On Sunday, April 1, 2001, Jose Santos Victor Mejia Poot was shot to death by Portland police while a patient at Pacific Gateway Hospital (PGH). The circumstances which led to his death are the subject of this report. Rather than duplicate the efforts of the other investigations into PGH and the Portland police, this report seeks to outline broader problems within the mental health system itself, which we believe were contributing factors in Mr. Mejia’s death.

This report is prepared by the staff of the Oregon Advocacy Center (OAC), a nonprofit law firm whose mission is to promote and defend the rights of individuals with disabilities. OAC is designated as the federally mandated protection and advocacy system for the state of Oregon, and as such, investigates allegations of abuse and neglect of persons with disabilities. The report is prepared by attorneys and advocates, and any medical opinions expressed herein are the product of their review of third-party investigation reports.

The facts presented in this report are derived from numerous sources, including: Federal, State, and County investigation reports, police reports, medical records, internal policies of PGH, media reports, and personal interviews.

The purpose of this report is to make observations and recommendations for change so that the mental health system in Oregon, and Multnomah County, can recognize the mistakes that were made and avoid them in the future. The report is written from the standpoint of consumers of mental health services in Oregon. We believe that psychiatric hospitals should be the ultimate safe haven and refuge for those who are suffering from a psychiatric crisis. People come to these facilities, either voluntarily or involuntarily, for protection and treatment in an environment that removes them from the stress of daily life. The transgression of that boundary by armed police officers, and the use of deadly force against a patient, constitutes a violation of the very basic principles and purposes of psychiatric hospitals. The damage done to Mr. Mejia is tangible; the damage done to the integrity of the mental health system in the eyes of the community of current, former, and future psychiatric patients who utilize these facilities, is incalculable.

Although the facts have been repeated many times in the media and in other investigations, a brief outline bears repeating to give context to this report. Mr. Mejia was a twenty-nine year old native of Mexico and spoke Mayan as his primary language, with some Spanish and a little English. Mr. Mejia suffered from epilepsy, and had been living in Portland for several years to earn money to pay for medication and treatment. Mr. Mejia had no history of mental disability. He worked as a farm laborer, lived with his father and brother, and his wife lived in Mexico.

On Friday, March 30, 2001, Mr. Mejia was seeking employment, could not afford his anti-seizure medication, and had not taken his medication for nine days. Early that morning he was boarding a Tri-Met bus when the bus driver informed him he was twenty cents short of the bus fare. Mr. Mejia appeared dazed, and did not respond to the bus driver’s request that he either get off the bus or sit down. The bus driver flagged down a nearby police officer who attempted to communicate with Mr. Mejia. The interaction with the officer resulted in a physical altercation between Mr. Mejia and several officers during which, in an attempt to restrain him, he was sprayed with mace, hit with police batons, and placed in physical restraints. Mr. Mejia was arrested, charged with harassment and resisting arrest, and was taken to the city jail. A police officer reported Mr. Mejia “was intoxicated.” While in the jail, Mr. Mejia was involved in another physical altercation with deputies due to his refusal to turn over his wrist watch. He was wrestled to the floor and his watch was removed. While in jail, he was examined by a nurse who did not find any injuries. Approximately twelve hours later, Mr. Mejia was released from jail and was observed by a police officer to be lying on the ground in front of parked cars, crying, and holding his head. The officer transported Mr. Mejia to the crisis treatment center of Providence Hospital (CTC) at approximately 10:00 p.m, and placed him on a police hold to determine whether he was a danger to himself or others.

