Patient deaths prompt inquiries at Perkins

The strangulation death of a patient at the Clifton T. Perkins Hospital Center in Jessup last month was the first apparent murder in the facility's 50-year history, but the third death there since 2008 to raise questions about staffing and operations at the state-run psychiatric hospital, according to documents reviewed by The Sun.

On the morning of Sept. 26, nurses discovered the body of patient Susan Sachs lying face-down on her bed with a shoelace wrapped around her neck. State police charged her hall mate, El Soudani El-Wahhabi, with first-degree murder, and he was indicted on Friday.


A year earlier, a patient was found dead under his bed, which staff had allowed him to use as an exercise weight. The prior year, a woman complaining of pain received limited treatment until she fell unconscious and later died.

The three deaths, along with a recent spike in patient-on-patient attacks at the hospital, reveal shortcomings about operations at Perkins, Maryland's lone maximum-security hospital, a review of records and interviews shows. The facility holds more than 200 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.


Doctors, nurses and security workers face chronic staffing shortages and tight budgets, and operate under what some describe as pressure from administrators to move patients quickly from high-security rooms to less-restrictive settings and eventually out of the facility, hospital and state investigative reports and interviews with former employees show.

State officials are reviewing the Sachs case to determine how and why hospital employees decided to place El-Wahhabi, a killer with a history of violence against women, in a room near the victim.

In the two earlier cases, investigators concluded that staff errors and oversights contributed to the deaths. Details of the incidents are contained in subsequent reports from the Office of Health Care Quality, the state agency that licenses and regulates Maryland health facilities. According to the reports:

• Investigators examining the May 30, 2008, death of a Perkins patient found that staff did not check a woman complaining of deep pains in her leg for blood clots, even though the 41-year-old was obese, sedentary and HIV-positive — which can all lead to blood clots — and was taking medication that increased the clotting risk. After falling unconscious, the woman, whose identity was not revealed in reports, was rushed to another hospital, where she died nearly three hours after her initial complaints. An autopsy determined that the cause of death was pulmonary artery blockage, often caused by a blood clot originating in a leg or pelvic vein. "The lack of a complete assessment," the report on the incident concluded, "contributed to the delay in obtaining necessary emergency interventions for the patient."

• In September 2009, a man under evaluation for his competency to stand trial was found unconscious underneath his bed. Staff originally thought the man had committed suicide by dropping the bed on himself, but an autopsy discovered that he suffered a cardiac arrhythmia because of a rare heart condition while using his bed as a makeshift bench press. An autopsy report revealed that staff knew the man used his bed for exercise, a violation of hospital protocol, but did nothing to stop him. The review concluded that while the man died of "natural" causes, "[w]hen the patient encountered a health crisis, the 78-pound bed was left resting on his neck/chest acting to impair his chances of resuscitation following the crisis."

Perkins administrators conducted internal reviews after each incident and took corrective action, said David Paulson, a spokesman for the state Department of Health and Mental Hygiene.

While the investigative reports identified concerns about the care provided by hospital staff, the agency "did not conclude, and could not have concluded from the facts, that the identified concerns were the cause of these unfortunate tragedies," Paulson said.

Incidents not rare


Roy Praschil, director of operations for the National Association of State Mental Health Program Directors, said the incidents at Perkins are tragic, but not rare in hospitals that treat violent patients.

"It's very difficult often to mix security with treatment priorities, although that's what these facilities are forced to do," Praschil said. "This is not unique to Perkins or any other forensic facility."

Kenneth Powers, a spokesman for the Joint Commission, the national body that accredits hospitals and has recognized Perkins for meeting standards, said the patient deaths indicate that some of the organization's protocol are not being followed, although he added that bad incidents can happen even when proper procedures are in place.

Powers said the Joint Commission is looking into Sachs' death. He said the organization had been aware of the death in 2009 but did not know of the 2008 incident before being told about it by The Baltimore Sun.

Maryland's state-run psychiatric hospitals have undergone great change in the past decade, with the closing of several regional hospitals and the shrinking of others. Since 2000, Maryland has focused on moving patients not accused of committing crimes to private hospitals, said Brian Hepburn, director of the state Mental Hygiene Administration. Some state facilities have been able to close and others downsize as a result, he said, while Perkins' capacity has increased, from 206 beds in 2004 to 218 today and a projected 262 after the scheduled opening of a new ward this year.

Sheilah A. Davenport, the hospital's chief executive for the past four years, said one of her goals has been to shorten the list of patients waiting to get into Perkins. Because judges know that the hospital typically operates at or near capacity, they will often order that the patient be held at a detention center until a Perkins bed becomes available.


"If someone has a mental illness and they are sitting in a detention center, they're not necessarily going to be getting the best psychiatric service," Davenport said in an interview.

The waiting list was reduced in several ways, Paulson said, including by asking judges to order patients who are found competent to stand trial back to jail more immediately, and by eventually moving eligible patients in less-restrictive Perkins wards to regional hospitals.

But former employees said that sometimes patients who are not ready for less supervision are moved to medium-security areas to open up a bed. El-Wahhabi, also known as Saladin Taylor, was found not criminally responsible for the 1995 killing and sexual assault of 26-year-old Mona Johnson and for the earlier sexual assault of his sister-in-law. He went from an all-male maximum-security ward at Perkins to a less-restrictive, coed one about two months before Sachs' killing.

A former Perkins doctor who left in the last few years said the atmosphere promoted by the hospital leadership was to move patients more quickly through the hospital's security levels, even if the responsible treatment team had not recommended relocation.

