Oregon State Hospital chief promises better communication

Roy Orr apologizes to the advisory board in the wake of an undisclosed federal critique of care preceding a patient’s Oct. 17 death

From the Salem Statesman Journal, March 19, 2010

Oregon State Hospital Superintendent Roy Orr apologized Thursday to the hospital’s advisory board, saying he was “personally remiss” in failing to notify board members about a scathing federal critique of patient care before it hit the press.

“I failed myself, and I failed all of you,” he said.

It won’t happen again, Orr said, promising to give the citizen-led panel far more information about thorny issues at the Salem psychiatric facility

“You will start receiving a lot more communications from us,” he said during the board’s regular meeting. I won’t apologize for the volume.”

Thursday’s mea culpa by the hospital chief came in the wake of a recent furor that erupted about his non-disclosure of a blistering federal critique of hospital care for patient Moises Perez in the year leading up to his Oct. 17 death.

Perez, 42, was found dead in his bed in a secure treatment unit in the hospital’s forensic program. His death sparked complaints from other patients and mental health advocates who alleged that staffers neglected Perez and that he was dead for hours before anybody noticed.

An autopsy determined that Perez died from coronary artery disease.

The U.S. Department of Justice reviewed Perez’s care as part of its prolonged and ongoing investigation into patient care and hospital conditions.

After reviewing Perez’s medical records, Shanetta Cutlar, leader of the agency’s Special Litigation Section, sent Oregon a letter in January that cited sweeping defects in his care.

Cutlar said the department was alarmed by the breakdowns and concerned that similar defects in patient care might “give rise to serious harm or death in other situations.”

Hospital advisory board members first read about the damning federal critique in the Statesman Journal, and some publicly complained about Orr not making them privy to it before it appeared in the newspaper.

In his Thursday apology, Orr said he made a mistake by not telling board members about the letter and by not notifying them in advance that the newspaper had obtained it through a public-records request and intended to run a story about it.

Orr said his mistakes “very appropriately created quite a furor.”

In the wake of the flap, the state has notified the U.S. Department of Justice that Oregon no longer intends to honor the federal agency’s request for total secrecy on back-and-forth correspondence between the two sides, Orr said.

Under the state’s new stance, hospital officials will review any written materials received from the federal agency, and, in most cases, quickly share the information with the advisory board, he said.

Expanded disclosure is necessary for the board to perform its oversight role, Orr said.

In his remarks to the board about Perez’s death, Orr said the hospital’s own review of the case found that “the system failed him.”

Although Perez often refused treatment, including medications and blood-pressure checks, Orr said, “It’s clear we didn’t do all we needed to do for Mr. Perez.”

The case has raised new and complex questions about whether the hospital can assume guardianship for a patient who refuses medical care, or take legal steps to compel such treatment.

“There is no precedent for that in this organization,” Orr said.

The case also has heightened awareness about the need to address the overall health of patients, not just their mental health, officials said.

Dr. Mark Diamond, the hospital’s chief medical officer, said a planned chronic-care clinic will expand care for state hospital patients with diabetes and hypertension.

Meanwhile, the hospital has taken measures to improve patient care and monitoring since Perez’s death, officials said.

Kathy Deacon, the hospital’s chief nursing officer, said the hospital has revised its rounds policy. Staffers making hourly checks on patients now are required to confirm they are alive through observation, touch or the sound of breathing.