After months of mediated talks, the state of Washington has tentatively settled a landmark lawsuit brought by Pierce County over the discharge of still-ill mental patients by Western State Hospital. The two-year-old suit alleged that from 2001 to 2004, certain patients' constitutional rights to mental-health care were violated and that Pierce County was forced to pay for patient services that were the state's responsibility.
In some cases, psychotic and suicidal patients were discharged from the psychiatric hospital to the streets of Tacoma or into facilities that could not meet their needs. Many of the patients soon cycled back to the hospital, according to court documents. Some ended up in jail. In one case, Western released a homeless man who was so psychotic that he was communicating by grunting, according to the court record. In another case, a skinhead known to be menacing to others, with schizoaffective disorder, was released to a boarding home in Pierce County, despite medical evidence indicating that he should still be in the hospital.
The Feb. 11 settlement requires the state to provide $2.5 million a year to Pierce County's mental-health system so the county can provide intensive services to about 100 patients such as these. The patients cited in the lawsuit, whose identities are protected by a court order, regularly cycled between the streets, Pierce County–funded mental-health agencies, and Western State, which is in the Pierce County town of Steilacoom.
In addition, the state Department of Social and Health Services, which operates Western State Hospital, agreed to provide adequate discharge planning for patients.
Outside experts working for Pierce County and the Washington Protection and Advocacy System found that about half of the patients discharged into Pierce County were handled in ways that were troubling.
Despite the settlement, it is unclear whether Gov. Christine Gregoire or the Legislature will include money for the lawsuit in the 2005–07 budget. Gregoire's proposed budget will be made public on Monday, March 21. Without funding from the state, the case could end up back in court. Says Fran Lewis, director of human services for Pierce County: "We are confident both the governor and Legislature will act upon this agreement."
Western State Hospital officials declined to comment on the settlement and the patient discharges. In the settlement, neither the state nor Western State admit wrongdoing. But it's clear from court documents that something very wrong was going on at the once-notorious mental hospital.
In one of the more disturbing cases described in court filings, a 54-year-old man, who had suffered from schizophrenia for 30 years and had committed violent crimes, was admitted to Western on April 10, 2003, on a 90-day involuntary commitment order. At the time of his admission, the man had been homeless for several months, had been assaulted on the streets, had been admitted to psychiatric hospitals multiple times, and was known to abuse cocaine and alcohol, according to court documents.
A psychological assessment of the man on April 23, 2003, notes that he "is not capable of caring for himself independently" but that he will be "discharged to a homeless shelter in Tacoma," according to the record. The patient sometimes spoke in gibberish, claiming it to be German, during his short stay at Western.
He was released from Western on April 25, 2003. That's two weeks after he was admitted to the hospital for a 90-day stay. The patient, in the opinion of a plaintiff's expert who reviewed medical records, was delusional and responding to internal stimuli—imagined voices, according to court documents.
The expert, John Elpers, a psychiatrist in California who reviewed 82 admissions to Western from Pierce County between 2001 and 2004, found that discharging patients in such a state placed them "at risk of suffering [irreparable] harm," according to court documents.
In another case, a 51-year-old woman was admitted to Western on Jan. 10, 2001, on a 90-day commitment. Western documents indicate that the woman had a long history of mental illness and commonly ended up in a psychiatric hospital after being abused by her husband. She was discharged from Western on Feb. 20, 2001, and was returned to the home where her abusive husband still lived.
A review of hospital records by Ivor Groves, a Florida-based psychologist, found that a 20-year-old man who was actively hallucinating was discharged to a boarding home in Pierce County. According to Groves, the man was a 6-foot-1 skinhead weight lifter who intimidated others. Groves asserted in court filings that the boarding house was inappropriate for the man and predicted that the patient would soon cycle back to Western State.
In other cases, Groves found, Western personnel had cut-and-pasted treatment plans from one patient's records into the records of another. "The implication of these findings is that a significant number of persons cycle in and out of WSH and other inpatient facilities," Groves states in a court filing. "This cycling results from inadequate discharge planning, a lack of community services to keep these persons stable, premature discharges, or a combination thereof." He adds that Western's discharge planning is not professionally acceptable.
Elpers found that 53 percent of the patients who were discharged should not have been discharged under any circumstances, according to court documents. In more than half of the cases he reviewed, patients discharged from Western were rehospitalized within six months to one year.
Meanwhile, Groves also found that some well-stabilized patients were being held in Western's specialized Program for Adaptive Living Skills (PALS) years beyond when they should have been discharged (see "No Exit," Aug. 11, 2004).
What Groves describes is a scenario that has plagued chronically mentally ill patients since state mental hospitals were downsized, or closed altogether, in the 1980s. Patients around the country were discharged from hospitals, regardless of the severity of their illness, to a community mental-health system that was not funded to provide housing and intensive ongoing medical care for psych patients.
Under the settlement, Western State Hospital will hire someone to coordinate discharge planning at the hospital, who will be overseen by the Washington Protection and Advocacy System. The system's mandate under state law is to ensure that the rights of the disabled population are not violated. The settlement also requires that the state give Pierce County's mental-health system $2.5 million a year to manage patients in living situations where care can be provided 24 hours a day. "I think this will give us the opportunity to make a very strong system in Pierce County," says Lewis.
A similarly intensive approach has been used in recent years by West Seattle–Highline Mental Health to help patients discharged after years of cycling in and out of Western. The approach has proven successful. Only one of 15 patients in a Highline program for former Western patients has been readmitted to Western.
The fate of patients in Pierce County is now in the hands of Gregoire and the Democrat-controlled Legislature. If they give Pierce County $2.5 million a year for the program, the lawsuit will go away. But if the Legislature and governor don't fund Pierce County, the litigation, which is currently stayed, will resume. The memorandum of understanding that explains the settlement terms seems to imply that this funding would be permanent.
Gregoire's office declined to comment, and the state Office of Financial Management, which drafts the governor's budget, did not return a request for comment late Tuesday, March 15. Legislative leaders were unavailable for comment.
Lawyers with the state attorney general's office tried to back away from the agreement soon after it was reached last month. They argued in court filings that DSHS did not have the authority to enter into a settlement that required new state spending—that such authority rested with the governor and Legislature alone.
"The parties have made significant progress toward a negotiated settlement of the dispute and are continuing to work on finalizing terms of a resolution," says Jeff Weathersby, a spokesperson for DSHS's Mental Health Division. He declined to answer questions about Western's patient discharges.
Pierce County Superior Court Judge Paula Casey considers the settlement a done deal. On March 10, she ordered the state to abide by the agreement. If the state doesn't fund the $2.5 million in its forthcoming budget, she stated that court proceedings could begin anew on May 2.