Mr. Mejia’s primary care physician was affiliated with Providence Health System, from whom he had been receiving treatment for his epilepsy. When admitted to CTC, Mr. Mejia had an appointment card from his physician in his possession that stated he was a patient of Providence Health System. While at CTC Mr. Mejia was determined to have no drugs or alcohol in his system. Mr. Mejia was examined by a Spanish speaking psychiatrist for twenty minutes, who was unable to obtain any personal history from Mr. Mejia. No effort was made to contact his family (even though Mr. Mejia’s telephone number was available from telephone directory assistance) . No effort was made to contact Mr. Mejia’s primary care physician (in spite of the appointment card). Although a translator was available to assist Mr. Mejia in interacting with other staff, CTC sent the translator away, and Mr. Mejia was denied the benefit of communicating with other staff members. Mr. Mejia was repeatedly secluded in a locked room during his placement at CTC, and he was not administered any medications. The CTC psychiatrist diagnosed Mr. Mejia with schizophrenia, disorganized type, and recommended that he be hospitalized.

On Saturday, March 31, 2001 at 5:30 a.m., Mr. Mejia was transferred to PGH for inpatient treatment. He was seen by a psychiatrist, who communicated with him through a Spanish interpreter. Mr. Mejia disclosed that he was supposed to take Tegretol (a drug used primarily to treat epilepsy), that he was a patient at Providence Health System, and that he had an MRI done a week previously. His family was called, and a message was left, to determine the proper dosage of the Tegretol, and to get more history. Mr. Mejia disclosed that he had no psychiatric history. Mr. Mejia explained to the psychiatrist that ever since a head injury suffered several years earlier, he was paranoid about others trying to assault him, and that he would run away if he felt threatened. The doctor noted that Providence should be contacted on Monday, and he predicted that Mr. Mejia would be released after he was evaluated by the county pre-commitment investigator (who would also visit him on Monday). He was prescribed a number of medications, including anti-seizure medication and a sedative. Mr. Mejia was placed in the intensive care unit for observation. Mr. Mejia called his family; his father and brother appeared at the hospital with Mr. Mejia’s seizure medication. The hospital staff took the medication from the family, but did not probe the family for further history of Mr. Mejia. The family members felt unwelcome at the hospital and were asked to leave shortly after their arrival. Some Spanish speaking staff were made available to Mr. Mejia on this day. In the evening, Mr. Mejia became more difficult to manage and was placed in locked seclusion to prevent him from wandering into other patient rooms. Mr. Mejia escaped from the locked seclusion room (possibly due to the defective locking mechanism), but no critical incident occurred as a result.

On Sunday, April 1, 2001 Mr. Mejia also had some access to Spanish speaking staff. At approximately 9:00 p.m., the staff on the ward were unable to control Mr. Mejia’s behavior, and called police for assistance with placing him in a locked room. PGH did not have a security service and none of the staff on duty with Mr. Mejia were trained to respond to an emergency situation. Mr. Mejia was confronted by three officers, one of whom was trained to interact with persons in psychiatric crises. Mr. Mejia was placed in a secure room without incident. A police officer reports seeing that the door to the secure room “did not appear to be secure, as it rattled loosley (sic) within the door frame.” However, there is no indication that the officer notified the hospital staff of this observation. This was the same room from which Mr. Mejia had escaped the previous day.

At approximately 10:00 p.m. Mr. Mejia escaped from the seclusion room and police were again called to PGH. Three police officers arrived, none of whom spoke fluent Spanish or were trained to interact with persons in psychiatric crisis. While the officers were on the premises, Mr. Mejia was able to shut one of the police officers in a seclusion room with a staff member; they were eventually freed with the assistance of the other officers. The police attempted to control Mr. Mejia by verbally redirecting him in English and simple Spanish. Mr. Mejia was also sprayed with mace, and shot with a bean bag shot gun. After pulling an aluminum locking mechanism rod from a door, while apparently trying to flee the officers, and then approaching the officers with the rod, Mr. Mejia was fatally shot by police.

In response to Mr. Mejia’s death, a number of investigations have been commenced: Multnomah County Department of Community and Family Services (Patient Care); State of Oregon Mental Health and Developmental Disabilities Services Division (Abuse and Neglect); East Multnomah Major Crimes Team / Multnomah County District Attorney (Grand Jury presentation); United States Health Care Financing Administration (compliance with federal licensing regulations); FBI (referral for possible civil rights investigation); Portland Police Bureau Internal Affairs Division (police use of excessive force re: bus incident and shooting incident); Pacific Gateway (internal investigation). It has also led to an unprecedented amount of press coverage relating to a psychiatric patient death, and generated a wrongful death lawsuit against PGH, the Portland police, and CTC.

