident violence at the five facilities. Multiple brutal assaults at Fairview in early 2012 left one resident hospitalized with “skull and facial fractures and bleeding in the brain.” Another victim was pulled to the ground and kicked in the face. Yet another Fairview resident suffered multiple fractured ribs in a vicious attack.
Later in 2012, Fairview staff “neglected to provide adequate interventions” during an assault that left a resident with a broken nose and eye socket. At Canyon Springs, one resident tortured another by repeatedly burning him with cigarettes. In December 2002, a Sonoma patient stabbed another in the eye with a butter knife.
The abuse was sometimes deadly. In July 2011, a teenage Fairview resident smothered another teen with a pillow and stabbed the victim with a pencil. The report cites the “facility’s neglect” as a contributing factor in the brutal slaying.
Verbal and psychological abuse, as well as humiliation, are documented with regularity. Multiple patients who soiled themselves were forced to wear their dirty clothing as punishment. Others were called derogatory names, including “retard.” The report also documents health and sanitation violations, including a rat and cockroach infestation in the Porterville kitchen.
Despite overwhelming evidence, police repeatedly failed to prosecute or even investigate crimes involving mental institution residents. California Department of Developmental Services (DDS) spokeswoman Nancy Lungren told Moral Low Ground her agency “obviously regrets” the abuses that occurred at the state institutions, but that the Department of Public Health documents—which consist exclusively of citations for violations—tell “only one side of the story.”
“It’s not all bad if you visit the facilities,” Lungren said in a phone interview. She insisted the facilities named in the DPH citations “are committed to the health and safety of [their] residents and are continuously improving conditions in areas found to be deficient in the citations.” Lungren added “there are plans of correction in place” to address the issues highlighted in the citations. She said corrective actions include “firing people, upgrading staffing and changing how we do things.”
Recurring incidents of resident abuse in state institutions have rekindled a long-running debate among mental health professionals, advocates and policymakers about the effectiveness of housing patients in larger institutions. While some important health outcomes have been demonstrably superior in such facilities, many professionals favor housing patients with relatives or in small group homes. According to research published by the National Council on Disability, an independent government policymaking agency, this home- and community-based services (HCBS) approach boosts patient independence, behavior and happiness.
HBCS advocates also say their approach is more likely to encourage patients to participate in their own wellness process.
“The problem with many institutions, and I’m not saying this is true for all of them, but many take a clinician point of view, which means mental illness is diagnosed as a disease that needs to be treated, not as a person that can participate in their own recovery,” Maureen DeCoste, communications director of the Mental Health Association of San Francisco, a charitable advocacy, education, research and service organization, told Moral Low Ground via email. “Often, this type of treatment can be dehumanizing [and] the person becomes secondary.” DeCoste said that this may not be applicable to the abuse documented in the DPH citations.
Others argue larger institutions play an important role in patient care and that the movement to deinstitutionalize the developmentally disabled and mentally ill has been a failure.
“Asylums for the severely mentally disabled would provide stability and structure,” wrote Christine Montross, a psychiatrist at Butler Hospital in Providence, Rhode Island in a recent New York Times op-ed. “They deserve the relief modern institutionalization would provide.”
Tagged California Department of Developmental Services, California Department of Public Health, California mental institution abuse, Canyon Springs Developmental Center, Fairview Developmental Center, HCBS, Lanterman Developmental Center, Porterville Developmental Center, Sonoma Developmental Center