Inquiry Clears Mental Hospital of Wrongdoing

Times Staff Writer

A county investigation into allegations of mismanagement and poor patient care at San Diego County’s mental health hospital has cleared the facility of any wrongdoing.

At the same time, however, the lengthy report on Hillcrest Mental Health Facility, released Tuesday by the county’s top administrator, conceded that some disciplinary action and policy changes may be in order. And Chief Administrative Officer Clifford Graves promised the county Board of Supervisors that he will submit within 45 days a more detailed review of the hospital. That analysis may recommend additional policy and personnel changes, he said.

Graves’ report, prepared in response to a list of mostly anonymous allegations released earlier this month through the office of Assemblyman Larry Stirling (R-San Diego), responded point-by-point to 33 specific charges.

The most serious allegations--those surrounding the deaths of four patients and the competency of the psychiatrists who handled their cases--have been referred to the San Diego Psychiatric Society’s peer review committee.


All the charges are also being reviewed by state and federal agencies that will report their findings separately.

“Even though we found nothing to substantiate these specific allegations, staff findings indicate a need for review of the organizational structure of the Hillcrest Mental Health Facility and may imply some basic changes in that structure,” Graves said in a cover letter submitted with the report.

In essence, the report said no evidence was found to support allegations that several of the hospital’s patients were discharged even though they were a danger to themselves or others.

The report said one former hospital employee--the in-patient program manager--was working without a proper license until she was fired on April 19. But several other unlicensed workers have been kept on, either because they still have time to obtain a license or because they need not comply with changes in the law that took effect after they were hired.


In several specific cases in which it was alleged that patients were released improperly, the report responded in what Graves called “a narrative form” to avoid compromising the patients’ rights of privacy.

To an allegation that a woman was released “although the medical team said she was suicidal,” the report responded that the psychiatrist who handled the case was solely responsible for the decision and was not required to abide by the advice of a “team.”

In another case, in which it was alleged that a woman who “begged to be admitted” to the mental health hospital was released and jumped from the Coronado Bridge 14 hours later, the report said the woman in fact had been taken to the facility by police and did not wish to be admitted.

Hospital records “reveal that the person expressed a desire to get on with her life, that she had a job and needed to be at work by noon,” the report said. “The person had a private therapist and stated she would contact her private therapist. The person returned home, went to work, apparently left work early and returned to the bridge.”

Although the case of a patient who died--apparently of a drug overdose--four hours after being placed in seclusion was not discussed specifically, the report said that the policy governing such cases will be changed to “include the newly revised procedures for the direct observation and documentation of patients in seclusion and restraints.”

In addition, suspensions have been recommended for a nurse and a nursing assistant apparently involved in the case, the report said. No other details were provided, and county officials were unavailable for further comment.

No mention was made in the report of the death of Ermerito Cabel Mateo, a patient who was strangled by fellow patient Garland Alan Marcroft. Marcroft was found not guilty of murder by reason of insanity, and the case is apparently one of those under review by the psychiatric society.

Although the report generally addressed weighty issues, it also provided some light moments, perhaps inadvertently.


For example, the report responded to a charge that the county’s deputy director for mental health services was “more concerned about staff coffee breaks” than patient care.

“Untrue,” the document said. “One memo on coffee breaks (dated Sept. 14, 1984) was distributed at the request of a regional manager who was experiencing abuse of breaks among his staff. Much more of the Deputy Director, Mental Health time and energy goes into patient care activities than into one coffee break memo.”