Documentary provides insight and explores mental illness at Oregon State Hospital

By Michelle Cole, The Oregonian, Portland, Ore.

June 25–The latest film about Oregon’s infamous state mental hospital contains scenes from Hollywood’s “One Flew Over The Cuckoo’s Nest,” but the stories it tells are real.

“Guilty Except for Insanity” is a 90-minute documentary offering viewers a chance to get to know three men and two women who are patients at the Oregon State Hospital. It chronicles the haunting events that landed them in the hospital, what life is like on the ward and just how difficult it is to get better and get out.

The film started as a class project for Portland State University psychology professor Jan Haaken, who turned more than two years and 70 interviews into a documentary slated for its Portland premiere Sunday night.

Haaken talked with The Oregonian Thursday about the film, including her plans to do a final edit in response to the feedback she gets from Sunday’s audience. Here is condensed version of that interview:

The five patients you featured have interesting yet terrible stories how did you choose them?

I wanted ethnic diversity and gender diversity. I found that over half of the patients we approached wanted to have their story told. Those stories, in one way or another, involve people whose lives had fallen apart quite a bit before the state steps in — and we step in with a heavy boot.

What did you learn from making this film?
I started thinking the hospital was an evil place. I don’t any more. I see these places as shock absorbers in a very troubled system.

During the time you were making this documentary, there were a number of controversial events, yet you don’t mention the patient who was dead in his bed for hours before staff noticed or the ongoing U.S. Department of Justice investigation. Was that on purpose?
Yes. I wanted to focus on the people in the hospital and those who carry out the work.

What do you want Oregon viewers to take away from your documentary?
The film is different from social-problem documentaries in that it doesn’t direct you to do a particular thing at the end or offer a clear resolution in terms of who the bad guy is.

People carry these images of the “criminally insane,” I’m hoping people will see more of the complex humanity.

Have the patients and staff seen this film and will any of them be there for the Portland premiere?
Yes. All five of the featured patients will be with me and taking questions and comments from the audience.

— Michelle Cole

Documentary Website:


A mental health system still strapped in restraints

The Oregonian Editorial Board
Oregon State Hospital patients and staff remain locked in a “culture of despair” even as a new hospital rises and the state acts to reverse decades of neglect

Just outside the brick walls of the Oregon State Hospital, where 550 construction workers are building the nation’s newest mental hospital, there’s hammering, heavy machinery and hope.

Inside those walls, though, nothing seems to be working. There’s a growing number of patient assaults, more injuries, greater use of seclusion and restraints, more grinding despair.

How could this be happening? Didn’t the state decide four years ago to spend more than $450 million to replace the wreck of a state hospital that provided the stark backdrop to the movie “One Flew Over the Cuckoo’s Nest”? Didn’t it commit more than $60 million, even during these hard times, to add more than 500 new hospital employees? What about all those promises of a modern, compassionate system of mental health?

It’s not here yet. None of it. The new building on the Salem campus remains a work in progress. Scores of new staff, especially nurses, have arrived, but furloughs ordered across state government wreaked havoc on hospital staffing, and required more than 5,000 hours of overtime in the past month alone. Meanwhile, vulnerable, volatile patients remain crammed four or five to a room in soon-to-be-abandoned buildings.

It’s still a mess, this mental health care system in Oregon. That much was obvious in two legislative oversight hearings in Salem last week. There’s still twice as many criminally insane patients locked in the hospital as the decrepit facility was designed to hold.

Moreover, there’s been no change in state policy that prompts the Psychiatric Security Review Board, the mental health equivalent of the state parole board, to keep patients locked in the hospital for years, even decades, after they could be safely released to far less expensive community mental health facilities. If that policy isn’t changed, within a decade the new hospital will be so overwhelmed by the criminally insane that it will no longer have space for civil commitments of the mentally ill.

