Tuesday, August 24, 2010

Milwaukee Journal Sentinel investigates violence, sexual assaults against vulnerable people at Mental Health Complex

The intro to the series in The Journal Sentinel:

This is the baby no one wants to talk about:

He was born at Froedtert Hospital on the morning of Thursday, April 29, weighing 6 pounds, 4 ounces. His color was poor, his pulse weak, his breathing labored. Nurses huddled around him, fussing with monitors, cheering for him to rally. His 23-year-old mother paid no attention to the commotion.

Diagnosed as moderately mentally retarded and dangerously mentally ill, she had been sedated by doctors who feared she might hurt them and the baby as her hallucinations flared.

The woman became pregnant in July 2009 while a patient at the Milwaukee County Mental Health Complex (pictured), where she was supposed to be on birth control injections, a Journal Sentinel investigation has found.

The complex is home to some of the most vulnerable people in the county, those found to be dangerous to themselves or others and who are kept behind locked doors under the care of taxpayer-financed doctors and nurses.

Instead of keeping her safe, hospital administrators put the woman in the same unit as Omowale Atkins, a patient with a history of violence and sexual assault who once punched a nurse so hard he shattered the man's eye socket.

Atkins had sex with the woman on the day she arrived and at least several times after that for the next three weeks, records from a federal inspection of the hospital show. Her guardian was never told about the sex, a violation of hospital policy.

When the medical staff discovered months later that she was pregnant, they further ignored hospital policy by waiting weeks before informing her guardian.

By the time her guardian was told of the pregnancy, the woman was believed to be in her second trimester, and it was too late to spare the fetus from the most dangerous effects of three psychiatric medications she had been taking.

Knowledge of the pregnancy became public in March, after the Journal Sentinel obtained a copy of inspection reports under state and federal open records laws.

Since then the newspaper's investigation has determined that county health workers - from nursing assistants to administrators - mismanaged the case from the beginning, ignored medical orders and falsified documents to hide their mistakes.

The Journal Sentinel estimates their errors have cost federal, state and county taxpayers at least $700,000 in extra patient care costs and legal fees in the past year, a figure that may easily top $1 million.

The woman, who is not being named because she may be a victim of a sexual assault, likely would have stayed at the complex for only a few weeks until her condition could be stabilized, her guardians said. Instead, she had to be hospitalized throughout her pregnancy and for weeks beyond that at a cost of roughly $400,000.

For Atkins, who at times required greater supervision at a higher cost, the higher tally for care has been at least $300,000.

Add to that the expense of the woman's prenatal care, the baby's delivery, the costs of his foster care and adoption, costs to examine Atkins and other legal fees associated with his criminal cases, and the costs to correct the errors found in the federal and state inspections.

Shirin Cabraal, managing attorney for the Milwaukee office of Disability Rights Wisconsin, a patient advocacy organization, termed the newspaper's findings "appalling," particularly the county's failure to notify the woman's guardian of her pregnancy.

"These are two very blatant violations of the Wisconsin guardianship laws," Cabraal said. "Staff responsible for not informing the guardian and exposing the fetus to strong psychotropic medications should have been disciplined."

Even after the federal inspection - and despite at least seven policy violations, repeated falsification of reports and failure to follow orders regarding patient care - no county employee is known to have been disciplined.

However, a private lawyer has been paid $395 an hour to represent the county and a public relations staffer has been hired at $49,200 a year to protect the complex's image.

Atkins, facing charges of sexually assaulting a different female patient in the same ward, was not aware the woman had a baby until he was told by a reporter.

He is presumed to be the baby's father, though he is not named on the birth certificate and has not been given a paternity test. It is certain, though, that the woman became pregnant while a patient at the complex, according to officials at the agency that oversees her medical care.

For more than five years, Atkins was repeatedly transferred from jail to the Mental Health Complex, where he was left unsupervised alongside fellow patients, some psychotic, others with the reasoning skills of young children.

Federal inspection records show Atkins was allowed to leave the ward to buy cigarettes while nurses signed false reports claiming he had been checked every 15 minutes as his doctor had ordered. On July 26, 2009, Atkins was found outside the ward in the hallway of the complex's nursing home, talking to three 8-year-old girls and blocking their path. Nurses failed to include the incident in the notes that Atkins' doctors review to determine if he should be allowed to leave the secure ward.

Twice after that Atkins was allowed to leave the complex for overnight visits to a group home. Hospital staff did not tell the group home's operators about Atkins' full history of violent behavior, federal inspection records show. County officials won't identify the group home or its location, and it was not identified in federal records.

Atkins was charged with sexually assaulting a woman on the ward less than a week after returning from his second visit to the group home. In the course of two months last summer, staff caught Atkins having sex with three patients.

The case is but one in a series of problems at the troubled Mental Health Complex, where roughly 2,000 patients receive care in the acute wards each year.

The newspaper reviewed thousands of pages of court documents, sheriff's reports and federal and state inspection records. The inspection reports cite patients' medical records, including those of Atkins, the pregnant woman and the woman he is charged with sexually assaulting.

Reporters also interviewed former mental health care administrators and workers, current medical staff, Atkins, the woman whom Atkins is accused of sexually assaulting, other patients, their families and their advocates. Guardians of the pregnant woman were interviewed but declined to permit her to talk to reporters.

County mental health administrators would not answer questions about this case. They posted signs at the Mental Health Complex and e-mailed all employees, warning them not to talk to the media.

John Chianelli, director of the county's Behavioral Health Division, which oversees the complex, turned down repeated requests to be interviewed. He answered some of the questions sent to him by e-mail.

County officials said they have aggressively addressed safety problems at the complex, in the wake of the federal inspection. In response to questions about the Atkins case, the county's private attorney - Mark Cameli - said officials were legally prohibited from disclosing information related to the care and treatment of specific patients.

His statement reads in part: "We wish we could encourage you to contact the thousands of patients successfully served by the county over the years - many of whom are living healthy, productive lives because BHD helped them when no one - no institution or resource - would provide any service."