"Absolutely the sense in the hospital was the goal was to get people moving much faster than we were before," said the doctor, who asked not to be identified for fear of retribution from state officials. "There's no harm in wanting that; it's just a matter of you have to listen to the treatment team and respect their decision."

Another former Perkins employee, who worked there for close to a decade and left the hospital this year, said attendance by staff at meetings of the panel deciding patient treatment and setting declined over time "because people felt they weren't heard or that what they said was not taken into consideration." The employee also declined to be named for fear of retribution by state officials.


Davenport said the review panel's decisions were never influenced by pressure to move patients through the hospital system, and Paulson said any patient moved from maximum security to less-restrictive wards "has undergone a lengthy and thorough treatment and evaluation beforehand."

A dangerous workplace

While the nature of the patients housed at Perkins make it an inherently dangerous place to work and receive care, public records indicate that in the past few years, it has become even more so.

According to the state health department, there were 100 patient-to-patient attacks at Perkins in fiscal year 2008, and 129 in 2009. The number of patients injured in such attacks also rose.

Since 2006, the number of Perkins employees hurt on the job — not just in patient attacks, but all categories of injuries — has increased by almost 50 percent, from 59 in 2006 to 88 in 2009. So far this year, 67 employees have been injured on the job, the state health department reported. Almost all the injuries required some first aid or the intervention of hospital managers, and several were so serious as to require treatment at another hospital.

Hepburn, of the Mental Hygiene Administration, said year-to-year increases in injuries may be an aberration, or due to the retirement of experienced staff who knew best how to deal with difficult patients.


"Overall, the trend in our hospitals has been favorable," Hepburn said, "especially when you compare it to national averages."

Praschil, with the National Association of State Mental Health Program Directors, said Perkins is seen nationwide as a model forensic psychiatric hospital.

"A lot of people in other states will either call Perkins or talk to staff about programs that they're running," Praschil said.

Rita Ward, a former Perkins nurse and union representative who retired in June, said that because of increased attacks on staff, her main focus in recent years had been on improving safety, such as a suggestion she made that two employees conduct routine patient rounds together. But Ward said she was told by hospital administration that understaffing made that recommendation impractical.

The state health department has endured its share of budget cuts in recent years, with Perkins and other hospitals receiving less than what officials have said they require to meet rising costs and patient needs.

Understaffing has been a continuing issue at Perkins and other state psychiatric hospitals, according to the Department of Legislative Services, the General Assembly's nonpartisan research arm, which noted this year that the state's facilities suffer from a 25 percent staffing shortage, mostly in nursing.


The agency also reported that state psychiatric hospitals meet their needs through the "extensive use of overtime," which Ward believes is a root cause of the failure to follow proper protocol.

"There's no continuity of care because they move staff around so much, because they're so short," Ward said. "Sometimes you don't do your job at 100 percent if you're working overtime, because you are tired."

Davenport acknowledged in an interview that the hospital uses "a lot of overtime," but said administrators closely monitor staff to make sure they are not working too much.

"The overtime is given to people on a voluntary basis," Davenport said. "Staff are kind of complaining that there's not enough overtime."

From maximum to medium security

When state investigators complete their report on what happened in Perkins on the night of Sept. 25, they are expected to address two decisions made weeks before that arguably determined Sachs' fate: the move of El-Wahhabi to a medium-security ward, and, once he was there, the decision to place him in a coed hallway just three doors down from Sachs.


Every patient who comes into Perkins lands first in one of the hospital's seven maximum-security wards. Then, Davenport said, based on a patient's clinical and behavioral history — whether or not the patient follows hospital rules and abides by a prescribed treatment plan, for instance — the Clinical/Forensic Review Board, made up of department directors and administrators, determines whether a patient should move to one of the two less-restrictive wards available.

All medium-security wards at Perkins Hospital house both men and women. The ward El-Wahhabi and Sachs were placed on is shaped like a "V," with a nurse's station in the crook, from which two hallways of patient rooms — one male-only, one coed — extend outward. If El-Wahhabi had been placed in the male ward, he would have had to walk by the nurses' station to reach Sachs' room.

As it happened, he was able to slip in and out of Sachs' room in the span of 10 minutes, apparently unseen by staff, according to a police review of video surveillance footage.

"If they were going to put him over there, if they really had to make the move, they at least could have put him on the other side," Ward said. "But no, they put him a few doors down from this young lady's room. That was just poor planning."

Davenport and Paulson declined to comment on the reasons for El-Wahhabi's placement, citing the continuing investigation. Paulson said that the health department is reviewing hospital policy for coed units at Perkins.

Records of the review board's meetings are not available, Paulson said, because meeting minutes are not kept and the board's decisions are recorded in patient health records, which are not public.


While she declined to comment specifically on El-Wahhabi's case, Davenport said that a patient's recent history usually weighs more heavily than the crime that got him into Perkins in the first place.

"When we have people who have been there for a number of years, we have to look more critically at their more recent behavior and their more recent ability to maintain an appropriate level of personal responsibility," she said. "Over a period of time, we look more at what it is they're doing as opposed to a crime that they allegedly committed 'x' number of years ago."

Hepburn acknowledged that mistakes sometimes happen in the movement process.

"It's a process, and if we knew exactly how to move somebody from max to medium to the community, without having difficulties, everybody would be better off," Hepburn said. "Generally, Perkins moves very slowly. And if there's any complaint it's usually that they move too slowly, not too quickly."