You get the sense that Oregon legislators keep waiting to hear that when it comes to mental health, their job is done. But mental health is a linked system, and it’s only as strong as its weakest links. For now, that’s a shortage of community beds and the policy that sends far too many mentally ill criminals to the hospital and never lets them out.

Legislators and Gov. Ted Kulongoski need to agree on this: No more staff furloughs at the state hospital. With the new budget shortfall announced last week, it’s likely that state employees will be sent home more days over the next year. That can’t happen again at the hospital. It caused too much stress and led to too much unrest among patients and too much expensive, exhausting overtime for staff.

Like its patients, the state hospital needs a real fighting chance to get better. The first 120 beds in the new hospital will open late this year, and the remaining 500 will come on line late next year. It will be safer for patients and staff. There will be more privacy, more places to walk, exercise, blow off steam. There will be more green space, more vocational activities. There will be air conditioning and a roof that doesn’t let rain drip, drip, drip into plastic buckets.

Yes, it’s just a building. Yes, it’s what goes on inside those walls that matters. And yes, it was painful to hear a patient tell legislators the hospital is enveloped in a “culture of despair.”

But better days are coming to Oregon’s mental health system and the patients and families it serves. Of course, one can’t see them from the barred windows of the hospital, which is as overcrowded and violent as ever. Yet there’s real change going on out here, where construction crews are working, where more hospital staff are being sought, where new community facilities are opening, where lawmakers vow to re-examine laws that keep patients locked away. The work is far from done, but there’s reason for hope.


Bratcher stays at OSH


SALEM – Jessie L. Bratcher will remain at the Oregon State Hospital, the state Psychiatric Security Review Board (PSRB) has decided.

Bratcher’s confinement was the subject of an April 28 hearing before the PSRB, the state panel that now is in control of his fate.

A Grant County jury last December found Bratcher guilty except for insanity for the shooting death a John Day man, Jose Ceja Medina, in 2008. He was turned over to the jurisdiction of the PSRB for life.

Bratcher was diagnosed with post traumatic stress disorder (PTSD) stemming from his military service in Iraq.

The hearing in April was his first session before the review board. The board routinely sets hearings in such cases every two years, but Bratcher also has the right to request a hearing as often as every six months.

Grant County District Attorney Ryan Joslin, who attended the hearing, said the board had three questions to consider: Does Bratcher still have the mental disease or defect, PTSD? When the condition is active, is he a threat to the community? And could he be safely monitored in the community, rather than in the hospital?

The board said yes to the first two questions and no to the last, ruling that Bratcher should remain confined to the state hospital.

Markku Sario, Bratcher’s attorney, was seeking – at trial and before the PSRB – to have his client sent to New Directions, a secure treatment facility that specializes in veterans with PTSD. The founder of the Los Angeles-based facility for veterans even testified for the defense in Bratcher’s trial.

However, Sario said there seem to have been some changes in the management of the program since then, and he was surprised when New Directions notified the PSRB that Bratcher had not been analyzed or assessed for admission.

Sario said he’s looking into the situation, and he will continue to press for Bratcher to be sent to New Directions or some other PTSD program. He noted that the state hospital has no program focusing on PTSD.

Meanwhile, he said Bratcher is doing well at the hospital in Salem, attending group counseling and working on stress reduction techniques. His symptoms are “in remission,” Sario said.

“He’s very invested in his treatment,” he said.

Sario said that with many more Oregon veterans coming home with PTSD, after serving the nation in the Middle East, specialized programs are going to be a critical need.


OSH Client Intends to Sue The PSRB

Patient will stay at state hospital
Lawyer criticizes board’s decision, saying it breaks a previous agreement

By Alan Gustafson
Statesman Journal
April 1, 2010

In a controversial ruling Wednesday, a state board decided that an Oregon State Hospital patient must remain at the psychiatric facility until his attorney finds a suitable place for him to live.

Steve Gorham, a Salem lawyer representing Richard Laing, accused the state Psychiatric Security Review Board of breaking its previous agreement with his client. The agreement called for Laing to be freed once he finished a prison stint for escaping from the state hospital in 2005.

