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“Cumulative Failure” Lets Mentally Ill Teen Leap to Death
A “cumulative failure” contributed to the death of an Oregon teenage mental patient, state investigators determined. Eighteen-year-old Heather Williams was a patient at the Blue Mountain Recovery Center, a state-run psychiatric hospital in Pendleton, Oregon. While being transported on December 13, 2007, Williams leaped from the moving van as it was traveling on Interstate 84. She was struck and killed by a passing SUV.
An investigation by the Oregon Department of Human Services’ Office of Investigations and Training, found no individual responsible for neglecting Williams. Instead, the neglect was a “cumulative failure between management, programs, policies and direct care staff to appropriately protect [Williams], which ultimately contributed to her death,” concluded Investigator James Myrick-Duckett.
Williams had jumped from a facility van earlier that year and staff were aware of that incident. Witnesses and treatment team members “recognized and discussed the need to ensure [Williams’s] safety during transport,” Myrick-Duckett found. Yet, staff did not know how to properly secure the van with child safety locks and the Center hadn’t provided training, according to Myrick-Duckett.
The Center has since modified its travel policy. The driver is now required to thoroughly check the vehicle, including safety locks. Once the patient is inside the vehicle, the driver is required to check the safety locks a second time. Source: The East Oregonian
An investigation by the Oregon Department of Human Services’ Office of Investigations and Training, found no individual responsible for neglecting Williams. Instead, the neglect was a “cumulative failure between management, programs, policies and direct care staff to appropriately protect [Williams], which ultimately contributed to her death,” concluded Investigator James Myrick-Duckett.
Williams had jumped from a facility van earlier that year and staff were aware of that incident. Witnesses and treatment team members “recognized and discussed the need to ensure [Williams’s] safety during transport,” Myrick-Duckett found. Yet, staff did not know how to properly secure the van with child safety locks and the Center hadn’t provided training, according to Myrick-Duckett.
The Center has since modified its travel policy. The driver is now required to thoroughly check the vehicle, including safety locks. Once the patient is inside the vehicle, the driver is required to check the safety locks a second time. Source: The East Oregonian
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