Given the extensive press coverage and investigation reports that already exist, we highlight below the major findings that have been released to date:

Mr. Mejia was likely suffering from epileptic seizures from the time he was arrested on the bus until the day he died. His behavior during this time is consistent with someone suffering from uncontrolled epilepsy.

The police did not recognize that Mr. Mejia was most likely suffering from epilepsy at the time of his arrest, and that restraining someone who was experiencing a seizure could result in the violent behavior he exhibited at the time of his arrest.

CTC did not recognize that he was suffering from uncontrolled epilepsy; did not have a medical or psychiatric history; did not make efforts to contact his doctor, who they knew, or should have known, was affiliated with Providence Health Systems; did not contact his family or provide adequate translation services; and misdiagnosed him with a mental disability.

PGH had a persistent pattern of under-staffing its units; failed to adequately train staff in emergency procedures; routinely relied upon police to handle difficult patients, and allowed armed police officers on the wards; had insufficient translation services; failed to follow seclusion and restraint protocol; and failed to have adequately locking doors on seclusion rooms. State investigators found that these deficiencies constituted patient abuse and neglect.

 

1) Mental Health System in Crisis

The Oregon mental health system has been operating in crisis mode for a number of years. There is a serious shortage of acute care beds in the Portland area. Patients in need of hospitalization often are treated, at State expense, in private facilities until less costly beds at the state hospital become available. Patients cannot be released from the state hospital because of a shortage of community placement facilities. As a result, the facilities that are available become overcrowded and understaffed. People who work in the system become less able to focus upon quality of care and more concerned with crisis management and triage. County officials who are attempting to operate a system in crisis are reluctant to investigate and enforce health and safety laws, at the risk of losing more beds. In December of 2000, OAC filed a lawsuit against the State of Oregon to attempt to force it to correct these problems. It is our belief that Mr. Mejia’s death is partially attributable to the breakdown of the mental health system in Oregon.

2) Monitoring of Psychiatric Hospitals

The County and State regulators appear to rely upon federal regulators (such as the HCFA (Health Care Financing Administration) and JCAHO (Joint Commission of Accreditation of Healthcare Organizations)) for proof that psychiatric hospitals are in compliance with health and safety laws. This reliance is substituted for its own monitoring of patient care and compliance with Oregon law. We believe that the ultimate responsibility for persons taken into custody lies with the state and county governments. Reliance upon the fact that a hospital has been certified to receive federal funding is insufficient to guarantee the health and safety of the citizens of Oregon. Especially in the context of a psychiatric hold, where a person is held against his or her will, the state and local government have a duty to independently ensure that those persons are held in safe facilities that comply with state and federal law. The state and county must also account to taxpayers for their expenditure of taxpayer dollars, which are used to pay the cost of such treatment (PGH was paid $700 per day, per patient, by the county for treatment services). The state and county should not contract with facilities to provide treatment services, and pay for them with tax dollars, without evaluating the quality of the services provided. It is our opinion that Mr. Mejia’s death is partially attributable to the failure of county and state agencies to adequately monitor facilities with which they contract: including PGH.

3) History of Problems at PGH

Pacific Gateway Hospital had a long history of problems that were well known to the Multnomah County mental health community. There had been meetings between Multnomah County officials, Portland Police, and PGH staff, regarding the necessity of calling police to PGH. A wrongful death lawsuit was filed in 2001 on behalf of a patient that committed suicide while residing at PGH. OAC had published a report concerning the unlawful use of seclusion and restraint at PGH. Staff at PGH had repeatedly complained about under-staffing. Multnomah County regularly had pre-commitment investigators at the hospital who were aware of problems at the facility. PGH was not a “preferred” facility for referrals within the county mental health system. All these events occurred while PGH was licensed to provide services under HCFA and JCAHO, the federal agencies upon whom the county relied to ensure quality of care at PGH. Although it is evident that there were many problems with the operation of PGH, the responsibility for monitoring patient care at PGH ultimately lies with the state and county agencies who contracted with PGH. We believe that the failure to adequately investigate and correct known health and safety violations at PGH contributed to Mr. Mejia’s death.