Gorham blasted the board’s decision.

“It’s no wonder the state hospital is overcrowded when the board can’t even follow the law,” he said after the hearing. “The bottom line is, never make an agreement with the state of Oregon, because they will violate it.”

In May 2008, the board cut a deal with Laing, leading to him being moved from OSH to the Department of Corrections to serve a negotiated 32-month prison sentence for his November 2005 escape. Upon completion of his sentence, Laing, barring mental health problems, would be released into the community and serve a two-year term of post-prison supervision, according to the agreement.

Laing completed his prison time March 18 and was taken back to the state hospital, pending the outcome of Wednesday’s hearing.

During the hourlong hearing, Gorham argued that Laing doesn’t have a mental illness and doesn’t belong at the state hospital.

Laing entered OSH in 2002 after getting drunk and hitting his Portland landlord in the head with a coffee mug. His heavy drinking caused alcohol-induced psychosis, but his symptoms cleared once he was taken into custody, records show.

Laing pleaded guilty except for insanity to avoid a 70-month mandatory prison term for assault.

His November 2005 escape from OSH came on the heels of repeated denials by the PSRB of his release requests. Given a pass to visit the Salem library, Laing hopped a bus to Portland.

During two years on the lam, Laing was arrested once for sleeping under a Portland bridge, but he experienced no mental health problems and had no other scrapes with the law, Gorham said.

Laing was captured in October 2007, when the executive director of the PSRB, Mary Claire Buckley, spotted him on a Portland street and alerted police.

In prison, Laing diligently attended Alcoholics Anonymous meetings and received a 30 percent “earned time” reduction in his sentence.

Laing, 70, does not show symptoms of mental health deterioration, according to a recent report written by Dr. Luvy Ruiz-Martinez, a state hospital psychiatrist.

Appearing before the review board Wednesday, Ruiz-Martinez described Laing as “very charming, very interesting.” But she told the board that it would take her about a month to perform a full mental health evaluation.

Gorham told the board that Laing should be allowed to go back into the community on post-prison supervision, as specified by the 2008 agreement, which he called binding.

Under that scenario, Laing planned to start off at a Portland halfway house for newly released prison inmates and eventually move into a hotel room or apartment. He intended to pay his rent with monthly Social Security income and wages earned by selling newspapers.

Douglas Marshall, a senior state assistant attorney general, told the board that he concurred with Gorham’s assertion about the 2008 agreement. He, too, called it binding.

But the board ruled otherwise after a half-hour of closed-door deliberations. The panel said Laing will remain at the state hospital until Gorham delivers a plan spelling out living arrangements deemed acceptable by the PSRB.

Outside the hearing room, Gorham strongly criticized the PSRB and Laing’s ongoing hospitalization.

“They should have discharged him,” he said. “He’s no more dangerous than you or I.”

Laing said he intended to sue the PSRB.

“That was a joke,” he said. “They went against their own attorney general. I’m going to sue them for false imprisonment.”

To open hospital doors for Laing, Gorham said he will attempt to craft a housing plan that will pass muster with the PSRB.

“Hopefully, sooner rather than later,” he said. “If this is what is going to get him out, we’ll do what we can.”

Patient has been trying to prove he’s not mentally ill


Cooped up at Oregon State Hospital, Richard Laing became a frustrated and fiery critic of patient care and hospital conditions.

Despite evidence that he wasn’t mentally ill, Laing couldn’t get out of the crowded, run-down mental institution.

In late 2005, he took off. Given a solo pass to visit Salem Public Library, Laing hopped a bus and left town.

Nearly two years later, police collared Laing in Portland. His negotiated punishment for the escape: 32 months in prison.

Laing figured he got a good deal. As he saw it, serving prison time was preferable to being stuck at the psychiatric facility, and he would be free upon completing his sentence.

