Oregon Mental Patient’s Death Nets $1.4 Million
by Mark Wilson
The family of a man who died in his bed, just feet from a nurse’s station at the Oregon State Hospital (OSH), but whose body was not discovered for hours, accepted $1.4 million to settle a lawsuit filed against hospital officials.
Moises Perez had been confined at OSH for 15 years after being found guilty except for insanity of violently attacking and attempting to murder his mother, Dora Perez, during a psychotic break. At the time he had asked a police officer to shoot him.
Diagnosed with chronic paranoid schizophrenia, Perez was sentenced to the jurisdiction of Oregon’s Psychiatric Security Review Board for a maximum of 40 years and sent to OSH for treatment.
Shortly after complaining of chest pains on October 17, 2009, Perez, 42, died of coronary artery disease. On the day of his death he was last seen at breakfast at 7:15 a.m., according to records obtained by The Oregonian. Nobody missed him when he did not show up for lunch, scheduled medication rounds or dinner.
Staff finally found him dead, in his bed across the hall from the nursing station, when they tried to wake him for medication at 7:35 p.m. Medical Examiner Karen Gunson placed the time of death at six to eight hours before the Marion County Medical Examiner saw Perez’s body at 8:30 p.m. – that is, sometime between 12:30 and 2:30 p.m.
An internal review found that Perez was denied adequate medical care by OSH employees and blamed staffing issues for his death. While the ward had an “appropriate number of staff” on duty, the review suggested that some were not regularly assigned to the ward, so they did not know the patients’ habits. Others were working mandatory overtime to cover employees who were on unpaid furloughs.
In January 2011, after submitting a tort claim notice, Perez’s family filed a wrongful death action against a long list of OSH staff. The suit alleged that OSH employees and others had routinely ignored attempts by Perez’s mother, for years, to alert them about her son’s deteriorating medical condition.
On May 20, 2013, the state agreed to pay the family $1.4 million to settle their suit but refused to admit liability. The settlement was not made public and first came to light four months later, following a public records request by the Associated Press. See: Estate of Perez v. Oregon State Hospital, U.S.D.C. (D. Ore.), Case No. 6:10-cv-01274-TC.
The hospital has made improvements since Perez’s death, stated OSH spokeswoman Rebeka Gipson-King. Most notably, officials have hired additional medical staff, improved policies and training for patients who refuse critical medical care, implemented a policy requiring nurses to check on patients at least hourly, and established guidelines for routine patient monitoring and treatment.
The year before Perez died, the U.S. Department of Justice had threatened to sue the state over conditions at OSH; following his death the Department issued a warning letter, saying Perez had received care that “consistently fell well below constitutional and statutory standards.”
The famous classic movie One Flew Over the Cuckoo’s Nest, starring Jack Nicholson, was filmed at OSH. Some of the extras in the film were real mental patients.
Source: The Oregonian
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Related legal case
Estate of Perez v. Oregon State Hospital
|Cite||U.S.D.C. (D. Ore.), Case No. 6:10-cv-01274-TC.|