4) Treatment Fundamentals

Good medical and psychiatric diagnosis and treatment require good information about a patient. Key sources of information are the patient, the patient’s family and the patient’s other treatment providers. Mr. Majia, however, was not provided with ongoing observation, diagnosis or treatment by staff who were familiar with his culture or language. His family’s attempts to provide information were largely disregarded and there was no apparent effort made to contact his physician. We fear that this fundamentally inadequate level of care is indicative of a system that is either incompetent, overburdened or otherwise willing to provide second-class services. For Mr. Mejia, systemic failures to communicate and collect vital information were fatal omissions.

5) The Mental Health System on Weekends

Some of the investigation reports indicate that there appeared to be a lower level of patient care on the weekend. Further, the civil commitment investigator, who traditionally plays the role of advocate for the person detained, was not scheduled to meet with Mr. Mejia until the following Monday (indeed, the PGH psychiatrist believed he would be released at that time). Oregon state rules state: “The investigator shall investigate persons in custody in an approved hospital . . . as soon as reasonably possible but no later than one judicial day after the initiation of the detention and 24-hours prior to the hearing. Whenever feasible, the investigator shall:

(A) Make face-to-face contact with the person within 24 hours of admission to a hospital or nonhospital facility, including weekends . . .” OAR 309-033-0930 (emphasis added). Although not required to meet with detainees on the weekends, they are required to do so “whenever feasible.” We believe that failing to meet with Mr. Mejia over the weekend contributed to his death.

1#)     Armed police officers should not be permitted in psychiatric facilities except in the most extreme cases to protect the citizens of Oregon from criminal behavior. Under these circumstances, they should preferably be officers trained in dealing with persons in psychiatric crises, speak the language of the people with whom they will be dealing, and have sufficient numbers of officers to avoid the use of deadly force. Lethal firearms should only be allowed on hospital premises only after every available alternative has been tried

2)     All police responses to psychiatric facilities, including the circumstances that precipitated the response, should be reported by the facility and the police to the county or state agencies responsible for monitoring health and safety of patients.

3)     The state and county agencies responsible for contracting with psychiatric facilities for services should monitor those contracts by regularly inspecting the facilities for compliance with heath, safety, and patient rights laws.

4)     Pre-commitment investigators should meet face-to-face with persons involuntarily detained within 24 hours of their detention, including weekends.

5)     Multnomah County must assure that treatment staff are on site or on call who can adequately communicate with patients in a culturally appropriate manner.

6) Given the failure of state and county agencies to adequately investigate the quality of care at PGH, an independent agency should be established to investigate allegations of abuse and neglect in psychiatric facilities. State and county agencies that contract with facilities rely upon those facilities to provide beds, which are in short supply. As a result, these agencies are poorly motivated to confront those facilities with quality-of-care concerns that may result in a temporary, or permanent, loss of beds in a community mental health system. An independent agency would avoid that conflict of interest.

Conclusion

Pacific Gateway ceased operations on June 7, 2001 after making numerous attempts at remedying deficiencies to satisfy county, state, and federal regulators.

Mr. Mejia’s unnecessary and violent death was the tragic consequence of systemic problems in Oregon’s mental health system that extend far beyond the mental health community. His death has become the subject of broad ranging outrage concerning how poor and disadvantaged individuals, and particularly immigrants, are treated in our community. As such, it is a bellwether for change. It is our sincere hope that this report assists in bringing about that change, and that his death leads to needed reforms in public services to assure the safety of all.

For questions regarding this report, please contact:

Stephen J. Mathieu, Staff Attorney, Oregon Advocacy Center: 503-243-2081

Robert Joondeph, Executive Director, Oregon Advocacy Center: 503-243-2081