Much to his dismay, Laing now is back inside the hospital he hates. He was hauled back to OSH on March 18, the day he completed his prison sentence for the 2005 escape.

A hearing today before the state Psychiatric Security Review Board will determine whether Laing, 70, remains at the mental hospital or receives a green light to live in the community — subject to post-prison supervision and separate monitoring by the PSRB.

Laing’s bid to get out of the state hospital renews his long-running battle to prove he’s not mentally ill.

“If you’re not crazy, you don’t belong in a mental institution,” he said by telephone this week from Ward 50G in the hospital’s forensic psychiatric program.

Steve Gorham, a Salem attorney representing Laing, said his client should be discharged from OSH.

“It’s clear that he has been in the state hospital for years and not been treated for anything there,” Gorham said. “He’s not under any medication.”

Laing had no mental health problems while on escape status from the hospital and received no psychiatric treatment during his prison stint, Gorham said.

“It seems to me that there’s pretty good evidence that he doesn’t have a psychiatric illness,” he said.

Laing entered OSH in 2002 after getting drunk and hitting his Portland landlord in the head with a coffee cup. He was in the throes of an alcohol-induced psychosis.

Laing said he pleaded guilty except for insanity to avoid a 70-month mandatory prison term for assault.

In Oregon, criminal defendants found guilty of crimes but insane at the time go to the hospital’s forensic program for treatment instead of prison. More than 400 forensic patients are housed at OSH.

Laing was unable to get out of the hospital, even though therapists and staffers said he had no symptoms of mental illness.

The state Psychiatric Security Review Board, which monitors the progress of forensic patients and controls their discharge dates, repeatedly turned down Laing’s release requests amid concerns about his checkered participation in group therapy sessions, whether he would be accepted into a community-based program for drug and alcohol abusers and his prospects for staying sober on the outside.

In December 2004, the Statesman Journal profiled Laing in a story that raised questions about his hospitalization.

It reported that taxpayers had shelled out $300,000 for his stay at OSH and quoted Laing’s assessment of the tab: “You could put somebody in a Hilton Hotel for that kind of price. It’s just insane.”

The following November, the PSRB again refused to release Laing.

Fed up, Laing used his off-grounds pass like a ticket to freedom. Instead of going to the city library, he boarded a Greyhound bus to Portland.

The escapee stayed free for almost two years, sleeping under bridges and roaming Portland. His meager income came from selling newspapers and collecting cans and bottles for refunds.

Laing’s days on the lam ended in October 2006. By happenstance, he was spotted on a Portland street by Mary Claire Buckley, executive director of the Psychiatric Security Review Board.

Buckley called police and she followed Laing until officers arrived and put him in handcuffs.

Laing looks back on Buckley’s role in his capture with a mix of irony and disbelief.

“It was just a fluke. I’m walking around in downtown Portland and I just walked right into her,” he said. “She had her cell phone and called police. Of all the things.”

Laing served part of his prison sentence at the Snake River Correctional Institution in Eastern Oregon. Last year, he was transferred to the Oregon State Correctional Institution in Salem.

Laing got a break when about nine months were lopped off his sentence through a controversial early-release program approved by the 2009 Legislature. To save money on lockup costs, lawmakers approved an expanded “earned time” program for prisoners. The new law increased from 20 percent to 30 percent the amount of time many inmates could have shaved off their sentences.

Laing’s prison time expired March 18, but he didn’t go free. Instead, he was sent back to the mental hospital, pending the outcome of today’s hearing before the PSRB.

Returning to OSH has rekindled Laing’s hatred of the hospital. He describes it as a crowded and violent warehouse.

Laing said he was punched in the face last week by another patient, a sneak attack that came as Laing was watching television on Ward 50C. Two blows to the face broke his prescription glasses and left him shaken.

“I’m no spring chicken anymore,” he said.

By Laing’s account, the assault was committed by a patient assigned one-on-one staff supervision due to recurring acts of violence.

