DOC report rips cultural failures at Western State: ‘We’re not in the confinement business’

Open doors, missing keys, lax security at psychiatric facility housing murderers, rapists

By David Guest

Tacoma Daily Index editor

Western State Hospital has taken steps to improve safety and security at the psychiatric facility in Lakewood, following the release of a scathing report by the Department of Corrections detailing a culture where “patients are dangerously imperiled by failing to put safety first.”

A news release from the Washington State Department of Social and Health Services, which runs WSH, acknowledged that the department is trying to “fix systemic operating problems” at the state’s largest mental health hospital.

“Western State Hospital remains laser-focused on ensuring safety, security, active treatment, quality care and meeting the requirements set by the federal Centers for Medicare and Medicaid Services,” said Cheryl Strange, Western State Hospital CEO.

The day after two violent patients escaped from Western State, Gov. Jay Inslee directed the Department of Corrections to revue and investigate security at the psychiatric hospital, where some violent offenders are committed after being found incompetent to stand trial.

On June 6, 2016, Anthony Garver and Mark Alexander Adams escaped confinement at the hospital by crawling out of a ground-floor window with easy access to a nearby park and bus stop. Both were recaptured days later – Garver near his mother’s house near Spokane; Adams in the Tacoma area.

Garver was committed to Western State after being found mentally incompetent to stand trial for the 2013 murder of a 20-year-old Lake Stevens women who he tied to a bed and stabbed more than 40 times. Garver had previously been found with bomb-making materials and assault weapons ammunition, threatened to blow up a government building, threatened to kill a judge and prosecutor along with making threats “of shooting into schools.”

Adams has multiple domestic violence convictions on his criminal record, and according to WSH records, acts out violently when frustrated or disappointed. Adams has been committed to mental health facilities multiple times.

The DOC report said that Garver has a history of committing violence toward women and is a threat to WSH female staff. Staff informed the DOC that Garver was identified to hospital leadership as an escape risk.

Western State Hospital made Garver and Adams roommates, along with two others “of similar circumstances” and placed them in a room with four 3-foot by 6-foot windows with a clear view of a city park and “immediate access to public transportation.”

Inslee fired WSH CEO Ron Adler days after the April escape and named Strange his replacement.

The report issued by the DOC team on June 6, 2016, offered a forceful rebuke of security practices at the hospital calling the WSH executive leadership team lacking in “presence, communication, authority and accountability.”

The DOC report claimed that when their team offered recommendations, observations and relayed staff concerns, they were met with “difficult conversations” with WSH executive leadership. The report said that investigators were told “we’re not a prison, we are a hospital” and “we’re not in the confinement business.”

Richard Morgan, DOC secretary, appointed Keri Waterland, assistant secretary of the offender change division; David Flynn, associate superintendent of the Washington Corrections Center for Women; and Charlotte Headley, chief of prisons security to the DOC team of investigators.

According to the DOC report, a hospital security officer responded to the patients’ room on the night of the escape in an attempt to determine how the window was used by Garver and Adams to leave the facility. The security officer told the DOC that maintenance staff arrived before he did, and had already started to repair the window and refused to halt work to allow photos to be taken. As a result, neither WSH security or local police were able to determine exactly  how the patients were able to open the window.

DOC investigators said that patients had reported to WSH staff that the window had been loose for “quite some time,” and complained that wind blowing through the opening caused a whistling noise that often disrupted their sleep. The report went on to say that not all screws used to fasten the window were of a secure type, requiring a special tool to remove, but rather, common Phillips head screws – some could be removed with a fingernail.

During their on-site investigation, DOC members found open exit doors, unattended key rings and were told by staff members that “security is not prioritized in the decisions impacting patient housing assignments or hospital grounds access.” While on-site, the DOC team was informed that one of the escapees had been captured and incredulously noted they were told by WSH staff that he would be returning “to the same room from which he escaped.”

Lakewood police reports acquired by The Associated Press found that hospital officials didn’t report the escape to police for almost two hours.

