Corrections officials who investigated the April escape of two violent patients from Washington state’s largest psychiatric hospital say they discovered a list of mistakes, blunders and deceptions at what should be a secure facility.
Investigators tasked with assessing security at Western State Hospital determined there were no routine inspections; 25,000 master keys were missing; thousands of tools used to open patient windows had been misplaced; and management was unwilling to recognize that failing to focus on security puts patients and the public at risk, according to a report obtained by The Associated Press in response to a public records request.
The report said that attitude was the main cause of the April 6 escape by Anthony Garver, who was confined amid allegations that he tortured and killed a woman, and Mark Alexander Adams, who has multiple domestic violence convictions. Adams was caught the next day, but Garver made it across the state and was captured several days later.
Hospital CEO Cheryl Strange said the hospital had made significant safety improvements since the escapes.
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“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,” Strange said in a statement.
Strange said hospital officials would replace locks and issue new keys on all exterior doors.
The escapes prompted Gov. Jay Inslee to order a team of experts to evaluate security at the 800-bed hospital. Their report said staff cooperated with the investigation, but hospital leaders weren’t responsive to requests for documents or open to feedback.
Inspectors said the problems they found were similar to those identified during a security assessment six years ago.
“Just as in its 2010 report, the 2016 team also found that there is a lack of awareness of the foundational role security plays in the operation of a psychiatric hospital” that houses dangerous patients, investigators said.
Garver and Adams were civilly committed to the hospital after treatment failed to restore their competency to face trial.
Garver was charged with murder in the 2013 killing of a woman who was tied to a bed and stabbed to death. Since arriving at the hospital in 2014, he was known for his violent outbursts, primarily against women, the report said.
The reports also said that Garver was “clearly identified to hospital leadership as an escape risk.”
The two men were housed in a ground-floor room with a window facing a busy street and bus stop. They escaped through a window that other patients had complained to staff about “for quite some time” because it was broken to the point that wind blew through the room, creating a whistling sound that disrupted their sleep, the report said.
When a security officer went to the ward after the escape to inspect the window, maintenance staff were already repairing it and refused to stop to allow photos or an inspection, which hampered law enforcement efforts to learn what had happened, the report said.
When Adams was caught the next day, the hospital planned to put him back into the same room, but the security team nixed that idea. The team also questioned the ward’s “ability to securely house patients without risk of escape.” The team reported seeing exit doors left open, staff distracted by using personal cellphones, key rings lying around and a lack of security personnel.
Staff must seek help from Lakewood police when a patient goes missing, but the initial report of the escape was delayed by an hour and a half because the switchboard sent the report form back to the supervisor so that the box marked “dangerous” could be changed to “not dangerous.”
The assessment team’s report referenced an Associated Press story revealing that 185 patients had escaped or walked away since 2013 and many “were not identified as dangerous despite being charged with crimes such as murder, rape, kidnapping, assault and robbery,” the report said.
When a report is marked “dangerous,” the public must be notified. Lakewood police told investigators they rarely see “dangerous” on reports and were in the process of revising the notification form to ensure it provides accurate information.
Staffing was sometimes a problem, since requests for time off were rarely denied, leaving a large amount of vacancies on each shift, the report said.
When the assessment team pressed hospital leaders on staffing, they received comments like “we’re not a prison; we are a hospital,” and “we’re not in the confinement business,” the report states.