“In 22 months in state prison, this never happened to me,” he said. “I’m back here eight days and some nut hits me in the head.”

Laing faces two years of post-prison supervision once he leaves OSH. In addition, he will continue to be monitored by the PSRB.

As Laing hopes for board approval to leave the hospital, he is taking legal action against the state.

After being assaulted, Laing filed a tort claim notice with the state, alleging the hospital was negligent in failing to properly supervise his attacker. Laing said he intends to sue the state unless he’s offered an out-of-court settlement. or (503) 399-6709

State hospital adviser re-admitted as patient

A conditionally released mental patient who serves on the Oregon State Hospital advisory board is back inside the psychiatric facility after a relapse of mental illness.

Mike Adelman, appointed to the OSH advisory board last year by Gov. Ted Kulongoski, landed back in the state hospital after what he described as “a manic episode.”

The state Psychiatric Security Review Board revoked his conditional release March 18, acting on a county case manager’s concerns about Adelman’s deteriorating mental health.

Now housed in the hospital’s forensic program, Adelman said by telephone that he hopes for a quick recovery and short stint of care at the Salem facility.

“Relapse is a part of life,” he said. “It happens, and you recover from it, and you get back on track as fast as you can.”

Adelman’s hopes for a fast release from the facility hinge on evaluations of his mental health by hospital therapists and a review of his case by the PSRB. A board hearing is scheduled for April 7.

“The board will decide on that date whether he’s ready to go back out, and where that should be,” said Mary Claire Buckley, PSRB executive director. “He had graduated to an independent level. A determination has to be made as to whether he should be at that level or whether for a period of time he should go to a supervised type of housing.”

Adelman’s conditional release was revoked based on the recommendation of his Marion County case manager, according to a March 18 affidavit written by a PSRB staff member.

It says the case manager, Bev Shoopman, reported to the PSRB that he had been hostile, irritable and “unwilling or unable to take direction from her,” and that “in her opinion, Mr. Adleman’s conditional release should be revoked because his mental health has deteriorated such that he can no longer be managed (in) the community.”

Adelman, 42, initially was committed to the state hospital in December 2003 after a Marion County judge found him guilty except for insanity of arson and resisting arrest.

In Oregon, criminal defendants found guilty of crimes but insane at the time go to the forensic program for treatment instead of to prison. More than 400 forensic patients are housed in outdated, crowded facilities along Center Street NE in central Salem.

The PSRB reviews each patient’s progress at the hospital and determines patient discharge dates.

Conditionally released patients can be sent back to the hospital for violating conditions set by the board or because of recurring mental illness.

In 2005, Adelman was conditionally released from OSH after about 16 months of treatment. Back in the community, he made regular visits with his case manager and progressed to independent living. He also became an advocate for better patient care and conditions at the state hospital.

Adelman linked his recent psychiatric problems, in part, to flawed medication management and a rocky relationship with his case manager. As his condition deteriorated, he experienced sleeplessness and mania.

Before his conditional release was revoked, Adelman was hospitalized for about a week at Salem Hospital’s psychiatric center. By March 18, therapists there determined that he was ready to be discharged, according to the PSRB affidavit. However, Shoopman reported to the PSRB that Adelman still required hospitalization.

“In Ms. Shoopman’s opinion, Mr. Adelman cannot be managed in the community,” states the PSRB affidavit. “This opinion is based on her past experience with Mr. Adelman when he has been in a similar manic state.”

On the afternoon of March 18, Adelman was transported from Salem Hospital to the state hospital. That same afternoon, the most recent meeting of the hospital advisory board occurred at OSH.

Adelman said he was disappointed about not being able to attend the board meeting. He also described his return to the forensic program as “rough, really rough.”

Adelman initially was housed on Ward 50G, a medium-security treatment unit packed with 40 patients. He shared a room with four other patients.

“The ward’s overcrowded. Every single bed is full,” he said.