The DOC report blasts Western State for delays in notifying local law enforcement about escapes from the hospital. WSH requires forms be submitted to initiate assistance from law enforcement to help apprehend escapees. The report said that hospital management established a policy that escapees would not be marked as “dangerous” without the “express permission or signature of the CEO or designee.”

In the Garver/Adams escape, the ward supervisor initially submitted the form and marked both patients as “dangerous,” but the initial contact sent the form back, requiring the supervisor to revise the form and uncheck the box indicating the escapees as “dangerous.”

The DOC report highlights an Associated Press story in May 2016, which found that Western State has had over 180 escapees since 2013, although many were not considered a danger to the community. Some simply walked out through unlocked doors, some crawled out windows and over fences and some just walked away during appointments or approved visits away from the facility. Some remain missing.

The report said many of those patients who escaped, or were “walkaways,” were not identified as dangerous even though they had been charged with crimes such as murder, rape, kidnapping, assault and robbery. Lakewood police told investigators that on the night of the Garver/Adams escape, the form provided to them by WSH was marked “not dangerous.” Lakewood police said they receive numerous notifications from WSH about patient escapes and walkaways, but rarely are they marked as “dangerous.”

A 2010 DOC security assessment of WSH and Eastern State Hospital, in Medical Lake, near Spokane, said at the time, “Historically, the culture in the organization has been that the treatment and recovery is paramount to all things. Staff members are clear on this. However, staff members are not clear about the role of safety and security in an environment focused on good treatment and recovery.”

The 2010 report found a lack of respect for security officers by other staff members and a lack of key control, of tool control, of security inspections, of contraband management, staff training, and accountability.

Forward six years to the 2016 report:

“The cultural ideology that treatment with staff, patient and ultimately safety and security is somehow impossible at WSH still exists, and is currently supported and promoted by several members of the existing executive leadership team.”

In a statement through a spokesperson, Republican challenger for the 2016 governor’s seat Bill Bryant said that he found the report “troubleing, particularly as the exact same problems were revealed in 2010.”

The former Port of Seattle Commissioner went on to attack Inslee on his slow response to problems at Western State over the years.

“The Inslee Administration has done nothing to address them,” Bryant said in a statement. “This is a failure of leadership from the Governor’s office and his lax attention to these problems put Washingtonians at risk.”

Gov. Inslee’s office said that they were reviewing the report.

Mark Alexander Adams, left, and Anthony Garver. Credit: Lakewood Police Department

Mark Alexander Adams, left, and Anthony Garver. Credit: Lakewood Police Department

“Western State is a hospital and not a correctional institution, therefore staff and leadership are working to maintain a therapeutic environment while making safety and security a priority,”  Tara Lee, the governor’s deputy communications director said in an email.

“The governor and his staff are continuing to work closely with DSHS, Western State leadership, and legislators to ensure safety, security, and compliance.”

DOC findings:

  • Hospital policy did not allow windows to be opened by patients, however, they were not inspected on a regular basis.
  • Exit doors were left open.
  • Key rings were left lying around, unattended by staff.
  • A master key, dubbed “WW1” is on every key ring for the civil side of the hospital. The key can be used for movement from each civil patient ward all the way out through each perimeter gate. The report said there are approximately 25,000 lost or unaccounted for WW1 keys.
  • Staff members were distracted with personal cellphones.
  • Security-related documents were requested from WSH staff, but never received.
  • The WSH security director expressed reluctance to search patient rooms for contraband, explaining that written orders from a doctor were required before searches could be conducted.
  • Hospital leadership admitted that the hospital’s security director has not been included in executive leadership team meetings or in security-related decisions.
  • Psychiatric security attendants at the vehicle security gate do not search incoming or outgoing vehicles; do not verify staff identification for entry into the secure perimeter; and do not verify grounds privileges of patients accessing the gate under staff escort.
  •  A lack of security personnel in patient areas.
  • Maintenance staff estimated thousands of tools used to open patient windows are unaccounted for.