D.C.’s mental health agency was asked to speak to several concerning incidents during a Council oversight hearing Wednesday night, including why the city’s sole public psychiatric hospital went without clean water for a month, and what systems are in place to prevent that from happening again. But the head of the agency could not provide satisfactory answers, as the department is still reviewing what exactly happened in September.
Dozens of residents gathered at Pennsylvania Avenue Baptist Church in Southeast D.C. with lots of questions and demands for the Department of Behavioral Health, whose director was present for the hours-long hearing beginning at 5:30 p.m. Before Department of Behavioral Health Director Barbara Bazron testified, dozens of residents voiced concerns to her and Ward 7 Councilmember Vince Gray, who oversaw the hearing. Topics ranged from the city’s response to the soaring homicide rate to the overall mental health of students. But the troubles at St. Elizabeths Hospital dominated a discussion that lasted more than six hours.
The meeting was not live-streamed by the Council.
St. Elizabeth Hospital went without running water for more than a month, which public witnesses attribute to the city government’s overall neglect of a public hospital that primarily serves low-income black residents. This is the second time in three years that the hospital experienced a water outage. As first reported by City Paper, the hospital’s water supply tested positive for dangerous bacteria on Sept. 25. The hospital, that serves an average of 270 patients, wasn’t cleared until Oct. 23. For a month, patients and staff were without running water, using bottled water for drinking and cooking and wipes for bathing. The temporary fixes cost $1 million.
Disability rights lawyers also reported patient abuse at the hospital, namely the repeated use of seclusion and restraint. Indeed, the number of patients locked in secluded rooms more than doubled since 2014, according to the hospitals own records.
“The mission of St. Elizabeths hospital is to provide person-centered care… the story of St. Elizabeths changed over time, evolving theories of how to care for the mentally ill along with racist psychiatric treatment and lack of care or concern that has directly impacted your ward,” Jacob Smith, of Black Youth Project 100, told Gray. “I urge you to think beyond temporary issues with the hospital, fund the efforts of its mission to be a hospital committed to providing intensive services for recovery.”
While most residents that stopped by the church to testify at Wednesday’s hearing talked about the water emergency and patient abuse, Bazron spent most of her opening testimony detailing the city’s response to the opioid crisis; albeit, she began by addressing problems at St. Elizabeths.
Gray, for his part, began his tough line of questioning on the tragic death of Javed Bhutto, who was fatally shot by a patient discharged from St. Elizabeths. Nafisa Hoodbhoy, Bhutto’s widow, attended the hearing.
Bazron said DBH failed to monitor Hilman Jordan, who killed Bhutto. Jordan was a patient convicted of murder in 1998, discharged from St. Elizabeths Hospital in 2015, and went on to kill Bhutto this year.
DBH found the agency’s Forensic Outpatient Department and the Outpatient Forensic Review Board failed to follow protocol; these sub-agencies are responsible for supervising patients released by D.C. Superior Court so they can live in the least restrictive setting possible for further treatment. Specifically, the sub-agencies failed to comply with five of the 19 requirements outlined in the court order. For example, FOPD did not notify the court of four urine tests in which Jordan tested positive for weed during a 37 day period between June and August 2018. Testing positive for drugs should have meant that Jordan return to hospital confinement.
“Mr. Bhutto would still be alive if this order had been obeyed,” said Gray, looking to Bazron for a reaction. As she searched for the words to respond, Bazron let out a quiet yes and shrugged.
“I share the grief and the deep concern of Mr. Bhutto’s widow,” said Gray. “It seems to me there’s an awful lot of explaining for the District of Columbia to do at this stage.”
In response, Bazron said, “we have put procedures in place to make sure that the forensic review board and the forensic staff really examines what’s happening with every single one of the [court] conditions. What we found was that process was not in place before and it is in place now.”
Bazron outlined various steps taken in the aftermath of Bhutto’s murder, including the replacement of the chair of the Outpatient Forensic Review Board. Actions that followed the St. Elizabeths Hospital water emergency pale in comparison.
“We thank the staff for their determination to do the best for patients at all times and the patients for their resilience,” said Bazron in her opening testimony.
“With the support of water management experts, the hospital is working to identify the possible sources of water borne bacteria and will put policies and practices in place where needed to minimize the risks and prevent a reoccurrence.”
During questioning, she elaborated, saying DBH is in the process of securing a water expert to develop a management plan. She also stressed there were no reports of patient or staff illness during the emergency.
“We are reviewing everything that happened during that time period. We are doing it internally and external consultants will help us with that,” she said.
When her office got word of the Disability Right DC report that outlined severe patient abuse, however, Bazron said she was quick to dispatch clinical staff to review and other government agencies investigated as well.
“DC Health found that no patient abuse took place,” she said. However, her chief clinical officer and the Accountability Administration recommended more staff training to make sure hospital staff follows its own protocol on seclusion and restraint.
Andrea Procaccino, with Disability Rights DC at University Legal Services, said she’s pleased that Bazron has agreed to her organization’s recommendations and hired a consultant that has a lot of experience in trauma-informed care.
“Our report recommended DBH develop a strategic plan to significantly reduce seclusion and restraint and hire a consultant to analyze the causes of the increase, to develop strategies to ultimately eliminate the use, and to oversee the implementation of the strategies,” said Procaccino.
Disability Rights DC has recently met with the consultant. But as Procaccino noted to the consultant last Friday and again at the hearing, past changes and oversight had not lasted.