A day or two after Adelman was admitted to the ward, an altercation occurred — one patient assaulted another in the 50G laundry room. The violent patient was moved to a maximum-security unit.

For Adelman, the assault revived bad memories about violence he witnessed and experienced during his previous hospital stay. In an upbeat development Friday afternoon, Adelman said he was looking forward to a planned transfer to a minimum-security unit.

“I’ve heard the milieu is a lot better,” he said. “The patients are good, and I’ve heard they allow you a lot more privileges.”

Hospital superintendent Roy Orr said Friday in an e-mail to members of the advisory board that Adelman’s position on the panel will be placed on hold.

“We all know recovery is non-linear,” Orr wrote. “It is not a step-by-step process. It involves some setbacks, and it involves learning from experience.

“I know we all support Mike in his recovery and look forward to his return to active board membership.” or (503) 399-6709

Patient’s death points to persistent problems at Oregon’s state mental hospital

Patient’s death points to persistent problems at Oregon’s state mental hospital
By Michelle Cole, The Oregonian
March 16, 2010, 9:45PM
The Oregonian

The body of Moises Perez, 42, was discovered in this bed located just to the left of the door of a room he shared with four other men. The Oregon State Hospital patient had been dead several hours before he was discovered during evening medication checks.T he last time anybody can be sure that they saw Moises Perez alive was about 7:15 a.m. Oct. 17.

A nurse at the Oregon State Hospital saw Perez lumbering down the hallway in Ward 50 F, a medium-security unit inside the state’s mental hospital.

He seemed, the nurse told police, “just like he always was.”

Diagnosed with chronic paranoid schizophrenia, Perez had been institutionalized for nearly 15 years. In that time, he’d developed physical problems often linked with powerful psychiatric drugs and years spent behind locked doors.

At 5-foot-8, Perez weighed 300 pounds, had high blood pressure and was at risk for diabetes. He was 42 and in terrible shape.

So nobody was shocked that Perez died later that day. The shock came in knowing he died in a room across the hall from the nurses’ station and nobody discovered his body for several hours.

His death, according to public records gathered by The Oregonian, points to serious problems that persist at the Oregon State Hospital despite multiple outside reviews, the threat of a federal lawsuit and millions spent on hiring and other improvements.

Police concluded that no crime had been committed. The state medical examiner ruled Perez died of coronary artery disease. Still, his case prompted a sharp rebuke from the U.S. Department of Justice, which had threatened federal legal action two years ago if the state did not address the abysmal conditions at the same hospital where “One Flew Over the Cuckoo’s Nest” was filmed.

After reviewing Perez’s hospital records, Shanetta Cutlar, head of the department’s special litigation section, sent Oregon a warning letter that said Perez received care that “consistently fell well below constitutional and statutory standards.” What’s more, Cutlar wrote, the hospital has systemwide deficiencies that could cause “serious harm or death in other situations.”

Perez’s history

Perez’s family has declined to talk to the reporters. But public records and interviews paint a picture of a closely knit family that stood behind a young man, even in the worst of times.

Born in Cuba, Perez immigrated to the United States with his family in 1982, when he was 15. He was the third of four children and the only son. He had a clubfoot that was corrected surgically but that left his right leg shorter, leading to a life of chronic back and foot pain.

His mental illness surfaced during his late teens. Perez was hospitalized multiple times, returning home to a small apartment on his parents’ property in Woodburn. His mother, Dora Perez, cooked his meals and did his laundry.

Just before Christmas 1994, 27-year-old Perez suffered a violent break. He had been unable to sleep since his release from the hospital two days prior. His mother told police she felt sorry for him: “He looked anxious and nervous and scared.”

She was cooking breakfast when he attacked. Perez punched his mother, cut her and bit off four of her fingers. She thought he was hallucinating. “He’d never done something like that before,” she said in a police report.

Later, Perez asked a Woodburn policeman to “shoot him” and “tell the other officers that he tried to get away.”

