Mental health advocates and labor union officials are calling for increased staffing and policy changes at the state's maximum security mental hospital — including a reassessment of how patients are paired as roommates — after one patient killed another at the Jessup facility last week.
State health officials are still investigating the second killing of a patient at the Clifton T. Perkins Hospital Center in just over a year.
Maryland Health Secretary Joshua M. Sharfstein said in an interview Monday that the investigation will allow the state to determine if further precautions need to be taken at the facility. Vitaly Davydov, who killed his psychiatrist five years ago, was charged Friday in the death of fellow patient and roommate David Rico-Noyola.
Noyola's death comes thirteen months after Susan Sachs was killed at the hospital by a fellow patient and known sex offender in September 2010. The hospital retrained staff and tightened security measures after an investigation found employees slept on the job and didn't regularly check rooms.
"Both of these incidents are very concerning, perhaps in different ways," Sharfstein said. "So, we need to understand them and learn from them and recognize our goal is always to prevent instances like that."
But mental health advocates and the union that represents the hospital's workers said the previous changes were little more than a temporary fix and the latest killing is proof that not enough has been done.
They are calling for broad-based policy changes at the 50-year-old mental health facility.
"Violence prevention is more than how many staff you have and alarms and cameras," said Laura Cain, managing attorney of the adult mental health unit for the Maryland Disability Law Center, an advocacy group. "The hospital needs to create a culture of nonviolence."
Cain said the hospital needs to reassess policies such as how they decide what patients share rooms and what kinds of treatment patients are receiving beyond medication. She also questioned whether the staff was using the most effective methods to look for signs a patient is about to become violent.
A representative with the Maryland office of the American Federation of State, County and Municipal Employees said Perkins is still understaffed despite the state adding some employees. The state says the hospital added one person per shift after Sachs died, though the facility did this in part by reassigning current employees.
A health department spokeswoman said current and former staffing figures were not immediately available.
"We think there are some very common sense things that can be done to make places like Perkins safer," said Sue Esty, assistant director of AFSCME Maryland.
The union at Perkins has formed a joint committee with hospital staff to come up with safety measures, Esty said. She said the hospital should look at everything from making sure employee hand-held radios work to better tracking violent incidents.
"I think policies and procedures go along with things such as infrastructure and equipment, and they all need to be reviewed," Esty said.
A void in leadership at Perkins is not helping stabilize the facility, critics said. Sheila A. Davenport, the chief executive when Sachs was killed, stepped down in February, saying her resignation had nothing to do with the case. She was replaced by interim head Susan Steinberg, who left Perkins recently to take another job within state government. Dr. Muhammed Ajanah, clinical director at Perkins, took over as interim director.
Perkins houses 241 patients, many of whom are under evaluation for their competency to stand trial or who have committed felonies and would otherwise be sentenced to prison if not for their mental illness.
W. Lawrence Fitch, director of forensic services for the Maryland Department of Health and Mental Hygiene, said a killing of a patient is unusual. Rico-Noyola's death was the second killing at Perkins in its 50-year history, according to the state.
"These are extremely rare incidents," Fitch said, "even though these are people who come with violent pasts and extreme mental illness."
Davydov, the Montgomery County man who killed his psychiatrist in 2006, was returned to Perkins after being charged Friday.
Police said Davydov came out of the room he and Rico-Noyola shared in a maximum-security area of the hospital about 2:30 p.m. Friday and asked a security guard for help. Hospital staff then found Rico-Noyola on the floor, bleeding and suffering from trauma to his body and head. An autopsy showed he suffered from blunt-force trauma likely inflicted by a person's hands.
A nurse had checked their room 30 minutes before the attack and found nothing out of the ordinary, police said. Fitch said it was a room shared by three people but the third person was not believed to be in the room at the time.
He said it is not uncommon for a patient whose case hasn't gone to trial to room with someone who has been sentenced. He also said it is not unusual for extremely violent patients to share a room because most patients there have a history of violence.
"Their legal status is less important than their clinical status," he said.
The Department of Health and Mental Hygiene deemed Rico-Noyola incompetent to stand trial in the death of his mother in 2008.
In the case of Davydov, a judge found that severe mental illness prevented him from realizing that he was committing a crime and ordered him committed to Perkins until he was determined to no longer be dangerous, The Washington Post reported.
In last year's killing, El Soundani El-Wahhabi, 51, was charged with the murder of Sachs, who was found dead in her bed at the hospital with a shoelace around her neck. The two lived on a co-ed floor, a practice Perkins has since eliminated.
Two other patient deaths since 2008, one accidental and the other health-related, have also raised questions about staffing and operations at the facility.
Del. James W. Hubbard, a Prince George's County Democrat who sponsored legislation after the killing at Perkins last year, said more policy changes or funding may be needed to further protect patients.
The legislation, which passed, was aimed at improving safety for patients by separating men and women and requiring additional patient screening and incident reporting.
"From a standpoint of someone being hurt, if there is something we can do to eliminate that, we should do that," Hubbard said. "I'll look for the report from Dr. Sharfstein first and have them back for a hearing when we come back in session in January."
He expressed frustration with a health care system that, he said, often produces policy based on the budget. Shared rooms, for example, are due to lack of funding for individual rooms, he said. And training for workers and pay are not "commensurate with the responsibilities we give these people," he said.
"Hopefully we keep learning from our mistakes," Hubbard said. "If we can save a person at Perkins, that's a responsibility."