Trouble at Perkins

It may be some time before we know the exact circumstances surrounding the killing last week of a patient at Clifton T. Perkins Hospital Center in Jessup. What we do know is that this was the second such tragedy to occur there in little over a year, and state health officials need to make figuring out what went wrong their top priority before anyone else is killed.

Both the victim and the alleged perpetrator in this tragedy had histories of serious mental illness and violent behavior. That's not unusual at Maryland's maximum security mental hospital, but cases in which a patient is killed have been rare. Before the deaths this year and last, no patient had been killed in 50 years.

One of the first questions investigators are going to have to answer is whether anything has changed recently to make such incidents more likely. Another is why the two men, both of whom were considered extremely dangerous, were assigned to room together in the first place.

David Rico-Noyola, who was found on the floor of his room suffering from blunt-force trauma to the head and body, was committed to Perkins in 2008 after a judge deemed him mentally unfit to stand trial for killing his mother. His roommate, Victor Davydov, who has been charged with the killing, was sent to Perkins in 2006 after he killed his psychiatrist.

Mr. Rico-Noyola's death comes just 13 months after another patient at the hospital, Susan Sachs, was killed by a male patient and known sex offender who lived on the same floor. That killing prompted hospital officials to beef up security measures and improve staff training in sexual abuse and harassment prevention after an investigation revealed that workers had been sleeping on the job and failing to check patients' rooms on a regular basis.

Yet it's not at all clear that more security cameras, video monitors or hand-held communications devices would have prevented Mr. Rico-Noyola's death, even though the union representing hospital workers believes they have made conditions safer for employees. A nurse who checked the victim's room 30 minutes before he was killed reportedly found nothing amiss, and the number of staffers on duty at the hospital has increased slightly since Ms. Sachs' death.

Advocates for patients in Maryland's mental health hospitals say those kinds of institutional reforms ignore the real source of the problem, which they call a "culture of violence" fostered by the system of punishments hospital staffers use to maintain control. In their view, confining patients in physical restraints or isolating them from others for prolonged periods brutalizes already troubled individuals.

Such harsh methods, advocates charge, fuel an anger and frustration that makes patients more likely to lash out through the very kind of violent behavior treatment is intended to prevent. Patients as well as hospital staffers would be far safer, they say, if more humane treatment strategies were adopted that gave patients broader control over their lives and opportunities to take responsibility for their actions.

We suspect there may be some truth to that argument. But it's equally true that many patients at Perkins are there precisely because they are mentally incapable of controlling themselves or taking responsibility for their actions — and for that reason pose a danger to themselves as well as others.

Today's patients may well be more violent than those of previous decades. But the reason may have less to do with how they are treated — in general, conditions inside mental hospitals are a far cry from the nightmare described in Ken Kesey's 1962 novel "One Flew Over the Cuckoo's Nest" — and more to do with the increasing willingness of judges to commit mentally ill offenders to psychiatric hospitals rather than send them to prison.

Maryland health Secretary Dr. Joshua M. Sharfstein has assigned a working group to look into the facts surrounding the most recent death at Perkins and make recommendations to improve safety there. Of crucial importance will be determining how the victim came to be assigned to live in the same room as the man accused of killing him. On the face of it, that sounds more like a possible error by the clinicians responsible for treating the men rather than a problem caused by lax security or misbehavior among low-level staffers.

Moreover, the hospital has been without a permanent director for some time, and clearly there's been a lack of leadership from the top. Currently, none of the institution's high-level administrators are even psychiatrists. Dr. Sharfstein will have to make the final call on what Perkins needs, but finding an outstanding professional who can make the institutional and staffing changes required to provide safe and effective treatment for patients at the hospital should be at the top of his list.

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