He was found guilty except for insanity of attempted murder and assault. Instead of prison, the court placed him under the jurisdiction of Oregon’s Psychiatric Security Review Board for a maximum of 40 years.

Dora Perez filed a federal civil rights lawsuit against the doctor, the private hospital and Marion County. The suit, which ended in a settlement, claimed that Moises Perez had been discharged before his medication took hold.

Dora Perez’s lawyer, Les Swanson, said the 1995 case is among the few he won’t ever forget.

Dora Perez forgave Moises, Swanson said. “This was a mother who had an ill son and who loved him very much. She understood that he did not do this voluntarily but it was a result of his illness.”

Hospital routine

Perez’s family routinely visited him at the Oregon State Hospital, where he lived on the third floor of a beige building that from the outside resembles a 1970s college dorm.

On weekdays, Perez spent much of his day watching game shows on the giant-screen TV. “The Price is Right” was among his favorites.

But Oct. 17 was a Saturday, and there were no game shows on. Nurses, staff and patients told investigators they didn’t think it all that unusual when Perez stayed in bed.

He could be a difficult patient. Perez often refused to take a bath unless staff bribed him with a soda. His slovenly eating habits got him barred from the ward’s main dining room. That meant he ate alone from a tray set up elsewhere.

Acknowledging that Perez was difficult, the Department of Justice’s review of his medical records still criticizes the hospital and staff for the care Perez received.

Federal officials note that from April 30 until his death on Oct. 17, Perez’s medical file contained only two recorded blood pressure readings in nurses’ notes.

Doctors had identified his risk for diabetes, but Perez was not regularly monitored for the disease. He also refused his psychiatric medications at times. Federal officials described his contact with his psychiatrist as “infrequent” in the months prior to his death — once in July and once in September.

Federal officials also question whether Perez actively refused medication or simply didn’t show up at the appointed hour to get his pills.

His file contained no nursing notes for the 10 weeks leading up to his death despite the fact that hospital policy requires nursing notes on each patient at least once every four weeks.

On the day he died, Perez didn’t wake up and have lunch. He was scheduled to receive medications at 4 p.m. but did not show up at the medication window near the nursing station. An aide told police that he called out to remind patients to come for their pills. When Perez failed to show, the aide wrote an “R” with a circle around it in his chart to indicate that Perez had refused his meds.

Perez shared room 379 with four other men. His bed was just to the left of the door. Police reports indicate patients and staff were in and out throughout the day.

Staff later noted it was odd that he did not show up for dinner at 4:30. But it wasn’t until 7:35 p.m. that staff tried to wake him up for medications. That’s when they discovered Perez, who lay covered by two thin hospital blankets, had died. They called his family and then the police.

Improvements questioned

Perez’s death has prompted some advocates and state leaders to ask: Has the hospital changed at all?

On Thursday, a newly formed hospital advisory committee is expected to question hospital Superintendent Roy Orr about the death and the Department of Justice letter.

During a recent interview, Orr said he was surprised by suggestions from federal officials that conditions at the hospital have not improved. Those same officials visited in July and “they all said it was clear to them that we’d made progress,” he said.

Since the federal government issued its scathing report in 2008, Oregon has broken ground on a $250 million hospital. Lawmakers have committed more than $60 million to hire more than 500 new employees. Officials are pushing a “continuous improvement” plan that addresses everything from patient aggression to electronic record-keeping.

Still, Orr concedes, “Mr. Perez’s death was a real opportunity for us to zero in on changes.”

The hospital has revisited its policy on what to do when a patient refuses medications.

Because people with severe mental illnesses die, on average, 25 years earlier than those without mental illness, doctors are paying more attention to a mental patient’s physical well-being.

And since Perez’s death, the hospital has changed its rounds policy. From now on, for each hour a patient is in bed, staff is required to “confirm patient viability” through observation, touch — or the sound of breathing.

— Michelle Cole